• Patients with uncomplicated dyspepsia that is unresponsive to lifestyle change and antacids, following a single one month course of proton pump inhibitor (PPI), without alarm symptoms (see below). In patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made
• Patients with peptic ulcer disease
• Patients with gastric cancer (particularly if undergoing curative endoscopic therapy or partial gastrectomy)
• Patients with functional dyspepsia (dyspepsia in the presence of a structurally normal upper endoscopy)
• Patients with a first degree relative with gastric cancer
• Patients with MALToma

Investigations required  (one of the following)

• Stool sample (faecal antigen test)
• CLO test (Campylobacter-like organism or rapid urease test - requires biopsy during endoscopy)

Non-antimicrobial management

• The following washout periods are recommended before testing for H. pylori
  • PPIs – 2 weeks
  • Bismuth and antibiotics - 4 weeks
  • H2-receptor Antagonists – 48 hours
• Follow NICE guidance for other non-antimicrobial treatment of uninvestigated dyspepsia, peptic ulcer disease, and functional dyspepsia.
   https://www.nice.org.uk/guidance/cg184

Patients who should be re-tested

Stool sample (faecal antigen test): this should be at least 4 weeks after eradication for PUD, gastric cancer of MALToma. 

Empirical options for H pylori eradication

Durations
1st line and 2nd line therapy: 7 days
MALToma: 14 days

First line options - all options to be given orally (PO)

1st line

Penicillin allergy

Penicillin allergy and previous exposure to clarithromycin¹

Lansoprazole  30mg 12-hourly
AND 
Amoxicillin  1g 12-hourly
AND EITHER
Clarithromycin  500mg  12-hourly
OR
Metronidazole  400mg 12-hourly

Lansoprazole  30mg 12-hourly
AND 
Clarithromycin  500mg 12-hourly
AND 
Metronidazole  400mg 12-hourly

Lansoprazole  30mg 12-hourly
AND 
Metronidazole  400mg 12-hourly
AND
Doxycycline  100mg 12-hourly
AND
Bismuth subsalicylate (Peptobismol) 525mg 6-hourly

Second line options - all options to be given orally (PO)

• Offer to patients who still have symptoms after completing first-line eradication treatment

2nd line

Previous exposure to clarithromycin and metronidazole

Penicillin allergy

Penicillin allergy and previous exposure to a quinolone¹

Lansoprazole  30mg 12-hourly
AND
Amoxicillin  1g 12-hourly
AND EITHER
Clarithromycin  500mg 12-hourly
OR
Metronidazole  400mg 12-hourly (whichever was not used first line)

Lansoprazole  30mg 12-hourly
AND
Amoxicillin  1g 12-hourly
AND EITHER
Levofloxacin  250mg 12 hourly
OR
Doxycycline  100mg 12-hourly

Lansoprazole  30mg 12-hourly
AND
Metronidazole  400mg 12-hourly
AND
Levofloxacin  250mg 12 hourly

Lansoprazole  30mg po 12-hourly
AND
Bismuth subsalicylate (Peptobismol) 525mg 6-hourly
AND
Metronidazole  400mg 12-hourly
AND
Doxycycline  100mg 12-hourly

Third line options

Seek advice from Gastroenterology if failure of eradication with second line regimens (peptic ulcer disease or MALToma only).