A new patient presents to your clinic in St. Louis as a referral from her PCP. She was recently treated for H. Pylori infection with two weeks of Clarithromycin, Amoxicillin and omeprazole. Her symptoms of dyspepsia partially resolved but returned off of therapy. Approximately 5 weeks after completing therapy an Helicobacter pylori stool antigen was sent and positive. She does not have any drugs allergies and has not received other recent antibiotics.
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Correct Answer: Tetracycline, metronidazole, bismuth, and omeprazole
Correct answer is C. This case describes a patient with H. pylori who failed initial treatment regimen of Clarithromycin based triple therapy.
This regimen is appropriate when risk of macrolide resistance is low
- specifically if the patient has not had recent macrolide exposure
- and the background resistance levels are < 20%.
There is evidence to suggest increasing rates of macrolide resistance and up to 1 in 5 patients with H pylori will fail their first regimen. The American College of Gastroenterology has a guidance from 2017 to help in selecting a follow up regimen. The algorithm is listed below. The follow up regimen is often based on the regimen that the patient failed, avoiding medications in the initial regimen, and their antibiotic allergies. Of the above regimens, the bismuth quadruple therapy is the only one that avoids macrolides and fits in the algorithm below.
Written by Nathaniel Nolan, edited by Gerome Escota from Washington University St. Louis
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This question was uploaded on 4/13/2022