A prospective trial of lansoprazole triple therapy for pediatric Helicobacter pylori infection

Helicobacter pylori Infections in Children

In the context of epidemiology, host response, disease presentation, diagnosis, and treatment management, the manifestation of Helicobacter pylori (H. pylori) infection diverges between children and adults. H. pylori infection stands out as one of the most prevalent bacterial infections globally, and its prevalence in both children and adults is decreasing in many developing countries but some still struggle with a high prevalence of pediatric H. pylori infection and its consequences. The majority of infected children are asymptomatic and pediatric studies do not support the involvement of H. pylori in functional disorders such as recurrent abdominal pain. The pathophysiology of H. pylori infection relies on complex bacterial virulence mechanisms and their interaction with the host immune system and environmental factors. This interaction gives rise to diverse gastritis phenotypes, which subsequently influence the potential development of various gastroduodenal pathologies. In clinical settings, the diagnosis of this infection in childhood requires an upper gastrointestinal endoscopic exam with mucosal biopsy samples for histology and culture, or Polymerase Chain Reaction (PCR) at the very least. When warranted, eradication treatment should be given when good compliance is expected, and there should be systematic use of a treatment adapted to the antimicrobial susceptibility profile. To combat the burgeoning threat of multidrug resistance, vigilant surveillance of resistance patterns and strategic antibiotic management are paramount.

Effects of eradication of Helicobacter pylori on oral malodor and the oral environment: a single-center observational study

Objective

Although a relationship between Helicobacter pylori and oral malodor has been suggested, it remains to be confirmed. One reason for this is that many studies assess oral malodor subjectively. Another reason for the uncertainty is that the reduction in oral malodor may be due to the effect of antibiotics on the oral microbiota. In this study, changes in oral malodor along with the eradication treatment of H. pylori were investigated by organoleptic test and gas chromatography. In addition, the salivary bacterial composition and clinical parameters were analyzed.

Results

The organoleptic test score, hydrogen sulfide and dimethyl sulfide concentrations, and all clinical parameters except for tongue-coating score were significantly decreased at 1 week compared with baseline. Although antibiotic treatment also altered the overall composition of the salivary bacterial population, it had recovered at 7 weeks. On the date that H. pylori was determined to have been eradicated from all of the subjects (7 weeks after treatment), only the organoleptic test score was significantly lower compared with baseline. The hydrogen sulfide and dimethyl sulfide concentrations were non-significantly lower than those at baseline.

A Clinical Trial of Proton Pump Inhibitors to Treat Children with Chronic Otitis Media with Effusion

OBJECTIVE

Gastroesophageal reflux (GER) is considered a cause of otitis media with effusion (OME). This study aimed to investigate whether OME can be effectively treated with a proton pump inhibitor (PPI), therefore implicating GER as a causative factor of OME.

MATERIALS AND METHODS

A PPI or placebo was randomly administered to enrolled subjects for 4-8 weeks. To monitor effusion status, subjects underwent monthly pneumatic otoscopy and acoustic reflectometry. At enrollment and at completion of treatment, subjects underwent an audiogram and tympanogram for assessing changes in hearing due to altered fluid levels in the middle ear. After the treatment period, tympanostomy tube placement was recommended for subjects with unresolved effusion.

RESULTS

This study enrolled 16 patients with an average age of 5.17 years. Between the treatment and placebo groups, there was no significant difference in the need for tympanostomy tubes. At completion of this study, patients receiving Lansoprazole demonstrated a significant improvement in pure tone average (p<0.01) and speech recognition thresholds (p=0.04). Four patients (25%) from the cohort dropped out of the study. Eight patients (50%) from the cohort required tympanostomy tube placement.

CONCLUSION

Owing to difficulties with recruitment and small sample size, this study was unable to demonstrate the use of PPI in treating OME. A larger study is needed for further evaluation of this process.

