H. Pylori Eradication Therapy

Diagnosis and Treatment Initiation

Ensure the positive test represents active infection, not past exposure, before initiating treatment, as recommended by the American Gastroenterological Association 1
The American College of Gastroenterology suggests that serology cannot distinguish active from past infection and should not be used for treatment decisions, instead opting for urea breath test (UBT) or stool antigen test 2
Patients should be off PPIs for at least 2 weeks and off antibiotics and bismuth for at least 4 weeks before UBT or stool antigen testing, as per the guidelines from the Annual Review of Medicine 1, 2

All patients with confirmed H. pylori infection should receive eradication therapy, as infection causes chronic gastritis and increases risk for peptic ulcer disease and gastric cancer, according to the American College of Gastroenterology 1
The European Helicobacter Study Group recommends that even asymptomatic patients benefit from eradication as it halts progression toward gastric cancer 1
After two treatment failures, obtain antimicrobial susceptibility testing to guide third-line therapy, as suggested by the American Gastroenterological Association 2

Patients under age 45 without alarm symptoms can be treated empirically after positive H. pylori testing without endoscopy, as recommended by the European Society of Gastrointestinal Endoscopy 3
Patients over age 45 or those with alarm symptoms at any age require endoscopy before treatment to exclude gastric malignancy, according to the American College of Gastroenterology 3

Do not test too soon after treatment—testing before 4 weeks yields unreliable results due to temporary bacterial suppression rather than true eradication, as per the guidelines from the American Gastroenterological Association 2
Do not continue PPIs during diagnostic testing—they reduce bacterial load and cause false negatives, according to the Annual Review of Medicine 1
A positive test can be trusted even if the patient is on PPIs, but a negative test cannot, as recommended by the European Helicobacter Study Group 1

In patients with previous macrolide or fluoroquinolone exposure, avoid clarithromycin and levofloxacin due to high likelihood of resistance, as suggested by the American College of Gastroenterology 2
Counsel patients on adherence—completing the full 14-day course is critical for success, according to the American Gastroenterological Association 2