What is the recommended follow-up protocol after treatment of Helicobacter (H.) Pylori infection?

Follow-up Protocol After H. Pylori Treatment

Post-treatment testing should be performed at least 4 weeks after completion of eradication therapy using urea breath test (UBT) or stool antigen test (SAT) to confirm successful eradication of H. pylori infection. 1

When to Confirm Eradication

Confirmation of H. pylori eradication is strongly recommended in the following situations:

• Complicated peptic ulcer disease
• Gastric ulcer
• Low-grade gastric MALT lymphoma
• When treatment has low efficacy or compliance is poor 2
• After any treatment for H. pylori to ensure eradication 3

Timing of Follow-up Testing

• Wait at least 4 weeks after completion of eradication therapy 2, 1
• Avoid testing while patient is on PPIs, antibiotics, or bismuth preparations as these can lead to false-negative results 1

Recommended Testing Methods

Non-invasive Methods (Preferred for Uncomplicated Cases)

1. Urea Breath Test (UBT)

   • Sensitivity: 94.7%, Specificity: 95.7% 1
   • First-line test due to higher accuracy
   • Less affected by PPI use than other tests

2. Stool Antigen Test (SAT)

   • Sensitivity: 88.8-92.1%, Specificity: 87.3-87.6% 1
   • Good alternative when UBT not available
   • Use validated laboratory-based monoclonal tests for best accuracy 2

Invasive Methods (For Complicated Cases)

• Endoscopy with biopsy specimens from both antrum and body 2
• Recommended for:
  • Complicated peptic ulcer disease
  • Gastric ulcer (to exclude malignancy)
  • MALT lymphoma

Management of Persistent Infection

If H. pylori eradication is unsuccessful:

1. Review prior antibiotic exposures:

   • Avoid clarithromycin-based regimens if previous macrolide exposure
   • Avoid levofloxacin-based regimens if previous fluoroquinolone exposure 2

2. Second-line therapy options:

   • If bismuth quadruple therapy failed as first-line:
     • Levofloxacin or rifabutin-based triple therapy with high-dose PPI and amoxicillin
     • Alternative bismuth-containing quadruple therapy 2
   • 10-day levofloxacin-amoxicillin triple therapy if first-line therapy failed 2

3. Consider antibiotic susceptibility testing for patients with multiple treatment failures 3

Common Pitfalls to Avoid

1. Using serology to confirm eradication (cannot differentiate between active and past infection) 1
2. Testing while patient is still on PPIs, antibiotics, or bismuth 1
3. Testing too soon after treatment completion (less than 4 weeks) 2, 1
4. Inadequate dosing of medications in retreatment regimens 2
5. Not addressing barriers to adherence before prescribing therapy 2

Long-term Follow-up Considerations

• No routine long-term follow-up is needed after confirmed eradication in uncomplicated cases
• For patients with gastric ulcer, follow-up endoscopy with histological examination should be performed to exclude malignancy 2
• Patients with MALT lymphoma require intensive follow-up and may need alternative treatments (chemotherapy, radiotherapy) if the lymphoma fails to respond or progresses 2

By following this structured approach to post-H. pylori treatment follow-up, clinicians can ensure successful eradication, prevent recurrence, and minimize the risk of complications associated with persistent infection.