A 46-year-old man with a confirmed bleeding duodenal ulcer and positive rapid urease test is to receive H. pylori eradication therapy. Local clarithromycin resistance exceeds 15 percent. Which regimen should be prescribed?

• A PPI, amoxicillin, and clarithromycin for 14 days
• B PPI, amoxicillin, and metronidazole for 7 days
• C PPI and levofloxacin dual therapy for 14 days
• D PPI, bismuth, tetracycline, and metronidazole for 10 to 14 days ✓

Explanation

When clarithromycin resistance exceeds 15 percent, standard triple therapy should be avoided, and bismuth-containing quadruple therapy for 10 to 14 days is the recommended first-line regimen. This applies especially in India, where clarithromycin resistance rates are high and quadruple therapy achieves reliable eradication. Levofloxacin regimens are reserved for salvage therapy because fluoroquinolone resistance is even higher, seven-day triple therapy has inferior eradication rates, and dual PPI-amoxicillin therapy performs poorly against resistant strains.

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

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Written and medically reviewed by the StethoPrep medical team.