What is the recommended treatment for a patient who tests positive for Helicobacter Pylori (H. Pylori)?

Treatment of H. Pylori Positive Test

All patients with confirmed H. pylori infection should receive eradication therapy with a 14-day regimen consisting of a proton pump inhibitor (PPI) plus two antibiotics, regardless of symptoms. 1, 2

Confirm Active Infection Before Treatment

• Ensure the positive test represents active infection, not past exposure, before initiating treatment 1
• Serology cannot distinguish active from past infection and should not be used for treatment decisions—use urea breath test (UBT) or stool antigen test instead 1
• Patients must be off PPIs for at least 2 weeks and off antibiotics and bismuth for at least 4 weeks before UBT or stool antigen testing to avoid false negatives 1
• A positive test can be trusted even if the patient is on PPIs, but a negative test cannot 1

First-Line Treatment Regimens

Triple therapy is the standard first-line approach: PPI twice daily + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily for 14 days 2, 3, 4

• In areas with high clarithromycin resistance (≥15%), bismuth quadruple therapy (BQT) for 14 days is preferred over triple therapy 5, 4
• In patients with previous macrolide or fluoroquinolone exposure, avoid clarithromycin and levofloxacin due to high likelihood of resistance 1
• The combination of omeprazole plus clarithromycin plus amoxicillin achieved 69-83% eradication rates in intent-to-treat analyses across multiple studies 3

Age-Based Evaluation Strategy

• Patients under age 45 without alarm symptoms can be treated empirically after positive H. pylori testing without endoscopy 1, 2
• Patients over age 45 or those with alarm symptoms at any age require endoscopy before treatment to exclude gastric malignancy 1, 2

Post-Treatment Confirmation

Test-of-cure is mandatory to confirm eradication:

• Perform follow-up testing no earlier than 4 weeks after completing therapy using UBT or stool antigen test 1, 2
• Testing before 4 weeks yields unreliable results due to temporary bacterial suppression rather than true eradication 1
• Confirmation of eradication is particularly critical in complicated peptic ulcer disease, gastric ulcer, and gastric MALT lymphoma 2

Management of Treatment Failure

• After two treatment failures, obtain antimicrobial susceptibility testing to guide third-line therapy 1
• Patients not eradicated following triple therapy will likely have clarithromycin-resistant H. pylori isolates 3
• Clarithromycin susceptibility testing should be done if possible, and patients with clarithromycin-resistant H. pylori should not be retreated with any clarithromycin-containing regimen 3
• In treatment-experienced patients, "optimized" BQT for 14 days is preferred for those not previously treated with BQT 4

Critical Adherence Counseling

• Counsel patients that completing the full 14-day course is critical for success 1
• Poor patient compliance leads to treatment failure and should be addressed through patient education 2
• Mono-antibiotic therapy increases the risk of antibiotic resistance and must be avoided 2

Rationale for Universal Treatment

• H. pylori infection always causes chronic gastritis and increases risk for peptic ulcer disease and gastric cancer 1, 5
• Even asymptomatic patients benefit from eradication as it halts progression toward gastric cancer 1
• Successful eradication reduces rebleeding rates from 26% to near zero in patients with H. pylori-associated bleeding ulcers 6
• Eradication has been shown to reduce the risk of duodenal ulcer recurrence 7