What is the impact of Helicobacter pylori density on the success of eradication therapy: a clinico-histopathological study

Efficacy of Helicobacter pylori Eradication Based on Rabeprazole–Bismuth–Tetracycline–Tinidazole Regimen in Vietnamese Patients with Duodenal Ulcers

(1) Background: In Vietnam, H. pylori bacteria has a resistance rate of 63% to the antibiotic clarithromycin. The initial therapy of H. pylori eradication with a standard three-drug regimen has low efficacy. Objective: Assess the efficacy of H. pylori eradication therapy which uses a four-drug regimen of rabeprazole–bismuth–tetracycline–tinidazole in patients with duodenal ulcers. (2) Methods: We performed gastrointestinal endoscopy on patients with a diagnosis of duodenal ulcers, gastric mucosa biopsy for a rapid urease test, and histopathology to diagnose H. pylori bacteria before and after treatment. Treatment for eradication of H. pylori bacteria using a rabeprazole–bismuth–tetracycline–tinidazole regimen was prescribed for 14 days. (3) Results: The rate of successful H. pylori eradication treatment according to per protocol (PP) and intention to treat (ITT) was 91.3% (95%CI: 84.8–96.7) and 82.4% (95%CI: 74.5–89.2) respectively. The success rate of H. pylori eradication therapy in males was 96.0% (95%CI: 92–100), higher than in females, which was 70.6% (95%CI: 47.1–88.2), p < 0.01. (4) Conclusions: Treatment of H. pylori with rabeprazole–bismuth–tetracycline–tinidazole regimen is highly effective. Men had higher H. pylori eradication results than women.

Helicobacter pylori infection: How does age influence the inflammatory pattern?

The inflammatory pattern during Helicobacter pylori (H. pylori) infection is changeable and complex. During childhood, it is possible to observe a predominantly regulatory response, evidenced by high concentrations of key cytokines for the maintenance of Treg responses such as TGF-β1 and IL-10, in addition to high expression of the transcription factor FOXP3. On the other hand, there is a predominance of cytokines associated with the Th1 and Th17 responses among H. pylori-positive adults. In the last few years, the participation of the Th17 response in the gastric inflammation against H. pylori infection has been highlighted due to the high levels of TGF-β1 and IL-17 found in this infectious scenario, and growing evidence has supported a close relationship between this immune response profile and unfavorable outcomes related to the infection. Moreover, this cytokine profile might play a pivotal role in the effectiveness of anti-H. pylori vaccines. It is evident that age is one of the main factors influencing the gastric inflammatory pattern during the infection with H. pylori, and understanding the immune response against the bacterium can assist in the development of alternative prophylactic and therapeutic strategies against the infection as well as in the comprehension of the pathogenesis of the outcomes related to that microorganism.

Effect of gastric microbiota on quadruple Helicobacter pylori eradication therapy containing bismuth

BACKGROUND

Helicobacter pylori (H. pylori) is an important pathogen that can cause a variety of diseases. Yet, full eradication of H. pylori remains a significant challenge in clinical practice. H. pylori and other microbial communities have complex interactions in the unique gastric microecological environment. However, it is not clear whether the interactions have any effect on the therapeutic effect of H. pylori.

AIM

The aim was to investigate the characteristics of the gastric microbiota with H. pylori infection and the influence on the H. pylori eradication treatment.

METHODS

Patients with H. pylori infection underwent gastroscopy and received treatment for eradication. The prescription included esomeprazole 20 mg bid, Livzon Dele 220 mg bid, amoxicillin 1000 mg bid, and clarithromycin 500 mg bid for 14 d. Patients who did not respond to treatment and failed eradication were compared with those who achieved eradication by 1:2 propensity matching. High-throughput sequencing of the gastric mucosal microbiota was performed, and the results were evaluated by alpha diversity analysis, beta diversity analysis, species correlation analysis, and metabolic pathway correlation analysis.

