Antibiotic Resistance in Helicobacter pylori in the Asia-Pacific Region: A Call for Coordinated Regional Strategies.

Helicobacter pylori infection remains globally prevalent and is a major cause of chronic gastritis, peptic ulcer disease, and gastric cancer (GC). The Asia-Pacific region has the highest global burden of infection and GC mortality; however, the effectiveness of eradication therapy is increasingly being compromised by antibiotic resistance. Between 1990 and 2022, resistance to clarithromycin (CAM), metronidazole (MNZ), and levofloxacin (LVX) increased markedly from 7%, 37%, and 9% to 30%, 61%, and 35%, respectively, whereas resistance to amoxicillin and tetracycline remained low at approximately 4%. Multidrug-resistant H. pylori strains are increasingly being reported in Southeast Asia. The resistance rates among the pediatric and adolescent population in East Asia are similarly high, 37% for CAM, 51% for MNZ, and 19% for LVX, suggesting intrafamilial transmission. The key molecular mechanisms include genetic mutations in 23S rRNA, rdxA/frxA, and gyrA/gyrB, along with adaptive traits such as efflux pump activation and biofilm formation, and coccoid transformation. East Asian countries have adopted divergent strategies, including vonoprazan-based triple therapy in Japan, bismuth-containing quadruple therapy as the preferred first-line regimen in Taiwan, Hong Kong, and China, and tailored regimens based on susceptibility testing in Korea. Future directions include susceptibility-guided therapy, molecular diagnostic testing, family-based eradication, and the development of nonantibiotic therapies. Establishing regional resistance surveillance networks and integrating H. pylori management into national antimicrobial stewardship programs are essential to maintain eradication success and prevent GC. Addressing antibiotic resistance in H. pylori is an urgent public health priority, and coordinated regional strategies are required in the Asia-Pacific region.