Resistance reversal: Taiwan's Helicobacter pylori trends defy global norms

Abstract

Antibiotic resistance in Helicobacter pylori is reshaping eradication strategies worldwide. Analysis of 1408 treatment-naive isolates collected across Taiwan between 2019 and 2024 reveals a striking shift in resistance patterns. Tetracycline resistance, once negligible, rose to 3.5%, threatening the durability of bismuth-based quadruple therapy. Conversely, metronidazole resistance declined markedly, while clarithromycin and levofloxacin resistance remained stable at moderate levels, with levofloxacin showing significant regional variation. Emerging dual resistance involving tetracycline underscores the fragility of empiric regimens and highlights the need for culture-guided or molecular approaches. These findings reflect the dual influence of stewardship successes and environmental antibiotic pressures, while also signaling the limits of empiricism in eradication therapy. Potassium-competitive acid blockers provide a promising pharmacologic pivot, capable of enhancing antibiotic efficacy and sustaining eradication outcomes. Taiwan's resistance profile thus offers both cautionary lessons and actionable insights for future regional and global treatment strategies.

Keywords: Antibiotics; Eradication; Helicobacter Pylori; Potassium-competitive acid blockers; Proton pump inhibitors; Resistance.

Figure 1

Evolving trends in Helicobacter pylori antibiotic resistance in Taiwan (2019-2024). This infographic summarizes six-year surveillance data from 1408 treatment-naive patients across Taiwan. It highlights the rising prevalence of tetracycline resistance, the decline in metronidazole resistance, and the relative stability of clarithromycin and levofloxacin resistance. Dual resistance involving tetracycline is emerging, and regional variation in levofloxacin resistance is noted. Mechanistic insights include genetic mutations and environmental exposure contributing to resistance evolution. H. pylori: Helicobacter pylori.