RESULTS

The eradication rate of all the patients was 95.5% (171/179). Twenty-four patients were enrolled in the study after propensity-matched scoring. There were eight cases in the failure group (patients who did not respond well to therapy) and 16 cases in the success group. The majority phyla in the two groups were the same, and included Proteobacteria, Bacteroides, Firmicutes, Actinomycetes, and Fusobacteria. The microbial diversity in the failure group had a decreasing trend (P = 0.092) and the species abundance was significantly lower (P = 0.031) compared with the success group. The high rate of H. pylori eradication was associated with Rhodococcus, Lactobacillus, and Sphingomonas, as they were significantly enriched in the successful group (P < 0.05). Veronococcus and Cilium were enriched in the mucosa of chronic atrophic gastritis patients compared with chronic superficial gastritis patients (P = 0.0466 and 0.0122, respectively). In both study groups, H. pylori was negatively correlated with other bacterial genera. More bacterial genera were directly related to H. pylori in the successful group compared with the failure group.

CONCLUSION

The effectiveness of quadruple H. pylori eradication therapy containing bismuth depended on gastric microbiota, and the high rate of H. pylori eradication was associated with the presence of Rhodococcus, Lactobacillus, and Sphingomonas.

Three-Decade Failure to the Eradication of Refractory Helicobacter pylori Infection and Recent Efforts to Eradicate the Infection

BACKGROUND

Helicobacter pylori causes dangerous and deadly diseases such as gastric cancer and duodenal ulcers. Eradication and treatment of this bacterium are very important due to the deadly diseases caused by H. pylori and the high cost of treatment for countries.

METHODS

Thus, we present a complete list of the most important causes of failure in the treatment and eradication of H. pylori, and address new therapeutic methods that may be effective in controlling this bacterium in the future.

RESULTS

Many efforts have been made to control and eradicate this bacterium over the years, but no success has been achieved since its eradication is a complex process affected by the bacterial properties and host factors. Previous studies have shown that various factors are involved in the failure to eradicate H. pylori, such as new genotypes of the bacterium with higher pathogenicity, inappropriate patient cooperation, mutations, biofilm formation and dormant forms that cause antibiotic resistance, acidic stomach pH, high bacterial load, smoking, immunosuppressive features and intracellular occurrence of H. pylori. On the other hand, recent studies reported that the use of probiotics, nanoparticles, antimicrobial peptides, natural product and vaccines can be helpful in the treatment and eradication of H. pylori infections.

CONCLUSION

Eradication of H. pylori is crucial for the treatment of important diseases such as gastric cancer. Therefore, it seems that identifying the failure causes of treating this bacterium can be helpful in controlling the infections. Besides, further studies on new therapeutic strategies may help eradicate H. pylori in the future.

Delay in Retreatment of Helicobacter pylori Infection Increases Risk of Upper Gastrointestinal Bleeding

BACKGROUND & AIMS

Little is known about risk of upper gastrointestinal bleeding (UGIB) in patients failed by Helicobacter pylori eradication therapy. We investigated the effects of different time until retreatment, after failure of initial H pylori eradication therapy, on subsequent risk of UGIB.

METHODS

We performed a territory-wide retrospective cohort study of 70,518 patients with H pylori infection who had received their first course of clarithromycin-based triple therapy from January 2003 through December 2012 in Hong Kong. Patients who required retreatment after failed initial therapy (n = 8330, 11.8%) were categorized based on time between initial and final H pylori eradication (3 months or less, 3-12 months, and more than 12 months). We collected clinical data from 30 days after prescription of the last course of H pylori therapy until hospitalization for non-variceal UGIB, death, or the end of the study (30 Jun 2016; median follow-up time, 7.65 years). The primary outcome was difference in development UGIB (determined from ICD-9 codes) between patients who required retreatment and those who did not (reference group).

RESULTS

Compared with the reference group, patients who required retreatment had an overall higher risk of UGIB, even after last eradication therapy (adjusted hazard ratio (HR), 1.50, 95% CI, 1.34-1.69). There was a progressive increase in risk of UGIB with longer time from initial until final eradication therapy: hazard ratio for time less than 3 months, 1.16; 95% CI, 0.88-1.54, hazard ratio for time 3-12 months, 1.35; 95% CI, 1.07-1.69, and hazard ratio for time more than 12 months, 1.68; 95% CI, 1.46-1.94 (P for trend = .038).

CONCLUSION

In a retrospective study of patients in Hong Kong, we found that those failed by initial H pylori eradication have an increased risk of UGIB, compared to patients who responded to the initial therapy. Risk increased progressively with longer time until retreatment. Early retreatment within 3 months should be considered to minimize subsequent UGIB risk.