Helicobacter pylori Infection in Pediatric Patients: Update on Diagnosis and Eradication Strategies

Helicobacter pylori infection is acquired mainly in childhood and remains an essential cause of peptic ulcer disease and gastric cancer. This article provides commentary on the last ESPGHAN/NASPGHAN guidelines and on publications made after the consensus conference of 2015. The majority of infected children are asymptomatic and pediatric studies do not support a role for H. pylori in functional disorders such as recurrent abdominal pain. The role of H. pylori infection in failure to thrive, children's growth, type I diabetes mellitus (T1DM), and celiac disease remains controversial. The diagnosis of infection should be based on upper-digestive endoscopy with biopsy-based methods. Eradication control after treatment should be based on validated non-invasive tests. Nodular gastritis is the main endoscopic finding of childhood H. pylori infection, but gastroduodenal erosions/ulcers are seen in some children, especially after 10 years of age. When indicated, eradication treatment should be given when good compliance is expected and based on the antimicrobial susceptibility profile.

Eradication rate of Helicobacter Pylori infection is directly influenced by adherence to therapy in children

BACKGROUND

Current commonly accepted strategies to eradicate Helicobacter pylori in children are a 10-day sequential treatment or a triple therapy for 7-14 days. To avoid further expensive and possibly risky investigations as well as induction of secondary antimicrobial resistance, a success rate of elimination strategies over 90% in a per-protocol analysis is the target goal but rates observed in clinical trials are lower. Antimicrobial resistance is a well-recognized risk factor for treatment failure; therefore, only a treatment tailored to susceptibility testing should be recommended. Adherence to therapy is also a risk factor for treatment failure but that has been poorly studied. The purpose of this study was to evaluate the influence of adherence to therapy on the elimination rates obtained with different treatment regimens.

METHODS

Cohort study analysis of children, aged 2-17 years, treated for Helicobacter pylori infection between October 2011 and December 2013. As a routine clinical practice, children infected with a strain susceptible to clarithromycin and to metronidazole received either a sequential regimen or a 10-day triple therapy while children infected with a strain resistant to clarithromycin or metronidazole received a 10-day triple regimen tailored to antimicrobial susceptibility. The eradication rate was assessed by a negative ¹³ C-urea breath test performed at least 8 weeks after the end of the treatment and adherence evaluated using a diary.

RESULTS

One hundred forty-five children (67 girls/78 boys, median age 9.7 years) fulfilled the inclusion criteria, 118 being infected with a strain susceptible to both clarithromycin and metronidazole, 10 with a clarithromycin resistant, and 17 with a metronidazole resistant strain. A sequential regimen was prescribed in 44, a triple therapy containing clarithromycin in 84 and containing metronidazole in 17. Follow-up data were available for 130/145 and clearance of the infection observed in 105 of them. A concordance of more than 90% between the prescribed and the ingested drugs was observed in 109 children, between 50 and 90% in eight, less than 50% in 11 while these data were unknown for 2/130. A successful eradication was achieved for 89.9% of patients that received at least 90% of the prescribed drugs, whereas the eradication rate for nonadherent patients was 36.6%. Adherence above 90% was significantly higher in the absence of chronic concomitant disease, in the absence of adverse event and results in a significantly higher eradication rate. With the proposed strategy and an adherence higher than 90%, eradication was obtained in 98/109 children, the rate being only significantly superior to 90% with the sequential regimen.

CONCLUSION

Adherence to therapy is a very important factor for the outcome and has to be assessed when evaluating the outcome of an H. pylori eradication regimen in order to understand the reasons of treatment failure. As we treated only after evaluation of the resistance of the H. Pylori strains, we were expecting to reach the given objective of 90% successful treatment. Children with adherence to treatment above 90% had a successful outcome of 89,9%, whereas nonadherent had a successful outcome of 36,8%. This is the first time that adherence has been assessed accurately.

Halitosis and helicobacter pylori infection: A meta-analysis

BACKGROUND

Halitosis is used to describe any disagreeable odor of expired air regardless of its origin. Numerous trials published have investigated the relation between Helicobacter pylori (H pylori) infection and halitosis, and even some regimes of H pylori eradication have been prescribed to those patients with halitosis in the clinic. We conducted a meta-analysis to define the correlation between H pylori infection and halitosis.

OBJECTIVES

To evaluate whether there is a real correlation between H pylori infection and halitosis, and whether H pylori eradication therapy will help relieve halitosis.

