The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults.
OBJECTIVE
Helicobacter pylori infection is increasingly difficult to treat. The purpose of these consensus statements is to provide a review of the literature and specific, updated recommendations for eradication therapy in adults.


METHODS
A systematic literature search identified studies on H pylori treatment. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an online platform, finalized, and voted on by an international working group of specialists chosen by the Canadian Association of Gastroenterology.


RESULTS
Because of increasing failure of therapy, the consensus group strongly recommends that all H pylori eradication regimens now be given for 14 days. Recommended first-line strategies include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]). PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options.


CONCLUSIONS
Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC or PBMT should play a more prominent role in eradication of H pylori infection, and all treatments should be given for 14 days.
Division of Gastroenterology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada. Electronic address: carlo.fallone@mcgill.ca.
Carlo A
CA
Fallone
Guelph GI and Surgery Clinic, Guelph, Ontario, Canada; Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.
Naoki
N
Chiba
Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Sander Veldhuyzen
SV
van Zanten
Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
Lori
L
Fischbach
Gastroenterology Service, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
Javier P
JP
Gisbert
Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
Richard H
RH
Hunt
Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Departments of Paediatrics and Physiology, University of Toronto, Toronto, Ontario, Canada.
Nicola L
NL
Jones
Kelowna General Hospital, Kelowna, British Columbia, Canada.
Craig
C
Render
Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
Grigorios I
GI
Leontiadis
Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
Paul
P
Moayyedi
Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
John K
JK
Marshall
D000328:Adult; D000658:Amoxicillin / Q000008:administration & dosage / Q000592:standards; D000890:Anti-Infective Agents / Q000008:administration & dosage / Q000592:standards*; D001729:Bismuth / Q000008:administration & dosage / Q000592:standards; D002170:Canada; D017291:Clarithromycin / Q000008:administration & dosage / Q000592:standards; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination / Q000592:standards; D016481:Helicobacter Infections / Q000188:drug therapy*; D016480:Helicobacter pylori; D006801:Humans; D064704:Levofloxacin / Q000008:administration & dosage / Q000592:standards; D008795:Metronidazole / Q000008:administration & dosage / Q000592:standards; D054328:Proton Pump Inhibitors / Q000008:administration & dosage / Q000592:standards*; D013752:Tetracycline / Q000008:administration & dosage / Q000592:standards
D000890:Anti-Infective Agents; D054328:Proton Pump Inhibitors; D008795:Metronidazole; D064704:Levofloxacin; D000658:Amoxicillin; D013752:Tetracycline; D017291:Clarithromycin; D001729:Bismuth
Amoxicillin; Bismuth; Clarithromycin; Eradication; Helicobacter pylori; Levofloxacin; Metronidazole; Proton Pump Inhibitor; Resistance; Rifabutin; Tetracycline