The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults

Gastroenterology. 2016 Jul;151(1):51-69.e14. doi: 10.1053/j.gastro.2016.04.006. Epub 2016 Apr 19.


Background & aims: Helicobacter pylori infection is increasingly difficult to treat. The purpose of these consensus statements is to provide a review of the literature and specific, updated recommendations for eradication therapy in adults.

Methods: A systematic literature search identified studies on H pylori treatment. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an online platform, finalized, and voted on by an international working group of specialists chosen by the Canadian Association of Gastroenterology.

Results: Because of increasing failure of therapy, the consensus group strongly recommends that all H pylori eradication regimens now be given for 14 days. Recommended first-line strategies include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]). PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options.

Conclusions: Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC or PBMT should play a more prominent role in eradication of H pylori infection, and all treatments should be given for 14 days.

Keywords: Amoxicillin; Bismuth; Clarithromycin; Eradication; Helicobacter pylori; Levofloxacin; Metronidazole; Proton Pump Inhibitor; Resistance; Rifabutin; Tetracycline.

Publication types

  • Consensus Development Conference
  • Review

MeSH terms

  • Adult
  • Amoxicillin / administration & dosage
  • Amoxicillin / standards
  • Anti-Infective Agents / administration & dosage
  • Anti-Infective Agents / standards*
  • Bismuth / administration & dosage
  • Bismuth / standards
  • Canada
  • Clarithromycin / administration & dosage
  • Clarithromycin / standards
  • Drug Administration Schedule
  • Drug Therapy, Combination / standards
  • Helicobacter Infections / drug therapy*
  • Helicobacter pylori*
  • Humans
  • Levofloxacin / administration & dosage
  • Levofloxacin / standards
  • Metronidazole / administration & dosage
  • Metronidazole / standards
  • Proton Pump Inhibitors / administration & dosage
  • Proton Pump Inhibitors / standards*
  • Tetracycline / administration & dosage
  • Tetracycline / standards


  • Anti-Infective Agents
  • Proton Pump Inhibitors
  • Metronidazole
  • Levofloxacin
  • Amoxicillin
  • Tetracycline
  • Clarithromycin
  • Bismuth