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

Empirical vs. Susceptibility-Guided Treatment of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

Background

Treating Helicobacter pylori infection according to antibiotic resistance has been frequently recommended. However, information on its real effectiveness is scarce.

Aim

The aim of this study is to perform a meta-analysis comparing empirical vs. susceptibility-guided treatment of H. pylori.

Methods

Selection of studies: Studies comparing empirical versus susceptibility-guided treatment were selected. Search strategy: electronic and manual up to August 2021. Data synthesis: by intention-to-treat (random-effects model).

Results

Overall, 54 studies were included (6,705 patients in the susceptibility-guided group and 7,895 in the empirical group). H. pylori eradication rate was 86 vs. 76%, respectively (RR: 1.12; 95% CI: 1.08-1.17; I 2: 83%). Similar results were found when only RCTs were evaluated (24 studies; RR: 1.16; 95% CI: 1.11-1.22; I 2: 71%) and when susceptibility testing was assessed by culture (RR: 1.12; 95% CI: 1.06-1.18) or PCR (RR: 1.14; 95% CI: 1.05-1.23). For first-line treatments (naïve patients; 30 studies), better efficacy results were obtained with the susceptibility-guided strategy (RR: 1.15; 95% CI: 1.11-1.20; I 2: 79%). However, for empirical first-line quadruple regimens, in particular (both with and without bismuth, excluding the suboptimal triple therapies), not based on CYP2C19 gene polymorphism, no differences in efficacy were found compared with the susceptibility-guided group (RR: 1.04; 95% CI: 0.99-1.09); this lack of difference was confirmed in RCTs (RR: 1.05; 95% CI: 0.99-1.12). For rescue therapies (13 studies, most 2nd-line), similar results were demonstrated for both strategies, including all studies (RR: 1.09; 95% CI: 0.97-1.22; I 2: 82%) and when only RCTs were considered (RR: 1.15; 95% CI: 0.97-1.36).

Conclusion

The benefit of susceptibility-guided treatment over empirical treatment of H. pylori infection could not be demonstrated, either in first-line (if the most updated quadruple regimens are prescribed) or in rescue therapies.

Efficacy of Phenotype-vs. Genotype-Guided Therapy Based on Clarithromycin Resistance for Helicobacter pylori Infection in Children

BACKGROUND

Clarithromycin resistance reduces the eradication rate of Helicobacter pylori (H. pylori). Cultures with susceptibility testing and molecular determination of genotypes are recommended to guide-tailored therapy.

METHODS

We retrospectively enrolled patients aged 6 and 18 years with H. pylori infection, who underwent an endoscopy and agreed to undergo both culture and genetic testing for clarithromycin resistance. Patients receiving tailored therapy based on traditional culture results (phenotype-guided therapy) or genetic testing results (genotype-guided therapy) were included in the study. ¹³C-urea breath test was used to evaluate the success of eradication at least 4 weeks after the completion of treatment. We aimed to determine whether the eradication rate of phenotype- or genotype-guided therapy based on clarithromycin resistance is greater than 90% in children.

RESULTS

Between September 2017 and October 2020, 226 eligible patients were enrolled. There were 71 with clarithromycin-sensitive strains in the phenotype-guided therapy group and 87 without 23S rRNA point mutations (A2142G, A2142C, and A2143G) in the genotype-guided therapy group. Eradication rates were 70.4% (50/71, [95% CI: 58.4-80.7%] for phenotype-guided therapy and 92.0% (80/87, [95% CI: 84.1-96.7%]) for genotype-guided therapy (P < 0.01). The incidence of side effects was 4.2% (3/71) and 10.3% (9/87), with no major differences between these two groups (P = 0.15), respectively. The compliance rate was also similar (97.2 vs. 95.4%, P = 0.87).

CONCLUSION

Tailored therapy according to genetic testing results achieved eradication rates of 92% and was superior to tailored therapy guided by traditional culture results.

