There are ample data to support the antimicrobial eradication of H. pylori infection in patients with peptic ulcer disease. All patients with gastric or duodenal ulcers who are infected with H. pylori should be treated with antimicrobials regardless of whether they are suffering from the initial presentation of the disease or from a recurrence. H. pylori- infected peptic ulcer patients who are receiving maintenance treatment with antisecretory agents or who have a history of complicated or refractory disease should also be treated for the infection. The presence of NSAID's, including aspirin, as a contributing factor should not alter the antimicrobial regimen, but whenever possible, these drugs should be discontinued. However, in asymptomatic H. pylori-infected patients without ulcers, the data are not sufficient to support prophylactic antimicrobial therapy to prevent ulcer disease in the future or to reduce the likelihood of developing gastric neoplasia. Also, no convincing data exist to support routine treatment of patients with nonulcer dyspepsia who are infected with H. pylori. Thus, at the present time there is no reason to consider routine detection or treatment of H. pylori infection in the absence of ulcers. Carefully controlled prospective studies are needed to assess the benefits of treating nonulcer dyspepsia patients with H. pylori infection. It is self-evident that no patient should be treated for H. pylori unless one of the sensitive and specific tests previously discussed demonstrates infection.

Bleeding is the complication of peptic ulcer disease associated with the highest mortality rate and, therefore, demands aggressive therapy. The available data suggest that after these ulcers heal, the likelihood of recurrence with bleeding is significantly reduced by maintenance antisecretory therapy. Preliminary studies indicate that eradication of H. pylori infection may be equally efficient in preventing the recurrence of ulcer bleeding. Until these studies can be confirmed, maintenance antisecretory therapy may be prudent in such patients even after H. pylori eradication in view of the high risks associated with rebleeding.