Antibiotic Regimen for Perforated Ulcer Patients
·
For all patients receiving an operation, send
cultures to guide antimicrobial therapy, especially for patients at risk for
fungal infection or antimicrobial resistance.1
o
Risk factors for fungal infection: immunocompromised,
advanced age, comorbidities, prolonged ICU-stay, unresolved intra-abdominal
infections1
·
Primary antibiotic regimen1
o
Zosyn 4.5 g IV every 6 hours
o
Antifungal medications should not be routinely
added unless above risk factors present. If risk factors and critically ill, add
micafungin 100 mg IV every 24 hours for ICU patients. For stable patients with
risk factors, use fluconazole 800 mg x 1 then 400 mg q 24 hr.
o Continue antibiotics for four days following source control1,2
Antibiotic Regimen for Treatment-Naïve Patients3-5
|
Regimen |
Drug Doses |
Frequency |
Duration |
|
Optimized bismuth quadruple therapy (BQT) |
PPI (standard dose) |
|
14 days |
|
Bismuth subcitrate 120-300 mg or subsalicylate 300 mg |
QID |
||
|
Tetracycline 500 mg |
QID |
||
|
Metronidazole 500 mg |
TID or QID |
||
|
Rifabutin triple (Talicia) |
Omeprazole 10 |
4 capsules TID |
14 days |
|
Amoxicillin 250 mg |
|||
|
Rifabutin 12.5 mg |
|||
|
PCAB dual (Voquezna DualPak) |
Vonoprazan 20 mg |
BID |
14 days |
|
Amoxicillin 1,000 mg |
TID |
||
|
PCAB triple (Voquezna TriplePak) |
Vonoprazan 20 mg |
BID |
14 days |
|
Clarithromycin 500 mg |
|||
|
Amoxicillin 1000 mg |
·
Doxycycline should not be substituted for
tetracycline due to decreased effectiveness.
·
Clarithromycin and levofloxacin regimens should
not be used unless susceptibility testing performed.
·
Before initiating treatment, ensure that patient
has not been treated previously for H pylori.
·
There continues to be a lack of robust trials on
IV antibiotics.6 A complete 14-day course of a recommended oral
regimen should still be prescribed whenever possible, even if partial treatment
with IV medications has occurred.
·
Before considering one of the newer Vonoprazan
regimens, consider patient’s insurance coverage and cost. Pharmacy consultation
is recommended.
Antibiotic Regimens in Treatment-Experienced Patents3-5
·
If not previously used, optimized BQT should
remain the first line regimen for 14 days.
·
Optimized BQT is also acceptable if prior use of
BQT involved duration <14 days, substitution of doxycycline for
tetracycline, or metronidazole doses below the recommended 1.5-2 g/day.
·
Otherwise, it is recommended not to repeat the
prior regimen. The treatment-naïve regimens above may be utilized depending on
prior treatment.
·
Before considering one of the newer Vonoprazan
regimens, consider patient’s insurance coverage and cost. Pharmacy consultation
is recommended.
H pylori
Testing
·
All patients with ulcer disease should receive H
pylori testing as inpatient, including those associated with Roux-en-y or
Bilroth II anatomy, as H pylori may still be contributory to marginal ulcer
development (as many as 31.2% of cases)7.
·
Stool antigen testing is the current available
modality at UK Healthcare. Stool antigen testing may be falsely negative in
those who have significant blood in the stools or who have been on PPI. Thus,
treatment should not be withheld if suspicion is high.
High Risk for Complications
·
Patients with ulcerative disease are at high
risk for complications and need close attention at discharge and follow-up
·
Give a minimum of 6 months Rx for PPI to ensure
the patient has adequate supply to reach GI follow-up
·
Patients should be instructed to continue PPI
BID until outpatient GI follow-up and direction on management. PPI should be
taken before meals.
·
All patients should have follow-up scheduled
with GI for repeat endoscopy and ensuring H pylori eradication at the time of
discharge
·
All patients should have a follow-up scheduled
with EGS Clinic. At the EGS appointment, must reemphasize staying on PPI,
importance of follow-up endoscopy to ensure H pylori eradication and exclude
malignancy.
References
1.
Tarasconi A, Coccolini F, Biffl WL, Tomasoni M,
Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan
FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick
AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I,
Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F.
Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg. 2020
Jan 7;15:3. doi: 10.1186/s13017-019-0283-9. PMID: 31921329; PMCID: PMC6947898.
2.
Sawyer RG, Claridge JA, Nathens AB, Rotstein OD,
Duane TM, Evans HL, Cook CH, O'Neill PJ, Mazuski JE, Askari R, Wilson MA,
Napolitano LM, Namias N, Miller PR, Dellinger EP, Watson CM, Coimbra R, Dent
DL, Lowry SF, Cocanour CS, West MA, Banton KL, Cheadle WG, Lipsett PA, Guidry
CA, Popovsky K; STOP-IT Trial Investigators. Trial of short-course antimicrobial
therapy for intraabdominal infection. N Engl J Med. 2015 May
21;372(21):1996-2005. doi: 10.1056/NEJMoa1411162. Erratum in: N Engl J Med.
2018 Feb 15;378(7):686. doi: 10.1056/NEJMx180006. PMID: 25992746; PMCID:
PMC4469182.
3.
Chey, William D. MD, FACG1; Howden, Colin W. MD,
FACG2; Moss, Steven F. MD, FACG3; Morgan, Douglas R. MD, MPH, FACG4; Greer,
Katarina B. MD, MSEpi5; Grover, Shilpa MD, MPH6; Shah, Shailja C. MD, MPH7. ACG
Clinical Guideline: Treatment of Helicobacter pylori Infection. The American
Journal of Gastroenterology 119(9):p 1730-1753, September 2024. | DOI:
10.14309/ajg.0000000000002968
4.
Shah SC, Moss SF, Kao JY. Approach to the
diagnosis of Helicobacter pylori infection in adults. UpToDate, Jan
2026.
5.
Shah SC, Kao JY, Moss SF. Treatment of Helicobacter
pylori infection in adults. UpToDate, Jan 2026.
6. Chau YA, Milic T, Perrott J.
Intravenous Antibiotics in the Management of H. pylori Infection:
A Systematic Review. J Intensive Care Med. 2025 Aug;40(8):818-828. doi:
10.1177/08850666241245364. Epub 2024 Apr 11. PMID: 38602137.
7. Schulman
AR, Abougergi MS, Thompson CC. H. Pylori as a predictor of marginal ulceration:
A nationwide analysis. Obesity (Silver Spring). 2017 Mar;25(3):522-526. doi:
10.1002/oby.21759. PMID: 28229552.
May 21, 2026
