H. pylori Eradication Re-Testing
Test for H. pylori eradication at least 4 weeks after completing treatment using either a urea breath test or validated monoclonal stool antigen test. 1
When to Perform Test of Cure
Timing is critical:
- Wait a minimum of 4 weeks after treatment completion before testing 2, 1
- For bleeding peptic ulcers specifically, delay testing to 4-8 weeks after the bleeding episode 2, 1
- Testing before 4 weeks yields false-negative results because the gastric mucosa requires adequate recovery time and temporary bacterial suppression can mimic true eradication 1
Who Requires Mandatory Confirmation Testing
Strongly recommended in high-risk scenarios:
- Complicated peptic ulcer disease 2
- All gastric ulcers (requires endoscopic follow-up to exclude malignancy and confirm healing) 2, 1
- Low-grade gastric MALT lymphoma 2
- Cases with poor compliance or low treatment efficacy 2
- Bleeding ulcer complications 2
Generally advisable but may be omitted:
- Uncomplicated duodenal ulcer with complete symptom resolution 2
- Non-ulcer dyspepsia with symptom resolution 2
The rationale for universal testing is that it provides indirect surveillance of antimicrobial resistance patterns in the population and confirms successful eradication, which is now considered standard of care 1. Persistent infection is a negative prognostic marker for ulcer recurrence and complications 2.
Recommended Testing Methods
Non-invasive options (preferred for most patients):
- Urea breath test (UBT): Gold standard with sensitivity 94.7-97% and specificity 95-100% 1
- Monoclonal stool antigen test: Equally accurate alternative with sensitivity and specificity >90%, particularly useful when patients must continue PPI therapy 1
Invasive option (when endoscopy is clinically indicated):
- Endoscopy with biopsy from antrum and body (two biopsies from each site plus one for rapid urease test) for complicated peptic ulcer, gastric ulcer, and MALT lymphoma 2
- Mandatory for gastric ulcers to exclude malignancy that may only be detected during healing 2
Do not use serology: It cannot distinguish active infection from past exposure and has no role in determining eradication success 1, 3
Pre-Testing Medication Washout
Critical to avoid false-negative results:
- Stop proton pump inhibitors (PPIs) for at least 2 weeks, preferably 7-14 days 1
- Discontinue antibiotics and bismuth for at least 4 weeks 1
- Ensure fasting for at least 6 hours before testing 1
Management Based on Test Results
If eradication confirmed:
- Discontinue PPI in uncomplicated duodenal ulcer patients 1
- Continue PPI in gastric ulcer patients until complete healing is confirmed 1
- Continue PPI in complicated duodenal ulcer or bleeding ulcer patients until eradication is confirmed 1
If H. pylori persists after initial treatment:
- Use a completely different antibiotic regimen, avoiding antibiotics used previously 1, 4, 5
- Consider 14-day levofloxacin triple therapy or 14-day bismuth quadruple therapy if initial treatment was not optimized bismuth quadruple therapy 1
- Consider 14-day rifabutin triple therapy or 14-day levofloxacin triple therapy if initial treatment was optimized bismuth quadruple therapy 1
After two treatment failures:
- Pursue antimicrobial susceptibility testing to guide third-line therapy 1, 5, 3
- Molecular testing can detect clarithromycin and fluoroquinolone resistance directly from gastric biopsies 1
- If susceptibility testing unavailable, use antibiotics not previously used (amoxicillin, tetracycline, bismuth, or furazolidone) 5
Common Pitfalls to Avoid
- Testing too early: Results before 4 weeks are unreliable due to temporary bacterial suppression rather than true eradication 1
- Inadequate PPI washout: False-negative results occur if PPIs are not stopped for sufficient duration 1
- Using serology for test of cure: Cannot distinguish active from past infection 1, 3
- Repeating the same failed regimen: Leads to further resistance and treatment failure 1