H. pylori treatment (Canada)

How to use it

Answer the patient and treatment-history questions. Susceptibility results and the PPI are optional; a blank susceptibility means “unknown”, never “susceptible”. The result gives one recommended regimen with a prescription you can copy, the alternatives, what to avoid, and the test of cure.

Reading the result

Situation	Regimen (14 days)	Basis
First treatment	Bismuth quadruple (PBMT), or Pylera + PPI	Toronto 3; ACG 1; Maastricht VI
First treatment, no macrolide use, no penicillin allergy	PAMC is an alternative	Toronto 4 (ACG does not prefer it over BQT)
Penicillin allergy	PBMT	Toronto; ACG; Maastricht VI 17
Failed clarithromycin regimen	PBMT	Toronto 8, 10; ACG 7
Failed PBMT	Rifabutin triple, or levofloxacin triple if susceptibility is confirmed	ACG 8, 10; Toronto 9, 13
Failed PBMT and rifabutin	Refer for susceptibility testing	ACG; Toronto
Pregnant or breastfeeding	Defer	Product monographs

Test of cure

Test everyone after treatment (ACG 2024). Use a urea breath test or stool antigen test at least 4 weeks after finishing, with the PPI stopped 2 weeks before and no antibiotics or bismuth for 4 weeks. H2 blockers and antacids don’t affect these tests. Don’t use serology. Toronto 2016 does not address test of cure.

Where the guidelines disagree

After PBMT fails. Toronto 2016 suggests levofloxacin-containing therapy and keeps rifabutin until 3 options have failed. ACG 2024 suggests rifabutin triple therapy and allows levofloxacin only with confirmed susceptibility. In Edmonton, levofloxacin triple therapy worked in only 35–38% after first-line failure, and the 2025 Canadian commentary now prefers rifabutin. In refractory isolates from Vancouver (2009–2023), only 50% were levofloxacin-susceptible and 13% clarithromycin-susceptible, while 97–99% were susceptible to amoxicillin and tetracycline (Hamze 2025). This tool follows ACG 2024 and the Canadian commentary and shows the Toronto position as a caution. Susceptibility testing settles the question.
PAMC. Toronto lists it as a first-line option. ACG 2024 does not suggest it over BQT, and it fails when clarithromycin resistance is present. The tool offers it only as an alternative, with no penicillin allergy, no past macrolide use and no known resistance.
High-dose PPI–amoxicillin dual therapy. Toronto and ACG found too little evidence to recommend it in North America. Maastricht VI lists it as a rescue option. It’s a specialist choice here.

Canadian practicalities

Not available: vonoprazan (no Health Canada approval), Talicia, Hp-PAC, and standalone bismuth subcitrate.
Pylera has been marketed in Canada since December 2025. Its label is 10 days with omeprazole; 14 days follows the guidelines and is off-label.
Bismuth subsalicylate 262 mg caplets (2 four times daily) or 524 mg Extra Strength caplets (1 four times daily). Avoid the chewables: they contain calcium carbonate, which blocks tetracycline.
Tetracycline comes only as 250 mg capsules from one maker. Check pharmacy stock before prescribing.
Metronidazole 500 mg is a capsule; amoxicillin 1000 mg is two 500 mg capsules.
Rifabutin (Mycobutin) is off-label for H. pylori, may need special authorization; check supply before prescribing. Rule out active tuberculosis first.
Ask the pharmacy for blister packs: they help adherence (Toronto).

Pitfalls

Under-dosing metronidazole in PBMT. Use 1500–2000 mg a day.
Doxycycline for tetracycline. Not recommended; eradication is lower (ACG).
Reported penicillin allergy. Fewer than 1% of people have a true IgE-mediated allergy. Refer for assessment: it opens the amoxicillin regimens for later.
Repeating failed antibiotics. Don’t reuse clarithromycin or levofloxacin after a regimen containing them has failed (Toronto).

