Peptic ulcer disease (PUD)
- Including past history of PUD, unless there is documented cure of previous H. pylori infection.
- WITHOUT alarming symptoms such as age > 60 with new and persistent symptoms (> 3 months); unintended weight loss; severe pain; persistent vomiting; GI bleeding; or dysphagia. If the patient presents with an alarming symptom, refer promptly to gastroenterology or general surgery/endoscopist for investigations
Early gastric cancer
May also consider testing if:
Patients taking chronic NSAIDs (including low-dose ASA)
- May be particularly useful in patients at higher risk of bleeding (such as history of PUD, corticosteroid use, etc.)
Unexplained iron-deficiency anemia
Idiopathic thrombocytopenic purpura
Unexplained vitamin B12 deficiency
Patients with the following conditions should generally not be tested:
Gastroesophageal reflux disease (GERD)
Hyperplastic gastric polyps
Non-invasive testing usually preferred:
H. pylori stool antigen (use a dry sterile container)
Urea breath test (not available at all sites, contact local laboratory)
In patients undergoing endoscopy for dyspepsia, gastric biopsy urease testing can be used as well. Contact laboratory prior to submitting a sample.
To prevent false negatives, prior to testing and if clinically safe to do so: stop antibiotics and bismuth for at least 4 weeks; PPI for at least 2 weeks; and H2 receptor antagonists (H2RAs) and antacids for at least 24 hours.
DO NOT use serologic testing, as it cannot differentiate between active or prior infection
Treatment Criteria and Considerations
- There is no universally effective therapy of H. pylori; even a threshold of 90% efficacy is difficult to achieve.
- Culture and susceptibility testing is generally NOT available in North America.
- We are limited to extrapolating data from other jurisdictions around the world.
Recent use of antibiotics increases the risk of antimicrobial resistance.
Antimicrobial resistance is associated with greater risk of treatment failure; particularly for clarithromycin-based and quinolone-based regimens.
Treatment adherence tends to decrease as the amount of daily doses increases.
It is essential that patients are aware of the importance of treatment adherence.
May consider compliance packaging (e.g. "Blister packs").
Smoking cessation can improve ulcer healing rates and also reduce ulcers unrelated to H. pylori
- Pregnant and nursing women should not be treated for H. pylori
Majority of patients reporting a history of a "penicillin allergy" do not have a TRUE penicillin allergy.
90% of patients reporting an "allergy" to penicillin will have a negative penicillin skin test and tolerate penicillin without hypersensitivity.
Recommend to take a detailed penicillin allergy history and assess the true nature of the allergy
Guideline and content adapted from Vitalite Health Network H. Pylori Guideline.
Revised January 14, 2021
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