Eradication of Helicobacter pylori (Antimicrobial)


Check antibiotic history as each additional course of clarithromycin, metronidazole or levofloxacin increases resistance risk in H. pylori infection.
Triple treatment attains >85% eradication. 

* Bismuth subsalicylate tablets (262·5mg per tablet) are available as Pepto-Bismol brand. Suspension is also available with an equivalent dose of 30mls 4 times daily.  Prescribe as the generic chemical name as Pepto-bismol brand is on NHS blacklist and the prescription will not be paid. 

In treatment failure despite following the options provided, contact infection specialist or gastroenterologist for advice.

Drug details

Use a combination of 2 of the 3 antibiotics recommended. Avoid amoxicillin in penicillin allergy.  Avoid clarithromycin or metronidazole if prescribed in the past 12 months due to rising resistance. (3 agent regime)
For ongoing symptoms after first line, try alternative combination of first line antibiotics, if suitable.

Lansoprazole 30mg twice daily
PLUS 2 antibiotics from
Amoxicillin 1 gram twice daily
OR Clarithromycin 500mg twice daily
OR Metronidazole 400mg twice daily

7 days

If Penicillin allergy AND previous exposure to clarithromycin (4 agent regime)

Lansoprazole 30mg twice daily
PLUS Bismuth subsalicylate * 525mg (2 tablets) 4 times daily
PLUS Metronidazole 400mg twice daily
PLUS Tetracycline 500mg 4 times daily

7 days

Relapse AND previous exposure to clarithromycin and metronidazole (3 agent regime)

Lansoprazole 30mg twice daily
PLUS Amoxicillin 1 gram twice daily
PLUS either Tetracycline 500mg 4 times daily
OR Levofloxacin 250mg twice daily (see BNF warnings and MHRA Drug Safety Alert (updated 22 January 2024))

7 days

If unable to tolerate lansoprazole

Omeprazole 20mg twice daily

7 days

Editorial Information

Last reviewed: 30/11/2018

Next review date: 30/11/2020

Author(s): Antimicrobial Management Team.

Approved By: TAM Subgroup of ADTC

Reviewer name(s): Alison Macdonald, Area Antimicrobial Pharmacist.

Document Id: AMT116