Evidence-Based Guidelines for the Diagnosis and Treatment of Helicobacter pylori Infection in Korea: 2025 Revised...

Since the 2020 Korean guidelines for Helicobacter pylori treatment, clarithromycin resistance rates have risen from 17.8% to 33.3%, dual-priming oligonucleotide-based polymerase chain reaction (DPO-PCR)-based tailored therapy has been adopted, and P-CABs have become available. This fourth revision addresses these changes.

Nine key questions were addressed through systematic reviews with meta-analyses. Thirteen recommendations were evaluated via modified Delphi process involving 64 experts.

Twelve recommendations achieved first-round consensus; one required revision and achieved 73.9% agreement. Key changes: (1) dual-pillar strategy of tailored therapy and empirical quadruple therapy; (2) restricted use of empirical clarithromycin-based triple therapy under specific conditions; (3) removal of sequential therapy; (4) P-CABs as PPI alternatives; (5) expansion of eradication indications to include gastric cancer prevention in H. pylori gastritis and regression of hyperplastic polyps ≤ 10 mm; and (6) positioning of bismuth quadruple therapy as a conditionally recommended first-line empirical option with preference for reservation as salvage therapy, and introduction of modified bismuth quadruple therapy (addition of bismuth to conventional regimens) as an additional first-line empirical option.

This fourth revised guideline provides updated, evidence-based recommendations for the diagnosis and treatment of H. pylori infection, reflecting the rapidly changing antibiotic resistance landscape and the introduction of new diagnostic and therapeutic tools in Korea. These guidelines aim to assist clinicians, patients, policymakers, and medical educators in optimizing H. pylori management. They may differ from current medical insurance standards and will be revised further based on emerging evidence.