Detection of Helicobacter pylori (H. pylori) has traditionally relied on two main approaches – invasive and noninvasive. The invasive approach involves gastroscopic examination with or without biopsy. When biopsy specimens are obtained, they are commonly followed by rapid urease testing (RUT), microbiological culture, and polymerase chain reaction (PCR). Noninvasive methods include serological assays, stool antigen tests (SAT), and the urea breath test (UBT). However, inherent limitations, methodological inconsistencies, and assay cross-reactivities compromise diagnostic validity, rendering many global and country-specific prevalence estimates – as well as test-driven treatment decisions – unreliable and in need of critical reassessment. Therapeutically, the sequential use of single-, dual-, triple-, and quadruple-antibiotic regimens has failed to achieve consistent or durable eradication and has been associated with multiple unintended consequences. Collectively, these observations call for a fundamental reconsideration of the microbe-centric diagnostic paradigm and test-driven therapeutic strategies currently applied to H. pylori. Such reconsideration should be grounded in microbiota science to redefine the ecological role of H. pylori within the gastric ecosystem and to promote more balanced, ecology-based management strategies, including lifestyle modification and the rational use of herb-based dietary supplements.