Omeprazole combined with amoxicillin and clarithromycin in the eradication of Helicobacter pylori in children with gastritis: A prospective randomized double-blind trial

Safety assessment of omeprazole use: a review

BACKGROUND

Risks regarding hospital admission due to adverse drug reactions and drug interactions from use of omeprazole have been reported. The question guiding the present review was "Which adverse events occur in patients using omeprazole in a Food and Drug Administration-approved and/or off-label manner?" It was also proposed to evaluate the safety of use of omeprazole.

DESIGN AND SETTING

Qualitative narrative review with critical evaluation, in a public university.

METHODS

The PubMed, SCOPUS, LILACS, SciELO, EMBASE and EBSCO databases were searched on July 31, 2018. Studies evaluating adverse events were screened.

RESULTS

72 articles were included, among which 58 reported on adverse drug events (47, adverse drug reactions; 5, drug interactions; and 6, situations of ineffectiveness). 28 adverse drug reactions not described in compendia and drug leaflets were described in these studies: myocardial infarction (6); stroke (2); spontaneous abortion (1); proliferative changes (1); chills (1); heart failure (1); thrombosis (2); and dementia (1), among others. Severe adverse reactions, for instance cardiac problems, Steven-Johnson syndrome and proliferative changes, were identified. The antiplatelet effects of drugs such as clopidogrel, in patients who underwent heart-related surgery, increased the risk of developing cardiac problems, such as cardiovascular death, myocardial infarction and stroke. In newly transplanted patients, decreased absorption of mycophenolate mofetil occurred, thus leading to rejection of transplanted organs.

CONCLUSION

Use of omeprazole should be monitored primarily in patients with heart disorders using antiplatelet agents concomitantly, and in newly transplanted patients using mycophenolic acid, in order to avoid serious adverse reactions.

Safety of first-line triple therapy with a potassium-competitive acid blocker for Helicobacter pylori eradication in children

BACKGROUND

Helicobacter pylori infection is a risk factor for gastric cancer, and it has been reported that eradication of H. pylori is effective for preventing such cancer. Recently, H. pylori eradication has been performed in children as first-line therapy against gastric cancer. Here, we report use of triple therapy with a potassium-competitive acid blocker (P-CAB) for H. pylori eradication in children.

METHODS

H. pylori infection testing and eradication therapy began in fiscal year 2015 in junior high school students located in Yurihonjo city and Nikaho city, Akita prefecture, Japan. Urine-based immunochromatography, stool antigen enzyme-linked immunosorbent assay tests, and serum antibody tests were performed as the initial screening examination. Those who tested positive on one of the three examinations then underwent a urea breath test (¹³C-UBT). Those who tested positive on ¹³C-UBT and expressed the desire to undergo H. pylori eradication then received eradication therapy comprising 20 mg P-CAB, 750 mg amoxicillin, and 200 mg clarithromycin twice a day for 7 days. At least 8 weeks after treatment, eradication success was evaluated using ¹³C-UBT.

RESULTS

A total of 118 students received eradication therapy. Eradication rates were 81.3% (95% confidence interval: 74.3-88.4, 96/118) in ITT analysis and 85.7% (95% confidence interval: 79.1-92.9 96/112) in PP analysis. Adverse effects associated with eradication therapy were observed in 25 of 118 subjects (21.1%), seven of whom required hospital treatment (rash in five, vomiting in two). All seven subjects either discontinued therapy or were administered anti-allergy drugs, which resulted in swift alleviation of symptoms.

CONCLUSIONS

First-line triple therapy with a P-CAB for H. pylori eradication in children was found to be safe.

Meta-analysis of randomized controlled trials on the efficacy of probiotics in Helicobacter pylori eradication therapy in children

The efficacy of probiotics supplementation in children undergoing Helicobacter pylori (H. pylori) eradication therapy remains controversial. This study aimed to meta-analyze whether probiotics supplementation in triple therapy could improve H. pylori eradication rates and reduce therapy-related side effects in children. Electronic databases PubMed and Embase were searched to identify all randomized controlled trials in pediatric patients comparing probiotics supplementation with placebo or no extra intervention in H. pylori eradication therapy. Two authors independently extracted the data. Results were expressed as odds ratios (ORs) and accompanying 95 % confidence intervals (CIs). Stata version 12.0 was used to perform all statistical analyses. Seven studies consisting of 508 pediatric patients were included in our study. The pooled ORs (studies n = 7) of eradication rates by intention-to-treat and per-protocol analysis in the probiotics group versus the control group were 1.96 (95 % CI 1.28-3.02) and 2.25 (95 % CI 1.41-3.57), respectively. The pooled OR (studies n = 5) of incidence of total side effects was 0.32 (95 % CI 0.13-0.79), with significant heterogeneity observed (I (2) = 71.9 %).

CONCLUSION

Probiotics supplementation in triple therapy for H. pylori infection may have beneficial effects on eradication and therapy-related side effects, particularly diarrhea, in children.

Randomised controlled trial: sequential vs. standard triple therapy for Helicobacter pylori infection in Chinese children-a multicentre, open-labelled study

BACKGROUND

Studies have showed that 10-day sequential treatment regimen achieved higher Helicobacter pylori eradication rate than standard triple therapies.

AIM

To compare a 10-day sequential therapy and standard triple therapy in Chinese children with H. pylori infection.

METHODS

A prospective, multicentre, open-label, randomised controlled trial was conducted in four tertiary medical centres in China. Children with H. pylori gastritis were randomly assigned to a 10-day sequential therapy consisting of omeprazole and amoxicillin for 5 days followed by omeprazole, clarithromycin and metronidazole for the remaining 5 days, or 7-day or 10-day standard triple therapy comprising of omeprazole, amoxicillin and clarithromycin. H. pylori eradication was assessed by H. pylori stool antigen test.

RESULTS

A total of 360 patients were included. The eradication rate achieved with the 10-day sequential therapy was significantly higher than either the 7-day or 10-day standard triple treatment, either by the intention-to-treat analysis (81.4% vs. 61.9% or 67.7%, P < 0.05) or per-protocol analysis (89.7% vs. 70.8% or 77.8%, P < 0.05).

CONCLUSIONS

The 10-day sequential regimen was significantly more effective than standard 7-day or 10-day triple regimens in eradicating H. pylori infection in Chinese children.

Sequential therapy versus tailored triple therapies for Helicobacter pylori infection in children

AIMS

The aim of the study was to compare sequential versus tailored triple therapy regimens on Helicobacter pylori (H pylori) eradication rates in children and to assess the effect of antimicrobial susceptibility.

PATIENTS AND METHODS

Prospective, open-label, multicenter study. Children received randomly either a 10-day sequential treatment comprising omeprazole (OME) with amoxicillin for 5 days and OME, clarithromycin (CLA), and metronidazole (MET) for the remaining 5 days, or a 7-day triple therapy comprising OME with amoxicillin and CLA in cases of a CLA-susceptible strain or MET in cases of CLA-resistant strain. H pylori eradication was assessed by C-urea breath test.

RESULTS

One hundred sixty-five children, 95 girls and 70 boys, of median age 10.4 years, were included. The intention-to-treat (ITT) eradication rate was 76.9% (sequential 68/83 = 81.9%, triple therapy 59/82 = 71.9%, ns), and the per-protocol (PP) eradication rate was 84.6% (sequential 68/77 = 88.3%, triple therapy 59/73 = 81.8%, ns). Eradication rates tended to be higher using the sequential treatment, but the difference was only statistically significant for ITT analysis in children harboring both CLA- and MET-susceptible strains (87.8% vs 68.5%, odds ratio [OR] 3.3, P = 0.03). Both ITT and PP eradication rates were significantly lower with sequential treatment in CLA-resistant compared with CLA-susceptible strains (ITT: 56.2% vs 72.7%, OR 5.5, P = 0.008; PP 64.3% vs 80.0%, OR 7.9, P = 0.009). Both treatments were well tolerated.

CONCLUSIONS

Sequential treatment is greatly effective for eradicating H pylori in children except in CLA-resistant strains. Sequential treatment can be used as a first-line therapy, but only in areas with a low CLA resistance rate.

Evidence-based guidelines from ESPGHAN and NASPGHAN for Helicobacter pylori infection in children

OBJECTIVE

As the clinical implications of Helicobacter pylori infection in children and adolescents continue to evolve, ESPGHAN and NASPGHAN jointly renewed clinical guidelines using a standardized evidence-based approach to develop updated recommendations for children and adolescents in North America and Europe.