METHODS

We searched several electronic databases (The Cochrane Library, MEDLINE, EMBASE, PubMed, Web of Science, and Wanfangdata) up to December 2015. Studies published in English and Chinese were considered in this review. After a final set of studies was identified, the list of references reported in the included reports was reviewed to identify additional studies. Screening of titles and abstracts, data extraction and quality assessment was undertaken independently and in duplicate. All analyses were done using Review Manager 5.2 software.

RESULTS

A total of 115 articles were identified, 21 of which met the inclusion criteria and presented data that could be used in the analysis. The results showed that the OR of H pylori infection in the stomach between halitosis-positive patients and halitosis-negative patients was 4.03 (95% CI: 1.41-11.50; P = 0.009). The OR of halitosis between H pylori-positive patients and H pylori-negative patients was 2.85 (95% CI: 1.40-5.83; P = 0.004); The RR of halitosis after successful H pylori eradication in those H pylori-infected halitosis-positive patients was 0.17 (95% CI: 0.08-0.39; P <0.0001), compared with those patients without successful H pylori eradication. And the RR of halitosis before successful H pylori eradication therapy was 4.78 (95% CI: 1.45-15.80; P = 0.01), compared with after successful H pylori eradication therapy.

CONCLUSIONS

There is clear evidence that H pylori infection correlates with halitosis. H pylori infection might be important in the pathophysiological mechanism of halitosis, and H pylori eradication therapy may be helpful in those patients with refractory halitosis.

Cure rate of Helicobacter pylori infection in Egyptian children related to CYP2C19 gene polymorphism

OBJECTIVES

This study was done in order to investigate the effect of CYP2C19 genetic polymorphism on the cure rate of children who received proton pump inhibitors (PPI)-based triple therapy for treating Helicobacter pylori (H. pylori) infection.

METHODS

Participants included 100 children with H. pylori-positive gastritis diagnosed by endoscopy and biopsy in addition to H. pylori stool antigen test. Cure rate was assessed after 1 month of completion of a triple treatment course for 14 days. CYP2C19 polymorphism was analyzed by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method.

RESULTS

Results showed that cases with a CYP2C19 genotypic status consistent with the heterozygote extensive metabolizers (HetEMs) had a higher cure rate of H. pylori when compared with the homozygote extensive metabolizers (HomEMs) although it was statistically nonsignificant (84.6 vs. 69.2). In addition, the poor metabolizers (PMs) had a higher cure rate compared with those of the HomEMs which was also statistically nonsignificant (77.8 vs. 69.2). The cure rate was also higher among both the groups of HetEMs and PMs combined together compared to the HomEMs (OR = 2.15, p > 0.05). Comparing cases regarding their age, gender, and severity of H. pylori gastritis revealed a better cure rate in the age group >10 years, in females and in mild and moderate cases than other cases although statistically nonsignificant.

CONCLUSION

The higher cure rate of H. pylori infection using the triple therapy for 2 weeks among HetEMs and PMs cases compared to the HomEMs might warrant a need for a therapy augmentation or modification for the HomEMs.

The gastrointestinal aspects of halitosis

BACKGROUND

Halitosis is a common human condition for which the exact pathophysiological mechanism is unclear. It has been attributed mainly to oral pathologies. Halitosis resulting from gastrointestinal disorders is considered to be extremely rare. However, halitosis has often been reported among the symptoms related to Helicobacter pylori infection and gastroesophageal reflux disease.

OBJECTIVE

To retrospectively review the experience with children and young adults presenting with halitosis to a pediatric gastroenterology clinic.

METHODS

A retrospective chart review of patients diagnosed with halitosis as a primary or secondary symptom was conducted. All endoscopies were performed by the same endoscopist.

RESULTS

A total of 94 patients had halitosis, and of the 56 patients (59.6%) who were recently examined by a dental surgeon, pathology (eg, cavities) was found in only one (1.8%). Pathology was found in only six of 27 patients (28.7%) who were assessed by an otolaryngology surgeon. Gastrointestinal pathology was found to be very common, with halitosis present in 54 of the 94 (57.4%) patients. The pathology was noted regardless of dental or otolaryngological findings. Most pathologies, both macroscopically and microscopically, were noted in the stomach (60% non-H pylori related), followed by the duodenum and the esophagus. Fifty-two of 90 patients (57.8%) were offered a treatment based on their endoscopic findings. Of the 74 patients for whom halitosis improvement data were available, some improvement was noted in 24 patients (32.4%) and complete improvement was noted in 41 patients (55.4%).

