Ofman and colleagues' decision analysis [1] supports the superior cost-effectiveness of empirical anti-Helicobacter pylori treatment compared with endoscopy-based therapy for patients with uncomplicated dyspepsia, but these authors do not consider whether widespread acceptance of this strategy could alter the epidemiology of this disorder in ways that would inflate its economic and ecologic costs. Although difficult to measure precisely, the prevalence of indigestion is undoubtedly large: In one study [2], 38% of respondents reported having had dyspeptic symptoms within the previous 6 months, another 26% reported having had such symptoms in the more distant past, and an 11.5% annual incidence of new onset dyspepsia was reported. Given an approximate 50% seroprevalence of H. pylori infection among adults [3], medical endorsement of empirical antimicrobial therapy could open up vast markets for pharmaceutical firms to exploit through both medical and lay media outlets ("Announcing an important new breakthrough for indigestion sufferers-ask your doctor if you might benefit from these new treatments"). Because the total number of patients seeking medical consultation for dyspepsia would increase, the aggregate costs for managing this condition could skyrocket, even though empirical therapy might still remain cost-effective on a per-patient basis. One can only speculate about the impact that this would have on antimicrobial resistance among H. pylori and other common pathogens-it is unlikely to be helpful.

Although empirical anti-H. pylori therapy for seropositive dyspeptic patients may be cost-effective when considered from the perspective of the individual patient, the possibility that such a strategy could be detrimental to the public health remains an important concern that will be difficult to dispel. From that standpoint, development of an effective vaccine or another preventive strategy may be a far wiser use of our resources [4].