Second-Line Strategies for Refractory Helicobacter pylori Infection

According to the AGA Clinical Practice Update on refractory Helicobacter pylori infection, management requires a tailored approach after first-line bismuth quadruple therapy failure. Clinicians should engage in shared decision-making to choose between two evidence-based second-line options: a levofloxacin- or rifabutin-based triple therapy (with high-dose PPI and amoxicillin) or an alternative bismuth quadruple regimen. Optimal acid suppression achieved through high-dose PPIs, CYP2C19-independent agents, or potassium-competitive acid blockers is critical for success. Additionally, 14-day regimens are strongly recommended over shorter courses, as extended therapy significantly improves eradication rates in these challenging cases.

References: https://www.gastrojournal.org/article/S0016-5085(21)00319-X/fulltext