A 38-year-old man is evaluated for persistent dyspepsia 2 months after a duodenal ulcer was detected and treated. He originally presented with new-onset epigastric pain, and esophagogastroduodenoscopy showed a duodenal ulcer; biopsy specimens showed the presence of Helicobacter pylori. The patient, who does not use NSAIDs and is penicillin-allergic, completed a 10-day course of therapy with omeprazole, metronidazole, and clarithromycin.

At this time, urea breath testing for H. pylori shows persistent infection.

In addition to a proton pump inhibitor, which of the following regimens is indicated for this patient?


Answer and Critique (Correct Answer: B)

Educational Objective:Treat persistent Helicobacter pylori infection.

Key Point

  • Bismuth-based quadruple therapy should be considered in a patient in whom initial proton pump inhibitor–based triple therapy has failed to eradicate Helicobacter pylori.

This patient has persistent Helicobacter pylori infection despite initial therapy with a proton pump inhibitor, clarithromycin, and metronidazole, an appropriate regimen for this patient with penicillin allergy. The most likely reason for failure of treatment in most patients is either noncompliance with therapy or antibiotic resistance; antibiotic resistance (probably to clarithromycin) is a likely cause of treatment failure in this patient. Therefore, an additional treatment regimen, one that does not contain clarithromycin, needs to be given. In the United States, bismuth-based quadruple therapy is indicated in a patient whose infection has failed to respond to proton pump inhibitor–based triple therapy. Levofloxacin-based triple therapy is also used in patients with persistent infection, but this regimen has not been validated in the United States.

Regimens containing amoxicillin would not be indicated in this patient with penicillin allergy. Therapy with the same regimen that failed initially to eradicate the organism because of likely antibiotic resistance would not be appropriate. H. pylori is naturally resistant to trimethoprim, and the regimen of trimethroprim–sulfamethoxazole and erythromycin is not an approved regimen for eradication of the organism.


  • Vakil N, Megraud F. Eradication therapy for Helicobacter pylori. Gastroenterology. 2007;133(3):985-1001. [PMID:17854602] - See PubMed

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