The Relationship between the Sydney Classification and the First-Line Treatment Efficacy in Helicobacter-Associated Gastritis

OBJECTIVE

Helicobacter pyloriis responsible for a wide spectrum of diseases. Due to ease of use and access, the standard triple therapy is being used as first-line eradication in many areas. Intestinal metaplasia (IM) is a precancerous lesion that requires eradication therapy. Our aim is to investigate the effect of IM on the standard triple therapy success in H. pylori-positive patients.

SUBJECTS AND METHODS

The patients who were referred to Düzce University Hospital and Avrasya Hospital Gastroenterohepatology clinic between January 2014 and December 2016 and diagnosed with H. pylori-positive gastritis and underwent first-line eradication were evaluated retrospectively. Biopsy specimens were evaluated according to the updated Sydney system. All patients diagnosed with H. pylori started treatment with pantoprazole 40 mg b.i.d., amoxicillin 1 g b.i.d. and clarithromycin 500 mg b.i.d. for 14 days.

RESULTS

The mean age of 181 patients included in the study was 55.5 ± 7.8. The success rate of H. pylori eradication was found to be low in severe chronic inflammation (p = 0.001). The success rate was found to be high among patients with no neutrophil activity (p = 0.009). As the intensity of IM increased, density of H. pylori was found to be decreased (p = 0.019). There was no correlation between glandular atrophy, IM, and H. pylori eradication success rate (p = 0.390 and p = 0.812).

CONCLUSION

The severity of chronic inflammation is the most effective Sydney criteria for success of eradication, while the presence on IM does not have any effect.

Colonization of Helicobacter pylori in the gastric cardia: A comparison between the UFT300 and CLO tests

Background and aim

To assess the detection rates of Helicobacter pylori colonization in the gastric cardia with two commercial kits of rapid urease test: 5 min UFT300 and 24 h CLO test in H. pylori‐infected patients.

Methods

Eighty consecutive dyspeptic patients with confirmed H. pylori infection (serology and ¹³C‐urea breath test) were prospectively studied. During endoscopy, tissue samples using separate biopsy forceps from the cardia were taken for the UFT300 and CLO tests. The results of the UFT300 were read at 5 and 30 min, and those of the CLO test were read at 24 h.

Results

Of 80 enrolled patients, 17 (21.3%) and 44 (55%) had positive findings with the UFT300 at 5 and 30 min, respectively, while 72 (90%) had positive findings with the CLO test at 24 h. The CLO test is significantly more sensitive than the UFT300 in evaluating H. pylori status in the cardia. On comparing patients with and without carditis, the detection rates of the CLO test were similar (91.1% vs 88.6%; P = 0.724), and the rates of the UFT300 were also similar at 5 and 30 min.

Conclusions

The rate of H. pylori colonization in the gastric cardia was 90% in H. pylori‐infected patients detected with the CLO test. Although the UFT300 provides a more rapid reading of H. pylori status, the diagnostic yield of the CLO test is much higher than that of the UFT300. However, a positive result of the UFT300 may indicate a higher bacterial load in the cardia, which warrants a more effective therapeutic strategy.

Comparison between different first-line therapy protocols in eradicating Helicobacter pylori in a region with high clarithromycin resistance

Introduction

Helicobacter pylori infection is encountered in more than 50% of the world population. A high rate of clarithromycin resistance is observed among Helicobacter pylori strains in some regions because clarithromycin is a drug commonly used for the treatment of other infections.

Aim

To identify an efficient eradication protocol for patients infected with H. pylori and to suggest an alternative first-line therapy particularly in countries with high clarithromycin resistance.

Material and methods

Patients (18-75 years old) having dyspeptic complaints in a 1-year period and diagnosed with H. pylori infection by gastric biopsy were included and randomised to three groups, each receiving different sequential eradication therapy (LAM-B: lansoprazole, amoxicillin, metronidazole, bismuth: LAM-T: lansoprazole, amoxicillin, metronidazole, tetracycline; LAM-BT: lansoprazole, amoxicillin, metronidazole, bismuth, tetracycline). Eradication was evaluated via urea breath test.

Results

This study included 166 patients (mean age: 40 ±12 years; female, 68.7%) with H. pylori infection. Among them, 50 (30.1%) were in the LAM-B group, 59 (35.5%) were in the LAM-T group, and 57 (34.3%) were in the LAM-BT group. The non-steroidal anti-inflammatory drug use was the lowest in the LAM-BT group. Eradication rates were over 80% and similar in each group, with the highest rate in the LAM-BT group (93%). Adverse event rate was the highest in the LAM-T group. Helicobacter pylori eradication was achieved in 143 (86.1%) patients.

