A single-center culture-based study of Helicobacter pylori in Kazakhstan with regional meta-analysis of prevalence and antibiotic resistance

Background: Helicobacter pylori (H. pylori) is a major gastric pathogen and class I carcinogen that causes chronic gastritis, peptic ulcer, and gastric cancer if left untreated. However, evidence on H. pylori prevalence and antimicrobial resistance in Kazakhstan, a country with a high gastric cancer burden, remains scarce. This study presents the first culture-based epidemiological investigation of H. pylori at a single center in Almaty.

Materials and methods: We conducted a cross-sectional study (2024–2025) of 150 dyspeptic patients in Almaty, Kazakhstan. A subset (n = 148) underwent rapid stool antigen (RAS) testing before gastric biopsy collection. Biopsy samples were cultured, and 86 (57.3%) yielded viable H. pylori isolates. Antimicrobial susceptibility testing by the agar dilution method was performed on these 86 isolates. Demographic and clinical data were analyzed, and a regional meta-analysis was conducted using data from recent studies across Central Asia and Russia to estimate pooled prevalence and clarithromycin resistance.

Results: Among 148 patients tested by RAS, 137 were positive. Resistance rates among 86 isolates were 87.2% to metronidazole, 33.7% to clarithromycin, and 3.5% to amoxicillin; no resistance was detected to minocycline or sitafloxacin. Multidrug resistance (defined as resistance to two or more antibiotics) was observed in 34.8% of isolates. The pooled H. pylori prevalence across Central Asian studies was 70% (95% CI: 59–80%), and pooled clarithromycin resistance was 29% (95% CI: 10–53%).

Conclusion: This study provides the first culture-based evidence of H. pylori infection and antimicrobial resistance in Kazakhstan. The high resistance to metronidazole and clarithromycin suggests a likely lower success of standard triple therapy in Almaty. Absence of resistance to minocycline and sitafloxacin supports their use in rescue regimens. These findings highlight the urgent need for national surveillance, updated treatment guidelines, and integration of molecular resistance monitoring to improve evidence-based management of H. pylori in Central Asia.

1 Introduction

The global burden of Helicobacter pylori (H. pylori) infection continues to rise in developing countries, with nearly two-thirds of all gastric cancer cases associated with H. pylori occurring in Asia (Park et al., 2025). Although the detailed mechanisms linking H. pylori infection to gastric carcinogenesis remain incompletely understood (Duan et al., 2025), approximately half of the world’s population carries the pathogen, predisposing them to chronic gastritis, peptic ulcer disease, and gastric adenocarcinoma (Wizenty and Sigal, 2025).

Despite extensive global research on H. pylori epidemiology, countries in Central Asia remain a geographical blind spot in global surveillance efforts. Kazakhstan, in particular, bears one of the highest gastric cancer burdens in the region (Chen et al., 2024). However, comprehensive studies that integrate field-based sampling, epidemiological analysis, and gold-standard culture-based methods, including antimicrobial susceptibility testing, are still lacking.

Antibiotic resistance in H. pylori has become a growing global concern, yet data from Central Asia remain limited and fragmented. Addressing this knowledge gap is essential for developing evidence-based treatment and eradication strategies tailored to the regional context. Therefore, the present study aims to fill this void by providing the first culture-based investigation of H. pylori infection and antimicrobial resistance in Kazakhstan.

East Asian countries such as Japan and Taiwan have established national surveillance systems and treatment guidelines for H. pylori, grounded in large-scale epidemiological studies that reflect trends in antibiotic resistance and population-based prevalence (Ono et al., 2025; Liang et al., 2020). These frameworks were initially built upon extensive strain culturing and phenotypic susceptibility testing. In Taiwan, national monitoring of antibiotic use has led to consistently low rates of amoxicillin resistance (<2–4%) and moderate rates of clarithromycin and metronidazole resistance (23.4 and 20.3%, respectively), reflecting long-standing regional prescribing patterns (Yeung and Lee, 2017). In contrast, studies from Japan and Korea report high rates of clarithromycin resistance (>15%) and an increasing prevalence of fluoroquinolone resistance, findings that have informed updates to national guidelines and encouraged the adoption of bismuth-based or susceptibility-guided regimens (Schulz et al., 2025).

