Most Helicobacter pylori strains are susceptible to tetracycline, an antibiotic commonly used for the eradication of H. pylori. However, an increase in incidence of tetracycline resistance in H. pylori has recently been reported. Here the mechanism of tetracycline resistance of the first Dutch tetracycline-resistant (Tet r ) H. pylori isolate (strain 181) is investigated. Twelve genes were selected from the genome sequences of H. pylori strains 26695 and J99 as potential candidate genes, based on their homology with tetracycline resistance genes in other bacteria. With the exception of the two 16S rRNA genes, none of the other putative tetracycline resistance genes was able to transfer tetracycline resistance. Helicobacter pylori is a spiral-shaped, gram-negative bacterium that causes chronic infections in the gastric mucosa (6). This infection will persist for life, unless treated with antibiotics. Cure of H. pylori infection results in ulcer healing and may reduce the risk of gastric cancer and gastric lymphoma (22,28). The highest cure rates have been obtained with antimicrobial treatments that include two or more antimicrobial drugs, a bismuth component, and/or a proton pump inhibitor (14, 25). For the treatment of H. pylori infections, tetracycline-based triple or quadruple therapies are often used as a second-line treatment (7,9,17). Until the end of the last century only a few reports were published on spontaneous tetracycline resistance (18; P. D. Midolo, M. G. Korman, J. D. Turnidge, and J. R. Lambert, Letter, Lancet 347:1194-1195, 1996), and it was generally accepted that tetracycline resistance (MIC Ն 4 g/ml) in H. pylori is very rare (5, 12). However, in the last 2 years an increase in the incidence of tetracycline resistance in H. pylori has been reported (2,11,13,20,30).Tetracycline inhibits the protein synthesis by binding to the 30S ribosomal subunit (3,19). In most bacteria resistance to tetracycline is due to an energy-dependent efflux of tetracycline-cation complexes across the cell membrane by membrane-associated efflux proteins. Export of tetracycline complexes out of the cell reduces the intracellular drug concentration and protects the ribosomes from tetracycline (4). Overexpression of the efflux genes confers tetracycline resistance, while the sensitivity to tetracycline increases by deletions in these genes. The second common mechanism of resistance is mediated through ribosomal protection proteins. These cytoplasmic proteins confer tetracycline resistance either by a reduction of the affinity of ribosomes for tetracycline or by releasing the bound antibiotic from the ribosome. The ribosomal protection proteins, such as TetM, TetO, and TetS, show homology with the elongation factors EF-G and EF-Tu (Table 1) (4). Beside these two most common tetracycline resistance mechanisms, two other mechanisms have been described. One is based on enzymatic inactivation of tetracycline by the product of TetX in the presence of oxygen and NADPH, and the other originates from mutations in the 16S rRNA ge...