H. Pylori Infection: Symptoms, Testing and Treatment Under the Latest Guidelines

Written by Cherlie Joseph, MSN, FNP-BC · Medically reviewed by Naurah Gaspard, DNP, FNP-C, FNP-BC · Updated November 2026

Helicobacter pylori (H. pylori) is a common bacterial infection of the stomach that often causes no symptoms but can lead to ulcers and, rarely, stomach cancer. It is diagnosed with a breath or stool test, and under the 2024 American College of Gastroenterology guideline it is usually treated with a 14-day combination of medicines, followed by a test to confirm it is gone.

What H. pylori is

H. pylori is a bacterium that lives in the stomach lining. It is usually picked up in childhood, likely through saliva, food or water, and can stay for decades. Many people with H. pylori never have symptoms. In others, it causes inflammation (gastritis) and peptic ulcers, and long-term infection is a known risk factor for stomach cancer. Clearing it lowers those risks.

Symptoms and who should be tested

When H. pylori causes symptoms, they usually look like indigestion or an ulcer:

• Burning or gnawing upper-belly pain, often when the stomach is empty
• Bloating, early fullness or nausea
• Frequent burping

The ACG recommends testing adults who have:

• Indigestion (dyspepsia), especially under age 60 without alarm features
• A current or past peptic ulcer
• Long-term NSAID use, or before starting daily aspirin
• Unexplained iron deficiency anemia
• A household member with H. pylori
• A family history of stomach cancer or roots in a region where stomach cancer is common

How H. pylori testing works

Test	How it works	Notes
Urea breath test	You drink a solution, then breathe into a bag	Detects active infection
Stool antigen test	Small stool sample collected at home and sent to a lab	Detects active infection
Endoscopy with biopsy	Tissue samples taken during an upper endoscopy	Used when alarm symptoms are present or older age
Blood antibody test	Blood draw	Not recommended to diagnose active infection; can stay positive after cure

Medicines can cause false-negative results. The ACG advises stopping proton pump inhibitors (PPIs) 2 weeks before a breath or stool test, and bismuth and antibiotics 4 weeks before, if it is safe to do so. Check with your provider first.

Treatment under the 2024 ACG guideline

Antibiotic resistance, especially to clarithromycin, has made older regimens less reliable. The 2024 ACG guideline recommends:

• Bismuth quadruple therapy for 14 days as the preferred first choice when antibiotic resistance is unknown: a PPI, bismuth, tetracycline and metronidazole.
• Vonoprazan plus amoxicillin (with or without clarithromycin) for 14 days as an alternative for people without a penicillin allergy. Vonoprazan is a newer acid blocker sold as Voquezna.
• Clarithromycin-based triple therapy only when testing shows the bacteria are sensitive to clarithromycin.

Finishing every dose matters, even if you feel better. Side effects such as a metallic taste, nausea or dark stools (from bismuth) are common. A provider will review which regimen is appropriate based on your allergies and past antibiotic use.

Test of cure: making sure it is gone

Because treatment does not always work, the ACG recommends a test of cure for everyone, using a breath test, stool test or biopsy at least 4 weeks after finishing treatment, with PPIs stopped for 2 weeks beforehand when possible. If H. pylori is still present, a different regimen is chosen, usually avoiding antibiotics already used.

Frequently asked questions

Is H. pylori contagious?

It can spread between people, likely through saliva or contaminated food and water, and it often runs in households. That is why the ACG suggests testing adult household members of someone who has it.

Can H. pylori go away on its own?

It rarely clears without treatment. Once found, it should be treated, and you should have a test of cure afterward.

What should I avoid during H. pylori treatment?

Avoid alcohol if your regimen includes metronidazole, and take each medicine exactly as the label and your pharmacist direct, since some must be taken with or apart from food or dairy. Ask your pharmacist about interactions with your other medicines.

Sources

• ACG Clinical Guideline: Treatment of Helicobacter pylori Infection (Chey et al., 2024)
• ACG Guideline Highlights: Helicobacter pylori (2024)

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This article is for general education and is not a substitute for medical advice. Treatment, including any prescription, is decided by a licensed provider after reviewing your health history. OurTopClinic is not for emergencies; if you have a medical emergency, call 911. OurTopClinic serves adults located in Florida, New Mexico, Oregon and Washington. Learn more at ourtopclinic.com.