Effectiveness of Helicobacter pylori Treatments According to Antibiotic Resistance

Am J Gastroenterol. 2024 Apr 1;119(4):646-654. doi: 10.14309/ajg.0000000000002600. Epub 2023 Nov 17.


Introduction: Antibiotic resistance is one of the main factors that determine the efficacy of treatments to eradicate Helicobacter pylori infection. Our aim was to evaluate the effectiveness of first-line and rescue treatments against H. pylori in Europe according to antibiotics resistance.

Methods: Prospective, multicenter, international registry on the management of H. pylori (European Registry on H. pylori Management). All infected and culture-diagnosed adult patients registered in the Spanish Association of Gastroenterology-Research Electronic Data Capture from 2013 to 2021 were included.

Results: A total of 2,852 naive patients with culture results were analyzed. Resistance to clarithromycin, metronidazole, and quinolones was 22%, 27%, and 18%, respectively. The most effective treatment, regardless of resistance, were the 3-in-1 single capsule with bismuth, metronidazole, and tetracycline (91%) and the quadruple with bismuth, offering optimal cure rates even in the presence of bacterial resistance to clarithromycin or metronidazole. The concomitant regimen with tinidazole achieved an eradication rate of 99% (90/91) vs 84% (90/107) with metronidazole. Triple schedules, sequential, or concomitant regimen with metronidazole did not achieve optimal results. A total of 1,118 non-naive patients were analyzed. Resistance to clarithromycin, metronidazole, and quinolones was 49%, 41%, and 24%, respectively. The 3-in-1 single capsule (87%) and the triple therapy with levofloxacin (85%) were the only ones that provided encouraging results.

Discussion: In regions where the antibiotic resistance rate of H. pylori is high, eradication treatment with the 3-in-1 single capsule, the quadruple with bismuth, and concomitant with tinidazole are the best options in naive patients. In non-naive patients, the 3-in-1 single capsule and the triple therapy with levofloxacin provided encouraging results.

Trial registration: ClinicalTrials.gov NCT02328131.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Anti-Bacterial Agents / pharmacology
  • Bismuth / pharmacology
  • Clarithromycin / pharmacology
  • Drug Resistance, Microbial
  • Drug Therapy, Combination
  • Helicobacter Infections* / drug therapy
  • Helicobacter Infections* / microbiology
  • Helicobacter pylori*
  • Humans
  • Levofloxacin / pharmacology
  • Metronidazole / pharmacology
  • Prospective Studies
  • Tinidazole / pharmacology


  • Anti-Bacterial Agents
  • Bismuth
  • Clarithromycin
  • Levofloxacin
  • Metronidazole
  • Tinidazole

Associated data

  • ClinicalTrials.gov/NCT02328131