What is the recommended treatment for a patient with a suspected H pylori (Helicobacter pylori) infection?

H. pylori Treatment Indications

All patients with confirmed H. pylori infection who have active or past peptic ulcer disease, gastric cancer, MALT lymphoma, or first-degree relatives with gastric cancer should receive eradication therapy. 1, 2

Strong Indications for Testing and Treatment

Mandatory Testing and Treatment

• Peptic ulcer disease (active or history): Eradication reduces ulcer recurrence risk by >90% 1, 2
• Gastric ulcer or duodenal ulcer: Both active disease and documented history warrant treatment 1, 3
• Gastric MALT lymphoma: Eradication is primary therapy for low-grade disease 1, 2
• Gastric cancer: After endoscopic or surgical resection to prevent recurrence 2, 4
• First-degree relatives of gastric cancer patients: Preventive eradication reduces cancer risk 2, 4

Additional Strong Indications

• Precancerous gastric lesions: Including severe pan-gastritis, corpus-predominant gastritis, severe atrophy, or intestinal metaplasia 2, 4
• Chronic NSAID or aspirin use: Test before initiating long-term therapy to reduce ulcer risk 4, 5
• Iron deficiency anemia: When no other cause identified 4
• Idiopathic thrombocytopenic purpura: Eradication may improve platelet counts 4
• Vitamin B12 deficiency: H. pylori can impair absorption 4

Testing in Dyspepsia

Young patients (<60 years) with chronic dyspepsia and no alarm symptoms should undergo non-invasive H. pylori testing, with eradication therapy if positive. 1

• This "test-and-treat" strategy reduces endoscopy workload and is cost-effective over time 1
• Alarm symptoms requiring endoscopy include: weight loss, dysphagia, persistent vomiting, gastrointestinal bleeding, or palpable mass 1
• Testing can be performed with urea breath test or validated monoclonal stool antigen test (both >90% sensitivity/specificity) 6, 2

Population Screening Considerations

In high-risk populations (e.g., immigrants from high gastric cancer prevalence regions, Native Americans, Native Alaskans), screening and eradication should be considered, particularly in young adults. 1

• Young adults benefit most as treatment interrupts progression before irreversible gastric mucosal damage occurs 1
• Screening programs are most cost-effective when targeting individuals before age 40 1
• Active screening of household contacts of infected individuals prevents transmission to next generation 1

Special Consideration: GERD Patients

H. pylori eradication should not be performed with the intent to improve GERD symptoms or prevent reflux complications. 7

• However, patients requiring long-term proton pump inhibitor (PPI) therapy should be tested and treated if positive, as PPIs can accelerate atrophic gastritis in H. pylori-infected mucosa 7
• Eradication does not cause de novo esophagitis or worsen existing reflux disease in most intervention trials 7

Key Testing Principles

When to Test

• Stop PPIs at least 1-2 weeks before testing to avoid false-negative results 6, 5
• Stop antibiotics and bismuth at least 4 weeks before testing 6, 5
• Stop sucralfate at least 4 weeks before testing 2

Preferred Testing Methods

• Non-invasive: Urea breath test (94.7-97% sensitivity, 95-100% specificity) or validated monoclonal stool antigen test (>90% sensitivity/specificity) 6, 2
• Invasive: Rapid urease test on gastric biopsies during endoscopy 5
• Never use serology for diagnosis or post-treatment confirmation—it cannot distinguish active from past infection 6, 2

Common Pitfalls to Avoid

• Do not treat without confirming infection: Empiric treatment contributes to antibiotic resistance 1
• Do not use clarithromycin-based triple therapy empirically in areas with >15% clarithromycin resistance (most of North America) 1, 2
• Always confirm eradication with test of cure at least 4 weeks after treatment completion 1, 6
• Do not test patients who do not warrant treatment: Testing should only be performed when eradication therapy will be offered if positive 1