to the editor: We read with interest the article, “Update on Helicobacter pylori Treatment” in the February 1, 2007, issue of American Family Physician.¹ The authors give the “test-and-treat” strategy in the evaluation of patients with dyspepsia an evidence rating of A, stating that it reduces the use of endoscopies and antisecretory medications. This strategy will indeed reduce the number of endoscopies—at the cost of an increase in antibiotic prescriptions. Seventy-five percent of these prescriptions will be unnecessary, because only one out of every four treated patients will have peptic ulcers and thus benefit from antibiotic therapy.² Therefore, the statement could instead be made that the “test-and-treat” strategy will lead to unnecessary antibiotic treatment in 75 percent of patients with dyspepsia.

The test-and-treat strategy risks unnecessary allergic reactions, antibiotic-associated diarrhea, and the development of antibiotic resistance. Assuming a prevalence of dyspepsia of about 25 percent in the adult U.S. population, with a yearly incidence of 7 percent,^3,4 and a prevalence of H. pylori seropositivity ranging from 20 percent in younger patients to 50 percent in 45 to 55-year-olds,² millions of unnecessary antibiotics would be prescribed every year. This would counteract the successful efforts to reduce antibiotic prescriptions for otitis media, bronchitis, and other viral infections.