CONCLUSIONS

Gastrointestinal pathology was very common in patients with halitosis regardless of dental or otolaryngological findings, and most patients improved with treatment.

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.

A review of the current literature on management of halitosis

Halitosis is an unpleasant or offensive odour, emanating from the oral cavity. In approximately 80% of all cases, halitosis is caused by microbial degradation of oral organic substrates. Major degradation products are volatile sulphur-containing compounds. In this review, the available management methods of halitosis and their effectiveness and significance are presented and discussed. Undoubtedly, the basic management is mechanically reducing the amount of micro-organisms and substrates in the oral cavity. Masking products are not, and antimicrobial ingredients in oral healthcare products are only temporary effective in reducing micro-organisms or their substrates. Good short-term results were reported with chlorhexidine. Triclosan seems less effective, essential oils and cetylpyridinium chloride are only effective up to 2 or 3 h. Metal ions and oxidizing agents, such as hydrogen peroxide, chlorine dioxide and iminium are active in neutralizing volatile sulphur-containing compounds. Zinc seems to be an effective safe metal at concentrations of at least 1%. The effectiveness of active ingredients in oral healthcare products is dependent on their concentration and above a certain concentration the ingredients can have unpleasant side effects. Tonsillectomy might be indicated if (i) all other causes of halitosis are managed properly; (ii) halitosis still persists and (iii) crypts in tonsils are found to contain malodorous substrates.

[Helicobacter pylori infection in children]

Knowledge about Helicobacter pylori infection in children continues to advance. While its prevalence appears to be falling in developed countries, it remains a major problem in developing nations. Its transmission pathway remains highly controversial. It has not yet been definitively elucidated, although the oral-oral route seems most probable. Infection is most often intrafamilial. Risk factors for infection are associated with low socioeconomic level, including overcrowding, unhygienic conditions, sharing beds in childhood, low maternal educational level. Infection in children differs from that in adults in three respects: symptoms, endoscopic appearance of the gastric mucosa, and histologic appearance of lesions. No study has established a clear association between recurrent abdominal pain and H. pylori infection. Nonetheless, in proven infections, recurrent abdominal pain is the most common marker. More recently, an association has been reported between H. pylori infection and iron deficiency anemia. The endoscopic aspect most suggestive of H. pylori infection in children is micronodular gastritis, but it is not specific to H. pylori infection. In children as in adults, H. pylori infection is always associated with histologic gastritis. Many questions about H. pylori remain unanswered, and numerous studies are still needed.

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.

Helicobacter pylori culture and antimicrobial resistance in Iran

OBJECTIVE

Helicobacter pylori is considered as an important etiologic factor in pathogenesis of peptic ulcer disease, chronic gastritis and gastric cancer. To eradicate this micro-organism, numerous regimens containing various antimicrobial agents have been suggested. However, H pylori antimicrobial resistance is a leading factor to treatment failure and recurrence of the disease. The aim of the study was to evaluate the prevalence of H pylori resistance to metronidazole, clarithromycin, tetracycline, amoxicillin, erythromycin and furazolidone in authors pediatric patients.

METHODS

Antral biopsy of all pediatric patients with negative history of receiving anti-H pylori regimen and endoscopic findings of nodular gastritis or peptic ulcer without previous history of NSAID consumption, burning and trauma were performed for H pylori histology, urease test and culture. All positive cultures were tested for antimicrobial susceptibility.

RESULTS

Twenty four patients (14 male and 10 female) between 3.5 and 14 years of age were culture positive. 54.16% of the isolates were resistant to metronidazole, 8.33% to amoxicillin, 4.16% to erythromycin and 4.16% to clarithromycin. None of authors patients were resistant to tetracycline and furazolidone.

CONCLUSION

H. pylori antimicrobial resistance could be a major contributor to failure of H pylori eradication. Continuous prospective surveillance of H. Pylori is essential. Moreover, culture and antimicrobial susceptibility test is recommended for resistant cases after the first failure to therapy.