High-quality, population-based studies on H. pylori prevalence and antibiotic resistance are crucial not only for pathogen eradication but also for the early detection and prevention of gastric cancer. Kazakhstan, despite its high gastric cancer burden, remains poorly characterized in this area, with no existing culture-based resistance profiling or population-level assessments. This study aims to fill this gap by using culture-based methods to determine infection prevalence and antibiotic resistance patterns among patients at a single center in Almaty, Kazakhstan. Our goal is to characterize H. pylori prevalence and resistance among dyspeptic patients using bacterial culture and to situate these findings within the context of available studies from other regions of Central Asia.

2 Materials and methods

2.1 Study design and sample collection

Between October 2024 and May 2025, we enrolled 150 adult patients presenting with dyspeptic symptoms at the Scientific-Research Institute of Cardiology and Internal Diseases in Almaty, Kazakhstan (Table 1). All participants provided written informed consent prior to inclusion and underwent upper gastrointestinal endoscopy.

Table 1

Table 1. Study flow summary.

Eligible participants were adults aged ≥18 years with no prior history of H. pylori eradication therapy. To minimize confounding factors, all patients completed a structured questionnaire confirming that they had not used the following medications within 4 weeks before enrollment: H₂ receptor antagonists, proton pump inhibitors (PPIs), bismuth compounds, antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulants. Patients with a history of gastric surgery, significant comorbidities or malignancies, or those who were pregnant or breastfeeding were excluded from the study.

Rapid stool antigen testing (RAS) was performed using a commercially available immunochromatographic assay (Adtec Inc., Oita, Japan) according to the manufacturer’s instructions. The assay is an in-house tool issued by the manufacturer in collaboration with Oita University and is being evaluated in other clinical studies demonstrating high diagnostic accuracy (Passang Lhamo et al., 2025). In the present study, RAS was used solely as a supportive diagnostic tool and was not used to estimate infection prevalence or to guide antimicrobial resistance workflow, which were based solely on culture-positive biopsy samples.

During endoscopy, three gastric antral biopsy specimens were collected from each patient. Endoscopic findings were classified according to the Kimura–Takemoto system, which classifies the extent of gastric atrophy based on the anatomical location of the atrophy. Closed-type atrophy (C-1, C-2, C-3) indicates atrophy confined to the antrum or lesser curvature, while open-type atrophy (O-1, O-2, O-3) reflects continuous extension toward the gastric body and fundus. An increasing grade of mucosal atrophy corresponds to more pronounced mucosal atrophy. Two biopsy samples were immediately placed in in-house transport medium routinely used in Prof. Yamaoka’s laboratory for international H. pylori collaborative studies (Syam et al., 2015; Tourrette et al., 2024). At the same time, the third was preserved in RNAlater (Thermo Fisher Scientific, Waltham, MA, USA), kept on ice, and stored at −80 °C.

2.2 Sample transport and culture conditions

The biopsy samples were transported from the Institute of Genetics and Physiology in Almaty (Kazakhstan) to Oita University (Japan) in insulated containers with −30 °C ice packs, maintaining a cold chain throughout transport. International flight time, including door-to-door laboratory transaction, was approximately 24 h. Upon arrival, samples were stored at −80 °C before being thawed at 4 °C for immediate culture. Despite adherence to standard transport protocols, loss of bacterial viability during long-distance shipment is a known limitation of culture-based H. pylori studies and likely contributed to differences observed between RAS test and culture results.

