Current and Future Treatment of Helicobacter pylori Infections

Helicobacter pylori is one of the most common human pathogens and it has been estimated that about 50% of the world's population is currently infected. The present consensus is that, unless there are compelling reasons, all H. pylori infections should be cured. Since the 1990s, different national and international guidelines for the management of H. pylori-related diseases have been published and periodically updated regarding indications for treatment, diagnostic procedures, and preferred treatment regimens. Most guidelines provide sophisticated meta-analyses examining the outcome of different regimens done in regions with variable, often high rates of resistance to antibiotics, for which the prevalence and effects of resistance was often ignored. Although successful antimicrobial therapy must be susceptibility-based, increasing antimicrobial resistance and general unavailability of susceptibility testing have required clinicians to generally rely on empiric regimens. Antibiotics resistance of H. pylori has reached alarming high levels worldwide, which has an effect to efficacy of treatment. The recommendations should provide regimes for multi-resistant infections or for those where susceptibility testing is unavailable or refused. The first rule is to use only proven locally effective therapies. Because of patient intolerances, drug allergies, and local experiences, the clinicians should have at least two options for first-line therapy. As with any antimicrobial therapy, a thorough review of prior antibiotic use is invaluable to identify the presence of probably resistance. The second key is patient education regarding potential and expected side-effects and the importance of completing the course of antibiotics. We also review here triple therapies, sequential-concomitant, hybrid therapies, bismuth therapies, dual therapy, vonoprazan, modern antibiotic treatments, probiotics and vaccination.