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The Unfinished Agenda in Helicobacter pylori Treatment: Resistance, Microbiome Effects, and Future Directions.

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Τίτλος: The Unfinished Agenda in Helicobacter pylori Treatment: Resistance, Microbiome Effects, and Future Directions.
Συγγραφείς: Rokkas T; Gastroenterology Clinic, Henry Dunant Hospital, Athens, Greece; Medical School, European University of Cyprus, Nicosia, Cyprus and. Electronic address: sakkor@otenet.gr., Graham DY; Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas.
Πηγή: Gastroenterology [Gastroenterology] 2026 Aug; Vol. 171 (2), pp. 271-284. Date of Electronic Publication: 2026 Mar 27.
Τύπος έκδοσης: Journal Article; Review
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: W.B. Saunders Country of Publication: United States NLM ID: 0374630 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1528-0012 (Electronic) Linking ISSN: 00165085 NLM ISO Abbreviation: Gastroenterology Subsets: MEDLINE
Imprint Name(s): Publication: Philadelphia, PA : W.B. Saunders
Original Publication: Baltimore.
Ιατρικοί όροι (MeSH): Helicobacter pylori*/drug effects , Helicobacter pylori*/pathogenicity , Helicobacter Infections*/drug therapy , Helicobacter Infections*/microbiology , Helicobacter Infections*/diagnosis , Anti-Bacterial Agents*/therapeutic use , Anti-Bacterial Agents*/adverse effects , Anti-Bacterial Agents*/pharmacology , Gastrointestinal Microbiome*/drug effects , Drug Resistance, Bacterial*, Proton Pump Inhibitors/therapeutic use ; Probiotics/therapeutic use ; Humans ; Treatment Outcome
Περίληψη: Background & Aims: Helicobacter pylori infection is the principal cause of peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and noncardia gastric cancer. The major advances in diagnostics and treatment and eradication success are threatened by rising antimicrobial resistance and concerns about disruption of the normal microbiome. This review summarizes current unresolved issues in H pylori treatment, with a focus on resistance, optimal regimens, ecological impact, and emerging therapies.
Methods: Extensive review of randomized controlled trials, meta-analyses, international consensus guidelines, molecular epidemiology studies, microbiome analyses, and translational research related to H pylori eradication, resistance, microbiome effects, and novel therapies.
Results: Global resistance to clarithromycin, metronidazole, and fluoroquinolones significantly undermines the performance of traditionally effective antimicrobial therapies. The corner stone of successful antimicrobial therapy is susceptibility-guided therapy but remains of limited use with H pylori because of lack of infrastructure. Eradication regimens potentially induce substantial alterations in gut and gastric microbiota and expand the antimicrobial resistome. Probiotics and N-acetylcysteine offer at best very modest improvements in eradication and tolerability. Novel and still experimental platforms, including engineered phage therapy, antimicrobial peptides, nanoparticle-delivered urease inhibitors, biofilm-targeting agents, and vaccines show promise. Implementation gaps, persistent use of suboptimal regimens, and global inequities constrain the impact of available therapies.
Conclusions: Optimizing H pylori treatment requires evidence-based regimen selection, precision-guided strategies, antimicrobial stewardship, and equitable access to essential medications. Advances in molecular diagnostics, antimicrobial development, and implementation science are all critical to reducing the global burden of H pylori-associated disease and gastric cancer.
(Copyright © 2026 American Gastroenterological Association Institute. Published by Elsevier Inc. All rights reserved.)
Contributed Indexing: Keywords: Antimicrobial Resistance; Antimicrobial Stewardship; Helicobacter pylori; Microbiome; Treatment
Substance Nomenclature: 0 (Anti-Bacterial Agents)
0 (Proton Pump Inhibitors)
Entry Date(s): Date Created: 20260329 Date Completed: 20260722 Latest Revision: 20260722
Update Code: 20260723
DOI: 10.1053/j.gastro.2026.02.041
PMID: 41905430
Βάση Δεδομένων: MEDLINE
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  – Url: https://www.doi.org/10.1053/j.gastro.2026.02.041?
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  Data: The Unfinished Agenda in Helicobacter pylori Treatment: Resistance, Microbiome Effects, and Future Directions.
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  Data: <searchLink fieldCode="AU" term="%22Rokkas+T%22">Rokkas T</searchLink>; Gastroenterology Clinic, Henry Dunant Hospital, Athens, Greece; Medical School, European University of Cyprus, Nicosia, Cyprus and. Electronic address: sakkor@otenet.gr.<br /><searchLink fieldCode="AU" term="%22Graham+DY%22">Graham DY</searchLink>; Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas.
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  Data: <searchLink fieldCode="JN" term="%220374630%22">Gastroenterology</searchLink> [Gastroenterology] 2026 Aug; Vol. 171 (2), pp. 271-284. <i>Date of Electronic Publication: </i>2026 Mar 27.
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  Data: <i>Publication</i>: Philadelphia, PA : W.B. Saunders<br /><i>Original Publication</i>: Baltimore.
