Antimicrobial resistance patterns of Helicobacter pylori in Thailand: a systematic review and meta-analysis

Background Rising antimicrobial resistance in Helicobacter pylori presents a significant challenge to therapy worldwide. In Thailand, success rates for treatment have decreased, and data on antimicrobial resistance remain limited. This systematic review and meta-analysis aimed to analyze the patterns and trends of H. pylori antimicrobial resistance in Thailand over time. Methods PubMed, Scopus, Embase, MEDLINE, Web of Science, ProQuest, Google Scholar, and the Thai-Journal Citation Index Centre were searched from database inception to 25 July 2025. Eligible studies reported antimicrobial susceptibility data for H. pylori isolates from Thai populations. Study selection and data extraction were conducted independently by reviewers. Study quality was assessed using the Joanna Briggs Institute checklist. Antimicrobial resistance rates with 95% confidence intervals were calculated using random-effects or fixed-effects models. Subgroups were analyzed by testing method, geographical region, publication year, study quality, and study design. Meta-regression was conducted using publication year as a moderator to explore temporal trends. Results Twenty-five studies (28 datasets) with 5202 H. pylori isolates were included. Antimicrobial resistance rates were highest for metronidazole (38.0%); moderate for clarithromycin (10.0%), levofloxacin (10.6%), and ciprofloxacin (10.4%); and low for amoxicillin (3.9%) and tetracycline (2.9%). Clarithromycin resistance differed by testing method and was higher in molecular-based studies. Amoxicillin resistance was higher in the Central region. Meta-regression revealed a significant increasing trend in ciprofloxacin resistance. Conclusions In Thailand, metronidazole resistance remains high, while resistance to clarithromycin and fluoroquinolones is clinically important and variable across settings and testing methods. These findings emphasize the need to strengthen nationwide surveillance with standardized susceptibility testing and the incorporation of molecular resistance diagnostics to guide therapy and sustain eradication effectiveness.