What is the relationship between Proton Pump Inhibitor (PPI) therapy and Helicobacter pylori (H. pylori) stool test results?

From the Guidelines

Proton pump inhibitors (PPIs) should be stopped at least 2 weeks before taking a Helicobacter pylori (H. pylori) stool test to minimize the risk of false-negative results. PPIs, such as omeprazole, esomeprazole, pantoprazole, lansoprazole, and rabeprazole, reduce stomach acid production, which can decrease the number of H. pylori bacteria present in the stomach, leading to false-negative test results 1. The Maastricht IV/Florence Consensus Report recommends stopping PPIs for 2 weeks before testing by culture, histology, rapid urease test, UBT, or stool test, with a grade of recommendation A and evidence level 1b 1.

Some key points to consider:

• PPI use can lead to local changes in the stomach, causing a decrease in bacterial load, especially in the antrum, resulting in false-negative test results 1.
• The urea breath test (UBT) and stool antigen test (SAT) have shown a 10-40% rate of false-negative results with PPI use 1.
• Histology results can be controversial, but stopping PPIs 2 weeks before testing allows the bacteria to repopulate the stomach, making tests previously negative become positive again 1.
• Serology is the only test not affected by PPI use, as H. pylori antibodies remain present for months after suppression and even eradication of H. pylori 1.

If stopping PPIs is not feasible due to severe symptoms, alternative testing methods like the urea breath test or endoscopy with biopsy may be recommended, although these may also be affected by PPI use 1. It is essential to discuss the temporary discontinuation of PPIs with a healthcare provider to determine the best course of action for individual patients.

From the FDA Drug Label

Decreased gastric acidity due to any means including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract The relationship between Proton Pump Inhibitor (PPI) therapy and Helicobacter pylori (H. pylori) stool test results is that PPI therapy can increase gastric counts of bacteria, including H. pylori, by decreasing gastric acidity. However, the label does not directly address the effect of PPI therapy on H. pylori stool test results. 2

From the Research

Relationship Between Proton Pump Inhibitor (PPI) Therapy and Helicobacter pylori (H. pylori) Stool Test Results

• The use of PPI therapy is recommended in combination with antibiotics for the eradication of H. pylori infection, as it increases the pH in the stomach, creating conditions for antibiotics to act effectively 3, 4, 5.
• PPIs are often used in triple therapy regimens, which include a PPI and two antibiotics, such as amoxicillin and clarithromycin, to achieve eradication rates of 80-90% 3, 4.
• The efficacy of PPI-based triple therapy can be affected by factors such as antibiotic resistance, with clarithromycin resistance being a significant concern 5, 6.
• Alternative therapies, such as quadruple therapy, are being evaluated due to the declining efficacy of traditional triple therapy regimens 6.
• Noninvasive testing for H. pylori, including stool antigen tests, is preferred for diagnosis, and treatment should be guided by test results and patient symptoms 7.

PPI Therapy and H. pylori Eradication

• PPIs are a crucial component of H. pylori eradication therapy, and their use is recommended in combination with antibiotics 3, 4, 5.
• The choice of PPI and antibiotic regimen can affect the efficacy of eradication therapy, with some regimens achieving higher eradication rates than others 3, 4, 6.
• Patient factors, such as age and symptoms, can influence the choice of treatment regimen and the need for endoscopy or other diagnostic tests 4, 7.

Potential Risks and Considerations

• Long-term use of PPIs can be associated with potential risks, including fractures, interactions with antiplatelet medications, and micronutrient deficiencies 7.
• The use of PPIs in combination with antibiotics can increase the risk of adverse effects, such as diarrhea and nausea 3, 6.
• Clinicians should carefully consider the benefits and risks of PPI therapy and H. pylori eradication treatment when making treatment decisions 7.