H. pylori

Patient presenting with dyspepsia-like symptoms

• Consider whether red flags are present that may indicate the need for referral for further investigation:
  • Age ≥ 55 years at first presentation of new-onset dyspepsia (ten years earlier for Māori, Pacific or Asian patients)
  • Family history of gastric cancer with age of onset < 50 years
  • Symptoms and signs of gastrointestinal bleeding, such as haematemesis, anaemia or melaena
  • Iron-deficiency anaemia, without obvious cause, e.g. menorrhagia
  • Difficulty swallowing
  • Palpable abdominal mass
  • Unexplained weight loss
• Recommend lifestyle changes, e.g. reducing meal size, avoiding large meals before bedtime, limiting alcohol intake, avoiding trigger foods, weight loss
• Trial a proton pump inhibitor (PPI), e.g. 20 mg omeprazole once daily, for four to eight weeks

If symptoms do not improve after a PPI trial

• Consider the risk of H. pylori infection. Factors influencing risk include geographic location (the prevalence is generally higher in Northland and Auckland regions), being of Māori, Pacific or Asian ethnicity, or having been born in a country with high rates of H. pylori infection
• If patients are considered to be at:
  • High-risk of H. pylori infection, request faecal antigen testing (stop PPI for two weeks before the test)
  • Low-risk of H. pylori infection, continue PPI treatment and investigate other potential causes. If none can be found or symptoms still do not resolve after alternative treatment options have been trialed or with continued PPI use, H. pylori testing can be considered, or refer patient to secondary care.

In patients with a confirmed H. pylori infection

• Prescribe first-line triple treatment (eradication) regimen for 14 days, consisting of a PPI (e.g. omeprazole, 20 mg twice daily); and clarithromycin (500 mg twice daily); and amoxicillin (1,000 mg twice daily) or metronidazole (400 mg twice daily)
• N.B. Consider previous antibiotic exposure before prescribing. If prior exposure to:
  • Any macrolide antibiotic – prescribe omeprazole + amoxicillin + metronidazole (dosing as above)
  • Metronidazole – prescribe omeprazole + amoxicillin + clarithromycin (dosing as above)
  • Both macrolide antibiotics and metronidazole – discuss options with a gastroenterologist, clinical microbiologist or infectious disease specialist
• Confirmation of eradication is not usually required if symptoms resolve

If symptoms remain following first-line treatment

• Re-test for H. pylori infection three months later
• If the test is still positive, consider whether the potential benefits of further antibiotic treatment outweigh the risks
• If a decision is made to provide further antibiotic treatment, prescribe a 14-day second-line regimen including a PPI (e.g. omeprazole, 20 mg twice daily); and tripotassium dicitratobismuthate (bismuth; 120 mg four times daily); and tetracycline (500 mg four times daily); and metronidazole (400 mg three times daily)

If symptoms remain following second-line treatment, or if second-line treatment is not undertaken for any reason despite continuing symptoms/infection, consider referral to a gastroenterologist.