NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Helicobacter pylori testing and eradication in adults bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 13 December 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Suspected H. pylori infection No additional information 2 H. pylori testing Test for H. pylori using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. Perform re-testing for H. pylori using a carbon-13 urea breath test. (There is currently insufficient evidence to recommend the stool antigen test as a test of eradication. 1 ) Do not use office-based serological tests for H. pylori because of their inadequate performance. Quality standards The following quality statement is relevant to this part of the interactive flowchart. Dyspepsia and gastro-oesophageal reflux disease in adults: investigation and management quality standard 3. Testing conditions for Helicobacter pylori 3 First-line treatment Offer people who test positive for H. pylori a 7-day, twice-daily course of treatment with: amoxicillin and either clarithromycin or metronidazole. Choose the treatment regimen with the lowest acquisition cost, and take into account previous exposure to clarithromycin or metronidazole. Offer people who are allergic to penicillin a 7-day, twice-daily course of treatment with: clarithromycin and Page 3 of 10

4 1 This refers to evidence reviewed in Page 4 of 10

5 metronidazole. Offer people who are allergic to penicillin and who have had previous exposure to clarithromycin a 7-day, twice-daily course of treatment with: bismuth and metronidazole and tetracycline. For the assessment of allergy to beta-lactam antibiotics and referral to specialist care, see the NICE pathway on drug allergy. Discuss treatment adherence with the person and emphasise its importance. Proton pump inhibitor doses for H. pylori eradication therapy in this pathway Proton pump inhibitor Dose Esomeprazole 20 mg Lansoprazole 30 mg Omeprazole mg Pantoprazole 40 mg Rabeprazole 20 mg 4 Eradication successful No additional information Page 5 of 10

6 5 Managing uninvestigated dyspepsia See Dyspepsia and gastro-oesophageal reflux disease / Managing uninvestigated dyspepsia in adults 6 Managing peptic ulcer disease See Dyspepsia and gastro-oesophageal reflux disease / Managing peptic ulcer disease in adults 7 Managing functional dyspepsia See Dyspepsia and gastro-oesophageal reflux disease / Managing functional dyspepsia in adults 8 Eradication unsuccessful No additional information 9 Second-line treatment Offer people who still have symptoms after first-line eradication treatment a 7-day, twice-daily course of treatment with: amoxicillin and either clarithromycin or metronidazole (whichever was not used first-line). Offer people who have had previous exposure to clarithromycin and metronidazole a 7-day, twice-daily course of treatment with: amoxicillin and a quinolone or tetracycline (whichever has the lowest acquisition cost). Page 6 of 10

7 Offer people who are allergic to penicillin (or who have not had previous exposure to a quinolone) a 7-day, twice-daily course of treatment with: metronidazole and levofloxacin. Offer people who are allergic to penicillin and who have had previous exposure to a quinolone: bismuth and metronidazole and tetracycline. For the assessment of allergy to beta-lactam antibiotics and referral to specialist care, see the NICE pathway on drug allergy. Proton pump inhibitor doses for H. pylori eradication therapy in this pathway Proton pump inhibitor Dose Esomeprazole 20 mg Lansoprazole 30 mg Omeprazole mg Pantoprazole 40 mg Rabeprazole 20 mg 10 Eradication unsuccessful No additional information Page 7 of 10

8 11 Specialist advice and referral Seek advice from a gastroenterologist if eradication of H. pylori is not successful with secondline treatment. Consider referral to a specialist service for people with H. pylori that has not responded to second-line eradication therapy. Page 8 of 10

9 Glossary H. pylori Helicobacter pylori H2RA H 2 receptor antagonist NSAID non-steroidal anti-inflammatory drug PPI proton pump inhibitor Sources Dyspepsia and gastro-oesophageal reflux disease (2014) NICE guideline CG184 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced Page 9 of 10

10 for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT Page 10 of 10