The management strategies for Helicobacter pylori treatment are still diverse, especially because of the unequal availability of the drugs needed. In addition, the development of resistance to some antibiotics leads to unsatisfactory results. The role of H. pylori in gastric cancer, which allows the possibility of prevention in the general population by eradicating the bacteria, is a stimulus to have well-established regimens. This article presents the antimicrobial stewardship principles that can guarantee appropriate treatment. The optimization of the clarithromycin-based triple therapy includes antimicrobial susceptibility testing for clarithromycin, a higher dose of amoxicillin than in the original regimen, more than twice a day, and a proton pump inhibitor (PPI) like rabeprazole or esomeprazole, all administered for 2 weeks. The other regimen often used, the bismuth quadruple therapy, is optimal with the 3-in-1 capsule and a standard or high dose of PPI. In all cases, an eradication control must be performed after 4 to 6 weeks. The so-called concomitant treatment does not meet stewardship principles. The availability of Potassium-Competitive Acid Blockers (P-CABs) in some countries could allow the use of a dual therapy with only amoxicillin, but it must be confirmed by proper trials in Western countries.

Helicobacter pylori is an emerging antibiotic-resistant and carcinogenic gastric pathogen. We developed nitrofuran derivatives with anti-H. pylori activity and found the analog CLI-19-009 (2-nitro-6,7-dihydrobenzofuran-4-one N-(cinnamoyl)hydrazone) inhibited H. pylori growth at 0.25 mg/L. Notably, CLI-19-009 contains a non-conjugated hydrazone side chain, which may influence nitroreductive activation compared with classical nitrofurans and retain activity under acidic conditions. CLI-19-009 exhibited an additive effect with clinical antibiotics and proton pump inhibitors, cleared H. pylori on gastric epithelial cells, reduced bacterial motility, and decreased vacuolation. CLI-19-009 also showed low cytotoxicity (IC50>64 mg/L) and significantly improved survival of H. pylori-infected wax moth larvae compared with untreated controls (p = 0.0002). Host-cell RNA sequencing revealed that CLI-19-009 treatment downregulated inflammatory genes (IL1B, IL18, IL23A, MAPK1, NFKB1, TNF, and IRAK1) during host-pathogen interactions. Long-term exposure generated CLI-19-009-resistant clones harboring a single-nucleotide polymorphism in rdxA in both lineages, demonstrated using whole-genome sequencing; this finding suggests alterations in nitroreductive activation. CLI-19-009 showed in vitro synergy with rabeprazole and additive activity with amoxicillin, and these combinations reduced gastric inflammation and colonization compared with untreated mice when tested in a murine infection model (p < 0.0001). These findings support further development of CLI-19-009 as an anti-H. pylori therapeutic alternative to clarithromycin-based regimens.

Antimicrobial resistance (AMR) is a global human health threat and wastewater analysis of antibiotics can help inform AMR policies. Accurate quantification of antibiotic use in urban populations is needed. This requires analytical methods capable of high sample throughput to support short-term laboratory antibiotic fate investigations where large sample numbers are generated, and sub-µg L[-1] quantification limits for wastewater monitoring studies. Therefore, a direct injection ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method was developed for 11 representative antibiotics and metabolites with a 13 min run time and quantitation limits in the range of 0.0012-0.69 µg L[-1]. Avoiding solid phase extraction simplified sample preparation whilst mitigating potential contamination or analyte loss, additional solvent use and single-use plastics. High throughput application of the method was demonstrated by assessing antibiotic stability in laboratory-scale gravity sewers (n = 6) with sampling intervals of 0, 0.5, 1, 2, 4, 6, 8, and 24 hours. Amoxicilloic acid, hydroxymetronidazole, trimethoprim and clarithromycin showed satisfactory short-term stability (4 h) for sampling influent wastewater at treatment plants for population use assessment. The sensitivity of the direct injection methodology was demonstrated by random influent wastewater monitoring (n = 5) at three treatment plants in North-East Scotland during August by 24 h pseudo flow-weighted composite sampling. This revealed amoxicillin, metronidazole, trimethoprim and clarithromycin use ranged from 263 to 3559 mg/1000 people per day. This was 0.5 to 1.8 times the corresponding average daily prescribed quantity (calculated from total August prescribing) within the treatment plant's catchment area, highlighting differences in prescription and consumption levels across locations. Findings demonstrated direct injection UHPLC-MS/MS to be ideal for supporting population use assessment of antibiotics through application to laboratory and monitoring wastewater studies.

