American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the ideal response for a treatment plan if Helicobacter pylori is not eradicated after the initial therapy?

1. Continue with the same therapy

2. Switch to another macrolide

3. Implement a second-line salvage therapy

4. Increase the dosage of the initial treatment

The correct answer is: Implement a second-line salvage therapy

When Helicobacter pylori is not eradicated after the initial therapy, the recommended approach is to implement a second-line salvage therapy. This involves using a different combination of medications targeted at eliminating the infection effectively. First-line therapy often includes a proton pump inhibitor along with two antibiotics, typically amoxicillin and clarithromycin, or metronidazole. If this treatment fails, simply repeating the same regimen (like continuing with the same therapy or increasing the dosage) is unlikely to be effective, as resistance to the antibiotics used may have developed. Switching to another macrolide, while it may seem like a viable option, does not address the broader issue of bacterial resistance and does not guarantee eradication. A second-line salvage therapy typically includes a different class of antibiotics (often including bismuth compounds or tetracycline) along with a proton pump inhibitor, which is designed to overcome any potential resistance and improve the likelihood of successful eradication. Implementing a second-line salvage therapy, therefore, represents the most effective and evidence-based strategy for managing persistent H. pylori infections following initial treatment failure.