Prevalence of primary Helicobacter pylori antibiotic resistance in Europe over the past four decades

Background & aims Antibiotic resistance is a major determinant of the efficacy of Helicobacter pylori (H. pylori) eradication treatment. Our objective was to evaluate the prevalence and geographical distribution of primary antibiotic resistance in patients infected with H. pylori across Europe over the last four decades.Methods Bibliographical searches were conducted from 1990 to 2024 in the PubMed database with no language restrictions. Selected studies evaluated the primary resistance of H. pylori to clarithromycin, metronidazole, levofloxacin, amoxicillin, tetracycline and rifampicin in adults. Data were grouped by country and time intervals (1990–1999, 2000–2009, 2010–2019, 2020–2024) to identify potential trends. High resistance thresholds were defined as ≥15% for clarithromycin and levofloxacin, and ≥30% for metronidazole.Results A total of 216 studies were included: 188 with information on clarithromycin resistant strains (86,917 patients), 138 on metronidazole (83,995 patients), and 77 on levofloxacin (40,619 patients). The overall prevalence of primary resistance to clarithromycin, levofloxacin, and metronidazole was 16% (95% confidence interval, 7–24%), 18% (10–21%), and 33% (29–36%), respectively. Primary resistance to clarithromycin and levofloxacin increased steadily across all periods, reaching 24% and 21%, respectively, in the most recent period. Primary resistance to amoxicillin, tetracycline, and rifampicin remained low, at 2.3%, 1%, and 4%, respectively. Overall, Southern European countries had higher resistance rates than Northern European countries.Conclusions In Europe, the prevalence of primary H. pylori resistance to clarithromycin and levofloxacin has increased over time and is high in recent years. Variability exists between countries, with Southern European regions showing higher rates.