Value of the "test and treat" strategy for uninvestigated dyspepsia at low prevalence rates of Helicobacter pylori in the population

Background and Aim: In populations with a low prevalence rate of <i>Helicobacter pylori (H. pylori)</i> infection from Western countries, guidelines for the management of uninvestigated dyspepsia generally recommend that the "test and treat" strategy should be avoided in favor of empiric proton-pump inhibitor therapy in younger patients (on average < 50 years of age) without alarm symptoms and signs. The prevalence of <i>H. pylori</i> infection has fallen from about 30% to about 10% in Sweden and other countries. We aimed to explore whether the rationale for test and treat is relevant in contemporary clinical practice. Materials and Methods: In settings with an infection rate in the adult population of 30% and 10%, we modeled the positive and negative predictive values for indirect (nonendoscopy) tests on current H. pylori infection with a presumed sensitivity and specificity of 95%. We then calculated the difference in false-negative and false-positive test outcome, and eradication prescription rates in the two scenarios. Results: While the positive predictive value for the test decreased from 0.89 to 0.68 when the prevalence of <i>H. pylori</i> fell from 30% to 10%, there were only 1% more false-negative tests and 1% less false-positive tests. The eradication prescription rate would decrease by 18% with a 10% prevalence rate. Conclusion: The recommendation to stop applying "test and treat" at lower prevalence rates of <i>H. pylori</i> should be reconsidered. The test and treat strategy is the preferred approach for most patients who present with dyspepsia