2021 Asian Pacific Digestive Week
Symposium G9: H pylori
Saturday, 21 August 2021
1740 - 1840 hours
What to Do with Antibiotics Resistant Helicobacter pylori infection?
Chuah Seng Kee MD
Chief, Department of Internal Medicine
Professor of Division of Hepato-gastroenterology
Department of Internal Medicine
Chang Gung Memorial Hospital-Kaohsiung Medical Center
Chang Gung University College of Medicine, Taiwan

Global problems in treating Helicobacter pylori (H. pylori) infection are the use multiple drugs in the prescription for treating H. pylori causing the risk of resistant strain. Resistant strain is one of the key point to the failure eradication. Prevalence of primary clarithromycin resistance in the Asia-Pacific region is increasing over the past decades especially China, Vietnam, Nepal and Pakistan (21%-34%). In these countries, the metronidazole resistance ranges from 61%-88%. Maastricht V/Florence Consensus states that in areas with low clarithromycin resistance (<15%), 14-day standard triple therapy is optimal treatment regimens. For areas where the clarithromycin resistance is > 15% and the metronidazole resistance is low such as Japan (10%), PPI-Amoxicillin-Metronidazole triple therapy is recommended. Bismuth or non-bismuth quadruple therapies (concomitant, hybrid, sequential therapy) are recommended in areas where the resistances to both clarithromycin and metronidazole are low. Bismuth quadruple therapy is recommended if both primary clarithromycin and metronidazole resistances are high. Vonoprazan-based dual or triple therapies are promising alternative.
If 14-day standard triple therapies failed among those with low primary clarithromycin resistance, Bismuth quadruple therapy is recommended or antibiotics not used previously or resistance is unlikely examples: amoxicillin, bismuth or tetracycline. Second line levofloxacin-based triple therapy is recommended but should be abandoned if the levofloxacin resistance is >10%. Bismuth-based quadruple therapy or Levofloxacin/bismuth-based quadruple therapy combining either amoxicillin or tetracycline are recommended for rescue therapy. High dose metronidazole can be partially overcome metronidazole resistance. Bismuth has a synergistic effect with anti biotics, and overcomes clarithromycin resistance.
Susceptibility-guided therapy or genotype resistance-guided therapy is recommended after multiple failures.