From the Guidelines
I would recommend H. pylori antimicrobial susceptibility testing for this patient. This 43-year-old gentleman has already failed multiple eradication regimens including bismuth-based quadruple therapy, clarithromycin-based triple therapy, and rifabutin-based therapy. When a patient has failed two or more appropriate treatment regimens, antimicrobial susceptibility testing becomes crucial to guide therapy selection, as noted in the 2021 AGA clinical practice update on the management of refractory Helicobacter pylori infection: expert review 1.
This testing will identify which antibiotics the specific H. pylori strain is resistant to, allowing for a targeted treatment approach rather than empiric therapy. Susceptibility testing typically involves culturing H. pylori from gastric biopsies and testing it against various antibiotics, as discussed in the same update 1. The results will help design a personalized regimen with antibiotics to which the organism remains susceptible.
Key considerations in the management of refractory H. pylori infection include:
- Identifying other contributing etiologies, such as inadequate adherence to therapy and insufficient gastric acid suppression 1
- Conducting a thorough review of prior antibiotic exposures to guide the selection of subsequent therapies 1
- Exploring barriers to adherence and addressing them prior to prescribing therapy 1
- Considering the use of high-dose and more potent PPIs, or potassium-competitive acid blockers if available, to ensure adequate acid suppression 1
Given the increasing prevalence of antibiotic-resistant H. pylori strains worldwide, as highlighted in the 2021 expert review 1, and the patient's history of serious complications (upper GI bleeding with a visible vessel), successful treatment will significantly reduce the risk of recurrent ulceration and bleeding. Therefore, antimicrobial susceptibility testing is the most appropriate next step to guide the selection of an effective treatment regimen for this patient, as supported by the 2019 reconciliation of recent Helicobacter pylori treatment guidelines 1.