METHODS

An international panel of 11 pediatric gastroenterologists, 2 epidemiologists, 1 microbiologist, and 1 pathologist was selected by societies that developed evidence-based guidelines based on the Delphi process with anonymous voting in a final face-to-face meeting. A systematic literature search was performed on 8 databases of relevance including publications from January 2000 to December 2009. After excluding nonrelevant publications, tables of evidence were constructed for different focus areas according to the Oxford classification. Statements and recommendations were formulated in the following areas: whom to test, how to test, whom to treat, and how to treat. Grades of evidence were assigned to each recommendation based on the GRADE system.

RESULTS

A total of 2290 publications were identified, from which 738 were finally reviewed. A total of 21 recommendations were generated, and an algorithm was proposed by the joint committee providing evidence-based guidelines on the diagnostic workup and treatment of children with H pylori infection.

CONCLUSIONS

These clinical practice guidelines represent updated, best-available evidence and are meant for children and adolescents living in Europe and North America, but they may not apply to those living on other continents, particularly in developing countries with a high H pylori infection rate and limited health care resources.

Helicobacter pylori chronic gastritis in children: to eradicate or not to eradicate?

OBJECTIVE

To evaluate the efficacy of triple eradication therapy versus symptomatic therapy in children with Helicobacter pylori-associated chronic active gastritis (H pylori-ACAG).

STUDY DESIGN

Symptomatic patients with H pylori-ACAG (n=31) were randomly assigned into two groups: (1) patients infected with H pylori who were treated with triple eradication therapy (n = 16); and (2) patients infected with H pylori who were treated with symptomatic therapy (n=15).

RESULTS

After 1 year of follow-up, macroscopic appearance was significantly different in group B (P=.023), and chronic inflammation, H Pylori density, and activity were significantly higher in group B than in group A (P=.022, .007, and .002, respectively); however, we did not find a significant difference in the symptoms comparing both groups (P=.287). After 1 year of follow-up, we observed the persistence of the H pylori infection in all children who had not received eradication treatment.

CONCLUSIONS

There is no correlation between eradication of H pylori infection and improvement of dyspeptic symptoms. Self-eradication does not occur within 1 year of follow-up. A trend toward a higher rate of chronic inflammation in noneradicated children at 1 year limited the time of our study.

Helicobacter pylori eradication rates in children upon susceptibility testing based on noninvasive stool polymerase chain reaction versus gastric tissue culture

BACKGROUND AND OBJECTIVES

In children with clarithromycin-resistant Helicobacter pylori, clarithromycin-containing therapies often fail. The present study aimed to assess the outcome of tailored therapy upon noninvasive versus invasive H pylori susceptibility testing.

PATIENTS AND METHODS

A retrospective cohort study was conducted in a pediatric outpatient clinic located in a region where H pylori clarithromycin resistance is highly prevalent. Between June 2007 and September 2009, 96 infected children (mean age 10.8 years), naïve to H pylori eradication treatment, were prescribed triple eradication therapies. These therapies were individually tailored upon susceptibility testing performed either noninvasively using stool polymerase chain reaction (stool PCR group) or invasively using endoscopy, biopsy, and culturing of gastric biopsies (gastric biopsy group). Eradication was defined by negative results upon noninvasive testing including stool PCR at least 5 weeks after the end of treatment.

RESULTS

H pylori was eradicated in 43 of 55 stool PCR group versus 30 of 41 gastric biopsy group children (78.2% vs 73.2%, P = 0.63). Of those H pylori strains with pretherapeutic clarithromycin susceptibility, 78.8% were eradicated in the stool PCR group and 69.2% in the gastric biopsy group (P = 0.41) following clarithromycin-containing therapy; clarithromycin resistance was acquired by 4.1% of strains in the former group versus 12% in the latter (P = 0.33).

CONCLUSIONS

Stool PCR is as effective as the invasive approach of H pylori susceptibility testing for targeting resistance-guided eradication treatments in children. Furthermore, stool PCR is a useful tool for tracking the emergence of clarithromycin resistance following eradication treatment.

Sequential therapy compared with standard triple therapy for Helicobacter pylori eradication in children: a double-blind, randomized, controlled trial

OBJECTIVE

To determine the effectiveness of sequential therapy compared with standard triple therapy for Helicobacter pylori eradication in children.

STUDY DESIGN

In 107 children with H pylori infection confirmed with 2 of 3 tests ((13)C-urea breath test, histopathology, rapid urease test), we conducted a double-blind, randomized, controlled trial comparing a sequential treatment (amoxicillin and omeprazole for 5 days followed by clarithromycin, tinidazole, and omeprazole for 5 days) to a 7-day standard triple eradication regimen (amoxicillin and clarithromycin plus omeprazole) followed by placebo for 3 days.

RESULTS

In the experimental group (n=52) compared with the control group (n=51), there was a significant difference in the H pylori eradication rate at 6 to 8 weeks after the completion of treatment (primary outcome), as confirmed with negative results on (13)C-urea breath test (45/52 or 86.5% versus 35/51 or 68.6%; relative risk, 1.26; 95% CI, 1.02-1.60). Groups did not differ in any of the secondary outcomes (ie, adverse effects, the need for discontinuation of the H pylori therapy, compliance with therapy).

CONCLUSIONS

In children with H pylori infection, sequential eradication therapy compared with standard triple therapy resulted in a higher eradication rate, although the difference was of borderline statistical significance.

The efficacy of a 1-week triple therapy for eradication of Helicobacter pylori infection in children

BACKGROUND AND STUDY AIMS

Poor compliance to therapy and antibiotic resistance are the main causes for failure of anti-Helicobacter pylori (H. pylori) therapy. The purpose of this study was to assess the effectiveness of omeprazole-based triple therapy in Iranian children.

PATIENTS AND METHODS

Fifty-seven children with H. pylori-related gastroduodenal disease received 1-week triple therapy with a combination of omeprazole, amoxicillin and clarithromycin (according to the susceptibility test). Success of eradication was assessed by (13)C-urea breath test and endoscopy.

RESULTS

Sixty-four patients (mean age 11.3years; range 2.7-16years) were included. Eradication was successful in 84.2% (95% confidence interval, 72.8% intention to treat).

CONCLUSION

One-week triple therapy was effective for the eradication of H. pylori infection in children.

Helicobacter pylori therapy in children: overview and challenges

Helicobacter pylori is one of the most common infections found in humans. It was first identified in 1982 and by 1989 had been associated with gastric inflammation and ulcers in adults and children. During the 1990's evidence emerged of its etiologic role in stomach cancers in adults. That the infection is common and may have serious consequences, has led to an avalanche of research during the last twenty years. During this time, there have been many studies on children which have sought an effective and safe treatment to eradicate the infection, but as yet, no therapy regimen has been found which is always effective and safe. This article provides information, from a pediatric point of view, on the major developments in the therapeutics and therapy of H. pylori infection. It examines first-line treatment regimens, evaluates the efficacy of the main drugs used in the management of (primary) H. pylori infection in children, assesses the potential for the use of probiotics and sequential therapy, examines therapeutic options after failure of initial treatment, and discusses factors affecting eradication rate, including antibiotic resistance, adherence to therapy, and bacterial factors.

Clarithromycin resistance of Helicobacter pylori strains isolated from children' gastric antrum and fundus as assessed by fluorescent in-situ hybridization and culture on four-sector agar plates

AIM

To assess validity of culture on four-sector agar plates and fluorescent in-situ hybridization (FISH) test, and clarithromycin resistance rate in Helicobacter pylori strains isolated from children in the last 10 years.

METHODS

In the last 5 years, gastric biopsy specimens from antrum and fundus were taken from 89 consecutive children (median age 9 years) with H. pylori gastritis and from 21 controls. Culture was performed on 176 gastric biopsies (89 from antrum, 87 from fundus) on four-sector agar plates, and FISH test with DNA ProbeMix. After its validity was evaluated, FISH test was applied on additional 119 biopsies from 68 children (68 from the antrum, 51 from the fundus) stored in the Pathology archive in the previous 5 years.