Conclusions

The combination regimens without clarithromycin achieved an eradication rate over 80% in all groups. Knowing and monitoring the regional antibiotic resistance rates is important for successful treatment of H. pylori infections.

Different bismuth-based therapies for eradicating Helicobacter pylori: Randomized clinical trial of efficacy and safety

BACKGROUND AND OBJECTIVE

Bismuth salts are used for treating dyspepsia, and they exert antibacterial effects on Helicobacter pylori. This study aimed to compare the efficacy and safety of three bismuth-containing combination regimens for H. pylori eradication in a Turkish population.

METHODS

In this single-center study, 149 patients, who were diagnosed with H. pylori infection with urea breath test and histopathological examination, were randomized to receive the following therapies for 14 days: (1) bismuth-containing clarithromycin-based triple therapy (CBS-LAC), (2) bismuth-containing levofloxacin-based triple therapy (CBS-LAL), and (3) bismuth-containing quadruple therapy (BCQT). Eradication rates were evaluated six weeks after the treatment by performing intention to treat (ITT) and per protocol (PP) analyses. In addition, data on side effect profiles and patient compliance were collected.

RESULTS

PP and ITT analyses showed that eradication rates were 86% and 81.1%, respectively, with BCQT; 68.3% and 66.7%, respectively, with CBS-LAL therapy; and 65.3% and 59.3%, respectively, with CBS-LAC therapy. Eradication rates obtained using PP and ITT analyses were statistically significant for all the regimens.

CONCLUSION

Addition of bismuth to standard triple and levofloxacin-based regimen did not show an acceptable increase in eradication rates. Therefore, BCQT may be preferred for the first-line treatment of H. pylori infection.

Inefficacy of triple therapy and comparison of two different bismuth-containing quadruple regimens as a firstline treatment option for helicobacter pylori

BACKGROUND/AIM

Increasing resistance of Helicobacter pylori to antimicrobials necessitated the development of new regimens and the modification of existing regimens. The present study aimed to compare the efficacy of two bismuth-containing quadruple regimens-one including clarithromycin (C) instead of metronidazole (M) and triple therapy.

PATIENTS AND METHODS

Patients with H. pylori infection given the following regimens were sequentially enrolled in this retrospective study: (1) Triple therapy: Lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and amoxicillin 1 g b.i.d., (2) bismuth group C: Lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., amoxicillin 1 g b.i.d., and bismuth subsalicylate 524 mg b.i.d., and (3) bismuth group M: Lansoprazole 30 mg b.i.d., amoxicillin 1 g b.i.d., metronidazole 500 mg t.i.d., and bismuth subsalicylate 524 mg b.i.d. for 14 days. Gastroscopy and 14 C-urea breath test were performed before enrollment, and urea breath test was repeated four weeks after the treatment.

RESULTS

At per-protocol analysis, the eradication rates were 64.7% (95% confidence interval 60.4-68.7) with the triple therapy (n = 504), 95.4% (95% confidence interval 91.5-99.4) with the bismuth group C (n = 501), and 93.9% (95% confidence interval 89.7-98.7) with the bismuth group M (n = 505). The eradication rates were similar between the two bismuth groups (P > 0.05) but significantly greater than that of the triple therapy (P < 0.05).

CONCLUSION

In our study, both of the bismuth-containing quadruple therapies reached high eradication rates, whereas triple therapy was shown to be ineffective. Moreover, clarithromycin may also be a component of bismuth-containing quadruple therapy.

Severe gastritis decreases success rate of Helicobacter pylori eradication

BACKGROUND

In several studies, different risk factors other than antibiotic resistance have been documented with Helicobacter pylori eradication failure. We aimed in this study to investigate the relationship of gastric density of H. pylori, the occurrence/degree of gastric atrophy, and intestinal metaplasia (IM) with success rate of H. pylori eradication.

METHODS

Two hundred consecutive treatment naive patients who received bismuth containing standart quadruple treatment due to H. pylori infection documented by histopathological examination of two antral or two corpal biopsies entered this retrospective study. The updated Sydney system was used to grade the activity of gastritis, density of H. pylori colonization, atrophy, and IM. Stages III and IV of operative link for gastritis assessment (OLGA) or the operative link on gastric intestinal metaplasia assessment (OLGIM) stages was considered as severe gastritis. H. pylori eradication was determined via stool H. pylori antigen test performed 4 weeks after the end of therapy.