H. pylori culture was performed using the homogenized biopsy specimen, which was inoculated onto H. pylori-selective media (Nissui Pharmaceutical Co., Ltd., Tokyo, Japan) and incubated for up to 10 days at 37 °C under microaerophilic conditions (10% O₂, 5% CO₂, and 85% N₂). The obtained colonies were then sub-cultured onto Brucella agar (Becton Dickinson, Sparks, MD, USA) supplemented with 7% horse blood (Nippon Bio-test, Tokyo, Japan) without antibiotics. H. pylori colonies were determined based on the Gram staining results, bacterial morphology, and positive results for catalase, urease, and oxidase tests. These criteria are consistent with standard diagnostic protocols for H. pylori. Isolated and confirmed strains were preserved in Brucella broth (Becton Dickinson, Sparks, MD, USA) containing 10% glycerol and 10% horse serum and stored at −80 °C. Antimicrobial susceptibility testing was performed on culture-positive isolates (n = 86) using the agar dilution method. All cultures and antimicrobial susceptibility testing were performed in duplicate, and results were independently verified by two investigators. Reference strains routinely used in the laboratory were included for quality control as needed.

In this study, H. pylori culture was used as the reference standard for infection diagnosis, and RAS test results were evaluated in relation to culture results. Antibiotic resistance phenotypes were determined for all culture-confirmed isolates, and multidrug resistance (MDR) was defined as resistance to two or three antibiotics. Resistance pattern combinations were also summarized.

The European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints (version 2022; https://www.eucast.org/clinical_breakpoints) were applied as follows: amoxicillin ≤ 0.125 mg/L, clarithromycin ≤ 0.5 mg/L, levofloxacin ≤ 1 mg/L, metronidazole ≤ 8 mg/L, and tetracycline ≤ 1 mg/L.

2.3 Statistical analysis and data visualization

All statistical analyses and data visualizations were performed using R software (version 4.3.1) (R Core Team, 2021). Summary tables were generated with the gtsummary and gt packages (Iannone et al., 2025; Sjoberg et al., 2021), and visual representations of antibiotic resistance and demographic variables were created using ggplot2 (Wickham, 2016) to produce publication-ready figures. The exploratory nature of resistance profiling conducted in this epidemiological study did not require formal correction for multiple comparisons. The results for antibiotic susceptibility and MDR are interpreted descriptively.

To place our findings within a broader regional context, we conducted a secondary meta-analysis using data extracted from a recently published systematic literature review on H. pylori prevalence and antibiotic resistance in Central Asia. The final dataset included studies from Kazakhstan, Kyrgyzstan, Russia, and Uzbekistan published between 2000 and 2025 (Seisenbekova et al., 2025; Mežmale et al., 2021; Abylkasymova, 2012; Aldiyarova, 2011; Kulmambetova et al., 2015; Zhangabylov et al., 2002; Nurgalieva et al., 2002; Abdiev et al., 2008, 2010; Dzhumabaev et al., 2015; Dzhumabaev, 2008; Akbarova et al., 2017; Lazebnik et al., 2012; Karimov et al., 2019; Lavrinenko et al., 2025). Sample sizes and event counts for H. pylori prevalence and clarithromycin resistance were obtained directly from published tables and supplemented with data from the present study.

Pooled prevalence estimates were calculated using random-effects models with the Freeman–Tukey double arcsine transformation, as implemented in the meta and metafor R packages (Balduzzi et al., 2019; Viechtbauer, 2010). Statistical heterogeneity among studies was assessed using the I² statistic, and forest plots were generated to visualize pooled estimates of H. pylori prevalence and clarithromycin resistance. The resulting pooled estimates were analyzed and interpreted cautiously, with emphasis on the overall picture of the region rather than on precise point estimates.

2.4 Ethics and regulatory compliance

The study protocol was approved by the relevant institutional ethics committees in Kazakhstan and Japan. Written informed consent was obtained from all participants prior to sample collection. International transfer of gastric biopsy specimens was conducted in compliance with institutional and national regulations governing the export and import of biological materials, including applicable ethics approvals and transfer agreements.

2.5 Study scope

This study was designed as a culture-based epidemiological approach to assess prevalence and perform phenotypic antimicrobial susceptibility testing of H. pylori. Although modern molecular and genomic methods are useful, they were beyond the scope of this work and are planned for future studies that will expand on this dataset.