RESULTS

Culture was positive in 157 of 176 biopsies (sensitivity: 89.2%, 95% confidence interval (CI) 85-94). In 33 of 89 children (37%) resistant strains were found in one or both gastric sites. FISH test was positive in 148 of 176 biopsies from infected children (sensitivity 84.1%, 95%CI 79-89) and in none of 42 biopsies from controls (specificity 100%). When applied on archive biopsies, FISH test was positive in 96 of 119 (80.7%, 95%CI 74-88). Total children harboring resistant strains in the last 10 years, as assessed by FISH test, were 66 of 157 (42%). Mixed infection with both sensitive and resistant strains were found in 40 children (25%) and in 12 of them resistant strains were in the fundus only.

CONCLUSIONS

Culture on four-sector agar plates and FISH test had a high sensitivity and specificity and showed co-presence of sensitive and resistant strains. In one-third of children with mixed infection, the resistant strains were in the fundus only. Clarithromycin resistance should be assessed in biopsies both from the antrum and the fundus, utilizing antral biopsies only can underestimate its prevalence.

Primary resistance in Helicobacter pylori isolated in children from Iran

Helicobacter pylori-associated infection is extremely common in Iran, as in other developing countries, but few data exist on the susceptibility of H. pylori to antimicrobials commonly used in the eradication schedules in this country. This study was performed to determine the resistance rate to six antimicrobial agents used in the treatment of H. pylori infection in dyspeptic Iranian children and to recommend an updated anti-H. pylori treatment regimen to use in children. All H. pylori isolated from children who were undergoing gastroscopy were prospectively collected and subcultured to yield their susceptibility to six antimicrobial agents, by E test and disk diffusion methods. Demographic data and presenting symptoms were also collected. A prospective study was carried out from January 2003 to January 2005 with 100 strains of H. pylori isolated from children (40 girls and 60 boys; age range, 1.5 to 16 years [mean, 9.22 +/- 3.25 years]); the strains had been successfully subcultured to yield antimicrobial sensitivity. Overall the H. pylori resistance rate was 95% to metronidazole, 59% to amoxicillin, 16% to clarithromycin, 9% to furazolidone, 7% to ciprofloxacin, and 5% to tetracycline. The most common presenting symptom was abdominal pain. There were no statistically significant differences in antimicrobial resistance rates related to age, sex, or clinical presentation. In the Iranian children, the prevalence of H. pylori resistance was very high to metronidazole and amoxicillin, moderate to clarithromycin, and low to ciprofloxacin and tetracycline.

Results from the pediatric European register for treatment of Helicobacter pylori (PERTH)

BACKGROUND AND AIM

Data on the eradication treatment for childhood Helicobacter pylori are scanty. A register was established on the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) website to collect data on treatment performed by European pediatricians to ascertain what is practiced in the field.

SUBJECTS

From January 2001 to December 2002, information on 597 children were entered by 23 European Centers, but only data of 518 treated children were completed and analyzed (86.7%, 262 male subjects, median age 9 years, range 1-14). According to their nationality, 226 children were from Southern Europe, 132 from Eastern Europe, 68 from Western Europe, and 4 from northern Europe, 68 from North Africa, and 20 from Asia. At endoscopy, 454 children had gastritis and 64 had ulcer (12.3%). Antibiotic sensitivity, tested in 361 cases, revealed 18% clarithromycin-resistant and 19% metronidazole-resistant H. pylori strains.

RESULTS

Treatment was performed for 1 week in 388 and for 2 weeks in 130 children. Antibiotics were associated with proton pump inhibitors (PPI) in 345 and with bismuth in 121 children. Triple therapy was given to 485 children, dual therapy to 26, quadruple to 7. Follow-up data, by (13)C-Urea-Breath Test or histology or both, were available for 480 children. Overall eradication rate was 65.6%, significantly higher in children with ulcer (79.7%) than without (63.9%, p = .001). When given as first treatment, bismuth-containing triple therapies were more efficacious than PPI-containing ones (77% versus 64%, p = .02, OR 1.88, 95% CI 1.1-3.3). Twenty-seven different treatment regimens were used, but only six were administered to at least 18 children (range 18-157). There was no difference between treatments given for 1 or 2 weeks, or given as first or second therapies.

CONCLUSION

European pediatricians entering data in the register used 27 different regimens. Bismuth-containing therapies resulted in higher eradication rate. Omeprazole-containing triple therapies were the most used although their efficacy was low. Therapies recommended for adults do not appear to be suitable for children.

Meta-analysis: Helicobacter pylori eradication treatment efficacy in children

BACKGROUND

Several meta-analyses assessing the efficacy of anti-Helicobacter pylori treatment in adults have been published but a comparable meta-analysis in children is lacking.

AIMS

To summarize the efficacy of treatments aimed at eradicating H. pylori in children and to identify sources of variation in treatment efficacy across studies.

METHODS

We searched Medline, reference lists from published study reports, and conference proceedings for anti-H. pylori treatment trials in children. Weighted meta-regression models were used to find sources of variation in efficacy.

RESULTS

Eighty studies (127 treatment arms) with 4436 children were included. Overall, methodological quality of these studies was poor with small sample sizes and few randomized-controlled trials. The efficacy of therapies varied across treatment arms, treatment duration, method of post-treatment assessment and geographic location. Among the regimens tested, 2-6 weeks of nitroimidazole and amoxicillin, 1-2 weeks of clarithromycin, amoxicillin and a proton pump inhibitor, and 2 weeks of a macrolide, a nitroimidazole and a proton pump inhibitor or bismuth, amoxicillin and metronidazole were the most efficacious in developed countries.

CONCLUSIONS

Before worldwide treatment recommendations are given for eradication of H. pylori, additional well-designed randomized placebo-controlled paediatric trials are needed, especially in developing countries where both drug resistance and disease burden is high.

Safety and tolerability of clarithromycin administered to children at higher-than-recommended doses

A tendency among pediatricians in Greece to use higher-than-recommended doses of clarithromycin was noted over several years, prompting this study of the safety and tolerability of this macrolide in 343 children over a period of 9 months. The study group comprised nonhospitalized patients of 29 pediatricians practicing in Athens. All were prescribed clarithromycin for upper respiratory (n = 257) or lower respiratory tract infection (n = 78). Overall, 77.8% were treated with doses that exceeded the recommended dose of 15 mg/kg/day, and 26% received doses of > or = 30 mg/kg/day (median dose, 20 mg/kg/day). The tolerability of clarithromycin was judged as "very good" in 75% of the children, as "good" in 16%, and as "moderate" in 5%, whereas intolerability was observed in 4% of the cases. Adverse reactions, mainly gastrointestinal in nature, were reported in 17.5% of the cases. With regard to both tolerability and adverse events recorded, there were no statistically significant differences between the group of patients who received the recommended dose and the group who received higher doses. Clarithromycin continues to present a safe and well-tolerated profile for the treatment of common pediatric infections, even when administered at higher-than-recommended doses. Whether it is more efficacious in this setting is a matter for further study.

Improvement of the eradication rate of Helicobacter pylori gastritis in children is by adjunction of omeprazole to a dual antibiotherapy

AIM

The possible improvement of efficacy and tolerability of a 7-day dual antibiotherapy amoxicillin-clarithromycin (AC) on the eradication of Helicobacter pylori (H. pylori) gastritis in children by the adjunction of omeprazole (OAC) was studied.

METHODS

Forty-six children presenting with H. pylori gastritis, assessed at inclusion by endoscopy, H. pylori urease test, histology and/or culture were randomised to a twice-daily regimen of AC or OAC. A (13)C-urease breath test was performed 4-6 weeks after the end of the treatment period to evaluate H. pylori eradication.

RESULTS

A larger proportion of patients was H. pylori negative (69%) in the OAC regimen treatment 4-6 weeks after eradication treatment compared with those who received dual AC therapy (15%). A total of seven patients (three in the OAC and four in the AC group) reported adverse events (AEs). Only vomiting was reported in more than one patient (one in each treatment regimen) and only one AE was severe (urticaria: in the OAC group, but considered not related to treatment).

CONCLUSION

A larger eradication rate of H. pylori was obtained in the triple OAC group than in the dual AC group. Both therapy regimens can be safely administered to children for 7 days.

Effect of a probiotic food as an adjuvant to triple therapy for eradication of Helicobacter pylori infection in children

OBJECTIVE

Current recommendations for treatment of Helicobacter pylori infection include a proton pump inhibitor in combination with two antibiotics. We evaluated the potential activity of a probiotic food as an adjuvant to antibiotic triple therapy for eradication of H. pylori infection in children from Buenos Aires, Argentina.