RESULTS

The presence of gastric atrophy and IM was significantly higher in patients with eradication failure (p = 0.001 and 0.01, respectively). Severe gastritis (OLGA III-IV and OLGIM III-IV) rates were higher in eradication failure group. A multiple linear regression analysis showed that OLGA and OLGIM stages were to be independent risk factors for eradication failure (p = 0.03 and 0.01, respectively).

CONCLUSION

Our results suggested that histopathologically severe gastritis may cause H. pylori eradication failure. In addition, we found that H. pylori density was not a risk factor for treatment failure in patients who receive quadruple treatment.

The impact of bismuth addition to sequential treatment on Helicobacter pylori eradication: A pilot study

The success of the current anti-Helicobacter pylori (H. pylori) treatment protocols is reported to decrease by years, and research is needed to strengthen the H. pylori eradication treatment. Sequential treatment (ST), one of the treatment modalities for H. pylori eradication, includes amoxicillin 1 gr b.i.d and proton pump inhibitor b.i.d for first 5 days and then includes clarithromycin 500 mg b.i.d, metronidazole 500 mg b.i.d and a proton pump inhibitor b.i.d for remaining 5 days. In this study, we investigated efficacy and tolerability of bismuth addition in to ST. We included patients that underwent upper gastrointestinal endoscopy in which H. pylori infection was diagnosed by histological examination of antral and corporal gastric mucosa biopsy. Participants were randomly administered ST or bismuth containing ST (BST) protocols for the first-line H. pylori eradication therapy. Participants have been tested by urea breath test for eradication success 6 weeks after the completion of treatment. One hundred and fifty patients (93 female, 57 male) were enrolled. There were no significant differences in eradication rates for both intention to treat population (70.2%, 95% confidence interval [CI]: 66.3-74.1% vs. 71.8%, 95% CI: 61.8-81.7%, for ST and BST, respectively, p>0.05) and per protocol population (74.6%, 95% CI: 63.2-85.8% vs. 73.7%, 95% CI: 63.9-83.5% for ST and BST, respectively, p>0.05). Despite the undeniable effect of bismuth, there may be several possible reasons of unsatisfactory eradication success. Drug administration time, coadministration of other drugs, possible H. pylori resistance to bismuth may affect the eradication success. The addition of bismuth subcitrate to ST regimen does not provide significant increase in eradication rates.

How to Effectively Use Bismuth Quadruple Therapy: The Good, the Bad, and the Ugly

Bismuth triple therapy was the first effective Helicobacter pylori eradication therapy. The addition of a proton pump inhibitor helped overcome metronidazole resistance. Its primary indication is penicillin allergy or when clarithromycin and metronidazole resistance are both common. Resistance to the primary first-line therapy have centered on complexity and difficulties with compliance. Understanding regional differences in effectiveness remains unexplained because of the lack of studies including susceptibility testing and adherence data. We discuss regimen variations including substitutions of doxycycline, amoxicillin, and twice a day therapy and provide suggestions regarding what is needed to rationally and effectively use bismuth quadruple therapy.

Evaluation of Exalenz Bioscience's BreathID for Helicobacter pylori detection

Carbon-labeled urea breath tests, which have high sensitivity and specificity, are the preferred method used in epidemiological studies, screening dyspeptic patients and assessing eradication or recurrence of Helicobacter pylori infection. The principle of the (13)C-urea breath test relies upon the ability of the H. pylori urease to hydrolyze the orally administered (13)C-urea. The BreathID (Exalenz Bioscience Inc., Union, NJ, USA) provides a competitive solution for breath testing, including unique features such as automatic continuous breath collection and analysis. This is an unattended convenient test, with no human error as the correct part of the breath is collected and patients' assistance is not required. The test results are available in real time at the point of care and enable shortened breath testing procedures. Additionally, several studies showing expanded utility of the BreathID in pediatrics, after therapy and during proton pump inhibitors intake, further support the safety and performance of the BreathID in the diagnosis of H. pylori.

Sequential therapy versus standard triple therapy for Helicobacter pylori eradication in children: any advantage in clarithromycin-resistant strains?

