Epidemiology of Helicobacter pylori Infection: Disease Management Implications for Peptic Ulcer Disease

The discovery of Helicobacter pylori revolutionised thinking about the cause of peptic ulcer disease. The most common causes of peptic ulcers are H. pylori infection and use of nonsteroidal anti-inflammatory drugs. H. pylori is typically acquired in childhood. The risk of acquiring an H. pylori infection is inversely related the standard of living especially sanitary conditions. As the general health of any population improves, the incidence of transmission of H. pylori infection declines. This decline in prevalence is in part due to a fall in the rate of acquisition of the infection and also to `spontaneous loss' of the infection possibly in relation to the use of antibiotics for other conditions. The change in epidemiology of peptic ulcer has made it critical to identify that H. pylori infection is present before embarking on anti-H. pylori therapy for a patient with ulcer disease. The use of multiple antibiotic-containing regimens in a patient with an ulcer but without H. pylori cannot provide any benefit to the patient or the community. It is also important to confirm that the H. pylori infection has been cured. The widespread availability of the urea breath test (and possibly the stool H. pylori antigen test) has made post-therapy testing simple, rapid, and affordable. In the US, the cure rate with the best therapies is less than 90% and is even lower in those with resistant H. pylori. A decision not to provide post-treatment confirmatory testing must include a discussion with the patient regarding the possibilities, options, costs, and outcomes of post-therapy testing and, to protect the physician, must also be recorded in the chart. Offering post-therapy testing should be the standard of care; failure to recommend and offer post-therapy testing gives reasonable grounds for malpractice litigation if the ulcer recurs and an ulcer complication ensues.