METHODS

Sixty-five children who tested positive for H. pylori, as diagnosed by (13)C-urea breath test and endoscopy, were included in this study. Patients were randomized to receive 1-wk triple therapy plus probiotic food (treated group) or milk placebo (control) that was administered for 3 mo. Probiotic food consisted of 250 mL of a commercial yogurt containing Bifidobacterium animalis and Lactobacillus casei (10(7) colony-forming units/mL). Post-treatment urea breath test controls were performed 1 and 3 mo after the end of triple therapy.

RESULTS

We found no significant differences in H. pylori eradication rates (ERs) at 1 and 3 mo between the treated group (ER = 45.5% and 42.4%) and the control group (ER = 37.5% and 40.6%). Relative risks between groups were 0.87 (95% confidence interval 0.58-1.32, P = 0.345) in the first month and 0.97 (95% confidence interval 0.64-1.46, P = 0.542) in the third month.

CONCLUSIONS

We could not demonstrate an adjuvant effect of the studied probiotic food to triple therapy in the eradication of H. pylori infection in children in Buenos Aires, Argentina. However, we found lower ERs than those reported for the same therapeutic scheme in developed countries, indicating that bacterial resistance and alternative therapeutic strategies should be studied.

Furazolidone-based triple therapy for H pylori gastritis in children

AIM: To evaluate the furazolidone-based triple therapy in children with symptomatic H pylori gastritis.

METHODS: A prospective and consecutive open trial was carried out. The study included 38 patients with upper digestive symptoms sufficiently severe to warrant endoscopic investigation. H pylori status was defined based both on histology and on positive ¹³C-urea breath test. Drug regimen was a seven-day course of omeprazole, clarithromycin and furazolidone (100 mg, 200 mg if over 30 kg) twice daily. Eradication of H pylori was assessed two months after treatment by histology and ¹³C-urea breath test. Further clinical evaluation was performed 7 d, 2 and 6 mo after the treatment.

RESULTS: Thirty-eight patients (24 females, 14 males) were included. Their age ranged from 4 to 17.8 (mean 10.9 ± 3.7) years. On intent-to-treat analysis (n = 38), the eradication rate of H pylori was 73.7% (95% CI, 65.2%-82%) whereas in per-protocol analysis (n = 33) it was 84.8% (95% CI, 78.5%-91%). All the patients with duodenal ulcer (n = 7) were successfully treated (100% vs 56.2% with antral nodularity). Side effects were reported in 26 patients (68.4%), mainly vomiting (14/26) and abdominal pain (n = 13). Successfully treated dyspeptic patients showed improvement in 78.9% of H pylori-negative patients after six months and in 50% of H pylori-positive patients after six months of treatment.

CONCLUSION: Triple therapy with furazolidone achieves moderate efficacy in H pylori treatment. The eradication rate seems to be higher in patients with duodenal ulcer.

Esomeprazole-based 1-week triple therapy directed by susceptibility testing for eradication of Helicobacter pylori infection in children

BACKGROUND

Poor compliance to therapy and antibiotic resistance are the main causes for failure of anti-Helicobacter pylori therapy.

OBJECTIVE

To evaluate the effectiveness of esomeprazole-based triple therapy directed by susceptibility testing.

METHODS

Symptomatic children with H. pylori infection, who underwent successful susceptibility testing and were colonized by no double-resistant strain, received 1-week triple therapy with esomeprazole, amoxicillin and either clarithromycin or metronidazole. Success of eradication was investigated by C-urea breath test.

RESULTS

Fifty-eight children (median age, 11.4 years; range, 2.2-17.7 years; 81% immigrants) were included. Helicobacter pylori was resistant to clarithromycin in 5 (9%) and to metronidazole in 9 children (16%). Eradication was successful in 49 (92%) of 53 children receiving esomeprazole, amoxicillin and clarithromycin and in all 5 children treated with metronidazole instead of clarithromycin, resulting in an eradication rate of 93% (95% confidence interval, 83%-98%, intention-to-treat analysis). All 4 treatment failures occurred in immigrants with language problems; 2 of them were obviously noncompliant.

CONCLUSION

Esomeprazole-based 1-week triple therapy directed by susceptibility testing is highly effective for eradication of H. pylori infection in children.

Seven-day is more effective than 4-day ranitidine bismuth citrate-based triple therapy in eradication of Helicobacter pylori in children: a prospective randomized study

BACKGROUND

Helicobacter pylori infection is common in paediatric population. To date, there is still no universally accepted recommendation on the treatment of this infection in children. Ranitidine bismuth citrate-based triple therapy has been shown to be effective in H. pylori eradication in adults but its use has rarely been validated in children.

AIM

To investigate the efficacy of ranitidine bismuth citrate-based triple therapy in eradication of H. pylori in children and to determine the shortest duration of treatment required.

PATIENTS AND METHODS

We conducted a prospective randomized study comparing ranitidine bismuth citrate plus amoxicillin plus clarithromycin given for 4 days vs. 7 days in H. pylori-infected children diagnosed by (13)C-urea breath test. Eradication was evaluated by repeat (13)C-urea breath test at 6 weeks after treatment.

RESULTS

A total of 206 children were recruited (median age 12 years, 97 boys and 109 girls). Ninety-eight (47.6%) and 108 (52.4%) children were randomized to receive 7-day and 4-day regimen respectively. The eradication rate of 4-day treatment arm was 77.8% (both intention-to-treat and per protocol) compared with 88.8% (intention-to-treat, P = 0.036) and 89.7% (per protocol, P = 0.022) of 7-day regimen. There was no statistical difference in terms of side effects between the two groups.

CONCLUSIONS

Seven-day ranitidine bismuth citrate-based triple therapy is an effective and well-tolerated treatment for eradication of H. pylori in children.

Evaluation of triple and quadruple Helicobacter pylori eradication therapies in Iranian children: a randomized clinical trial

BACKGROUND

Clinical trials in children concerning Helicobacter pylori eradication treatments are scarce. The purpose of this study was to assess the efficacy of proton pump inhibitor (PPI)-based triple therapy using PPI, amoxicillin and clarithromycin in Iranian children. We also evaluated the efficacy of quadruple therapy with PPI, metronidazole, amoxicilin and bismuth citrate in Iranian children.

METHODS

This was a randomized clinical trial performed in Emam Khomeini Hospital between 2003 and 2004. Patients with confirmed H. pylori infection by histology were divided into two groups in a randomized 1:1 scheme: the triple regimen group (omeprazole, clarithromycin and amoxicillin for 10 days) and the quadruple regimen group (omeprazole, amoxicillin, metronidazole and bismuth citrate for 10 days). The eradication was assessed by the C-urea breath test 4 weeks after the end of treatment and analyzed by per-protocol and intention-to-treat approaches.

RESULTS

One hundred and twenty-two patients (mean age 12.36+/-3.06 years) were entered into the study. Only 100 patients completed the study (50 patients in each regimen group). The eradication rates by triple therapy were 92% and 75.5% for the "per-protocol" and "intention-to-treat" approaches, respectively. In the quadruple regimen group, the eradication rates were 84% by the per-protocol approach and 68.8% in the intention-to-treat approach. Symptom responses to therapy were reported in all patients with successful eradication (88% of all patients).

CONCLUSION

With regard to recent recommendations, we also suggest PPI, amoxicillin and clarithromycin triple therapy as a first-line eradication treatment, and quadruple therapies as a second-line option, in Iranian children.

Improved efficacy of 10-Day sequential treatment for Helicobacter pylori eradication in children: a randomized trial

BACKGROUND & AIMS

The currently recommended first-line eradication treatment of Helicobacter pylori in children is usually successful in about 75%. Recently, in adults, a novel 10-day sequential treatment has achieved an eradication rate of 95%. The aim of the study was to assess the H pylori eradication rate of the sequential treatment regimen compared with conventional triple therapy in children.

METHODS

Seventy-eight consecutive children with H pylori infection were randomized to receive either sequential treatment (omeprazole plus amoxicillin for 5 days, followed by omeprazole plus clarithromycin plus tinidazole for another 5 days) (n = 38; 15 boys [39.5%]; median age, 11.0 years [range, 3.3-16 years]) or triple therapy (omeprazole, amoxicillin, and metronidazole) for 1 week (n = 37; 15 boys [40.5%]; median age, 9.9 years [range, 4.3-16 years]). H pylori infection was based on 2 out of 3 positive tests results: 13C-urea breath test, rapid urease test, and histologic analysis. Eradication was assessed by 13C-urea breath test 8 weeks after therapy.