Helicobacter pylori infection with a duodenal ulcer in a 6-year-old boy

A 6-year-old boy was hospitalized because of dark feces and facial pallor of 1 weeks duration. Other gastrointestinal symptoms, including vomiting and abdominal pain, were absent, but he felt dizziness when standing and fatigue on effort. Hematologic studies revealed iron-deficiency anemia, and endoscopy showed gastric erosions and a duodenal ulcer. All test results for Helicobacter pylori infection, including H. pylori antigen in stool, anti-H. pylori IgG immunoassay in serum, and the (13)C-urea breath test, were positive. Because an H. pylori-associated gastric ulcer had been diagnosed with endoscopy in the patients father 3 years earlier, father-son transmission was suspected. The patient was treated with triple-agent eradication therapy (proton pump inhibitor [lansoprazol], amoxicillin, and clarithromycin) for 2 weeks. One month after therapy was completed, eradication of H. pylori was confirmed by negative results on the stool antigen test. Peptic ulcer disease can occur in young children, as in this case. The stool antigen test kit is a useful and reliable method that can be used even in preschool children to diagnose H. pylori infection.

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.

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.

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.

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.

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 is not associated with specific symptoms in nonulcer-dyspeptic children

OBJECTIVES

To assess symptoms associated with Helicobacter pylori infection in children presenting with nonulcer dyspepsia (NUD).

STUDY DESIGN

A prospective double-blind study was conducted between March 2001 and April 2002 in children at least 6 years old with NUD who had been referred for upper gastrointestinal endoscopy for epigastric pain. A standardized questionnaire was administered blindly by a pediatric gastroenterologist. This questionnaire characterized epigastric pain and associated factors. Infection was confirmed by positive culture and histologic examination of the gastric mucosa.

RESULTS

From 100 children enrolled, 26 proved infected (12 female, 14 male; mean age: 11.4 +/- 2.6 years), and 74 were noninfected (44 female, 30 male; mean age: 10.4 +/- 3.1 years). There were no differences in age or symptom characteristics between groups except for epigastric pain during meals that was more frequent in noninfected than in infected children (25.6% vs 3.8%).

CONCLUSION

There were no specific characteristics of symptoms in nonulcer-dyspeptic H pylori-infected children as compared with noninfected children.

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.

Detection of Helicobacter ganmani-like 16S rDNA in pediatric liver tissue

BACKGROUND

To determine the presence of Helicobacter species in the liver biopsy specimens from children with various chronic liver diseases as data in adult literature suggests a possible role of these bacteria in their pathogenesis.

MATERIALS AND METHODS

Paraffin sections of 61 liver biopsies of pediatric patients with miscellaneous diseases and autopsy liver tissue from 10 control subjects with no evidence of preexisting liver disease were examined for the presence of Helicobacter species by a genus-specific seminested polymerase chain reaction (PCR) assay. PCR-products of positive samples were further characterized by denaturing gradient gel electrophoresis (DGGE) and DNA-sequence analysis. Based on those results, a seminested PCR assay for H. ganmani was developed and applied to the samples.

RESULTS

On analysis, 40/61 patient samples were positive in the genus-specific Helicobacter PCR and 4/10 from the control group. The nucleotide sequences of 16S rDNA fragments were 99-100% similar to mainly Helicobacter sp. 'liver' and H. ganmani. PCR-products similar to H. canis and H. bilis were also found. The 16S rDNAs of control specimens showed similarity to Helicobacter sp. 'liver'. In the H. ganmani-specific PCR analysis 19 patients, but none of the controls, were positive.

CONCLUSIONS

Amplified Helicobacter 16S rDNAs were related to Helicobacter sp. 'liver' or H. ganmani in liver biopsy specimens of pediatric patients. The possible significance of Helicobacter species in pediatric liver diseases needs to be evaluated further in prospective studies.

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.

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.

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.

Systematic review of treatments for recurrent abdominal pain

OBJECTIVE

To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children.

METHODS

Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results.

RESULTS

Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance.

CONCLUSIONS

Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.

