Practice Guidelines

H. pylori Infection: ACG Updates Treatment Recommendations


Am Fam Physician. 2018 Jan 15;97(2):135-137.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Testing for Helicobacter pylori is indicated for certain conditions, such as peptic ulcer disease, and it should be treated in any patient who tests positive.

• Patients should be asked about previous antibiotic exposure to help guide the treatment regimen and avoid failures because of resistance.

• A urea breath test, fecal antigen testing, or biopsy-based testing should be used to determine treatment success.

From the AFP Editors

Helicobacter pylori infection is one of the most common chronic bacterial infections. The American College of Gastroenterology (ACG) has updated its clinical guidelines in response to significant scientific advances in the management of this disease.

Because there is a lack of randomized controlled trials in North America (defined as the United States and Canada in this guideline) that assess modern treatment regimens, the ACG's treatment recommendations mostly rely on clinical trial data generated in other parts of the world. These treatment recommendations are based on a series of questions.

What Is Known About the Epidemiology of H. pylori Infection in North America? Which Are the High-Risk Groups?

H. pylori infection usually occurs during childhood, although the means of acquisition is unclear. Risk factors include low socioeconomic status; increased number of siblings; and having an infected parent, particularly a mother. The incidence and prevalence of the disease are generally higher among persons born outside of North America. Within North America, it is more common in immigrants and in certain racial groups. (in general, the prevalence is lower among non-Hispanic whites than among other groups such as blacks, Hispanics, Native Americans, and Alaska Natives).

What Are the Indications for H. pylori Testing and Treatment?

Testing for H. pylori is indicated in certain patients. Any patient who tests positive for H. pylori infection should be treated.

All patients with active or previous peptic ulcer disease should be tested for H. pylori infection unless there is documentation that the infection was previously cured. Patients with low-grade gastric mucosa–associated lymphoid tissue lymphoma or a history of endoscopic resection of early gastric cancer should also be tested. Testing in patients with gastroesophageal reflux disease is not recommended unless the patient has a history of peptic ulcer disease or dyspepsia. If a patient with gastroesophageal reflux disease is tested and found to have H. pylori infection, treatment should be offered with the acknowledgment that symptoms of gastroesophageal reflux disease are unlikely to improve.

Based on low-quality evidence, the ACG also recommends testing for those initiating long-term nonsteroidal anti-inflammatory drug therapy, those with unexplained iron deficiency anemia, and adults with idiopathic thrombocytopenic purpura.

Ideally, tests that identify active infection, such as a urea breath test, fecal antigen test, or endoscopic biopsy, should be used in the diagnosis of H. pylori infection. However, because the pretest probability of infection is higher in patients with documented peptic ulcer disease, immunoglobulin G antibody testing is acceptable in these patients. Nonendoscopic testing is an option in patients younger than 60 years with uninvestigated dyspepsia without red flags. If endoscopy is used in patients with dyspepsia, gastric biopsies should be performed.

There is insufficient evidence to make a recommendation about testing and treatment in asymptomatic patients with a family history of gastric cancer or in patients with lymphocytic ga

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



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