Helicobacter pylori retreatment: When clinical guidelines meet patient reality

Table 2 Proposed structured pathway after confirmed Helicobacter pylori eradication failure

Steps	Clinical questions	Suggested action
Verify failure	Was the test-of-cure performed at the appropriate interval, and off acid suppression or other confounding medications where relevant?	Confirm persistent infection before modifying treatment
Review the prior treatment course	Which drugs were used, for how long, and with what degree of dosing complexity? Were there missed doses, interruptions, or clinically relevant adverse events?	Review the prior regimen, duration, adherence, interruptions, and adverse-event history in detail
Identify the main driver of failure	Is the failure most likely related to resistance, poor adherence, treatment intolerance, or gaps in follow-up?	Define the principal contributors to failure and use this assessment to guide the next step
Choose rescue therapy	What were the previous antibiotic exposures, what is known about local resistance patterns, and are there allergy constraints or access to susceptibility testing?	Select an empiric or susceptibility-guided regimen that avoids likely cross-resistance and is feasible for the patient
Anticipate tolerability issues and support completion	Which symptoms or adverse effects mattered most during prior treatment, and what practical barriers may compromise completion this time?	Provide clear written instructions, anticipatory guidance on adverse events, and practical support to improve treatment completion
Arrange follow-up in advance	When and how will eradication be reassessed, and who will contact the patient if follow-up is missed?	Schedule test-of-cure and follow-up before the patient leaves, ideally with reminder support