Lansoprazole: an update of its place in the management of acid-related disorders

Lansoprazole is an inhibitor of gastric acid secretion and also exhibits antibacterial activity against Helicobacter pylori in vitro. Current therapy for peptic ulcer disease focuses on the eradication of H. pylori infection with maintenance therapy indicated in those patients who are not cured of H. pylori and those with ulcers resistant to healing. Lansoprazole 30 mg combined with amoxicillin 1g, clarithromycin 250 or 500mg, or metronidazole 400 mg twice daily was associated with eradication rates ranging from 71 to 94%, and ulcer healing rates were generally >80% in well designed studies. In addition, it was as effective as omeprazole- or rabeprazole-based regimens which included these antimicrobial agents. Maintenance therapy with lansoprazole 30 mg/day was significantly more effective than either placebo or ranitidine in preventing ulcer relapse. Importantly, preliminary data suggest that lansoprazole-based eradication therapy is effective in children and the elderly. In the short-term treatment of patients with gastro-oesophageal reflux disease (GORD), lansoprazole 15, 30 or 60 mg/day was significantly more effective than placebo, ranitidine 300 mg/day or cisapride 40 mg/day and similar in efficacy to pantoprazole 40 mg/day in terms of healing of oesophagitis. Lansoprazole 30 mg/day, omeprazole 20 mg/day and pantoprazole 40 mg/day all provided similar symptom relief in these patients. In patients with healed oesophagitis. 12-month maintenance therapy with lansoprazole 15 or 30 mg/day prevented recurrence and was similar to or more effective than omeprazole 10 or 20 mg/day. Available data in patients with NSAID-related disorders or acid-related dyspepsia suggest that lansoprazole is effective in these patients in terms of the prevention of NSAID-related gastrointestinal complications, ulcer healing and symptom relief. Meta-analytic data and postmarketing surveillance in >30,000 patients indicate that lansoprazole is well tolerated both as monotherapy and in combination with antimicrobial agents. After lansoprazole monotherapy commonly reported adverse events included dose-dependent diarrhoea, nausea/vomiting, headache and abdominal pain. After short-term treatment in patients with peptic ulcer, GORD, dyspepsia and gastritis the incidence of adverse events associated with lansoprazole was generally < or = 5%. Similar adverse events were seen in long-term trials, although the incidence was generally higher (< or = 10%). When lansoprazole was administered in combination with amoxicillin, clarithromycin or metronidazole adverse events included diarrhoea, headache and taste disturbance. In conclusion, lansoprazole-based triple therapy is an effective treatment option for the eradication of H. pylori infection in patients with peptic ulcer disease. Preliminary data suggest it may have an important role in the management of this infection in children and the elderly. In the short-term management of GORD, lansoprazole monotherapy offers a more effective alternative to histamine H2-receptor antagonists and initial data indicate that it is an effective short-term treatment option in children and adolescents. In adults lansoprazole maintenance therapy is also an established treatment option for the long-term management of this chronic disease. Lansoprazole has a role in the treatment and prevention of NSAID-related ulcers and the treatment of acid-related dyspepsia; however, further studies are needed to confirm its place in these indications. Lansoprazole has emerged as a useful and well tolerated treatment option in the management of acid-related disorders.

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

OBJECTIVES

The aim of this multicenter prospective, randomized, double-blind study was to assess the efficacy of the combination of omeprazole, amoxicillin, and clarithromycin (OAC) for the treatment of Helicobacter pylori gastritis in children.

STUDY DESIGN

Seventy-three children with dyspeptic symptoms were included in the trial (mean age 10.8 years; range, 3.3 to 15.4). Patients were randomized to receive OAC or amoxicillin and clarithromycin (AC) for 7 days. H pylori status was assessed before and 4 weeks after eradication treatment, by use of the carbon 13-labeled urea breath test.

RESULTS

In intent-to-treat analysis (n = 63), eradication rates were 74.2% (95% CI, 58.7 to 89.6) in the OAC group and 9.4% (95% CI, 0 to 19.5) in the AC group. In per-protocol analysis (n = 53), the eradication rate increased to 80% (95% CI, 64.3 to 95.7), remaining significantly higher than in AC group (10.7%; 95% CI, 0 to 22.2). Resistance of strains to clarithromycin was rare (3/39 = 7.7%) and was not associated with failure of treatment. Adverse events were reported in 24.6% of patients and remained mild.

CONCLUSION

This study shows that 1-week OAC triple therapy results in successful eradication of H pylori in 75% of children with gastritis.

Treatment of Helicobacter pylori in children with recurrent abdominal pain

BACKGROUND

The role of Helicobacter pylori remains unclear in children with recurrent abdominal pain (RAP). In this study children with RAP were included in a double blind treatment study to elucidate whether symptoms disappear in children with a H. pylori infection and RAP, if the bacteria are eradicated.