Antibiotic prioritization in wastewater treatment plants (WWTPs) commonly relies on influent-effluent changes. Such assessments may mask differences among configurations, treatment contexts, and endpoint media. Here, we established a process-resolved antibiotic Environmental Health Prioritization index (PA-EHPi). At the configuration × antibiotic scale, PA-EHPi integrates effluent occurrence, apparent removal, ecological risk, and antimicrobial resistance selection pressure. Across anaerobic-anoxic-oxic (AAO), sequencing batch reactor (SBR), and membrane bioreactor (MBR) treatment configurations with broadly comparable influent antibiotic profiles and conventional pollutant removals, PA-EHPi revealed distinct priority profiles. PA-EHPi identified 2 of 22 antibiotics as priorities in AAO, 9 of 26 in SBR, and 9 of 24 in MBR. Azithromycin and clarithromycin remained priorities across all three configurations. Treatment-train diagnosis further revealed stable apparent removal in the sampled AAO plants, fluctuating removal in SBR plants, and significant terminal rebound in MBR plants. Linking PA-EHPi with sludge partitioning and antibiotic resistance gene profiles translated effluent priorities into endpoint-specific management pathways, identifying quinolones as dual effluent-sludge concerns, macrolides as effluent residual targets, tetracyclines as sludge-associated concerns, and chloramphenicols as resistance-background monitoring targets. Overall, the established PA-EHPi extends static effluent ranking into a process- and endpoint-resolved diagnostic framework, helping identify priority targets for antibiotic control and multimedia management in WWTPs.

Remote ecosystems are often assumed to be insulated from chemical contamination; however, increasing human visitation may compromise this perception. We evaluated the occurrence, spatial distribution, and ecological implications of pharmaceutical active compounds (PhACs) in soils from the summit of Roraima-tepui, a high-elevation "sky island" in the Guiana Shield subjected to unregulated tourism and lacking sanitation infrastructure. Surface soils from anthropogenically influenced and naturogenic zones were analysed for 98 pharmaceuticals using HPLC-MS/MS, and potential risks were evaluated using environmental risk quotient (RQenv), cumulative and mixture-based approaches, and antimicrobial-resistance-specific thresholds (RQAMR). Eleven pharmaceuticals were detected, including antibiotics, antifungals, analgesics, and psychoactive compounds. Compounds associated with direct human use (e.g., ciprofloxacin, clarithromycin, acetaminophen) were primarily confined to anthropogenic areas, whereas others (notably fleroxacin, thiabendazole, pregabalin, and sulfadimethoxine) occurred more widely, including in naturogenic zones. These patterns suggest that heterogeneous inputs, compound-specific behaviour, intense rainfall, and shallow sandstone soils may interact to redistribute contaminants beyond their initial points of introduction. Ciprofloxacin reached concentrations up to 186 ng g[-1] and contributed substantially to cumulative environmental risk estimates. Several compounds exceeded predicted no-effect concentrations, and screening-level cumulative RQenv values indicated elevated potential environmental risk. Antimicrobial resistance assessment suggested pronounced selection potential for ciprofloxacin in tourist-impacted areas, although resistance genes or resistant bacteria were not directly measured. These findings indicate that tourism-related pharmaceutical residues can occur in remote high-elevation protected ecosystems under tourism pressure and highlight the need to integrate emerging contaminants into conservation and visitor management frameworks.