The updated JSPGHAN guidelines for the management of Helicobacter pylori infection in childhood

The Japan Pediatric Helicobacter pylori Study Group published the first guidelines on childhood H. pylori infection in 1997. They were later revised by the Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition (JSPGHAN). The H. pylori eradication rates, when employing triple therapy with amoxicillin and clarithromycin, currently recommended as the first-line therapy of H. pylori infection in Japan, have substantially decreased, creating an important clinical problem worldwide. In Japanese adults, the "test-and-treat" strategy for H. pylori infection is under consideration as an approach for gastric cancer prevention. However, the combined North American and European pediatric guidelines have rejected such a strategy for asymptomatic children. As risk for gastric cancer development is high in Japan, determining whether the "test-and-treat" strategy can be recommended in children has become an urgent matter. Accordingly, the JSPGHAN has produced a second revision of the H. pylori guidelines, which includes discussion about the issues mentioned above. They consist of 19 clinical questions and 34 statements. An H. pylori culture from gastric biopsies is recommended, not only as a diagnostic test for active infection but for antimicrobial susceptibility testing to optimize eradication therapy. Based upon antimicrobial susceptibility testing of H. pylori strains (especially involving clarithromycin), an eradication regimen including use of the antibiotics to which H. pylori is susceptible is recommended as the first-line therapy against H. pylori-associated diseases. The guidelines recommend against a "test-and-treat" strategy for H. pylori infection for asymptomatic children to protect against the development of gastric cancer because there has been no evidence supporting this strategy.

Empirical or susceptibility-guided treatment for Helicobacter pylori infection? A comprehensive review

Although susceptibility-guided therapy is frequently recommended for Helicobacter pylori infection, the evidence available to date supporting this strategy is limited. The aim of the present article is to review the advantages and limitations of the susceptibility-guided and the empirical strategies to treat this infection. We performed a bibliographic search to identify studies investigating H. pylori susceptibility-guided therapy. Culture is not the only way to assess antibiotic resistance, as different polymerase chain reaction-based approaches have been developed as alternative methods. For detecting H. pylori antimicrobial resistance, a molecular approach based on a stool sample might enable more convenient, time-saving methods. Unfortunately, the antimicrobial susceptibility cannot be obtained in all cases. Furthermore, antibiotic susceptibility testing in clinical practice yields useful information only for a few antibiotics: clarithromycin, metronidazole, and quinolones. In addition, susceptibility towards clarithromycin and metronidazole in vitro does not necessarily lead to eradication in vivo. In the case of H. pylori therapy failure, we should not re-administer any of the antibiotics against which H. pylori has probably become resistant. Our updated meta-analysis showed that susceptibility-guided treatment is not better than empirical treatment of H. pylori infection in first-line therapy if the most updated quadruple regimens are empirically prescribed, and similar efficacy results were also demonstrated with the two strategies for second-line therapy. Cumulative H. pylori eradication rate with several successive rescue therapies empirically prescribed reaches almost 100%. Finally, the studies that have evaluated the cost-effectiveness of the susceptibility-guided treatment have achieved contradictory results. In summary, we can conclude that the evidence is too limited to support the generalized use of susceptibility-guided therapy for H. pylori treatment in routine clinical practice, either as first-line or as rescue treatment. Nevertheless, it would be recommended that susceptibility tests are performed routinely, even before prescribing first-line treatment, in specialized centers with an interest in H. pylori management.

Adapted first-line treatment of Helicobacter pylori infection in Algerian children

BACKGROUND

Helicobacter pylori (H. pylori) infection is acquired in early life and continues to have a high prevalence, especially in developing countries. Growing antibiotic-resistant strains necessitate adapted treatments. This study aimed to compare the efficacy, side effects, and influence of resistance of H. pylori strains between two different treatments.

METHODS

This prospective, randomized blind study enrolled 112 symptomatic children infected with H. pylori (66 girls, mean age 11.1 years). Treatments, allocated randomly irrespective of the susceptibility of the strains, were either the standard omeprazole-amoxicillin-clarithromycin combination for 7 days (OAC7; group A) or omeprazole-amoxicillin with a higher dose of metronidazole (40 instead of 20 mg/kg/d) for 10 days (OAM10; group B).

RESULTS

Before treatment, the resistance rates of H. pylori strains to metronidazole or clarithromycin were 37% and 13%, respectively, with 7% resistant to both antibiotics and neither to amoxicillin. Eradication rates obtained with OAM10 (80% by intention-to-treat [ITT] and 88% by per protocol [PP] analysis) were higher than with OAC7 (68% in ITT and 71% PP) and the differences (12% in ITT and 17% PP) were statistically significant (P=0.03). Successful treatments with OAM10 were obtained in metronidazole resistant strains and were more effective in children aged >10 years (P=0.02 by ITT and P=0.04 by PP). Only light or moderate side effects, mainly digestive, were observed.

CONCLUSION

Because of its therapeutic efficacy, good tolerance and lower cost the OAM10 can be considered as an appropriate first-line therapeutic scheme in Algeria.