3 Results

3.1 Baseline characteristics of the study population

A total of 150 dyspeptic patients provided gastric biopsy samples for analysis (Table 1). Among them, 148 (98.6%) underwent RAS testing; 137 (91.3%) were positive, indicating a high background prevalence of H. pylori infection among symptomatic patients. Viable H. pylori cultures were obtained from 86 of 150 biopsies (57%), and all isolates were subjected to antimicrobial susceptibility testing by the agar dilution method. The mean age of culture-positive patients was not significantly lower than that of culture-negative patients (42.9 ± 15.4 vs. 46.4 ± 15.6 years; p = 0.2). The sex distribution was comparable between groups (female 70% vs. 66%; p = 0.5), and two participants did not report their age (Table 2).

Table 2

Table 2. Baseline characteristics by H. pylori culture result (n = 150) of patients who underwent endoscopic biopsy sampling.

Endoscopic findings based on the Kimura–Takemoto system showed significant differences between groups (p = 0.02). Culture-positive patients demonstrated a higher proportion of C-2 and C-3 lesions (progressive gastric atrophy). Non-atrophic mucosa was slightly more common among culture-positive patients (45% vs. 38%). No patients in the culture-positive group had a normal endoscopic report, whereas 6.3% in the negative group did.

3.2 Antibiotic resistance and multidrug resistance patterns

Antimicrobial susceptibility testing was performed for 86 isolates (Table 3) against metronidazole, clarithromycin, amoxicillin, minocycline, and sitafloxacin. Metronidazole resistance was alarmingly high (75/86, 87.2%), confirming its limited utility in current empirical regimens. Clarithromycin resistance was found in 29 isolates (33.7%), while amoxicillin resistance remained rare (3/86, 3.5%). No resistance was detected to minocycline or sitafloxacin, suggesting that these agents may serve as viable options for second-line or rescue therapy.

Table 3

Table 3. Antibiotic resistance and multidrug resistance profile among culture-positive H. pylori isolates (n = 86).

Multidrug resistance (MDR), defined as resistance to ≥ 2 antibiotics, was observed in 30 isolates (34.8%). Among them, 27 strains were dually resistant to clarithromycin and metronidazole, and 3 isolates were triple resistant to amoxicillin, clarithromycin, and metronidazole. These findings suggest the higher likelihood of emergence of complex resistance phenotypes in H. pylori circulating in the Almaty population.

3.3 Regional meta-analysis

To contextualize our results, we performed a secondary meta-analysis of eligible studies from Kazakhstan, Kyrgyzstan, and Uzbekistan. The pooled prevalence of H. pylori infection was 70% (95% CI: 59–80%; I² = 97.7%) (Figure 1), consistent with high endemicity across Central Asia. Our culture-based prevalence in Almaty (57.3%) closely aligned with previous reports from urban Kazakhstan, supporting regional heterogeneity ranging from 30 to 85%.

Figure 1

Figure 1. Forest plot of Helicobacter pylori prevalence across Central Asia. A random-effects meta-analysis was performed using published reports from Kazakhstan, Kyrgyzstan, and Uzbekistan, supplemented with our culture-based prevalence estimate. Our study identified H. pylori in 57% (86/150) of patients with evaluable biopsies and endoscopy. Pooled prevalence across Central Asia was 70% (95% CI: 58–80%; I² = 97.7%), reflecting both high endemicity and methodological heterogeneity among studies. Events are defined as positive H. pylori infection cases relative to the total number of patients recruited in each study.

Regarding antimicrobial resistance, four prior reports yielded a pooled clarithromycin resistance rate of 29% (95% CI: 10–53%; I² = 87.1%) (Figure 2). The resistance level observed in our study (33.7%) corresponds well with this regional estimate, validating the reproducibility of our findings. Collectively, these data highlight both the high burden and growing complexity of H. pylori infection and antibiotic resistance patterns in Central Asia.

