What question did this study set out to answer?

Assess the declining efficacy of standard triple therapy for Helicobacter pylori in Korea and propose new treatment guidelines.

March 7, 2026Open Access

Treatment of Helicobacter pylori Infection in Korea: An Evidence-Based Analysis of the Upcoming 2025 Guideline

CBChang Seok Bang SKSeung Joo KangSeoul National University Hospital SNSu Youn NamKyungpook National University Hospital

Key Points

Assess the declining efficacy of standard triple therapy for Helicobacter pylori in Korea and propose new treatment guidelines.
Reviewed current treatment efficacy data for helicobacter pylori in Korea
Analyzed proposed changes in the 2025 treatment guidelines
Examined the role of PCR-based tailored therapy as a new approach
Evaluated economic analyses of treatment cost-effectiveness
Identified recommended regimen combinations for various treatment lines.
First-line eradication rates for clarithromycin-containing triple therapy fell below 70%
Clarithromycin resistance exceeded 30%, prompting a guideline reevaluation
New dual-pillar strategies were established, favoring bismuth and tailored therapies
Quadruple therapies were recommended as the new standard, improving cure rates above 90%
Economic evaluations indicated tailored therapy is cost-effective compared to traditional regimens.

Abstract

The efficacy of clarithromycin-containing triple therapy (TT) against Helicobacter pylori has declined in Korea, with recent first-line eradication rates falling below 70%. Clarithromycin resistance exceeded 30%, undermining the standard regimen for H. pylori. These trends necessitate a change in the treatment strategy. This review analyzed the shift proposed in the draft of the 2025 Korean H. pylori guidelines. We examined the rationale for abandoning TT as a first-line empirical therapy and the establishment of a new dual-pillar strategy: 1) the declining role of clarithromycin-containing TT as a first-line treatment and 2) polymerase chain reaction (PCR)-based tailored therapy as the recommended precision approach. We explored the 1) emergence of new empirical regimen options, 2) application of tailored therapy, and 3) adoption of potassium-competitive acid blockers (P-CABs). Empirical regimens have shifted toward four-drug combinations to achieve higher cure rates. Concomitant therapy (proton-pump inhibitor PPI or P-CAB+amoxicillin+clarithromycin+metronidazole) offers high efficacy but raises concerns about antibiotic overuse. As a compromise, bismuth-augmented triple regimens (adding bismuth to TT) are now recommended; these modified quadruple therapies (e.g., PACB: PPI+amoxicillin+clarithromycin+bismuth, or PAMB: PPI+amoxicillin+metronidazole+bismuth) significantly improve eradication rates without requiring a third antibiotic class. Regarding tailored therapy, PCR-based domestic clinical research data consistently achieves ≥90% cure rates in first-line treatment—markedly higher than empirical TT in Korea. Economic analyses supported the cost-effectiveness of this approach. The guideline algorithm for salvage therapy was clarified. Bismuth quadruple therapy has been confirmed as the standard second-line treatment. For third-line therapy, we analyzed the efficacy of levofloxacin-based regimens, rifabutin-based therapy, and bismuth add-on therapy with two previously unused antibiotics. The 2025 Korean guidelines establish quadruple therapies as the new standard through a dual strategy: pragmatic empirical treatment and PCR-guided tailored therapy, with P-CABs and bismuth-based regimens as key components.

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