Helicobacter pylori eradication: a narrative review

Helicobacter pylori (H. pylori) is one of the most common chronic infections worldwide and a primary cause of peptic ulcer disease and gastric cancer. Increasing antibiotic resistance has made eradication more difficult, emphasizing the need for new strategies. This narrative review summarizes the current evidence on H. pylori eradication, focusing on epidemiology, resistance, treatment regimens, adjunctive therapies, cancer prevention, and extra-gastric outcomes.

We conducted a narrative literature search to identify current evidence on strategies for eradicating H. pylori. Both first-line and salvage regimens were considered, as well as adjunctive and novel approaches. The evidence was organized thematically.

Over half of the world's population is infected with H. pylori, with the highest prevalence observed in Africa, South America, and Asia. Clarithromycin resistance exceeds 15%-20% in most regions, which diminishes the effectiveness of standard triple therapy. Current recommendations for first-line treatments in areas with high resistance include bismuth quadruple and concomitant regimens, which achieve eradication rates above 85%. Vonoprazan-based and high-dose dual therapies also show promise as alternative options. For second-line therapy, levofloxacin- and bismuth-based regimens remain effective, while rifabutin and susceptibility-guided approaches offer salvage options. Additionally, probiotics and N-acetylcysteine have been found to improve eradication rates and treatment tolerability. Successful eradication reduces the risk of gastric cancer, particularly in East Asia, and provides benefits for extra-gastric conditions such as iron deficiency anemia, idiopathic thrombocytopenic purpura, and pregnancy-related complications.

Eradicating H. pylori is crucial for preventing gastric cancer and enhancing gastrointestinal and systemic health. Achieving success necessitates adapting treatment to resistance patterns, employing adjunctive strategies, using molecular antimicrobial sensitivity testing, and implementing eradication programs in areas with high prevalence.