Figure 2

Figure 2. Forest plot of clarithromycin resistance among H. pylori isolates in Central Asia and Russia. Pooled clarithromycin resistance was estimated from regional studies using phenotypic or molecular methods. Our study contributed culture-based data from 86 isolates, with a resistance rate of 33.7% (29/86). The pooled resistance across was 29% (95% CI: 10–53%; I² = 87.1%), underscoring the growing challenge of clarithromycin resistance in the region. Events are defined as clarithromycin-resistant H. pylori cases or strains relative to the total number of patients recruited in each study.

4 Discussion

Our study provides the first culture-based epidemiological and antimicrobial resistance data for H. pylori in Kazakhstan, complemented by a regional meta-analysis. Three main findings emerge. First, the burden of H. pylori infection in Almaty remains high, with more than half of symptomatic patients harboring viable bacteria. Second, in vitro antimicrobial resistance patterns observed for metronidazole (87.2%) and clarithromycin (33.7%) suggest a reduced likelihood of treatment success with the standard triple therapy; however, this cannot be reliably assessed without measured clinical eradication rates. Third, our pooled regional estimates of 70% prevalence and 29% clarithromycin resistance position Kazakhstan within the broader Central Asian context, demonstrating both consistency with neighboring countries and unique resistance features (Karimov et al., 2019; Lavrinenko et al., 2025).

RAS detected H. pylori antigens in a high proportion of patients, including some with culture-negative biopsies, suggesting detection of non-viable bacteria. Among culture-positive patients, 96% were RAS-positive, whereas 88% of culture-negative patients were also RAS-positive (p = 0.057). This near-significant difference supports the reliability of RAS as a practical screening tool in resource-limited clinical settings.

4.1 Comparison with previous studies in Central Asia

Our findings fill an essential gap in the existing literature for this region. The most recent systematic review on Central Asia reported H. pylori prevalence in Kazakhstan ranging from 62.4 to 85.3%, compared to Uzbekistan (72–80%) and Kyrgyzstan (51–81%) (Seisenbekova et al., 2025). However, variations in diagnostic methods may have affected these outcomes. In Kazakhstan, the most frequently reported method has been the enzyme-linked immunosorbent assay (ELISA), whereas clinicians in Kyrgyzstan and Uzbekistan commonly rely on polymerase chain reaction (PCR), histological confirmation, or urea breath tests (UBT) (Lavrinenko et al., 2025).

4.2 Within-country variability and risk factors

Within Kazakhstan, regional estimates vary considerably. A recent hospital-based study in Karaganda reported an H. pylori prevalence of only 27.6% (Seisenbekova et al., 2025). This wide variation underscores the need for a nationwide study using standardized diagnostic methods to accurately quantify the actual burden of active infection. Previous research has identified age and dietary factors, particularly high salt intake, as significant risk factors for H. pylori infection in Kazakhstan (Mežmale et al., 2021). In our study, there was no association between age and culture positivity, suggesting that active infection may be equally prevalent among younger and older patients. Because most earlier studies in Kazakhstan relied on antibody-based ELISA with modest sensitivity and specificity, the distinction between past and active infection has been unclear. Culture-based approaches, though technically demanding, remain essential for accurate diagnosis and antibiotic susceptibility testing, which are rarely implemented in routine clinical practice across Central Asia.