RESULTS

Seventy-four patients completed the study. H pylori eradication was achieved in 36 children receiving sequential treatment (97.3%; 95% confidence interval, 86.2-99.5) and 28 children receiving triple therapy (75.7%; 95% confidence interval, 59.8-86.7) (P < .02). Compliance with therapy was good (>95%) in all.

CONCLUSIONS

Our study shows, for the first time in children, that 10-day sequential treatment achieves a higher eradication rate than standard triple therapy, which is consistent with the results of adult studies.

A Randomized Trial of Triple Therapy for Pediatric Helicobacter pylori Infection and Risk Factors for Treatment Failure in a Population with a High Prevalence of Infection

BACKGROUND

Few trials of treatment for Helicobacter pylori infection have been conducted in high-prevalence or pediatric populations, and risk factors for treatment failure are poorly understood.

METHODS

As part of a study evaluating the effect of H. pylori therapy on iron deficiency, we conducted a household-randomized, open-label treatment trial involving children aged 7-11 years in 10 villages in western Alaska. We screened 690 children, of whom 219 with iron deficiency and H. pylori infection (determined on the basis of positive results of the 13C urea breath test) were enrolled in the treatment phase of the study. These 219 children received treatment with iron sulfate alone (the control group) or with iron sulfate combined with a 2-week course of lansoprazole, clarithromycin, and amoxicillin (the intervention group). Children in the intervention group who were allergic to amoxicillin or macrolides received metronidazole. Children in the intervention group who did not respond to treatment were re-treated with a 2-week course of metronidazole-based quadruple therapy.

RESULTS

Two months after initiating therapy, 34% of 104 children in the intervention group and 0.90% of 111 children in the control group tested negative for H. pylori. Among children in the intervention group, risk factors for treatment failure were lack of metronidazole (adjusted odds ratio [aOR], 145), fewer treatment doses (aOR, 0.74), larger household population (aOR, 1.5), and lower body mass index (aOR, 0.69). These 4 variables predicted most of the variation in H. pylori infection status. Among 50 children who were re-treated, 84% tested negative for H. pylori at the 8-month follow-up visit, including those with poor treatment compliance.

CONCLUSIONS

Among disadvantaged populations with a high prevalence of H. pylori infection, the response to standard treatment regimens may be low. Treatment compliance, household crowding, and re-treatment may influence treatment success. Metronidazole may be appropriate first-line therapy.

Effects of a specially designed fermented milk product containing probiotic Lactobacillus casei DN-114 001 and the eradication of H. pylori in children: a prospective randomized double-blind study

GOALS

To determine the efficacy of triple therapy supplemented with a specially designed fermented milk product containing specific probiotic Lactobacillus casei (L. casei) DN-114 001 strain on Helicobacter pylori eradication in children.

BACKGROUND

Lactobacillus species possess in vitro activity against H. pylori. There are no consistent data on the impact of eradication therapy supplemented with probiotics on H. pylori cure rates in childhood in vivo.

STUDY

Multicenter, prospective, randomized, double-blind controlled study. Eighty-six symptomatic H. pylori-positive children were randomized either to receive the control treatment of omeprazole, amoxicillin, and clarithromycin (OAC) for 7 days or the test treatment of omeprazole, amoxicillin, and clarithromycin for 7 days supplemented with fermented milk (Actimel) containing L. casei DN-114 001 (OAC-LC), for 14 days. H. pylori status was assessed at 4 weeks following therapy using two noninvasive tests.

RESULTS

Intention-to-treat (ITT) based eradication rates for the OAC-LC group were 84.6% (95% CI, 71.2%-95.5%), and 91.6% (95% CI, 76.9%-98.2%) by per-protocol (PP) analysis. Eradication in the OAC group was 57.5% (95% CI, 42.2%-72.3%) in the ITT set and 61.3% (95% CI, 44.4%-75.0%) in the PP group. Eradication success was higher in the OAC-LC group compared with the OAC group in both ITT (P=0.0045) and PP analysis (P=0.0019). Primary resistance for clarithromycin could be determined in 21.2%. Side effects were infrequent. Drug compliance was good throughout the study.

CONCLUSION

Supplementation with fermented milk, containing live special probiotic L. casei DN-114 001, confers an enhanced therapeutic benefit on H. pylori eradication in children with gastritis on triple therapy.

Pharmacokinetics of proton pump inhibitors in children

The use of proton pump inhibitors (PPIs) has become widespread in children and infants for the management of paediatric acid-related disease. Pharmacokinetic profiles of only omeprazole and lansoprazole have been well characterised in children over 2 years of age with acid-related diseases. Few data have been recently published regarding the pharmacokinetics of pantoprazole in children, and none are available for rabeprazole or esomeprazole. The metabolism of PPI enantiomers has never been studied in the paediatric population. A one-compartment model best describes the pharmacokinetic behaviour of omeprazole, lansoprazole and pantoprazole in children, with important interindividual variability for each pharmacokinetic parameter. Like adults, PPIs are rapidly absorbed in children following oral administration; the mean time to reach maximum plasma concentration varies from 1 to 3 hours. Since these agents are acid labile, their oral formulations consist of capsules containing enteric-coated granules. No liquid formulation is available for any of the PPIs. Thus, for those patients unable to swallow capsules, extemporaneous liquid preparations for omeprazole and lansoprazole have been reported; however, neither the absolute nor the relative bioavailabilities of these oral formulations have been studied in children. Intravenous formulations are available for omeprazole (in Europe), lansoprazole and pantoprazole. PPIs are rapidly metabolised in children, with short elimination half-lives of around 1 hour, similar to that reported for adults. All PPIs are extensively metabolised by the liver, primarily by cytochrome P450 (CYP) isoforms CYP2C19 and CYP3A4, to inactive metabolites, with little unchanged drug excreted in the urine. Similar to that seen in adults, the absolute bioavailability of omeprazole increases with repeated dosing in children; this phenomenon is thought to be due to a combination of decreased first-pass elimination and reduced systemic clearance. The apparent clearance (CL/F) of omeprazole, lansoprazole and pantoprazole appears to be faster for children than for adults. A higher metabolic capacity in children as well as differences in the extent of PPI bioavailability are most likely responsible for this finding. This may partly account for the need in children for variable and sometimes considerably greater doses of PPIs, on a per kilogram basis, than for adults to achieve similar plasma concentrations. Furthermore, no studies have been able to demonstrate a statistically significant correlation between age and pharmacokinetic parameters among children. Despite the small number of very young infants studied, there is some evidence for reduced PPI metabolism in newborns. The limited paediatric data regarding the impact of CYP2C19 genetic polymorphism on PPI metabolism are similar to those reported for adults, with poor metabolisers having 6- to 10-fold higher area under the concentration-time curve values compared with extensive metabolisers. Finally, because a pharmacokinetic/pharmacodynamic relationship exists for PPIs, the significant interindividual variability in their disposition may partly explain the wide range of therapeutic doses used in children. Further studies are needed to better define the pharmacokinetics of PPIs in children <2 years of age.

Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective

This article focuses on the five most common bacterial enteropathogens of the developed world--Helicobacter pylori, Escherichia coli, Shigella, Salmonella, and Campylobacter--from the perspective of how they cause disease and how they relate to each other. Basic and recurring themes of bacterial pathogenesis, including mechanisms of entry, methods of adherence, sites of cellular injury, role of toxins, and how pathogens acquire particular virulence traits (and antimicrobial resistance), are discussed.

Antibiotic-resistant Helicobacter pylori strains in Portuguese children

BACKGROUND

Data concerning the effectiveness of Helicobacter pylori eradication regimens based in antibiotic susceptibility testing are scanty in children.

AIMS

To identify the prevalence of antibiotic resistance in H. pylori strains isolated from Portuguese children in 1999-2003; to evaluate eradication rate after antibiotic susceptibility testing-based treatment; and to identify factors associated with resistance and eradication outcome.

METHODS

Included were 109 children with a gastric biopsy culture positive for H. pylori. First treatment (amoxicillin, omeprazole and clarithromycin or metronidazole) was guided by susceptibility testing (E test), and eradication was assessed by [C]urea breath test.

