**7. New treatment strategies**

*Hp* antibiotic resistance has been increasing all over the world in the last decade and this phenomenon constitutes an important challenge for the treatment of this fastidious bacterium. This has prompted the researchers to an obstinate search for new solutions such as the vaccine development and new treatments based on the use of natural resources such as plants, probiotics, and nutraceuticals [46, 47].

A new compound, a guanidine derivative bearing adamantane-1-carbonyl 2-bromo-4,6-difluouro-phenyl substituents (H-BDF), seemed to be promising against the strains tested [48]. Other substances were studied against *Hp* such as three known and five unknown N-substitute-2-oxo- H-1-benzopyran-3- carboxamides (coumarin-3-carboxamides). The compounds with a 4-acyl-phenyl group showed the best activity against *H. pylori* metronidazole- resistant strains [49].

Non-traditional therapies have been indicated as a means to target this important gastric pathogen. This approach also includes the use of antimicrobial peptides (core component of innate immune system of numerous eukaryotes) that interact with the anionic Gram-negative cell wall because of charge electrostatic attractions [50]. It also seems reasonable to investigate other options aimed at reinforcing the immune system of these patients, The potential role of N-acetil-cysteine which is capable of destroying bacterial biofilm, is an emerging treatment for recalcitrant infections [51]. Vonoprazan (potassium-competitive acid blocker P-CAB) is a new compound which could improve eradication rates by raising the intragastric pH and thus increasing bacterial antibiotic susceptibility [52]. Recent studies revealed that P-CAB-based triple therapy was more effective than PPI-based triple therapy (76.1% versus 40.2%) as a first-line *Hp* eradication method [53]. Furthermore, even in the presence of CLAresistant strains, P-CAB-based triple therapy showed good eradication rates [52].

Furazolidone (FUR) is a new antibiotic studied mainly in China which has demonstrted a great activity either alone or in combination with other antibiotics against *H. pylori.* It is a monoamine oxidase inhibitor which can interact with the metabolism of tyramine causing side-effects such as vomiting, diarrhea and nervous system disorders*.* In China, the FUR is available for the treatment of patients. Therefore, quadruple therapy with proton pump inhibitors, bismuth and a combination of two antibiotics specifically FUR, TET or AMX would be more suitable for Chinese patients [26]. This treatment is also recommended in the Maastricht V/Florence Consensus Report [29] the new treatment strategies are shown in **Table 4***.*


*Fur = Furazolidone, MZ = Metronidazole, TE = tetracycline, AMX = amoxicillin, R = Resistant. \*Used alone or in combination with other antibiotics (in western countries).*

#### **Table 4.**

*New treatment strategies and non-traditional therapies.*
