Should a test of cure be performed after completing a full‑dose 10‑14‑day Helicobacter pylori eradication regimen (triple, quadruple, or sequential therapy) in an adult?

Test of Cure After H. pylori Eradication: Mandatory Standard of Care

Yes, you must recheck H. pylori status after completing eradication therapy—confirmation of eradication is now considered the standard of care for all patients. 1

Why Test of Cure is Essential

Persistent H. pylori infection is a negative prognostic marker for ulcer recurrence, bleeding complications, and treatment failure in MALT lymphoma. 1, 2 The success of eradication directly determines whether ulcers will remain healed long-term, making confirmation testing critical rather than optional. 1

Additionally, confirming eradication provides an indirect measure of antibiotic resistance patterns in your patient population, which helps guide future treatment decisions. 1

Timing: When to Perform the Test

Wait at least 4 weeks after completing treatment before testing. 1, 3 Testing earlier than 4 weeks will yield false-negative results because the gastric mucosa needs time to recover from treatment effects, and you may detect temporary bacterial suppression rather than true eradication. 1, 3

Special timing considerations:

• Bleeding peptic ulcers: Delay testing to 4-8 weeks after the bleeding episode 1, 3
• Gastric MALT lymphoma: Wait at least 6 weeks after eradication therapy 3

Which Test to Use

Use either the urea breath test (UBT) or a validated monoclonal stool antigen test—both are equally accurate and interchangeable. 1

Test performance characteristics:

• Urea breath test: Sensitivity 94.7-97%, specificity 95-100% 1, 3
• Monoclonal stool antigen test: Sensitivity and specificity >90% 1, 3
• Serology has NO role: Antibody levels remain elevated after eradication, making serology useless for confirming cure 1

The stool antigen test is particularly useful when patients must continue PPI therapy, as it may be less affected by acid suppression than the UBT. 3

Critical Pre-Test Preparation Requirements

Failure to properly prepare patients before testing is a common pitfall that leads to false-negative results. 1

Mandatory washout periods:

• Stop antibiotics and bismuth: At least 4 weeks before testing 1, 3
• Stop PPIs: At least 2 weeks (preferably 7-14 days) before testing 3
• Fasting: At least 6 hours before the test 1, 3

The stool antigen test may allow continued PPI use with less interference, but stopping PPIs remains preferable when possible. 3

High-Risk Scenarios Requiring Endoscopic Follow-Up

While non-invasive testing suffices for most patients, certain clinical scenarios mandate endoscopy with biopsy-based testing: 1

• Gastric ulcer patients: Require endoscopic follow-up to ensure complete ulcer healing AND confirm H. pylori eradication 1, 3
• Gastric MALT lymphoma: Must undergo upper endoscopy with biopsy, as persistent infection predicts treatment failure 1, 3
• Complicated peptic ulcer disease: Should have endoscopic confirmation when clinically indicated 1

What to Do After Testing

If eradication is confirmed:

• Discontinue PPI therapy in uncomplicated duodenal ulcer cases 1
• Continue PPI in gastric ulcer patients until complete healing is documented 1
• Continue PPI in complicated duodenal ulcer or bleeding ulcer patients until eradication is confirmed 1
• No further H. pylori testing is needed unless symptoms recur 1

If H. pylori persists:

• Never repeat the same antibiotic regimen—this leads to further resistance and treatment failure 1
• Use a completely different antibiotic combination, avoiding any antibiotics used in the first regimen 1
• After two treatment failures, pursue antibiotic susceptibility testing to guide third-line therapy 1
• Review prior antibiotic exposures: Avoid clarithromycin if the patient has received any macrolide, and avoid levofloxacin if they have received any fluoroquinolone 1

Common Pitfalls to Avoid

• Testing too early (before 4 weeks): Yields unreliable false-negative results 1
• Using serology for test of cure: Cannot distinguish active infection from past exposure 1
• Inadequate medication washout: PPIs, antibiotics, or bismuth taken too close to testing will cause false negatives 1, 3
• Assuming symptom resolution equals eradication: Only 38% of successfully treated patients report complete symptom resolution, meaning symptoms are an unreliable marker of cure 4
• Repeating the same failed regimen: This guarantees treatment failure due to antibiotic resistance 1