H. pylori Eradication After Graham Patch Repair

Timing of Initiation

• Initiate H. pylori eradication therapy immediately when oral feeding is resumed after Graham patch repair; delaying until discharge reduces patient compliance and increases loss to follow‑up. 1

First‑Line Regimen (Bismuth Quadruple Therapy)

• Use a 14‑day bismuth quadruple regimen consisting of:

Alternative First‑Line Regimen (Non‑Bismuth Quadruple)

• If bismuth is unavailable and local clarithromycin resistance is documented to be <15 %, prescribe a 14‑day concomitant (non‑bismuth) quadruple therapy:

Treatment Duration

• A 14‑day course is mandatory; extending therapy from 7 to 14 days improves eradication rates by approximately 5 %. [1][3]

Post‑Eradication Management

• Continue high‑dose PPI therapy until successful eradication is confirmed in patients with complicated duodenal ulcer; for gastric ulcer, maintain PPI until endoscopic healing is documented. 1

Confirmation of Eradication

• Perform a urea breath test or a monoclonal stool antigen test at least 4 weeks after completing therapy to confirm eradication.
• Discontinue PPI at least 2 weeks before testing to avoid false‑negative results. 3

Clinical Outcomes of Eradication

• Eradication after simple closure of perforated ulcer reduces ulcer recurrence from ~26 % to near‑zero. 3

Indications for Testing in Perforated Ulcer

• All patients with perforated peptic ulcer should undergo H. pylori testing (via endoscopic biopsy, urea breath test with 88–95 % sensitivity, or stool antigen test with 94 % sensitivity). 3
• Empiric antimicrobial therapy without confirmed H. pylori infection is not recommended; a test‑and‑treat strategy is more cost‑effective than empirical treatment. [1][3]

Second‑Line Therapy (After First‑Line Failure)

• If bismuth quadruple therapy fails and the patient has no prior fluoroquinolone exposure, prescribe a 14‑day levofloxacin triple regimen:

Third‑Line Considerations

• After two documented eradication failures with confirmed adherence, obtain antibiotic susceptibility testing to guide further therapy. 3

Critical Pitfalls to Avoid

• Do not postpone eradication therapy beyond the reintroduction of oral feeding. 1
• Do not use 7‑day regimens; a 14‑day course is evidence‑based. [1][3]
• Do not skip post‑treatment confirmation testing in complicated peptic ulcer disease. [1][3]