A 45-year-old man with duodenal ulcer and H. pylori infection undergoes eradication therapy. One month after completing triple therapy, urea breath test remains positive. The most appropriate next step is:
- A H. pylori culture and sensitivity-guided therapy (or bismuth-based quadruple therapy/levofloxacin-based triple therapy as second-line) ✓
- B Repeat same triple therapy regimen for another 14 days
- C Clarithromycin-based quadruple therapy (bismuth-containing)
- D Surgical vagotomy and pyloroplasty for refractory H. pylori
Explanation
After failure of first-line clarithromycin-based triple therapy, current Maastricht VI/Florence Consensus (2022) recommends: (1) bismuth-containing quadruple therapy (PPI + bismuth + metronidazole + tetracycline) as the preferred second-line regimen in most regions; OR (2) levofloxacin-containing triple therapy in areas with low levofloxacin resistance; OR (3) culture-guided therapy where H. pylori susceptibility testing is available. Repeating the same failed regimen is not recommended as clarithromycin resistance is the most common cause of failure and resistance does not reverse. Surgery is not indicated for H. pylori eradication failure alone.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.