Every H. pylori diagnostic and every regimen is downstream of one fact: the organism survives in gastric mucus by producing urease in industrial quantities. Hold that, and the breath test, the stool antigen, the off-PPI timing rule, and the shift away from clarithromycin triple all follow. The case. A patient treated for a duodenal ulcer returns after clarithromycin triple therapy with a positive urea breath test. Which salvage regimen do you choose, and what must you avoid repeating? Topics covered Biology: a urease-producing spiral gram-negative living in gastric mucus Virulence: the cag pathogenicity island and vacA Urea breath test and stool antigen as active-infection tests The off-PPI rule: hold PPI 2 weeks and antibiotics/bismuth 4 weeks before testing Serology cannot distinguish active from past infection First-line has shifted: bismuth quadruple and vonoprazan-based dual/triple over clarithromycin triple Penicillin allergy and local resistance as regimen drivers Salvage: never repeat a failed macrolide or levofloxacin regimen Confirming eradication with a breath test or stool antigen after therapy Indications to test and treat: ulcer, MALT lymphoma, early gastric cancer resection, unexplained iron deficiency Key decisions Test for active infection off acid suppression: hold the PPI 2 weeks and any antibiotics/bismuth 4 weeks, or the breath test and stool antigen turn falsely negative Clarithromycin triple is no longer first-line where resistance exceeds 15 percent: use bismuth quadruple or a vonoprazan-based regimen Salvage never reuses the antibiotic class that just failed: a failed clarithromycin regimen goes to bismuth quadruple or levofloxacin-based therapy, not another macrolide Always confirm eradication after treatment, at least 4 weeks out and off PPI, with a breath test or stool antigen, not serology Every H. pylori-positive peptic ulcer gets eradication plus confirmation, because it changes recurrence risk For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Opening: urease is load-bearing (02:00) - Biology and virulence factors (05:00) - Diagnostics and the off-PPI rule (09:00) - First-line: bismuth quadruple and vonoprazan regimens (13:00) - Salvage: do not repeat a failed class (16:00) - Confirming eradication and test-and-treat indications

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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