<i>Helicobacter pylori</i> antibiotic resistance: a global challenge in search of solutions.

Abstract

<i>Helicobacter pylori</i> resistance to antibiotics commonly used in eradication regimens is increasing dramatically in many locations; new strategies are needed to manage this infectious disease. This study's aim was to collect and update information on antibiotic resistance (AR) rates in <i>H. pylori</i> as well as current strategies for <i>H. pylori</i> management, including public health issues, from a global perspective. An international survey was conducted in 31 countries on 6 continents to address key issues concerning the management of <i>H. pylori</i>-related AR. Individual aspects included the prevalence of AR for specific antibiotics, antibiotic susceptibility testing (AST) in different healthcare systems, availability of drugs, reimbursement issues and strategies for <i>H. pylori</i> AR surveillance. Resistance to the most effective antibiotics used in <i>H. pylori</i> eradication regimens is increasing globally, with clarithromycin and levofloxacin resistance exceeding 15% in 24/31 and 18/31 countries, respectively. Amoxicillin remains an exception, with resistance rates under 2% in 14/31 countries; though African countries have reported amoxicillin resistance rates of over 90%. Bismuth-based treatment regimens are the most effective and are recommended as first-line treatment in several countries. However, more than 1 billion inhabitants worldwide have no access to bismuth-based regimens. PCR-based tests for AR are used in 16/26 countries but are reimbursed in only 4, while next generation sequencing-based tests are available, but not reimbursed, in 3 countries. In 22/26 countries only culture-based methods are available (reimbursed in 9/26 countries). AR surveillance programmes have only been established in 4/26 countries. Therefore, in most countries, empirical therapy with the most effective local regimen available locally is practiced. The dramatic global rise in <i>H. pylori</i> antibiotic resistance requires an urgent revision of current management strategies. Possible solutions include AST-based selection of effective treatment regimens, identification of novel combinations of existing drugs and exploration of novel drugs.