H. pylori Follow-up After Treatment
All patients should undergo confirmation testing for H. pylori eradication at least 4 weeks after completing treatment using either a urea breath test (UBT) or a validated monoclonal stool antigen test—serology has no role in post-treatment assessment. 1
Recommended Testing Methods
The choice of test depends on availability and clinical context:
- Urea Breath Test (UBT): This is the gold standard non-invasive test with sensitivity of 94-97% and specificity of 95-100% for confirming eradication 1, 2, 3
- Monoclonal Stool Antigen Test: An equally accurate alternative with sensitivity and specificity >90%, particularly useful when patients must continue PPI therapy 1, 2, 4
- Serology has NO role: Antibody titers remain elevated for 6-12 months after successful eradication and cannot distinguish active from past infection 1, 2, 5
Timing of Confirmation Testing
The critical timing is at least 4 weeks after completion of therapy—testing earlier risks false-negative results due to temporary bacterial suppression rather than true eradication. 1, 2
The evidence is clear on this point:
- Testing before 4 weeks may show false-negative results as the gastric mucosa needs time to recover from treatment effects 2, 5
- While some proposed extending to 6-8 weeks, recent data do not support this—4 weeks remains the standard 1
- Exception: In bleeding ulcer cases, perform testing 4-8 weeks after the bleeding episode 1, 2
Important Pre-Test Preparations
To avoid false-negative results, patients must discontinue:
- PPIs: Hold for at least 7-14 days before testing 2
- Antibiotics and bismuth: Hold for at least 4 weeks 2
- Fasting: At least 6 hours before UBT 2
Special Clinical Scenarios Requiring Mandatory Confirmation
Certain high-risk situations absolutely require documented eradication:
- Gastric ulcer (GU): Endoscopic follow-up is necessary to ensure complete healing, and H. pylori eradication must be confirmed 1
- Gastric MALT lymphoma: Upper endoscopy with biopsy-based testing is required 1
- Complicated peptic ulcer disease: Including bleeding or perforated ulcers 2
- Persistent symptoms after treatment: Indicates possible treatment failure requiring second-line therapy 2
Post-Treatment PPI Management
The duration of PPI therapy after H. pylori treatment depends on the underlying condition:
- Uncomplicated duodenal ulcer (DU): Prolonged PPI is NOT recommended after successful eradication 1
- Gastric ulcer (GU): Continue PPI until complete healing is achieved and eradication is confirmed 1
- Complicated DU or bleeding ulcer: Continue PPI until H. pylori eradication is confirmed 1
Interpreting Breath Test Results
A critical caveat: Patients with borderline UBT delta values (2-4) have higher recrudescence rates and should undergo repeat testing 6-12 months later. 6
The recrudescence rate correlates with post-treatment UBT delta values:
- Delta 0-2: 3.4% recrudescence
- Delta 2-3: 11% recrudescence
- Delta 3-4: 60% recrudescence 6
If Eradication Fails
When confirmation testing shows persistent H. pylori:
- Do not repeat the same regimen—use a different second-line therapy 2
- Consider culture and susceptibility testing, especially in regions with high clarithromycin resistance 2
- Persistent infection is a negative prognostic marker for ulcer recurrence and complications 2
Common Pitfalls to Avoid
- Never use serology for post-treatment confirmation—it remains positive for months after successful eradication 1, 5
- Don't test too early—wait the full 4 weeks to avoid false-negatives from temporary bacterial suppression 1, 2
- Don't forget to stop PPIs before testing—they can suppress H. pylori and cause false-negative results 2, 4
- Don't assume eradication without testing—treatment failure rates are significant, and unconfirmed eradication leads to ongoing complications 2