Attitudes and practice related to Helicobacter pylori infection among primary care physicians

OBJECTIVES

Helicobacter pylori infection is a major public health concern and primary care physicians (PCPs) are at the forefront of H. pylori management. We aimed to assess PCP attitudes related to H. pylori and identify areas where PCP practice deviates from the accepted guidelines.

METHODS

A 13-item multiple-choice internet-based questionnaire was distributed to PCPs on a national level. Five questions were related to H. pylori detection, two were related to treatment, three were related to gastric cancer, and three were related to screening. The Maastricht IV/Florence Consensus Report was used as the benchmark for correct responses.

RESULTS

A total of 314 PCP responses were included [140 (52%) men, age 48.2±12.9 years]. Of the total, 292 (93.0%) prescribed clarithromycin-based triple therapy for first-line treatment, 95 (30.3%) prescribed levofloxacin or bismuth-based protocols for second-line treatment, and 137 (43.6%) routinely confirmed eradication. Screening relatives of gastric cancer patients and screening before NSAID treatment was reported by 87 (30.9%) and 39 (14.1%) PCPs, respectively. Of all, 130 (45.0%) believed that the organism is definitely carcinogenic and only 188 (65.0%) agreed that H. pylori eradication reduces the risk of developing gastric cancer. Adherence with guidelines was associated with younger age, central urban clinic location, and a high volume of H. pylori patients.

CONCLUSION

Overall PCP adherence to H. pylori management guidelines is low. Public health agencies should advance educational initiatives aimed at closing these gaps.

Pretreatment antimicrobial susceptibility-guided vs. clarithromycin-based triple therapy for Helicobacter pylori eradication in a region with high rates of multiple drug resistance

OBJECTIVES

Helicobacter pylori eradication rates with clarithromycin-based triple therapy are declining, and an alternative strategy is needed urgently. We sought to compare the efficacy of pretreatment antimicrobial susceptibility-guided vs. clarithromycin-based triple therapy for H. pylori eradication in a region with high rates of multiple drug resistance.

METHODS

Consecutive H. pylori-infected patients with gastric epithelial neoplasms were randomized to receive antimicrobial susceptibility-guided therapy or clarithromycin-based triple therapy for 7 days. In patients in whom the infection was not eradicated, antibiotics were given according to an initial antimicrobial susceptibility test as a second-line therapy in both groups. Eradication rates, antibiotics resistance rates, and drug compliance owing to adverse effects were compared between the groups.

RESULTS

In total, 114 patients were enrolled, and 112 completed the protocols. Drug compliance and side effects were similar between the groups. The intention-to-treat eradication rates were 94.7% (95% confidence interval (CI)=88.8-100%, 54/57) in the antimicrobial susceptibility-guided group and 71.9% (95% CI=60.2-83.5%, 41/57) in the clarithromycin-based triple therapy group after the initial treatment (P=0.002), whereas the per-protocol (PP) eradication rates were 96.4% (95% CI=91.5-100%, 54/56) in the antimicrobial susceptibility-guided group and 73.2% (95% CI=61.5-84.8%, 41/56) in the clarithromycin-based triple therapy group (P=0.001). In H. pylori with clarithromycin resistance, the eradication failure rate with first-line treatment was lower in the susceptibility-guided therapy group (0%, 0/12) compared with the clarithromycin-based triple therapy group (80.0%, 95% CI=59.7-100%, 12/15) by PP analysis (P<0.001).

CONCLUSIONS

Pretreatment antimicrobial susceptibility-guided therapy is more effective than clarithromycin-based triple therapy for H. pylori eradication in a region with high rates of multiple drug resistance.

Therapy of Helicobacter pylori: present medley and future prospective

The increasing prevalence of antimicrobial resistance has warned clinicians to adopt new strategies for dealing with the H. pylori infection. The success of various therapeutic regimens has recently declined to unacceptable levels. To date, first line therapies (including concomitant therapy and hybrid therapy), second line therapies (including bismuth-containing quadruple therapy and levofloxacin-containing therapy), and third line therapy (culture-guided therapy) had been introduced. In the near future, treatment of H. pylori is entering into a completely new resistance era. In this setting, despite the recent progress, we may only be targeting the patients with problematic H. pylori. Local preference for antibiotic selection should be an inevitable article in each therapeutic regimen worldwide. Meanwhile, improving the patients' compliance protocols and observed side effects in suggested therapeutic regimens should be considered cautiously. The new strategies in treatment should be adopted based upon local resistance patterns, which requires physician's resistance about the recommended guidelines. Designing new therapeutic regimen, which contains most effective available antibiotics with less possible side effects and high patient compliance, represents a challenging task in treatment of H. pylori infections.