RESULTS

Strains were susceptible to amoxicillin and tetracycline; 39.4% were resistant to clarithromycin, 16.5% to metronidazole and 4.5% to ciprofloxacin. No significant association was found between resistance and sex, age, clinical status, gastritis scores, H. pylori density scores and genotype. Clarithromycin resistance was significantly associated with European origin [odds ratio (OR), 3.9], previous H. pylori empiric therapy (OR 2.8) and amoxicillin minimal inhibitory concentration, > or =0.016 (OR 6.0). Eradication rate after susceptibility-based treatment was 74.7% (59 of 79; 95% confidence interval, 65.9-82.9), and a significant association was found between eradication failure and presence of resistance to 1 or more antibiotics (P < 0.05).

CONCLUSIONS

The prevalence of H. pylori antibiotic resistance was high in the studied population. The modest therapeutic success of clarithromycin and metronidazole susceptibility-based regimens suggests that in addition to resistance, other factors may be involved. The need of susceptibility-based treatment studies in children and of antimicrobial resistance surveillance in high prevalence areas for H. pylori are emphasized.

Treatment regimens for Helicobacter pylori infection in children: is in vitro susceptibility testing helpful?

BACKGROUND

Treatment regimens for Helicobacter pylori have variable success rates, and data comparing effectiveness with respect to strain sensitivity are relatively scarce.

OBJECTIVE

To evaluate the efficacy of two treatment regimens for eradication of H. pylori and the impact of bacterial susceptibility testing.

STUDY DESIGN

265 children endoscopically diagnosed with H. pylori infection were randomly assigned to receive omeprazole + amoxicillin with clarithromycin or omeprazole + amoxicillin with metronidazole. Bacterial culture and susceptibility was performed in a subgroup. Eradication was assessed by C-urea breath test.

RESULTS

Eradication was achieved in 73.4% by omeprazole + amoxicillin with metronidazole and in 62.6% by omeprazole + amoxicillin with clarithromycin (P = 0.078). H. pylori was cultured successfully in 105 patients. Resistance to metronidazole was detected in 31.4% of the isolates and resistance to clarithromycin in 15%. Eradication rate by omeprazole + amoxicillin with metronidazole for metronidazole-susceptible bacteria (N = 38) was 90%, and for resistant bacteria (N = 19) it was 42%. Only 75% of clarithromycin-sensitive strains were successfully treated by omeprazole + amoxicillin with clarithromycin, and none of the cases with clarithromycin-resistant strains responded to omeprazole + amoxicillin with clarithromycin treatment.

CONCLUSION

There is a trend of greater efficacy of eradication with omeprazole + amoxicillin with metronidazole versus omeprazole + amoxicillin with clarithromycin therapy. Although resistance negatively influences eradication, first-line sensitivity-based treatment would be expected to improve this rate only slightly. Susceptibility testing should probably be reserved only for treatment failures.

Helicobacter pylori infection: detection, investigation, and management

Helicobacter pylori infection causes gastritis and peptic ulcers and is associated with the development of gastric cancer. Approximately 50% of the world population is infected with H pylori , with the highest prevalence rates in developing countries. In the vast majority of individuals, infection is acquired during childhood with those of low socioeconomic means and having infected family members being at highest risk for early childhood acquisition. Definitive routes of transmission of the infection are unclear, with evidence suggesting oral-oral, gastric-oral, and fecal-oral routes. If untreated, H pylori infection is lifelong. Although clinical disease typically occurs decades after initial infection acquisition, children infected with H pylori may have gastritis, ulcers, mucosal-associated lymphoid type lymphoma, and, rarely, gastric atrophy with/without intestinal metaplasia (ie, both precursor lesions for gastric cancer). Controversy persists regarding testing for and treating H pylori , if found, in the large number of children who present with recurrent abdominal pain. Because young children (ie, younger than 5 years of age) who are treated and cured of their H pylori infection may be at risk for reinfection, the current recommendations do not recommend treatment unless an ulcer or gastric atrophy is present. However, despite the lack of clinical evidence, the trend is to more aggressively screen children for the presence of H pylori and to treat those children who are found to have the infection. H pylori infection can be eradicated by antimicrobial therapy plus a proton pump inhibitor, but no treatment regimen is 100% effective. Multiple drugs, frequent dosing, and length of treatment often contribute to poor patient compliance, and antibiotic eradication therapy is associated with increasing drug resistance.

Inhibidores de la bomba de protones en pediatría

In last years the use in the pediatric area of proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole) is more often, nevertheless the clinical trials carried out are poor. The aim of this work is to analyse the bibliography published about this kind of drugs in children and to make a revision of its use in the last seven years. More studies with omeprazole and lansoprazole have been developed, to be exact omeprazole and lansoprazole is present in 122 bibliographic appointments and 34 for lansoprazole, which include studies that demonstrate a good tolerance and efficacy. The remaining proton pump inhibitors count with very few studies. The main therapeutic indications were the eradication of Helicobacter pylori, gastroesophageal reflux disease and esophagitis. The number of patients included in the reviewed studies is quite heterogeneous, from 8 to 122 and the age range between 8 days and 17 years. On the other hand, it could be highlighted the non-existence of formulations adapted to the pediatric population and the difficulty of administration specially in the youngest patients. As in many other drugs, it would be necessary to carry out clinical trials in order to determinate the pharmacologic parameters at difference ages, which will allow a safe and effective administration, and its authorization by all Health Authorities.

A review of current guidelines for the management of Helicobacter pylori infection in children and adolescents

Helicobacter pylori infection is acquired in childhood and plays a causative role in chronic gastritis, peptic ulcer disease and the development of gastric cancer. The present review focuses on recent advances in the management of H pylori infection in children and provides an update of current Canadian guidelines regarding clinical sequelae, diagnosis and treatment.

Pediatric gastric and duodenal disorders

PURPOSE OF REVIEW

This review provides a summary of new developments regarding common diseases affecting the stomach and duodenum in children.

RECENT FINDINGS

Celiac disease seems to be more prevalent than previously thought in different areas of the world, including the United States. The value of different serologic screening tools and other noninvasive tests has been carefully assessed. HLA-DQ typing has been proposed as part of celiac disease screening testing for high-risk groups. The use of the newly defined pediatric Rome criteria is allowing recognition of nonulcer (or functional) dyspepsia as an entity that affects a sizable subset of children. Testing of gastric sensory and motor function is clarifying the pathophysiology of this condition in children and adolescents. Intriguing data are also emerging about the possible role of mucosal eosinophils and disaccharidase deficiencies in causing dyspeptic symptoms. Intrasphincteric injection of botulinum toxin A represents a novel technique to treat gastroparesis. In refractory cases, the use of a gastric electric stimulator has shown to be beneficial in idiopathic and diabetic gastroparesis. Progress has been made in understanding the epidemiology of Helicobacter pylori infection in developing countries and its role in causing a wide spectrum of symptoms in children. Several noninvasive methods for its diagnosis have been established.

SUMMARY

Recent developments in the diagnosis and management of gastric and duodenal pathologic conditions are making a significant impact on pediatric clinical care. Future studies will likely continue to explore the use of minimally invasive testing and interventions in such conditions.

Helicobacter heilmannii gastroduodenal disease and clinical aspects in children with dyspeptic symptoms

AIM

To evaluate the occurrence and clinical characteristics of Helicobacter heilmannii infection among children presenting with dyspeptic symptoms.

METHOD

Prospective cohort study of 580 patients.

RESULTS

Of all examined dyspeptic children, 26.4% were infected with spiral-shaped organisms, and 0.9% of patients were found to be infected with spiral H. heilmannii-like organisms.

CONCLUSION

In children with dyspeptic symptoms, the possible presence of gastroduodenal disease due to H. heilmannii should be considered. Further studies are needed to clarify H. heilmannii-related gastroduodenal pathology in the paediatric population.

Appropriate strategies for testing and treating Helicobacter pylori in children: when and how?