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  Data: <searchLink fieldCode="MM" term="%22Helicobacter+pylori%22">Helicobacter pylori*</searchLink>/<searchLink fieldCode="MM" term="%22Helicobacter+pylori+drug+effects%22">drug effects</searchLink> <br /><searchLink fieldCode="MM" term="%22Helicobacter+pylori%22">Helicobacter pylori*</searchLink>/<searchLink fieldCode="MM" term="%22Helicobacter+pylori+pathogenicity%22">pathogenicity</searchLink> <br /><searchLink fieldCode="MM" term="%22Helicobacter+Infections%22">Helicobacter Infections*</searchLink>/<searchLink fieldCode="MM" term="%22Helicobacter+Infections+drug+therapy%22">drug therapy</searchLink> <br /><searchLink fieldCode="MM" term="%22Helicobacter+Infections%22">Helicobacter Infections*</searchLink>/<searchLink fieldCode="MM" term="%22Helicobacter+Infections+microbiology%22">microbiology</searchLink> <br /><searchLink fieldCode="MM" term="%22Helicobacter+Infections%22">Helicobacter Infections*</searchLink>/<searchLink fieldCode="MM" term="%22Helicobacter+Infections+diagnosis%22">diagnosis</searchLink> <br /><searchLink fieldCode="MM" term="%22Anti-Bacterial+Agents%22">Anti-Bacterial Agents*</searchLink>/<searchLink fieldCode="MM" term="%22Anti-Bacterial+Agents+therapeutic+use%22">therapeutic use</searchLink> <br /><searchLink fieldCode="MM" term="%22Anti-Bacterial+Agents%22">Anti-Bacterial Agents*</searchLink>/<searchLink fieldCode="MM" term="%22Anti-Bacterial+Agents+adverse+effects%22">adverse effects</searchLink> <br /><searchLink fieldCode="MM" term="%22Anti-Bacterial+Agents%22">Anti-Bacterial Agents*</searchLink>/<searchLink fieldCode="MM" term="%22Anti-Bacterial+Agents+pharmacology%22">pharmacology</searchLink> <br /><searchLink fieldCode="MM" term="%22Gastrointestinal+Microbiome%22">Gastrointestinal Microbiome*</searchLink>/<searchLink fieldCode="MM" term="%22Gastrointestinal+Microbiome+drug+effects%22">drug effects</searchLink> <br /><searchLink fieldCode="MM" term="%22Drug+Resistance%2C+Bacterial%22">Drug Resistance, Bacterial*</searchLink><br /><searchLink fieldCode="MH" term="%22Proton+Pump+Inhibitors%22">Proton Pump Inhibitors</searchLink>/<searchLink fieldCode="MH" term="%22Proton+Pump+Inhibitors+therapeutic+use%22">therapeutic use</searchLink> ; <searchLink fieldCode="MH" term="%22Probiotics%22">Probiotics</searchLink>/<searchLink fieldCode="MH" term="%22Probiotics+therapeutic+use%22">therapeutic use</searchLink> ; <searchLink fieldCode="MH" term="%22Humans%22">Humans</searchLink> ; <searchLink fieldCode="MH" term="%22Treatment+Outcome%22">Treatment Outcome</searchLink>
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background & Aims: Helicobacter pylori infection is the principal cause of peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and noncardia gastric cancer. The major advances in diagnostics and treatment and eradication success are threatened by rising antimicrobial resistance and concerns about disruption of the normal microbiome. This review summarizes current unresolved issues in H pylori treatment, with a focus on resistance, optimal regimens, ecological impact, and emerging therapies.<br />Methods: Extensive review of randomized controlled trials, meta-analyses, international consensus guidelines, molecular epidemiology studies, microbiome analyses, and translational research related to H pylori eradication, resistance, microbiome effects, and novel therapies.<br />Results: Global resistance to clarithromycin, metronidazole, and fluoroquinolones significantly undermines the performance of traditionally effective antimicrobial therapies. The corner stone of successful antimicrobial therapy is susceptibility-guided therapy but remains of limited use with H pylori because of lack of infrastructure. Eradication regimens potentially induce substantial alterations in gut and gastric microbiota and expand the antimicrobial resistome. Probiotics and N-acetylcysteine offer at best very modest improvements in eradication and tolerability. Novel and still experimental platforms, including engineered phage therapy, antimicrobial peptides, nanoparticle-delivered urease inhibitors, biofilm-targeting agents, and vaccines show promise. Implementation gaps, persistent use of suboptimal regimens, and global inequities constrain the impact of available therapies.<br />Conclusions: Optimizing H pylori treatment requires evidence-based regimen selection, precision-guided strategies, antimicrobial stewardship, and equitable access to essential medications. Advances in molecular diagnostics, antimicrobial development, and implementation science are all critical to reducing the global burden of H pylori-associated disease and gastric cancer.<br /> (Copyright © 2026 American Gastroenterological Association Institute. Published by Elsevier Inc. All rights reserved.)
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  Data: 10.1053/j.gastro.2026.02.041
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