Antibiotic Resistance

Antibiotic Resistance Is Affecting H pylori Treatment

Antibiotic resistance has caused a decrease in efficacy of standard triple therapy for treating Helicobacter pylori infection, according to new research. However, quadruple therapy may be a viable alternative.

The research team conducted a systematic review and meta-analysis of 120 studies, in which only first-line therapy administered to more than 28,000 patients with H pylori was considered. They found that the eradication rate of H pylori in participants who received standard triple therapy have decreased to 80% or lower in many countries, while the rates of resistance to  clarithromycin, metronidazole, and levofloxacin are increasing.

They reported that a recent meta‐analysis of 178 studies that included 66,142 participants from 65 countries showed that clarithromycin, metronidazole, and levofloxacin resistance rates were 15% or higher in World Health Organization regions. The American and Southeast Asian regions showed primary clarithromycin resistance of approximately 10%, while Europe had a primary levofloxacin resistance of 11%. China showed the most severe resistance rates, with resistance rates of 77.2% to metronidazole, 22.1 % to clarithromycin, and 19.2% to levofloxacin.

The researchers determined that a quadruple therapeutic approach should be considered to ensure eradication of H pylori, such as bismuth quadruple therapy, quadruple sequential therapy, quadruple concomitant therapy, and hybrid therapy.

The team identified 2 likely causes for the increase in resistance to antibiotics: poor compliance by patients and/or practitioners with eradication guidelines and possible genetic mutations in H pylori. They suggest that patients be tested for susceptibility to antibiotic resistance before treatment is initiated, especially in areas with high rates of resistance. However, they noted that such susceptibility is rarely performed.

Whatever has caused the rising rates of antibiotic resistance, the researchers concluded that “[Clarithromycin]‐containing standard triple therapies are no longer suitable for unconditional empirical use.”


—Rebecca Mashaw



Zou Y, Qian X, Liu X, et al. The effect of antibiotic resistance on Helicobacter pylori eradication efficacy: a systematic review and meta‐analysis. Helicobacter. 2020;25(4):e12714.