Helicobacter Pylori “Test-and-Treat” Strategy for Management of Dyspepsia: A Comprehensive Review

Abstract

OBJECTIVES:Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.METHODS:Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.RESULTS:Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.CONCLUSIONS:The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

Guidelines for the management of Helicobacter pylori infection in Italy: The III Working Group Consensus Report 2015

“…unintentional weight loss, iron-deficiency anaemia, gastrointestinal bleeding, dysphagia) (5). European guidelines recommend this strategy in countries where HP prevalence is higher than 20% (1).…”

III Conferencia Española de Consenso sobre la infección por Helicobacter pylori

“…Las 3 aproximaciones a la dispepsia no investigada que se han mostrado más eficaces son la realización de una endoscopia inicial, el tratamiento empírico antisecretor y la denominada estrategia test and treat. Esta última opción consiste en la realización de una prueba «no invasiva» (que no precisa de una endoscopia) para H. pylori y el tratamiento erradicador consiguiente si se demuestra la infección 18,19 . La estrategia test and treat sería aplicable únicamente a pacientes dispépticos jóvenes (la edad de corte es variable, véase más adelante) y sin sín-tomas de alarma.…”

“…Por el contrario, en áreas de baja prevalencia de infección por H. pylori deberán realizarse más pruebas diagnósticas para detectar a un paciente infectado y tratarlo, redundando todo ello en un aumento de los costes y una menor efectividad. En este sentido, múltiples estudios de coste-efectividad muestran que en condiciones de prevalencia de H. pylori media o alta la estrategia test and treat resulta más coste-efectiva que el tratamiento antisecretor 19 . Por el contrario, el tratamiento antisecretor empírico inicial resulta más coste-efectivo cuando la prevalencia de infección por H. pylori es menor del 10-20% 19 .…”

Ensuring the highest eradication rates in H. pylori: the case of non-bismuth quadruple concomitant therapy

“…These problems range from which patients should be tested or which diagnostic tests should be used, to which antibiotic regimen should be prescribed. The general recommendation for bacterial infections to always test antibacterial susceptibility may not be applicable or even efficient in the case of H. pylori management, mainly due to the requirement of an endoscopy [2,3]. A procedure that is expensive and uncomfortable, and even if performed, culture and antibiogram are not available in most centers.…”