Table 5

 Recommendations for treatment of H pylori infection formulated in the Maastricht III Consensus Report, with levels of scientific evidence and grades of recommendation

RecommendationsLevel of evidenceGrade of recommendation
The threshold of clarithromycin resistance at which empirical use of this antibiotic should be abandoned, or pretreatment clarithromycin susceptibility testing performed, is 15–20%1aA
Testing for metronidazole susceptibility is not routinely necessary in the management of H pylori infection. Metronidazole susceptibility testing needs further standardisation before it can be recommended1a–cA
There is a small advantage in using a PPI-clarithromycin-metronidazole combination instead of PPI-clarithromycin-amoxicillin as the first choice treatment1aA
• PPI-clarithromycin-amoxicillin or metronidazole treatment remains the recommended first choice treatment in populations with less than 15–20% clarithromycin resistance prevalence. In populations with less than 40% metronidazole resistance prevalence PPI-clarithromycin-metronidazole is preferable
• Quadruple therapies are alternative first choice treatments
The same first choice H pylori treatments are recommended world wide, although different doses may be appropriate1bA
• Bismuth-based quadruple therapies remain the best second choice treatment, if available. If not, a PPI, amoxicillin or tetracycline and metronidazole are recommended
The rescue treatment should be based on antimicrobial susceptibility testing2cB