METHODS

Thirty-seven H. pylori-infected children aged 4.9-14.5 years (median 9.8 years) with RAP were included. H. pylori was identified by histology and culture. The children were treated with amoxicillin and metronidazole for 14 days. A re-endoscopy including biopsies for histology and culture was done at least one month after the end of treatment. Simple questions for symptoms were asked and blood for serology was repeated 3 and 6 months after the end of treatment. During the observation period the results of the re-endoscopy and the serology 3 and 6 months after the re-endoscopy were blinded for 23 patients and opened to 14 of the patients according to the choice of the families.

RESULTS

The eradication rates were 81% (30/37) in the total group and 74% (17/23) in the blinded group. The IgG antibodies to H. pylori decreased significantly 3 (p =.03) as well as 6 months after end of treatment (p <.001) in children with successful eradication. The number of children with RAP decreased after examination and treatment and the well-being improved after 6 months in almost 95% of the children. However, no correlation was seen between eradication of H. pylori and disappearance of RAP, neither after 3 nor after 6 months' observation in the total group of patients (p =.94 and p =.90) or in the blinded group (p =.42 and p =.65).

CONCLUSIONS

These results do not provide evidence for a causal relationship between RAP and H. pylori.

Infants differ from teenagers: use of non-invasive tests for detection of Helicobacter pylori infection in children

Reliable non-invasive tests that are feasible in early childhood are essential to the study of transmission of Helicobacter pylori, since most individuals get infected during the first years of life. New tests are validated by comparison with a "gold standard", but no single test for detection of H. pylori infection can be used as a fully reliable reference method. Therefore, concordant results of at least two biopsy-based tests (histology, culture, rapid urease test) are considered as the "gold standard". Most of the validation studies in children included only a few infants and toddlers, with low numbers particularly for H. pylori-infected individuals. Only when increasing numbers of patients were tested and separated into subgroups by age it became apparent that the accuracy of most tests is lower in young children if the same cut-off values are used as established for older children or adults. Therefore, statements such as "a test has been validated with good results in children" must be interpreted with caution, unless different age groups are considered with sufficient numbers of infected and non-infected children in each age group.

The role of Helicobacter pylori in paediatrics

Helicobacter pylori is a bacterium that colonizes the human stomach, especially during childhood. Although it has been studied intensively during the past decade, many controversies still exist on many important issues, including the clinical relevance of virulence factors, indications for treatment, recommended procedures for diagnosis and the typical symptom profile, among others. The lack of double-blind, placebo-controlled studies in children illustrates the paucity of hard scientific data, and is the major reason for differences in opinion. Therefore, the present review of literature published during the past 2 years raises many questions.

Helicobacter pylori culture and antimicrobial susceptibility from pediatric patients in Michigan

BACKGROUND

We recently observed a high failure rate in the eradication of Helicobacter pylori infection in children with 2-week triple therapy using lansoprazole, amoxicillin and clarithromycin. We performed a prospective evaluation of antral biopsies of all children subsequently diagnosed with H. pylori gastritis for culture and antimicrobial susceptibility assessment.

METHODS

All children with antral nodularity and/or an elevated anti-H. pylori IgG titer underwent antral biopsies for histology, urease test and culture while undergoing an upper endoscopy for routine indications. All positive cultures were tested for antimicrobial susceptibility by E-test for clarithromycin, amoxicillin, tetracycline and metronidazole.

RESULTS

Thirty-one children (16 male, 15 female) between 2 and 19 years of age were diagnosed with H. pylori gastritis by histology. However, culture was positive in only 22 of 31 (71%) patients. The E-test in vitro antimicrobial susceptibility testing revealed that 95.6% of the isolates were susceptible to amoxicillin, 59% to clarithromycin and 54.6% to metronidazole. There was no resistance to tetracycline.

CONCLUSION

Evaluation of antibiotic resistance profiles from pediatric patients from different geographic areas can help in optimizing therapeutic regimen to prevent treatment failures. Metronidazole and clarithromycin resistance is much higher in our pediatric population than reported in adults and could be a major contributor to failure of H. pylori eradication.