Impact of kimura-takemoto atrophy classification on first-line H. pylori eradication: a retrospective cohort study

We sought to determine whether the endoscopic grade of gastric atrophy (according to Kimura-Takemoto) affects the likelihood of successful first-line H. pylori eradication.

We conducted a retrospective analysis of consecutive patients hospitalized at Wuhan Fourth Hospital between November 2021 and November 2025. Eligible individuals had a positive urea breath test confirming H. pylori infection, were diagnosed with chronic atrophic gastritis via gastroscopy, received a bismuth-containing quadruple regimen as first-line therapy, and returned for a follow-up breath test at least 4 weeks post-treatment. Prior to therapy (within 28 days), each patient underwent high-definition white-light gastroscopy. Two independent endoscopists, unaware of patient allocation, retrospectively reviewed all images to grade atrophy using the Kimura-Takemoto system. Patients were assigned to either the closed-type (C-type) or open-type (O-type) atrophy group. The primary endpoint was eradication failure, defined as a positive follow-up breath test. Logistic regression (univariate and multivariate) was used to identify factors independently linked to treatment failure.

A total of 154 patients completed follow-up and were included. The overall eradication rate was 76.6% (118/154). In the open-type atrophy group (n = 26), the eradication rate was only 42.3% (11/26), significantly lower than the 83.6% (107/128) observed in the closed-type group (P < 0.001). After adjusting for confounders such as body weight and age, multivariate analysis revealed that endoscopic open-type atrophy was independently associated with eradication failure (OR = 8.287, 95% CI: 3.150-21.804, P < 0.001).

The extent of endoscopic gastric mucosal atrophy independently predicts a lower efficacy of first-line H. pylori eradication. For patients with Kimura-Takemoto open-type atrophy, clarithromycin-containing quadruple regimens should be used cautiously. Alternative clarithromycin-free regimens (e.g., tetracycline-, metronidazole-, or levofloxacin-based therapies, or high-dose amoxicillin with PPI/vonoprazan) or susceptibility-guided individualized therapy are recommended in clinical practice.