4.3 Clinical and microbiological implications

The antimicrobial susceptibility results raise significant concerns about the efficacy of currently recommended H. pylori eradication regimens. High resistance rates to metronidazole and clarithromycin suggest a diminished likelihood of success of standard triple therapy. Recent global consensus data indicate that clarithromycin resistance exceeding 15% and metronidazole resistance exceeding 40% are each associated with a lower eradication success rate in patients receiving standard triple therapy (Liou et al., 2025). Although amoxicillin resistance was rare (3.5%), the few resistant strains were concurrently resistant to clarithromycin and metronidazole, indicating the emergence of multidrug-resistant (MDR) H. pylori phenotypes. The absence of resistance to sitafloxacin and minocycline suggests that these agents may serve as viable components of second-line or rescue therapy regimens. Continuous monitoring of resistance patterns is essential to guide empirical therapy, as seen in Japan and Taiwan (Ono et al., 2025; Liou et al., 2025), where phenotype-guided regimens have improved eradication success rates. These inter-country differences we have observed in Kazakhstan also reflect disparities in healthcare access, diagnostic capacity, and antibiotic prescription practices. Empirical antibiotic use remains relatively common in Kazakhstan, which may have contributed to the higher resistance rates observed compared with its neighbors. While PCR and ELISA are widely available and helpful for non-invasive diagnosis, the lack of culture-based and genotypic testing limits the ability to monitor antibiotic resistance or virulence markers. There is a pressing need for laboratories in Central Asia to adopt such gold-standard approaches, which are routinely used in international H. pylori eradication guidelines (Bui et al., 2025; Yamaoka, 2024).

4.4 Regional genetic context

Despite the high prevalence of H. pylori infection, genetic data on antibiotic resistance from Central Asia remain scarce. A previous study in central Kazakhstan (n = 20) identified clarithromycin-associated 23S rRNA mutations in 13 strains, rdxA mutations in 8 strains, and PBP1a mutations associated with amoxicillin resistance in 1 strain (Kulmambetova et al., 2015). In Uzbekistan, 23S rRNA A2142G/C mutations were found in 4 of 30 (13.3%) isolates (Karimov et al., 2019), whereas in Kyrgyzstan, resistance rates to clarithromycin and metronidazole were approximately 16.2 and 45%, respectively (Moldobaeva et al., 2014). Compared with these reports, our study demonstrates a higher phenotypic resistance to metronidazole, moderately elevated clarithromycin resistance, and clear evidence of emerging MDR H. pylori in Kazakhstan.

4.5 Public health implications

Given Kazakhstan’s high gastric cancer burden, with 27,467 new cases reported between 2009 and 2018 (Taszhanov et al., 2022), our results emphasize the urgent need for coordinated national action. A combined approach integrating non-invasive screening, culture-based diagnosis, and molecular surveillance will be essential to develop evidence-based treatment guidelines tailored to regional resistance profiles. The current study, though limited to the Almaty region, represents the first step toward establishing a national H. pylori surveillance network. Expanding this framework to the other areas will provide comprehensive data to inform clinical protocols not only in Kazakhstan but also in neighboring Central Asian countries.

4.6 Limitations and technical considerations

Several limitations should be acknowledged. This study was conducted at a single center in Almaty among symptomatic patients referred for endoscopy; therefore, the findings may not be generalizable to the entire country without corroborating evidence from other regions or population-based surveys. The relatively small sample size of positive bacterial cultures obtained (n = 86) was insufficient for multivariable regression analyses examining sociodemographic factors associated with the spread of H. pylori in the region. Additionally, the identification of MDR in 34.8% of isolates, coupled with the small number of triple-resistant strains, does not allow a clear interpretation of antibacterial resistance patterns or conclusions regarding clinical outcomes in the studied population. Nevertheless, the occurrence of clarithromycin–metronidazole double resistance is clinically alarming and warrants in-depth investigation. In the future, multi-center, population-based studies will be required to identify independent predictors of H. pylori prevalence and MDR in Kazakhstan and Central Asia.

Among the 148 patients who underwent RAS testing, 81 of 86 culture-positive patients (96%) were also RAS-positive, while 56 of 64 culture-negative patients (88%) were RAS-positive. The partial mismatch between RAS and culture results may stem from methodological constraints: RAS detects H. pylori antigens, whereas culture requires viable bacteria. Because biopsy samples were transported from Kazakhstan to Japan for culturing, bacterial cell death during shipment may have led to culture-negative yet RAS-positive results. The higher proportion of RAS-positive results among culture-negative patients (88%) indicates that culture likely underestimates infection in the presence of non-viable or coccoid forms of the bacteria, particularly under conditions requiring international sample transport.

