Mascellino MT, et al. – This review seeks to describe the problem of antibiotic resistance, heteroresistance, the utility of cultures and antibiotic susceptibility tests in Helicobacter pylori (Hp) eradication, as well as the updated treatment strategies for this infection.

Methods

• Observations suggest increasing prevalence of antibiotic resistance all over the world, especially for metronidazole and clarithromycin, because of their heavy use in some geographical areas.
• Another important issue observed is heteroresistance (simultaneous presence of both susceptible and resistant strains in different sites of a single stomach), as an isolate could be mistakenly considered susceptible if a single biopsy is used for antimicrobial tests.
• Literature data regarding eradication success rates of culture–guided and empiric therapies is also reviewed.
• Authors realized several factors on which the empiric therapy and the one based on susceptibility testing, in Hp eradication, may depend; the factors included concomitant diseases, the number of previous antibiotic treatments, differences in bacterial virulence in individuals with positive or negative cultures, together with local antibiotic resistance patterns in real–world settings.
• This study reports updated treatment strategies in Hp infection presented in the guidelines of the Toronto Consensus Group (2016).
• The guidelines suggest to prolong eradication therapy up to 14 days, replacing the old triple therapy with a quadruple therapy based on proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline for most of the patients, or as an alternative quadruple therapy without bismuth, based on the use of PPI, amoxicillin, metronidazole, and clarithromycin.
• A promising solution for Hp eradication considered is the new drug vonoprazan, a first–in–class potassium–competitive acid blocker recently approved in Japan, even for clarithromycin–resistant strains.
• In addition, there appears a growing interest in finding new therapeutic strategies, such as the development of vaccines or the use of natural resources, including probiotics, plants, or nutraceuticals.