Changing pattern of antibiotic resistance of Helicobacter pylori in children during 20 years in Jinju, South Korea

BACKGROUND

The antimicrobial resistance capability of Helicobacter pylori is one of the critical factors in the failure to treat this pathogen. The purpose of this study was to investigate the changing pattern of primary antibiotic resistance rates in children in the southern central part of South Korea from 1990 to 2009.

METHODS

H. pylori strains were isolated from children who had undergone upper endoscopy at Gyeongsang National University Hospital, including 58 children from 1990-1994 and 33 children from 2005-2009. The susceptibility of H. pylori strains to erythromycin, clarithromycin, azithromycin, amoxicillin, tetracycline, metronidazole, furazolidone, levofloxacin, ciprofloxacin, moxifloxacin, and rifabutin was tested using the serial twofold agar dilution method.

RESULTS

The resistance rate to erythromycin increased significantly from 13.8% in 1990-1994 to 33.3% in 2005-2009 (P = 0.032). Clarithromycin resistance increased from 6.9% to 18.2%. Metronidazole resistance decreased from 32.8% to 27.3%. The minimum inhibitory concentration of azithromycin and erythromycin showed definite shifts to higher concentrations in 2005-2009 compared with the strains sampled in 1990-1994 (P = 0.021 and P = 0.025, respectively). The frequency of both macrolide- and metronidazole-resistant strains was 13.8% in 1990-1994 and 15.2% in 2005-2009. No associations were detected between multidrug-resistant strains and the two study periods.

CONCLUSIONS

The antibiotic resistance rates of H. pylori in Jinju had a different pattern to other regions. The antibiotic resistance rates of H. pylori showed geographic variation, and local data should be provided as a guideline for treating H. pylori infection.

Detection of clarithromycin-resistant Helicobacter pylori by stool PCR in children: a comprehensive review of literature

BACKGROUND

Helicobacter pylori infection is acquired mainly during childhood. To eradicate H. pylori, clarithromycin-based triple therapy has been recommended in children and adults by the latest Maastricht Consensus. However, the prevalence of clarithromycin-resistant H. pylori was higher in children than that in adults. Therefore, rapid, reliable and noninvasive methods for detecting clarithromycin-resistant H. pylori strains should be developed for children.

MATERIALS AND METHODS

Studies on evaluating stool PCR in detecting clarithromycin-resistant H. pylori and epidemiological surveys of the prevalence of clarithromycin-resistant H. pylori in children were searched in PubMed (from 1966 to December, 2011) for reviewing.

RESULTS

The average rates of primary clarithromycin-resistant H. pylori ranged from less than 10% to more than 40% in different regions. The rates of secondary resistance to clarithromycin were higher than primary resistance in the same population. In H. pylori isolated from children, the frequent point mutations that are responsible for the clarithromycin resistance included A2143G, A2142G, A2142C and A2144G, and they varied geographically. Comparing with culture-based susceptibility tests, stool PCR performed excellently for their rapidity, independence of bacterial growth, reproducibility and easy standardization. However, stool PCR showed lower sensitivity but perfect specificity in detection of clarithromycin-resistant H. pylori in children. Methodology and mixed infections of resistant H. pylori strains might contribute to the considerable discrepancies of stool PCR results.

CONCLUSION

Detection of clarithromycin-resistant H. pylori by stool PCR for children are reliable, rapid, noninvasive methods that are worthy of further clinical promotion. However, more evaluations of stool PCR in detection of clarithromycin-resistant H. pylori in children need to be conducted.

Eradication of Helicobacter pylori in children in Vietnam in relation to antibiotic resistance

BACKGROUND

Low Helicobacter pylori eradication rates are common in pediatric trials especially in developing countries. The aim of the study was to investigate the role of antibiotic resistance, drug dosage, and administration frequency on treatment outcome for children in Vietnam.

MATERIALS AND METHODS

 Antibiotics resistance of H. pylori was analyzed by the Etest in 222 pretreatment isolates from children 3-15 years of age who were originally recruited in a randomized trial with two treatment regiments: lansoprazole with amoxicillin and either clarithromycin (LAC) or metronidazole (LAM) in two weight groups with once- or twice-daily administration. The study design was an observational study embedded in a randomized trial.

