Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2017 Jul 28;11:2209-2220.
doi: 10.2147/DDDT.S136240. eCollection 2017.

Antibiotic Susceptibility, Heteroresistance, and Updated Treatment Strategies in Helicobacter pylori Infection

Free PMC article

Antibiotic Susceptibility, Heteroresistance, and Updated Treatment Strategies in Helicobacter pylori Infection

Maria Teresa Mascellino et al. Drug Des Devel Ther. .
Free PMC article


In this review, we discuss 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. The prevalence of antibiotic resistance is increasing all over the world, especially for metronidazole and clarithromycin, because of their heavy use in some geographical areas. Heteroresistance (simultaneous presence of both susceptible and resistant strains in different sites of a single stomach) is another important issue, as an isolate could be mistakenly considered susceptible if a single biopsy is used for antimicrobial tests. We also examined literature data regarding eradication success rates of culture-guided and empiric therapies. The empiric therapy and the one based on susceptibility testing, in Hp eradication, may depend on several factors such as 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. Updated treatment strategies in Hp infection presented in the guidelines of the Toronto Consensus Group (2016) are reported. These 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. The new drug vonoprazan, a first-in-class potassium-competitive acid blocker recently approved in Japan, is also considered to be a promising solution for Hp eradication, even for clarithromycin-resistant strains. Furthermore, there is growing interest in finding new therapeutic strategies, such as the development of vaccines or the use of natural resources, including probiotics, plants, or nutraceuticals.

Keywords: biopsies; eradication; rescue.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Similar articles

See all similar articles

Cited by 5 articles


    1. Atherton JC, Peek RM, Tham KT, Cover TL, Blaser MJ. Clinical and pathological importance of heterogeneity in vacA, the vacuolating cytotoxin gene of Helicobacter pylori. Gastroenterology. 1997;112(1):92–99. - PubMed
    1. Logan RPH, Berg DE. Genetic diversity of Helicobacter pylori. Lancet. 1996;348(9040):1462–1463. - PubMed
    1. Ando T, Minami M, Ishiguro K, et al. Changes in biochemical parameters related to atherosclerosis after Helicobacter pylori eradication. Aliment Pharmacol Ther. 2006;24(s4):58–64.
    1. Kanbay M, Gur G, Yucel M, Ylmaz U, Boyacioglu S. Does eradication of Helicobacter pylori infection help normalize serum lipid and CRP levels? Dig Dis Sci. 2005;5(7):1228–1231. - PubMed
    1. Goodman KJ, Correa P. The transmission of Helicobacter pylori: a critical review of the evidence. Int J Epidemiol. 1995;24(5):875–877. - PubMed

MeSH terms