Sources

Fallone CA, Chiba N, van Zanten SV, et al. The Toronto Consensus for the treatment of Helicobacter pylori infection in adults. Gastroenterology 2016;151:51–69. PMID 27102658 Canadian (CAG) guidance: 14 days for all regimens (statement 1); first line PBMT or PAMC (3–4); triple therapy restricted (5); no PAL first line (6); after failure PBMT or levofloxacin therapy (8–9); no repeat clarithromycin or levofloxacin (10–11); rifabutin only after ≥3 failed options (13); dose table 2.

Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori infection. Am J Gastroenterol 2024;119:1730–53. PMID 39626064 Optimized BQT first line; clarithromycin and levofloxacin only with confirmed susceptibility; rifabutin after BQT; test of cure for all ≥4 weeks after therapy with PPI stopped 2 weeks before; penicillin allergy referral. ACG's rifabutin triple regimen (ACG guideline highlights, 2024): omeprazole 40 mg, amoxicillin 1000 mg and rifabutin 50 mg three times daily (rifabutin 150 mg twice daily if 50 mg is unavailable).

Malfertheiner P, Megraud F, Rokkas T, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut 2022;71:1724–62. PMID 35944925 BQT first line where clarithromycin resistance is high or unknown; rescue after BQT; proven penicillin allergy (statement 17); PPI stopped 14 days and no antibiotics or bismuth for 4 weeks before testing.

Veldhuyzen van Zanten S, Krahn T. Do the new ACG H. pylori treatment guidelines have implications for Canada? J Can Assoc Gastroenterol 2025;8:85–8. PMID 40574829 Canadian commentary: vonoprazan not available; rifabutin restricted; PAL success 35–38% after first-line failure in Edmonton; rifabutin preferred to empiric levofloxacin as third line.

Hamze H, et al. Helicobacter pylori culture positivity and antimicrobial susceptibility profiles (Vancouver, Canada). J Antimicrob Chemother 2025;80:1640–6. PMID 40202867 Refractory H. pylori, British Columbia 2009–2023 (228 isolates): susceptible to amoxicillin 97.3%, tetracycline 99.1%, levofloxacin 50.4%, metronidazole 25.9%, clarithromycin 12.9%; stable over time.

Health Canada Drug Product Database and product monographs (checked October 2026): Pylera (DIN 02246962), tetracycline (AA Pharma), Mycobutin, metronidazole, clarithromycin, levofloxacin. Availability; Pylera label (3 capsules four times daily for 10 days); contraindications in pregnancy and breastfeeding; tetracycline interactions; metronidazole and alcohol; rifabutin and tuberculosis.

Changelog

2026-10-11 · v2.0.2Currency check (October 2026): no new Canadian H. pylori guideline since Toronto 2016; Pylera still marketed, vonoprazan and Talicia still not approved, Hp-PAC cancelled, Mycobutin and AA Pharma tetracycline still marketed (Health Canada DPD, 11 October 2026). Added 2025 Canadian susceptibility data from refractory cases in Vancouver (levofloxacin 50%, clarithromycin 13%, amoxicillin and tetracycline 97–99%), which support avoiding empiric levofloxacin after treatment failure.

2026-10-10 · v2.0.1The rifabutin triple regimen now says that its doses are the Toronto table 2 doses (all twice daily) and that the ACG 2024 regimen it is attributed to uses omeprazole 40 mg, amoxicillin 1000 mg and rifabutin 50 mg three times daily (150 mg twice daily where 50 mg is unavailable, as in Canada).

2026-10-08 · v2.0.0Rebuilt as an interactive, accessible selector replacing the image-only quick reference. Added the missing test of cure for everyone (at least 4 weeks after treatment, PPI stopped 2 weeks before), the ACG 2024 caution against empiric levofloxacin, the rifabutin restriction (Toronto: after 3 failed options; Canadian access and tuberculosis warnings), penicillin-allergy handling and delabelling, pregnancy and breastfeeding, Canadian availability (Pylera marketed since December 2025; vonoprazan not approved), prescriptions with quantities, and a chart note. PAC and PMC are no longer shown as one ambiguous row, and the Pylera label duration (10 days) is now stated next to the guideline duration (14 days).

2025-03-01 · v1.0.0First version.