According to the ACG 2017 guidelines for Helicobacter pylori management, which test-and-treat strategy is preferred for H. pylori in a patient with functional dyspepsia and no alarm features in a region with >15% clarithromycin resistance?

• A Clarithromycin-based triple therapy for 14 days
• B Sequential therapy (amoxicillin 5 days, then clarithromycin + metronidazole 5 days)
• C Bismuth quadruple therapy (bismuth + metronidazole + tetracycline + PPI) for 14 days ✓
• D Levofloxacin-based triple therapy for 10 days

Explanation

ACG guidelines and updated consensus recommend that when clarithromycin resistance is >15% in the local population, clarithromycin-based triple therapy should be abandoned as empiric first-line due to high eradication failure rates (<80%). Bismuth quadruple therapy (PBMT: PPI + bismuth + metronidazole + tetracycline) is the preferred alternative, achieving >90% eradication rates even in areas with high dual resistance. This is a critical clinical decision point requiring awareness of local antibiotic resistance patterns.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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