OBJECTIVE

There has been a marked decrease in the eradication rates of Helicobacter pylori infection with standard triple therapy worldwide. Hence, sequential therapy has gained attention as a promising treatment during the last few years. This study was carried out to compare the efficacy of sequential versus standard triple therapy in the context of clarithromycin (CLA) resistance.

MATERIALS AND METHODS

In this study, children between 3 and 18 years of age, who had documented H. pylori infection, were randomized to receive either standard triple or sequential therapy. H. pylori eradication was ascertained using the C-urea breath test 4-6 weeks after the completion of the treatment. Real-time PCR was performed on gastric biopsy samples for assessment of CLA resistance.

RESULTS

In all, 148 children (median age: 12.18±3.51 years) were recruited randomly into the study. The intention-to-treat eradication rates were 50% (37/74) for the sequential treatment group and 52.7% (39/74) for the standard triple treatment group (P=0.87). A total of 136 children completed the study. The per-protocol eradication rates were 56% (37/66) and 55.7% (39/70) for sequential and standard triple therapy groups, respectively. CLA resistance was assessed and 113 children were included in the final analysis. Of 113 participants, 53 were in the sequential treatment group and 60 were in the standard triple treatment group. The success rates of the respective therapies (29/53=54.7% in sequential, 33/60=55% in standard therapy) were similar (P=0.98). CLA resistance was detected in 29 (25.7%) of the patients. Eradication rates with sequential therapy in CLA susceptible and resistant cases were 60.5% (23/38) and 40% (6/15), respectively (P=0.23). The corresponding figures for the standard triple treatment group were 63% (29/46) and 28.6% (4/14) (P=0.033). Although a higher eradication rate was observed in CLA-resistant cases with sequential therapy, the difference did not reach statistical significance (P=0.69).

CONCLUSION

In this study, standard triple treatment failed to eradicate H. pylori infection in the majority of the children, and sequential therapy offered only a small advantage over standard triple therapy in the eradication of CLA-resistant strains.

Accuracy of stool antigen test for the diagnosis of Helicobacter pylori infection in children: a meta-analysis

INTRODUCTION

Helicobacter pylori (H. pylori) is regarded as a major pathogen in gastrointestinal diseases and the infection rate is still at a high level in children. Therefore, the diagnosis is of great clinical importance. The objective was to perform a meta-analysis on H. pylori stool antigen test (SAT) for the diagnosis of the infection in children.

METHODS

Published information on the sensitivity and specificity of stool antigen test in each study was collected to assess the accuracy of the test for the diagnosis of H. pylori infection. Forty-five eligible studies were selected for analysis. Data on the publication year, H. pylori prevalence, eradication rate and gold standard of each study were summarized.

RESULT

Forty-five studies, including 5931 patients, evaluated the accurancy of H. pylori SAT. Pooled sensitivity, specificity, LR+ and LR- were: 92.1%, 94.1%, 17.01, 0.085, respectively. Subgroup analyses were conducted to evaluate the sensitivity and specificity of H. pylori SAT in different situations and found that sensitivity and specificity were significantly higher when monoclonal H. pylori SAT and two or more reference methods were used.

CONCLUSIONS

Detection of H. pylori antigen in stools with ELISA monoclonal antibodies is a non-invasive efficient test for the diagnosis of infection in children. However, the available one-step and polyclonal SAT tests are still unreliable.

Helicobacter pylori: Future perspectives in therapy reflecting three decades of experience

The rising prevalence of antibiotic resistance has created a need to reassess the established Helicobacter pylori (H. pylori) eradication protocols, and to develop new ones. Various bacterial and host factors are evaluated, and their contribution to eradication failure is estimated. For a long time being considered the cornerstone eradication scheme, the standard triple therapy has been replaced with novel, more efficient regimens, namely sequential and concomitant, along with the emergence of a new design of bismuth quadruple therapy. A rescue levofloxacin based regimen has overcome the fear of therapy failure due to higher prevalence of dual resistant (clarithromycin and metronidazole) H. pylori. Culture-free and efficient susceptibility test are reestablishing the concept of tailored therapy, making eradication success close to originally desirable rates. Alleviating therapy side effects and improving patient compliance are as important as choosing appropriate eradication schemes, so various probiotic compound supplements are taken into consideration. Finally, we summarize the emerging efforts and obstacles in creating efficient H. pylori vaccine.