Is a test of cure recommended after treating Helicobacter pylori (H. pylori) infection?

Test of Cure After H. pylori Treatment

Yes, a test of cure is strongly recommended after treating H. pylori infection, with testing performed at least 4 weeks after completion of therapy using either urea breath test (UBT) or stool antigen test. 1, 2

Recommended Testing Methods

• The urea breath test (UBT) is considered an excellent test for follow-up after H. pylori eradication with sensitivity of 94.7-97% and specificity of 95-95.7% 2
• A laboratory-based validated monoclonal stool antigen test is also recommended as a non-invasive alternative with sensitivity and specificity >90% 1, 2
• There is no role for serology in determining eradication success 1, 2
• In cases where endoscopy is clinically indicated (e.g., gastric ulcer, MALT lymphoma), biopsy-based tests can be performed 1

Timing of Test of Cure

• Testing should be performed at least 4 weeks after completion of H. pylori treatment 1, 2
• This waiting period allows time for the gastric mucosa to recover from treatment effects and reduces the risk of false negative results 2
• Prior to testing, patients should discontinue:
  • Antibiotics and bismuth for at least 4 weeks 2
  • Proton pump inhibitors (PPIs) for at least 7 days 2
  • Food for at least 6 hours before the test 2

Clinical Scenarios Where Test of Cure is Particularly Important

• Complicated peptic ulcer disease 2
• Gastric ulcer cases 1, 2
• Low-grade gastric MALT lymphoma 2
• When treatment has low efficacy or poor compliance 2
• After treatment failure, to guide subsequent therapy choices 3

Rationale for Test of Cure

• Success should be confirmed by a test of cure after treatment of every patient as it provides an indirect measure of resistance/susceptibility in the population 1
• Persistent H. pylori infection is a negative prognostic marker for:
  • Ulcer recurrence 2
  • Risk of ulcer complications 2
  • Treatment failure in MALT lymphoma cases 2
• If H. pylori persists after initial treatment, a second different eradication regimen should be used 2, 3
• Confirmation of eradication using non-invasive diagnostic tests is now considered the standard of care 4

Common Pitfalls and Caveats

• False negative results may occur if testing is performed too soon after treatment (less than 4 weeks) 1, 2
• Continued PPI use can lead to false negative results in active testing methods 2
• Relapse seen in the 6-12 months after H. pylori eradication is mainly related to recurrence of the same infection rather than true reinfection 1
• In cases of bleeding ulcers, current consensus recommends performing a delayed test 4-8 weeks after the bleeding episode 1

Following these guidelines for test of cure helps ensure successful eradication, guides further management when needed, and contributes to antimicrobial stewardship by providing surveillance of treatment outcomes 1.