Increasing antimicrobial resistance has continued to plague successful anti-Helicobacter pylori eradication therapy. With rare exception, clarithromycin-containing triple therapy now provides unacceptably low treatment success. Here we discuss the factors that influence treatment outcome, how to predict outcome with new regimens, the 4-drug regimens that are currently effective in the West and their limitations, considerations about the approach to treatment failures and finally, based on the experience in the West, provide recommendations for choosing an empiric regimen in Japan. The dictum "use what works best locally" is probably the best advice for clinicians with a corollary that this dictum overrides results published by consensus conferences and advice from experts from elsewhere.
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