Helicobacter pylori for primary care
Dr Charlie Andrews talks to Dr Jan Bornschein.
This episode of Ingest discusses why we should be testing more strategically, treating more effectively first time, and always confirming eradication of Helicobacter pylori, because it is a lifelong gastric pathogen and a key modifiable risk factor for peptic ulcer disease and gastric cancer.
Why H. pylori matters
• H. pylori is now regarded globally as an infectious pathogen, not a commensal; when found in adults it should be eradicated, as it always causes chronic active gastritis and is the main risk factor for peptic ulcer disease and gastric cancer.
• Although the UK is in a very good position in that gastric cancer incidence is among the lowest and the prevalence of H. Pylori has also dropped because of the treatment plus the awareness over the last 25 years, it has now got a bit neglected. There is no valid UK data on prevalence and the general infection rates in the adult population for the last 15, 20 years. We don’t quite know what’s going on, with higher rates in migrants from high‑prevalence regions and strong family clustering.
Who to test in primary care
• Test-all groups include:
• Dyspepsia (test early rather than repeatedly escalating PPI and diet alone; NNT ≈14 for symptom benefit).
• Proven peptic ulcer disease (no empiric “treat for H. pylori” without confirming infection).
• Unexplained iron‑deficiency anaemia and idiopathic thrombocytopenic purpura, where H. pylori can drive disease even without visible ulcers.
• First‑degree relatives of gastric cancer patients and anyone with incidental H. pylori on biopsy for other indications.
• Do not test:
• Children without clear indications; asymptomatic children should generally be left until early adulthood before consideration of testing.
• Patients with isolated reflux/heartburn, as H. pylori does not cause reflux symptoms and reflux and dyspepsia should be distinguished.
How to test and avoid false negatives
• Preferred non-invasive tests in primary care are urea breath test or stool antigen (ELISA‑based assays with good performance; stool tests are cheaper and more convenient for many patients).
• Blood antibody tests are only for limited scenarios (e.g. acute bleeding) because they cannot distinguish past from active infection and must not be used for test‑of‑cure.
• To minimise false negatives:
• Stop PPIs for at least 2 weeks before any test other than serology; H. pylori density falls on PPIs and can give falsely negative histology, rapid urease test, breath test, and stool antigen.
• Avoid antibiotics for 4 weeks before testing, and wait at least 4 weeks after completing eradication therapy before test‑of‑cure.
How to treat in UK primary care
• Current UK first‑line remains clarithromycin‑based triple therapy with a PPI plus amoxicillin (or metronidazole if penicillin‑allergic), but first‑line failure is around 30% in UK registry data, largely due to resistance.
Practical optimisation points for GPs:
• Use longer courses: 14 days is preferred over 7 days to significantly improve eradication rates.
• Use stronger acid suppression: at least high‑dose PPI (e.g. omeprazole 40 mg twice daily) during therapy; better acid suppression improves antibiotic efficacy.
• Check prior antibiotic history and avoid regimens containing clarithromycin, metronidazole or levofloxacin if the patient has had those agents previously for any indication.
• Emphasise adherence: eradication drops sharply with <90% adherence, and metronidazole‑related side effects commonly undermine compliance.
• Never repeat the same eradication regimen twice; at minimum, change at least one antibiotic if a course fails.
Second line, rescue, and follow‑up
• After first‑line failure (confirmed by testing), switch regimen rather than “re‑doing” the same triple therapy; bismuth‑based quadruple therapy (including the newer combination capsule plus separate PPI) achieves >90% eradication but has high pill burden and cost.
• Consider early advice-and-guidance or referral to gastroenterology once two regimens have failed, supplying detailed previous antibiotic regimens and dates; endoscopy with culture‑guided therapy is often the next step but is resource‑intensive and centralised in the UK.
• Every treated adult should have a documented test‑of‑cure using a valid non‑serological test, despite current UK dyspepsia guidance wording; symptom response is not a reliable marker of eradication, and true reinfection after proven cure appears to be very rare.
