Diagnosis and treatment of Helicobacter pylori infection: past, present, and future

Helicobacter pylori infects more than half of the world's population. Chronic H. pylori infection is associated with the development of precancerous gastric conditions, including chronic atrophic gastritis and intestinal metaplasia, which may progress to peptic ulcer disease and gastric cancer. In 2020, an estimated 1.09 million new cases of gastric cancer were reported worldwide. Gastric cancer continues to pose a significant health burden and is the fourth leading cause of cancer-related deaths globally, with an estimated 769,000 deaths occurring annually. To decrease gastric cancer-related deaths, international guidelines recommend H. pylori eradication in all infected individuals. Increasing antibiotic resistance of H. pylori has significantly compromised the effectiveness of standard eradication regimens, highlighting the urgent need for alternative and effective treatment strategies. Over the past decade, molecular technologies and genome sequencing have advanced H. pylori diagnosis and treatment. This comprehensive review discusses the latest evidence on H. pylori management to guide the development of effective testing and treatment strategies. It also offers updates for clinicians, including the optimized H. pylori diagnosis, the history of H. pylori treatment and guideline development, updated empirical H. pylori treatment regimens, molecular testing for tailored H. pylori eradication, and next-generation sequencing of the gastric microbiome.