Helicobacter pylori infection is acquired primarily during childhood and carries a significant lifetime risk for morbidity. In developing countries, approximately 70% of children are infected with the bacterium by their 15th birthday. In the United States, the rate of H pylori infection among children varies widely--approximately 10% of all 10-year-olds are infected; however, this figure is substantially higher among populations of immigrant children and children born of recent immigrants to the United States. H pylori transmission is primarily "person-to-person" via fecal-oral, gastric-oral, or oral-oral routes, with evidence suggesting contaminated water as a potential source of infection. Risk factors for infection in childhood include an infected family member, having > or =2 siblings, crowded living conditions, lower socioeconomic means, and attendance at a daycare facility. The natural history of H pylori infection includes an increased lifetime risk for peptic ulcer and gastric adenocarcinoma or lymphoma. In children and adults who develop H pylori-related peptic ulcer, cure of the infection is associated with a <5% rate of ulcer recurrence. The ideal mode of H pylori detection among children is unclear--currently available serology and whole blood tests are unreliable, while the urea breath test and stool antigen tests have not been studied adequately. Children with confirmed H pylori-related peptic ulcer disease, iron-deficiency (sideropenic) anemia, or a first-degree relative with gastric cancer should be treated for the infection using 1 of 3 available 10- to 14-day triple therapy regimens recommended by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Symptomatic response to Helicobacter pylori eradication in children with recurrent abdominal pain: double blind randomized placebo-controlled trial

BACKGROUND

Controlled trials considering the effect of Helicobacter pylori (H. pylori) eradication on gastrointestinal symptoms in children are scant. We aimed to study the connection between recurrent abdominal pain and dyspepsia and H. pylori infection in children.

STUDY

This was a double blind randomised controlled trial. Twenty children with recurrent abdominal pain (RAP) being H. pylori positive as measured with the C urea breath test (UBT) were randomized either to receive omeprazole, amoxycillin and clarithromycin (n = 10), or omeprazole and 2 placebos (n = 10) for 1 week after gastroscopy. Symptoms were registered prior to the treatment and at follow up visits 2, 6, 24, and 52 weeks after stopping the treatment. Control UBT was performed on all patients 6 weeks post-treatment and again at the 52 week follow-up visit, when also re-endoscopy with biopsies was done to all participants.

RESULTS

All infected children had histologic gastritis. Bacterial eradication was achieved in 8/10 in the triple treatment group and in none in the placebo group. There was no change in symptom index in either group at 2 weeks post treatment. At 52 weeks a similar reduction in symptom index was observed in both groups irrespective of the healing of gastritis, which was more commonly achieved along the eradication.

CONCLUSIONS

Bacterial eradication and healing of gastric inflammation does not lead to symptomatic relief of chronic abdominal pain in children.

Helicobacter pylori eradication in children and adolescents by a once daily 6-day treatment with or without a proton pump inhibitor in a double-blind randomized trial

AIM

To evaluate two simplified Helicobacter pylori eradication treatment alternatives for children and adolescents.

METHODS

Study subjects were identified by enzyme-linked immunosorbent assay and immunoblot in a family screening project. Helicobacter pylori infected 10-21 year olds were offered treatment, individuals with abdominal pain underwent upper endoscopy and those with peptic ulcers were excluded. Participants were randomized to either azithromycin 500 mg daily and tinidazole 500 mg two tablets daily in combination with lansoprasole 30 mg daily for 6 days (ATL-group) or with placebo (ATP-group). Urea Breath Test was performed at inclusion and after a minimum of 6 weeks after end of therapy.

RESULTS

In total, 131 individuals were randomized, of whom 31 (24%) had undergone upper endoscopy. Full compliance was achieved in 93% (122 of 131). The intention-to-treat eradication rate was 67% (44 of 66) and 58% (38 of 65) for the ATL- and the ATP-group, respectively.

CONCLUSION

The double-blind randomized clinical trial did not identify a simplified, successful once daily H. pylori treatment for children and adolescents. Thus, twice daily proton pump inhibitor (PPI)-based triple therapies for 7 days remain as the choice of treatment in children. Further, powerful and controlled studies are needed to elucidate the best treatment strategies for H. pylori eradication in this age group.

Dual vs. triple therapy for childhood Helicobacter pylori gastritis: a double-blind randomized multicentre trial

BACKGROUND

Data on the efficacy of eradication treatment for Helicobacter pylori gastritis in children are scarce.

AIM

To evaluate the efficacy of triple therapy with lansoprazole plus amoxicillin and tinidazole vs. dual therapy with amoxicillin and tinidazole in a double-blind randomized multicentre trial, and the usefulness of eradication in terms of long-term symptom resolution.

SUBJECTS

We enrolled 43 consecutive children undergoing endoscopy for upper gastrointestinal dyspepsia with H. pylori gastritis. They underwent a 13C-urea breath test, completed a 2-week symptom diary card, and were randomized. Treatment was given in a Redidose box (Redidose Company Ltd., Brighton, UK) containing either lansoprazole-amoxicillin-tinidazole (triple therapy) or placebo plus amoxicillin-tinidazole (dual therapy) for 1 week. The completion of a 2-week symptom diary card and the performance of a breath test were repeated 6 weeks and 6 months after the end of therapy. One to two years later, a structured telephone interview was conducted with 36 of the children.

RESULTS

According to the breath test, 6 weeks after the end of therapy H. pylori was eradicated in 15 of 22 children on triple therapy [68.2%; 95% confidence interval (CI) = 45-88] and in 15 of 21 children on dual therapy (71%; 95% CI = 48-89; not significant), and 6 months after the end of therapy it was eradicated in 16 of 22 children on triple therapy (72.7%) and in 15 of 21 children on dual therapy. Six months after therapy, symptoms were analysed in 11 H. pylori-positive and 31 H. pylori-negative children, and it was found that dyspeptic symptoms had disappeared or improved in both groups, with no difference between them. One to two years later, 36 children were interviewed. Epigastric pain had recurred in three of 26 H. pylori-negative and in seven of 10 H. pylori-positive children (p = .001); in three of the latter, pain was severe and required additional treatment.

CONCLUSION

One-week triple or dual therapy with two antibiotics achieved similar eradication rates. Soon after treatment, symptoms disappeared or improved in most children irrespective of eradication, but epigastric pain recurred in the majority of the still-infected children within 2 years.

Helicobacter pylori infection in Turkish children: comparison of diagnostic tests, evaluation of eradication rate, and changes in symptoms after eradication

BACKGROUND

Helicobacter pylori infection is most frequently acquired in childhood. After this organism is eradicated, the rate of reinfection is low. Thus, it is very important to diagnose and treat the disease appropriately in childhood, and to be able to assess eradication with certainty. Eradication of H. pylori infection is reported to reduce or eliminate abdominal pain and dyspeptic symptoms in children.

PATIENTS AND METHODS

The study involved 102 children who had already been diagnosed with symptomatic H. pylori infection based on gastric histopathological examination, urea breath test, rapid urease test, serology and culture. Each patient's symptoms and family history of gastrointestinal problems were recorded. Using histology as the gold standard for identifying H. pylori infection, we determined the diagnostic sensitivity of each of the other methods. Omeprazole or lansoprazole, amoxicillin and clarithromycin were administered as eradication treatment, and each patient was re-evaluated by urea breath test 8 weeks later. Each child was re-interviewed about symptoms after treatment. These answers and the results of drug sensitivity testing were recorded. Cases of failed eradication were re-treated with a quadruple-drug regimen of tetracycline, metronidazole, bismuth subsalicylate and omeprazole.

RESULTS

The most frequent symptom was abdominal pain (89.2%). Fifty-four per cent of the subjects had a family history of dyspeptic symptoms. Sixty-six patients (64.7%) exhibited nodularity in the antral mucosa. The sensitivities of the diagnostic tests in histologically proven cases were as follows: urea breath test 100%, rapid urease test 89.2%, serology 71.9%, and culture 54.9%. Metronidazole had the highest frequency of resistance (36.4%) and the rate of clarithromycin resistance was 18.2%. The eradication rate after first-line therapy was 75.5%, and abdominal pain and dyspeptic symptoms were reduced or completely resolved in 75.7% of the successful-eradication cases. The proportion of failed-eradication cases that responded well to quadruple-drug therapy was 93.8%.

CONCLUSION

Symptomatic H. pylori infection in a child should always be treated. The urea breath test is an accurate and reliable way to identify H. pylori-positive patients and to determine the response to treatment. Triple-agent therapy is effective for eradicating H. pylori infection in children and usually helps reduce or eliminate dyspeptic symptoms. The level of H. pylori resistance to metronidazole is high in our region. The significant rate of resistance to clarithromycin (18.1%) may explain the treatment failure observed in this study.

