The American College of Gastroenterology (ACG) released updated treatment guidelines for Helicobacter pylori (H. pylori), a gram-negative bacteria that infects the stomach and raises the risk of peptic ulcers and gastric cancer. In some parts of the world, H. pylori is prevalent in more than 50% of the population, while in the U.S., about 26% of people are infected. The new guidelines differ from those released in 2017 in that regimens with a PPI and clarithromycin (e.g., Prevpac) are no longer preferred due to clarithromycin resistance that has lowered their efficacy to less than 70%. The guidelines also recommend two regimens with vonoprazan, a new acid-reducing drug that works by competing with potassium ions at proton pumps instead of covalently binding them like PPIs. Recommended first-line therapies are outlined in the table below.


The urea breath test and fecal antigen test are recommended for diagnosis because they detect active disease, whereas the serologic antibody test is nonspecific. A test for cure, using the same method performed for diagnosis, is recommended in all patients 30 or more days after treatment completion. Patients who are still positive should be treated with a salvage regimen with the choice based on prior therapy received and sensitivity testing if available. The recurrence rate in the U.S. after successful treatment is 1% per year. Regimen details for treatment-naive patients and salvage therapy are presented in the tables below.

• Whom to test for H. pylori
• H. pylori diagnosis

• All therapies given for 14 days
• Reference [40]

2024 ACG recommended H. pylopri regimens for treatment-naive adults (Duration of therapy is 14 days)

Optimized bismuth quadruple PPI standard dose twice daily Bismuth subcitrate 120 - 300 mg or subsalicylate 300 mg four times daily Tetracycline 500 mg four times daily Metronidazole 500 mg three or four times daily

Rifabutin triple (Talicia) Each Talicia capsule contains omeprazole 10 mg, amoxicillin 250 mg, and rifabutin 12.5 mg. Dosing is 4 capsules three times daily.

Voquezna DualPak Vonoprazan 20 mg twice daily Amoxicillin 1000 mg three times daily

Voquezna TriplePak Vonoprazan 20 mg twice daily Clarithromycin 500 mg twice daily Amoxicillin 1000 mg twice daily

• All therapies given for 14 days
• Reference [40]

2024 ACG recommended H. pylopri salvage regimens for treatment-experienced adults (Duration of therapy is 14 days)

Optimized bismuth quadruple PPI standard dose twice daily Bismuth subcitrate 120 - 300 mg or subsalicylate 300 mg four times daily Tetracycline 500 mg four times daily Metronidazole 500 mg three or four times daily

Rifabutin triple PPI standard to double dose twice daily Amoxicillin 1000 mg twice or three times daily Rifabutin 150 mg twice daily, 300 mg once daily, or Talicia, which contains 50 mg three times daily

Levofloxacin triple PPI standard dose twice daily Levofloxacin 500 mg once daily Amoxicillin 1000 mg or Metronidazole 500 mg twice daily

Voquezna TriplePak Vonoprazan 20 mg twice daily Clarithromycin 500 mg twice daily Amoxicillin 1000 mg twice daily

High-dose dual therapy Vonoprazan 20 mg or PPI double dose twice or three times daily Amoxicillin 1000 mg three times daily