The very high heterogeneity observed in the meta-analysis (I² > 97% for prevalence and I² > 85% for clarithromycin resistance) reflects methodological differences across studies, including diagnostic approaches (ELISA, PCR, UBT, histology and culture), population characteristics, and geographic regions. Therefore, pooled estimates should be interpreted descriptively for assessing the regional burden rather than used to make precise evaluations for policy-making and clinical protocols.

In future investigations, establishing in-country culture and susceptibility testing facilities will be essential to reduce sample degradation and achieve more accurate estimates of infection rates and resistance profiles. Our findings also indicate that RAS is highly sensitive but has limited practical value in the early stages of epidemiological work within a single-center design. While culture may underestimate infection under technically limited conditions, future surveillance programs should incorporate both culture-based and noninvasive diagnostic methods to ensure comprehensive detection of H. pylori infection in multicenter studies across Kazakhstan and Central Asia.

4.7 Future directions and conclusion

Considering these findings and limitations, we present the need for a coordinated national survey on H. pylori infection and antibiotic resistance in Kazakhstan. The high rates of resistance to clarithromycin (33.7%) and metronidazole (87.2%) observed indicate that current first-line therapies may be less effective than expected in a subset of patients. Based on our results, we propose the following clinical considerations for Almaty: (i) restrict clarithromycin-based triple therapy if other population-based studies confirm the resistance exceeding 15%; (ii) prioritize bismuth-based quadruple therapy in cases of confirmed clarithromycin-metronidazole MDR; (iii) reserve sitafloxacin or minocycline for rescue therapy; and (iv) establish local culture and molecular resistance microbiological facilities for ongoing monitoring and surveillance of antibiotic resistance. Future work should extend surveillance to other regions and incorporate molecular and genomic analyses to track geographic variation and resistance patterns.

Kazakhstan, as one of the countries with the highest gastric cancer incidence in Central Asia, must prioritize H. pylori control as part of its national cancer prevention strategy. This includes noninvasive population screening, the establishment of centralized diagnostic capacity, and the revision of treatment guidelines. Our study provides the first culture-based evidence supporting these initiatives, thereby bridging a critical research gap in understanding the regional patterns of H. pylori prevalence and antimicrobial resistance.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by study approval was obtained from the ethics committees of the Institute of Genetics and Physiology, Kazakhstan (№1 from 8 January 2024). Informed consent was obtained from all subjects involved in the study. Ethical approval was also given by the Ethics Committee at Oita University, Faculty of Medicine (P-12-10 and #1660). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

KD: Conceptualization, Writing – original draft. GZ: Writing – review & editing, Project administration, Funding acquisition. JK: Resources, Methodology, Writing – original draft. YB: Writing – original draft, Formal analysis, Investigation. AY: Writing – original draft, Validation. AM: Validation, Writing – original draft. AKa: Investigation, Writing – original draft. AKh: Investigation, Writing – original draft. KS: Methodology, Writing – original draft, Visualization. YY: Data curation, Supervision, Writing – review & editing.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This study was supported in part by grants from the Research Center for Global and Local Infectious Diseases, Oita University (Adoption number 2024B25). This work was also supported by the Japan Agency for Medical Research and Development (AMED) [Adopting Sustainable Partnerships for Innovative Research Ecosystem (ASPIRE); 23836904, Science and Technology Research Partnership for Sustainable Development (SATREPS); 21357105] and the Japan International Cooperation Agency (JICA) [SATREPS] (YY).

Acknowledgments

We thank Kanat Khazidinov for his help and guidance with the ethical approval of the study, Rumiko Suzuki for advice on bioinformatic analysis and study design, Kanash Zhaniya for clinical support during endoscopy sessions, the nurses and clinical staff of the Cardiology and Internal Disease Center for their assistance and professionalism during endoscopy sessions, and for patient recruitment. Aliya Medetbekova is a Ph.D. student supported by the Japanese Government (MEXT) Scholarship Program, 2025.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that Generative AI was not used in the creation of this manuscript.

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