What is the management for a patient with a positive Helicobacter (H.) Pylori test?

Management of Positive H. Pylori Test

All patients with confirmed H. pylori infection should receive eradication therapy immediately, as the infection causes chronic gastritis and increases risk for peptic ulcer disease and gastric cancer. 1

Initial Patient Stratification

Age and Alarm Symptom Assessment

• Patients under age 45 without alarm symptoms (anemia, weight loss, dysphagia, palpable mass, malabsorption) can be treated empirically after positive H. pylori testing without endoscopy 2, 1
• Patients over age 45 or those with alarm symptoms at any age require endoscopy before treatment to exclude gastric malignancy, as the standardized incidence rate of gastric cancer in those over 45 is 19 per 100,000 for men and 9 per 100,000 for women 2, 1
• Patients with known history of gastric ulcer should be referred for repeat endoscopy with biopsy until healed, as malignancy may be present 2
• Rule out family history of gastric cancer before treating without endoscopy, even in younger patients 2

First-Line Eradication Therapy

Treatment Selection Based on Clarithromycin Resistance

In areas of high clarithromycin resistance (≥15%):

• Bismuth quadruple therapy for 14 days is strongly recommended as first-line treatment 3, 4
  • Bismuth subsalicylate + tetracycline 500 mg four times daily + metronidazole 500 mg four times daily + PPI twice daily 5
  • This regimen provides superior eradication rates without requiring susceptibility testing 5
  • Duration should be 10-14 days 2, 5

In areas of low clarithromycin resistance (<15%):

• Standard triple therapy for 14 days consisting of PPI + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily 2, 3
• This should only be used in patients with no previous history of macrolide exposure 4
• Avoid clarithromycin in patients with previous macrolide or fluoroquinolone exposure due to high likelihood of resistance 1, 4

Alternative first-line option (any resistance pattern):

• Concomitant therapy (non-bismuth quadruple therapy) for 14 days: PPI + clarithromycin + amoxicillin + metronidazole 4, 6

Critical Treatment Principles

• Treatment regimens must achieve eradication rates over 80% on an intention-to-treat basis 2
• Counsel patients on adherence—completing the full 14-day course is critical for success 1
• Avoid mono-antibiotic therapy to minimize antibiotic resistance 2
• Take medications at the start of meals to minimize gastrointestinal intolerance 7

Second-Line Therapy (After First-Line Failure)

Salvage Regimen Selection

If first-line treatment contained clarithromycin:

• Bismuth quadruple therapy for 14 days (if not previously used) 3, 4
• Levofloxacin triple therapy for 10-14 days: PPI + levofloxacin + amoxicillin 2, 3, 4

If first-line treatment was bismuth quadruple therapy:

• Levofloxacin-containing salvage regimen 3, 4
• Clarithromycin-containing regimen (if no previous macrolide exposure) 4

Key Salvage Therapy Principles

• A salvage regimen must avoid antibiotics that were previously used 8, 4
• Review prior antibiotic exposures thoroughly before prescribing 8
• Consider longer treatment duration of 14 days for improved eradication rates 8

Third-Line Therapy (After Two Treatment Failures)

• Obtain antimicrobial susceptibility testing whenever possible to guide third-line therapy 1, 3
• If susceptibility testing is unavailable, use antibiotics not previously used or for which resistance is unlikely: amoxicillin, tetracycline, bismuth, or furazolidone 3
• Alternative candidates include quinolones, rifabutin, or high-dose PPI/amoxicillin therapy 9

Test of Cure

Mandatory Confirmation Scenarios

Strongly recommended for:

• Complicated peptic ulcer disease 2, 8
• Gastric ulcer cases (requires endoscopic follow-up to ensure complete healing) 2, 8
• Low-grade gastric MALT lymphoma 2, 8
• Cases with low treatment efficacy or poor compliance 2

Testing Method and Timing

• Perform urea breath test (UBT) at minimum 4 weeks after completing therapy with sensitivity of 94.7-97% and specificity of 95-100% 8, 5
• Laboratory-based validated monoclonal stool antigen test is an acceptable alternative with sensitivity and specificity >90% 8
• Do not use serology for determining eradication success—it cannot distinguish active infection from past exposure 8, 1

Pre-Testing Requirements

• Discontinue PPIs for at least 2 weeks (preferably 7-14 days) before testing 8
• Withhold antibiotics and bismuth for at least 4 weeks before testing 8, 1
• Patients should fast for at least 6 hours before UBT 8
• In bleeding peptic ulcers, delay testing to 4-8 weeks after the bleeding episode 8

Post-Eradication Management

PPI Continuation

• Uncomplicated duodenal ulcer: Prolonged PPI therapy is NOT recommended after successful eradication 8
• Gastric ulcer: Continue PPI until complete healing is achieved and eradication is confirmed 8
• Complicated duodenal ulcer or bleeding ulcer: Continue PPI until H. pylori eradication is confirmed 8

Follow-Up Considerations

• Consensus was not reached on whether to routinely test all patients with uncomplicated peptic ulcer or non-ulcer dyspepsia when symptoms resolve 2
• Regional centers should monitor changes in therapy efficacy and emergence of H. pylori resistance 2

Common Pitfalls to Avoid

• Do not test too soon after treatment—testing before 4 weeks yields unreliable results due to temporary bacterial suppression rather than true eradication 8, 1
• Do not continue PPIs during diagnostic testing—they reduce bacterial load and cause false negatives 1
• Do not use rapid "office" serological tests—validations show disappointing sensitivities (63-97%) and specificities (68-92%) 2
• Do not repeat previously failed antibiotics—select a completely different antibiotic regimen after confirmed treatment failure 8