NICE's standard approach to treating H pylori consists of a PPI (usually omeprazole or lansoprazole), and two antibiotics €“ amoxicillin and clarithromycin or metronidazole. Dosing is twice daily for a week. If the patient has had previous exposure to clarithromycin or metronidazole, then the alternative should be used. Cost should be taken into consideration.1

For those with a penicillin allergy, replace amoxicillin with clarithromycin, and use a PPI and metronidazole. If a patient has had clarithromycin previously, use a PPI, a bismuth antacid, metronidazole and tetracycline.

If the week-long therapy does not clear the H pylori, the therapy can be repeated, but using the alternative antibacterial option. Quinolone antibiotics are further considerations if allergy or previous exposure to one of the antibiotics has occurred.

After two such courses of treatment, if the H pylori appears not to have been eliminated, or symptoms persist, the patient should see a gastroenterologist.

Patients who have had a peptic ulcer (gastric or duodenal) and had tested positive for H pylori before treatment, should be tested again six to eight weeks after beginning a course of H pylori eradication therapy.