What is the recommended method for testing cure of Helicobacter (H.) pylori gastritis?

Test of Cure for Helicobacter Pylori Gastritis

The urea breath test (UBT) performed at least 4 weeks after completion of therapy is the recommended method for confirming eradication of H. pylori infection. 1, 2

Recommended Testing Methods for H. pylori Eradication

First-Line Test Options

1. 13C-Urea Breath Test (UBT)

   • Sensitivity: 95%, Specificity: 95% 2
   • Gold standard for non-invasive confirmation of eradication
   • Must be performed at least 4 weeks after completion of therapy 1
   • Avoid use within 2 weeks of PPI therapy (can cause false negatives) 1

2. Stool Antigen Test (SAT)

   • Sensitivity: 88-90%, Specificity: 91-100% 2
   • Validated monoclonal antibody-based tests preferred 1
   • Also requires at least 4 weeks after completion of therapy 1
   • Alternative when UBT is unavailable 1

When Endoscopy is Clinically Indicated

If endoscopy is being performed for another clinical reason, biopsy-based methods can be used:

• Histology
• Rapid urease test
• Culture (particularly useful after treatment failure to guide subsequent therapy) 1

Important Considerations for Test of Cure

Timing of Testing

• Minimum waiting period: 4 weeks after completion of eradication therapy 1, 2
• Testing too early can lead to false-negative results due to temporary suppression of bacterial load rather than true eradication 3

Medication Interference

• Stop proton pump inhibitors (PPIs) at least 2 weeks before testing 1
• Stop antibiotics at least 4 weeks before testing 1
• H2-receptor antagonists have less impact but ideally should be stopped before testing 1

Test Selection Based on Clinical Context

• For most patients: UBT is preferred due to highest accuracy 2
• When UBT unavailable: Monoclonal stool antigen test is a good alternative 1
• When endoscopy indicated: Biopsy-based methods can be used 1

Common Pitfalls to Avoid

1. Using serology for test of cure

   • Antibodies remain elevated for months after successful eradication
   • Serology is NOT recommended for confirmation of cure 1, 2

2. Testing too early after treatment

   • Can lead to false-negative results due to bacterial suppression rather than eradication
   • Always wait at least 4 weeks after completing therapy 1

3. Testing while on PPIs or antibiotics

   • Can significantly reduce test sensitivity
   • Stop PPIs 2 weeks before testing; antibiotics 4 weeks before 1

4. Using tests with inadequate sensitivity

   • Polyclonal stool antigen tests have lower accuracy post-treatment
   • Monoclonal antibody-based stool tests are preferred if UBT unavailable 1

Clinical Importance of Test of Cure

• Confirms successful eradication and guides need for further treatment
• Provides indirect measure of antibiotic resistance/susceptibility in the population 1
• Helps identify locally successful vs. unsuccessful treatment regimens 1
• Essential for antimicrobial stewardship and monitoring treatment effectiveness 1

By following these guidelines for H. pylori test of cure, clinicians can ensure accurate confirmation of eradication and appropriate management of patients with H. pylori gastritis.