Helicobacter pylori Infection — ABIM Board MCQ
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Correct answer: B — Bismuth quadruple therapy for 14 days
In areas with high clarithromycin resistance, the 2024 ACG guidelines recommend bismuth quadruple therapy (PPI, bismuth, metronidazole, tetracycline) for 14 days as first-line treatment. This regimen achieves eradication rates of 92–98% regardless of clarithromycin susceptibility. Option A (clarithromycin triple therapy) is contraindicated when resistance exceeds ~15%—the guideline threshold. Option C (levofloxacin) is suboptimal at 7 days and is reserved for second-line when clarithromycin has been used; fluoroquinolone resistance is also rising. Option D (high-dose dual amoxicillin-PPI) lacks supportive evidence as empirical first-line and carries risk of penicillin hypersensitivity. Option E (sequential therapy) is complex, poorly tolerated, and not preferred in current US guidance. The discriminating feature is the stem's explicit statement of 'high local clarithromycin resistance,' which mandates avoidance of clarithromycin and selection of a resistance-independent regimen.
Reference: American College of Gastroenterology (ACG) 2024 Guideline for the Management of Helicobacter pylori Infection (summary in NEJM Clinician, 2024). https://clinician.nejm.org/treating-patients-helicobacter-pylori-infections-nejm-jw.NA57981