Effectiveness of Second through Sixth Line Salvage Helicobacter pylori Treatment: Bismuth Quadruple Therapy is Almost Always a Reasonable Choice

Figure 1

Treatment algorithm based on prior antibiotic exposure. QUAD: a twice daily proton pump inhibitor (PPI) given with four times daily metronidazole 500 mg, tetracycline 500 mg, and peptobismol 2 tablets; SEQ: a PPI and amoxicillin 1000 mg for 5 days followed by the PPI, metronidazole 500 mg, and clarithromycin 500 mg, for the subsequent 5 days, all given twice daily; QUAD2: a PPI and clarithromycin 500 mg both given twice daily along with levofloxacin 500 mg daily and peptobismol 2 tables four times a day; PAL: a PPI and amoxicillin 1000 mg, both twice daily given with levofloxacin 500 mg once daily; PAC: a PPI, amoxicillin 1000 mg and clarithromycin 500 mg, all given twice daily. In case of penicillin allergy: PAC was replaced by PMC (a PPI, metronidazole 500 mg, and clarithromycin 500 mg, all given BID) unless previous exposure to metronidazole, and PAL was replaced by PCL (a PPI and clarithromycin 500 mg, both BID given with levofloxacin 500 mg once daily) unless previous exposure to clarithromycin.