Patient management recommendations that might become health care policy should be based on the highest level of evidence. The evidence supporting the recommendation to “test and treat” forHelicobacter pylori infection before starting long term antireflux treatment falls well short of this standard. This recommendation arose directly from the report by Kuipers and colleagues1 in 1996 that the prevalence of corpus glandular atrophy increased during chronic omeprazole treatment in patients infected with H pylori. We were pleased to have another reason to eradicate H pylori; the prevailing wisdom was that no H pylori should go unpunished. This aggressive approach has been challenged, particularly in the case of patients with gastro-oesophageal reflux disease (GORD). Approximately 42% of adults in the USA suffer from GORD.2 Nearly 7% experience heartburn on a daily basis,3 making them potential candidates for proton pump inhibitor (PPI) therapy and, therefore, testing for H pylori infection. Apart from the obvious economic and antimicrobial resistance implications, growing evidence indicates that H pylori infection protects against the complications of …