Dr. Schwartz raises some important and thought-provoking issues. First, public awareness of H. pylori has risen as a result of educational campaigns by the lay press, pharmaceutical companies, the American Gastroenterological Association's Digestive Health Initiative, and the National Institute of Health Consensus Development Conference [1]. Although there is the potential that heightened awareness may lead to more physician visits for dyspepsia, thus raising the "aggregate costs" of care, there is no reason to believe that this impact will be different if initial anti-H. pylori therapy or initial endoscopy is the recommended management strategy. The impact of this awareness on the utilization of services, however, has not been established. Increasing patient visits provides greater opportunity to deliver potentially curative therapy to infected patients who are sufficiently symptomatic to seek care. The potential benefits of curing H. pylori infection in dyspeptic patients beyond resolution of symptoms or reduction in recurrent peptic ulcer disease include 1) preventing peptic ulcer and its complications and 2) potentially preventing gastric cancer and lymphoma [2, 3].

The impact of treating large numbers of H. pylori-seropositive dyspeptic patients with antibiotics does raise concern about the emergence of antimicrobial resistance. Our analysis considers targeted therapy for seropositive patients, in whom the positive predictive value for active infection is 95% to 100% [4, 5] rather than empirical therapy for patients without known H. pylori infection. Although increased public awareness of H. pylori infection may result in increased revenues for the pharmaceutical industry, we hope that pharmaceutical companies will recognize that current regimens can be improved (for example, because of poor compliance of frequent side effects) and that the development of more targeted and effective antibiotic therapy to maximize patient compliance and reduce the risk for resistance must remain a priority.

We agree that an effective vaccine or "other preventive strategy" would be optimal; until that time, we believe that initial anti-H. pylori therapy is the optimal strategy for seropositive patients with dyspepsia. Well-designed, prospective outcomes trials, however, are needed to establish the effectiveness of alternate strategies.