Helicobacter pylori infection in pediatric population: epidemiology, pathophysiology, and therapy

Helicobacter pylori, one of the most commonly encountered human pathogens, has been recognized in more than half of adults and children with chronic nonspecific gastritis, and nearly all children with peptic ulcer disease demonstrate antral infection with H. pylori. A high prevalence and early colonization of H. pylori infection in childhood was described in developing countries in contrast to developed countries. The current diagnostic methods include histology, microbiological culture, urease activity detection, polymerase chain reaction, and stool antigen detection. The infection often presents with nausea, vomiting, and epigastric pain but may remain asymptomatic. The treatment modality options are multiple; however, the association of a proton-pump inhibitor and two antibiotics for 1 or 2 weeks gives the best eradication rates. Drug resistance is a growing problem in this microorganism and new therapeutic options are currently limited.

Helicobacter pylori infection in pediatrics

A high prevalence and early colonization of Helicobacter pylori infection in childhood was described again this year in developing countries in contrast to developed ones. Upper gastrointestinal endoscopy including gastric biopsies remains the diagnostic gold standard method for this infection. Also noninvasive tests have been studied in children, including serology, 13C-urea breath test and stool antigen test, showing good results in the different age groups as compared to the gold standard. However, the infection often remains asymptomatic in children and the role of this bacterium in gastric manifestations is the subject of conflicting reports. Extra-digestive manifestations are also reported in the course of this infection. The treatment of H. pylori infection is influenced by resistance of the bacteria to the antibiotics used. We suggest that eradication of H. pylori should take place only after susceptibility testing. The association of a proton pump inhibitor and two antibiotics for 1 or 2 weeks gives the best eradication rates. The crucial question to elucidate is whether asymptomatic children should be treated to prevent cancer in the future.

The use of proton pump inhibitors in children: a comprehensive review

Proton pump inhibitors (PPIs) belong to a group of chemically related compounds whose primary function is the inhibition of acid production in the final common metabolic pathway of gastric parietal cells. PPIs are highly selective and effective in their action and have few short- or long-term adverse effects. These pharmacologic features have made the development of PPIs the most significant advancement in the management of acid peptic related disorders in the last two decades. There are numerous published adult studies that describe the pharmacology, efficacy and safety of these anti-secretory agents; however, in the pediatric population, there are very few comparable studies, particularly multicenter studies with significant patient enrollment. In preparing this article, our aim was to perform a comprehensive review of the literature on the clinical pharmacology and use of PPIs in the pediatric population, and to briefly review some recent articles. Relevant literature was identified by performing MEDLINE/Pubmed searches from January 1990 to December 2001. Combinations of the following search terms were use to analyze these databases: proton pump inhibitor, children, pediatrics, gastroesophageal reflux disease (GERD), esophagitis, intestinal metaplasia, Helicobacter pylori, omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, and safety. Abstracts from the 14th annual conference of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) 2001, and the Disease and Digestive Week 2001, were also included in the review. All pediatric studies reviewed were limited to either omeprazole or lansoprazole. The dosage range used for the management of GERD and related disorders with lansoprazole was 0.73-1.66 mg/kg/day (maximum 30 mg/day). The dosage range for GERD management using omeprazole was 0.3-3.5 mg/kg (maximum 80 mg/day). The dosage range for omeprazole used for H. pylori was 0.5-1.5 mg/kg/day, with a maximum dosage of 40 mg/day, and lansoprazole-containing regimens for H. pylori eradication used dosages ranging from 0.6-1.2 mg/kg/day, with a maximum dosage of 30 mg/day. Few severe adverse events were reported with the use of either drug. Eradication rates for H. pylori were 56-87% for lansoprazole-based triple therapy, and 75-94% for omeprazole-based eradication regimens. To date, there are no published controlled trials of sufficient power comparing the efficacy of the five commercially available PPIs in children, for a variety of acid peptic diseases. Studies suggest that PPIs are highly effective for the management of GERD and related disorders, and are a critically needed component of triple therapy to eradicate H. pylori. PPIs have a very good tolerability profile in adults and children, but long-term tolerability studies are needed, particularly in the pediatric population. Multicenter studies are critically needed to evaluate the second-generation PPIs, to compare PPI efficacy to each other, and to assess the importance of developmental and genetic pharmacology of these drugs in children with acid-peptic disease.

[Is upper gastro-intestinal endoscopy required for diagnosis and treatment of Helicobacter pylori infection in childhood? Pro and cons]

Non invasive tests are available and accurate for the diagnosis of H. pylori infection in children. They are safer and cheaper than endoscopy. Peptic ulcer and severe gastro-intestinal lesions associated with H. pylori infection are rare in childhood. However since the resistance to antibiotics is steadily increasing, biopsies are still required to assess sensitivity of germs to antibiotics. Search of H. pylori infection should be limited to the children presenting digestive symptoms severe enough to justify endoscopy and treatment.

Fluorescence in situ hybridization vs. epsilometer test for detection of clarithromycin-susceptible and clarithromycin-resistant Helicobacter pylori strains in gastric biopsies from children

AIM

To compare the results of culture and epsilometer test with fluorescence in situ hybridization for the detection of Helicobacter pylori and the presence of clarithromycin-susceptible and clarithromycin-resistant strains in antral biopsies from children.

METHODS

Antral biopsies from 149 unselected children were investigated prospectively; 15 had previously received anti-H. pylori therapy. H. pylori status was defined by histology, rapid urease test and 13C-urea breath test. Fluorescence in situ hybridization was applied on fresh tissue with probes specific for the clarithromycin-susceptible wild type and three clarithromycin-resistant mutants. Susceptibility to clarithromycin was tested by epsilometer test in two laboratories.

RESULTS

Culture and fluorescence in situ hybridization gave negative results in all 66 H. pylori-negative children (specificity, 100%). Of 83 infected children, cultures were successful in 75 (90%), epsilometer test in 71 (86%) and fluorescence in situ hybridization in 77 (93%). Eleven children (13%) showed discrepant results between the applied methods, indicating mixed infection. Clarithromycin-resistant isolates were identified in 16 of 73 previously untreated children.

CONCLUSIONS

Primary resistance to clarithromycin is common (22%) in H. pylori isolates from children living in Germany. Fluorescence in situ hybridization is an excellent, fast method for the detection of H. pylori and clarithromycin-resistant mutants in gastric biopsies. Multiple biopsies identify mixed infections, indicating that clarithromycin-resistant and clarithromycin- susceptible strains are not evenly distributed within the stomach.

Helicobacter pylori infection in pediatrics

In the past year the main interest was focused on the role of family for transmission of Helicobacter pylori to children; the evaluation of noninvasive diagnostic tests, especially in young children; extra-intestinal clinical manifestations; the lack of consensus on treatment; and the problem of high resistance of the microorganism to antibiotics.

[Microbiological factors that influence the eradication of Helicobacter pylori in adults and children]

AIM

To study microbiological factors of Helicobacter pylori, such as antimicrobial susceptibility and virulence, which affect the eradication of the microorganism in gastric mucosa of adult and pediatric patients.

METHODS

Fifty-five H. Pylori strains were isolated from culture of biopsy specimens from 39 adult and 16 pediatric patients. Antibiotic susceptibility was determined by agar dilution and study of virulence factors (cagA gene and alleles s1 and s2 of the vacA gene) by PCR. Outcome of treatment with amoxicillin (AMX), clarithromycin (CLR) and omeprazole was assessed by the urea breath test. We studied the relation of minimum inhibitory concentration (MIC) of AMX and CLR and presence of virulence factors with eradication of the microorganism.Results. The eradication rate was 69% (38/55), 71.7% in adults and 62.5% in children. Resistance to CLR and AMX was 14.5% and 0%, respectively. Overall eradication rates with respect to the variables studied were: 75% and 53% in strains with AMX MICs of < or = 0.01 6mg/L and > or = 0.032 mg/L (range < or = 0.008-0.5) (p > 0.05), 79% and 12% in strains with clarithromicina MICs of < 1 mg/L and > or = 1mg/L (range # 0.008-64) (p < 0.05), 79% and 54% in cagA+ and cagA strains (p > 0.05) and 82% and 62% in s1 and s2 strains (p > 0.05), respectively.

CONCLUSIONS

H. pylori strains with higher amoxicillin and clarithromycin MICs, and cagA and vacA s2 strains were related with lower rates of eradication in both adult and pediatric populations treated with amoxicillin, clarithromycin and omeprazole.