When and How Should Resistance Testing Be Performed to Improve H. pylori Eradication?

Purpose of Review Treatment of Helicobacter pylori ( H. pylori ) has historically been managed with empiric regimens comprising proton pump inhibitors and a small number of common antibiotics. This has led to rising rates of antibiotic resistance, especially with regimens involving clarithromycin or levofloxacin. To improve falling eradication rates, there is now considerable interest in the role of antimicrobial susceptibility testing of H. pylori strains to individualize or “tailor” treatment according to the resistance profile. Recent Findings The rates at which antimicrobial resistance in H. pylori has shifted upwards globally. The major mechanisms responsible for resistance have been elucidated, though metronidazole resistance is less well understood. Molecular methodology to measure antimicrobial resistance in H. pylori is becoming more widespread. The decision-making process for deciding when to tailor susceptibility-based testing versus continuing with empiric approaches in first-line therapies in treatment naïve cases as well as in subsequent treatments for refractory cases remains poorly defined. Summary While most clinical trials do not yet show clear-cut advantages to susceptibility-guided treatment over empiric approaches, we consider that this reflects prior inappropriate study design. We foresee that future studies, while also utilizing molecular testing, will support the utility of increased susceptibility testing, especially for refractory cases.