Resistance reversal: Taiwan's Helicobacter pylori trends defy global norms.

Antibiotic resistance in Helicobacter pylori is reshaping eradication strategies worldwide. Analysis of 1408 treatment-naive isolates collected across Taiwan between 2019 and 2024 reveals a striking shift in resistance patterns. Tetracycline resistance, once negligible, rose to 3.5%, threatening the durability of bismuth-based quadruple therapy. Conversely, metronidazole resistance declined markedly, while clarithromycin and levofloxacin resistance remained stable at moderate levels, with levofloxacin showing significant regional variation. Emerging dual resistance involving tetracycline underscores the fragility of empiric regimens and highlights the need for culture-guided or molecular approaches. These findings reflect the dual influence of stewardship successes and environmental antibiotic pressures, while also signaling the limits of empiricism in eradication therapy. Potassium-competitive acid blockers provide a promising pharmacologic pivot, capable of enhancing antibiotic efficacy and sustaining eradication outcomes. Taiwan's resistance profile thus offers both cautionary lessons and actionable insights for future regional and global treatment strategies.