Should Antibiotics Be Started for Gastritis?
Antibiotics should be started for gastritis ONLY if Helicobacter pylori infection is confirmed by testing—not for gastritis alone. 1, 2
Diagnostic Testing Required Before Antibiotic Initiation
All patients with gastritis must be tested for H. pylori before considering antibiotics. 1 The recommended non-invasive tests include:
- Urea breath test (preferred method) 1
- Monoclonal stool antigen test (alternative method) 1
- Avoid serological testing as it remains positive after successful treatment and cannot confirm active infection 1
Do not start antibiotics empirically without confirmed H. pylori infection—gastritis without H. pylori does not require antibiotic therapy. 1, 2
When Antibiotics ARE Indicated: H. pylori-Positive Gastritis
If H. pylori testing is positive, bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance to clarithromycin and metronidazole. 1, 2
Recommended Antibiotic Regimen
Bismuth quadruple therapy includes: 1, 2
- Bismuth subsalicylate
- Tetracycline
- Metronidazole
- High-potency PPI (esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily) 1, 2
Treatment duration must be 14 days—shorter courses significantly reduce eradication rates. 1, 2
Alternative Regimens
If bismuth is unavailable, concomitant 4-drug therapy is an alternative option. 2 When selecting antibiotics, prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development. 1
When Antibiotics Are NOT Indicated
Do not start antibiotics for:
- H. pylori-negative gastritis—treat with PPIs alone 1, 2
- NSAID-induced gastritis—discontinue NSAIDs and use PPIs for gastroprotection 1, 2
- Autoimmune gastritis—manage with vitamin B12/iron supplementation and PPI therapy 1
- Atrophic gastritis without confirmed H. pylori—focus on surveillance and nutritional support 1
Post-Treatment Confirmation
Confirm H. pylori eradication 4-6 weeks after completing antibiotic therapy using non-serological testing (urea breath test or stool antigen test). 1, 2 Do not rely on symptom resolution alone to determine treatment success. 2
Critical Pitfalls to Avoid
- Never use antibiotic therapy for less than 14 days—this significantly reduces eradication rates 1, 2
- Never start antibiotics without confirming H. pylori infection first 1
- Never use serological testing to confirm eradication—it remains positive after successful treatment 1
- Never assume symptom resolution equals H. pylori eradication—always confirm with objective testing 2
Special Considerations for Atrophic Gastritis
In patients with atrophic gastritis and confirmed H. pylori, eradication treatment should still be administered despite reduced gastric acid secretion. 3 However, the efficacy of standard PPI-based regimens may be reduced in this population due to non-acidic intragastric pH. 3 Bismuth-based therapy may be particularly effective in the specific setting of atrophic gastritis. 3