What are the testing and treatment recommendations for family members of a confirmed Helicobacter pylori (H. pylori) infection using a urea breath test (UBT)?

Testing and Treatment Recommendations for Family Members of Confirmed H. pylori Infection

Family members of individuals with confirmed H. pylori infection should be tested and treated if positive, as this proactive approach is now recommended to reduce transmission, reinfection, and H. pylori-related diseases. 1

Testing Recommendations for Family Members

Who Should Be Tested

• All family members residing in the same household as patients with proven active H. pylori infections (91% agreement, moderate evidence level) 1
• This recommendation is particularly important as H. pylori infection:
  • Is generally acquired in childhood, especially via transmission within families 1
  • Tends to cluster within families, increasing the risk of peptic ulcer disease and gastric cancer 1

Preferred Testing Methods

1. Urea Breath Test (UBT):

   • Gold standard for non-invasive detection of active infection 1
   • Sensitivity and specificity >90% for active infection 1
   • Important precautions before testing:
     • Withhold antibiotics and bismuth for at least 4 weeks
     • Withhold PPIs for at least 7 days
     • Patient should fast for at least 6 hours 1

2. Stool Antigen Test:

   • Alternative non-invasive test with >90% sensitivity and specificity 1
   • Can be used interchangeably with UBT to identify H. pylori before antibiotic therapy 1
   • Requires laboratory processing by trained personnel

3. Serology Testing:

   • Less preferred as it only indicates exposure, not necessarily active infection 1
   • Cannot differentiate between current and previously eradicated infection
   • Should only be used for initial diagnosis, not for confirming cure 1

Treatment Recommendations

When to Treat

• Treat all family members who test positive for H. pylori, even if asymptomatic 1
• This approach helps:
  • Protect other family members from infection or reinfection
  • Prevent H. pylori-related diseases
  • Engage those who test positive to comply with eradication treatment 1

Treatment Regimens

For treatment-naive patients with H. pylori infection:

• Bismuth quadruple therapy (BQT) for 14 days is the preferred regimen when antibiotic susceptibility is unknown 2
• Alternative regimens include:
  • Rifabutin triple therapy for 14 days
  • Potassium-competitive acid blocker dual therapy for 14 days 2

Confirmation of Eradication

• Confirmation of eradication is generally advisable, especially in cases of:
  • Complicated peptic ulcer disease
  • Gastric ulcer
  • Poor treatment compliance 1
• For asymptomatic family members, confirmation may not be necessary if no symptoms develop 1
• If confirmation is needed:
  • UBT is the preferred non-invasive method
  • Testing should be performed no earlier than 4 weeks after cessation of treatment 1

Clinical Considerations and Pitfalls

Common Pitfalls to Avoid

1. False negative test results due to:

   • Recent use of antibiotics (within 4 weeks)
   • Recent use of PPIs (within 7 days)
   • Recent use of bismuth products (within 4 weeks) 1

2. False positive UBT results due to:

   • Presence of achlorhydria promoting overgrowth of non-H. pylori urease-producing organisms
   • When suspected, confirm with stool antigen test or endoscopy 1

3. Inadequate treatment regimens leading to:

   • Treatment failure
   • Development of antibiotic resistance
   • Avoid mono-antibiotic therapy and ensure high patient compliance 1

Public Health Perspective

• H. pylori should be considered a public health issue due to:
  • Mortality associated with infection (risk of bleeding and cancer)
  • Person-to-person transmission within families 1, 3
• Testing and treating family members represents a proactive approach similar to other public health models (e.g., hypertension screening) 1

By implementing these testing and treatment recommendations for family members of individuals with confirmed H. pylori infection, clinicians can help reduce the burden of H. pylori-related diseases and interrupt the cycle of transmission within households.