Optimizing Helicobacter pylori Treatment: An Updated Review of Empirical and Susceptibility Test-Based Treatments

Abstract

As the rate of discovery of drug-resistant Helicobacter pylori cases increases worldwide, the relevant societies have updated their guidelines for primary eradication regimens. A promising strategy against drug-resistant H. pylori is tailored therapy based on the results of an antibiotic susceptibility test; however, it is difficult to apply this strategy to all cases. Although culture-based antibiotic susceptibility tests can assess resistance to any antimicrobial agent, their greatest disadvantage is the time required to draw a conclusion. In contrast, molecular-based methods, such as polymerase chain reaction, can rapidly determine the presence of resistance, although a single test can only test for one type of antimicrobial agent. Additionally, the limited availability of facilities for molecular-based methods has hindered their widespread use. Therefore, low-cost, minimally invasive, simple, and effective primary regimens are needed. Several studies have compared the efficacy of the latest primary eradication regimens against that of tailored therapies, and their results have shaped guidelines. This article reviews the latest research on empirical and tailored treatments for H. pylori infections. Evidence for the superiority of tailored therapy over empirical therapy is still limited and varies by region and treatment regimen. A network meta-analysis comparing different empirical treatment regimens showed that vonoprazan triple therapy provides a superior eradication effect. Recently, favorable results towards vonoprazan dual therapy have been reported, as it reached eradication levels similar to those of vonoprazan triple therapy. Both vonoprazan dual therapy and tailored therapy based on antibiotic susceptibility tests could contribute to future treatment strategies.

Keywords: Antibiotics; Bacterial susceptibility test; Drug resistance; Helicobacter pylori; Vonoprazan.

Fig. 1

Global comparison of the proportion of antimicrobial-resistant Helicobacter pylori strains. Data were obtained from reports published since 2012.- Multidrug-resistant strains were defined as those resistant to at least two antimicrobial agents. CLA, clarithromycin; AMO, amoxicillin; MET, metronidazole; LEV, levofloxacin; TET, tetracycline; MD, multidrug resistance; ND, no data.

Fig. 2

Flowchart outlining future eradication strategies incorporating tailored therapy. The first-line therapy is vonoprazan-dual therapy, without considering clarithromycin-resistant strains. If eradication fails, an antibiotic susceptibility test (AST) is performed. A second-line therapy with a modified regimen of quadruple therapy may be needed depending on AST results.