In Europe, clarithromycin and levofloxacin should not be administered to patients with Helicobacter pylori (H pylori) infection without first assessing for antibiotic resistance. These findings were published in Gut.

Between 2018 and 2019, a total of 24 centers were asked to prospectively sample a maximum of 50 consecutive clinical isolates of H pylori. Macrolide and quinolone consumption data from the European Center for Disease Prevention and Control between 2008 and 2017 were assessed.

A total of 18 countries provided between 21 (the Netherlands and Denmark) to 186 (France) samples for a total of 1211 H pylori biopsy samples.

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Biopsies were sourced from patients who were aged mean 51.2 years (range, 17-91 years), 54.6% were women, and 91.2% were born in Europe. The reported symptoms included epigastric pain (42.2%) and other symptoms of dyspepsia (26.8%). Endoscopic results revealed patients had inflammation of the stomach (56.0%), gastric erosions (13.5%), ulcers (10.5%), and malignant lesions (1.2%).

Over one-third (37.3%) of isolates were resistant to at least 1 antibiotic, 16.6% had dual resistance, and 2.1% were multi-drug resistant.

Resistance to clarithromycin was highest in Italy (36.9%) and lowest in Denmark (4.8%). Levofloxacin resistance was absent in Denmark and the Netherlands and highest in Italy (29.2%).

Results of the multi-variable analysis revealed clarithromycin resistance was associated with Southern Europe (odds ratio [OR], 3.80; 95% CI, 1.47-9.83; P =.005) and Western/Central Europe (OR, 3.15; 95% CI, 1.10-8.97; P =.032). Levofloxacin resistance was associated with Southern Europe (OR, 3.63; 95% CI, 1.40-9.38; P =.008). Metronidazole resistance was associated with being born outside of Europe (OR, 2.8; 95% CI, 1.23-6.38; P =.014).

Clarithromycin resistance was associated with historical community consumption of macrolides (incidence rate ratio [IRR], 1.17; 95% CI, 1.07-1.29; P =.0019), intermediate-acting macrolides (IRR, 1.16; 95% CI, 1.05-1.28; P =.0050), and long-acting macrolides (IRR, 1.80; 95% CI, 1.11-2.92; P =.0199).

Levofloxacin resistance was associated with historical community consumption of quinolones (IRR, 1.57; 95% CI, 1.29-1.92; P =.0002) and second-generation quinolones (IRR, 1.63; 95% CI, 1.31-2.03; P =.0003).

This study was limited by a lack of even sampling across Europe either due to low local infection rates or to some aspect of regulation.

These data indicated that patients should be assessed for antibiotic resistance before treatment of H pylori across Europe.


Megraud F, Bruyndonckx R, Coenen S, et al. Helicobacter pylori resistance to antibiotics in Europe in 2018 and its relationship to antibiotic consumption in the community. Gut. Published online April 9, 2021. doi: 10.1136/gutjnl-2021-324032