RESULTS

 The overall resistance to clarithromycin, metronidazole, and amoxicillin was 50.9%, 65.3%, and 0.5%, respectively. In LAC, eradication was linked to the strains being susceptible to clarithromycin (78.2% vs 29.3%, p = .0001). Twice-daily dosage of proton-pump inhibitor (PPI) and clarithromycin was more effective for eradication than once-daily dosage for resistant strains (50.0% vs 14.7%, p = .004) and tended to be so also for sensitive strains (87.5% vs 65.2%, p = .051). Exact antibiotic dose per body weight resulted in more eradication for resistant strains (45.3% vs 8.0%, p = .006). These differences were less pronounced for the LAM regimen, with twice-daily PPI versus once daily for resistant strains resulting in 69.2% and 50.0% eradication (p = .096), respectively.

CONCLUSIONS

 Helicobacter pylori clarithromycin resistance was unexpectedly high in young children in Vietnam. Clarithromycin resistance was an important cause for eradication treatment failure. Twice-daily administration and exact antibiotic dosing resulted in more eradicated infections when the strains were antibiotic resistant, which has implications for the study design in pediatric H. pylori eradication trials.

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.

High eradication rates of Helicobacter pylori infection following sequential therapy: the Israeli experience treating naïve patients

BACKGROUND

Helicobacter pylori eradication rates following triple therapy are decreasing. Cure rates as low as 57%, mainly to claritromycin resistance, have been reported in Israel. Studies performed in Italy have shown eradication rates of 93%, following sequential therapy. Our aim was to evaluate the effect of sequential therapy on eradication rates of H. pylori in naïve Israeli patients.

MATERIAL AND METHODS

Consecutive patients referred for esophagogastroduodenoscopy with a positive rapid urease test and positive (13) C urea breath test were included. Patients received omeprazole 20 mg bid and amoxicillin 1 g bid for 5 days followed by omeprazole 20 mg bid, clarithromycin 500 mg bid and tinidazole 500 mg bid for the subsequent 5 days. A second (13) C urea breath test was performed at least 4 weeks after completion of therapy. Patients were asked to avoid antibiotics, bismuth compounds or proton pump inhibitor until after the second (13) C urea breath test. Adverse effects were documented by a questionnaire.

RESULTS

One hundred and twenty-four patients (mean age 56.1 ± 12.5 years, 55.6% women) were included; 120/124 (96.8%) completed treatment and performed the second (13) C urea breath test. Two patients (1.6%) were lost to follow-up; 2 (1.6%) were noncompliant with study regulations. One hundred and fifteen patients achieved eradication of H. pylori. The eradication rate was 95.8% by per protocol analysis and 92.7% by intention to treat analysis.

CONCLUSION

The sequential regimen attained significantly higher eradication rates in naïve patients than usually reported for conventional triple therapy. Sequential therapy may be an alternative first-line therapy in eradicating H. pylori in Israel.

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-resistant genotypes and eradication of Helicobacter pylori

OBJECTIVE

To compare the eradication rates among the different point mutations and the efficacy of triple therapy and a sequential regimen according to genotypic resistance.

STUDY DESIGN

Post hoc retrospective cohort study in a tertiary referral center for pediatric gastroenterology in southern Italy. All 168 children who were positive for Helicobacter pylori were enrolled. Patients had received clarithromycin-based 7-day triple therapy (73 children) or 10-day sequential therapy regimen (95 children). Real-time polymerase chain reaction for assessing clarithromycin resistance was performed on sections of paraffin-embedded gastric biopsy samples.

RESULTS

H pylori eradication was achieved in 16 of 32 (50%) children with the A2143G mutation, in 8 of 10 patients with either A2142G or A2142C strains (80%), and in 112 of 116 children with susceptible strains (88.9%). The presence of A2143G mutation was associated with a lower cure rate compared with the rate in the absence of this mutation (50% vs. 89%; P = .001). The sequential regimen achieved a higher cure rate than triple therapy in patients with A2143G mutant strains (80% vs nil; P < .001).

CONCLUSIONS

The A2143G mutation confers higher risk of treatment failure. Sequential regimen has higher efficacy than standard therapy, even in children with A2143G mutatant strains.

Antibiotic resistance of Helicobacter pylori in Israeli children

OBJECTIVES

To determine the antibiotic susceptibility of Helicobacter pylori isolates from Israeli children; assess the role of previous antibiotic use in the development of antibiotic resistance and examine the possibility of simultaneous colonization of strains with different resistance patterns in the same patients.

MATERIAL AND METHODS

A prospective case-series design was used. The study group included 174 patients aged 1-18 years referred to the Schneider Children's Medical Center of Israel for gastroscopy over a 2.5-year period. Antibiotic susceptibility to amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin was determined by E-test on gastric biopsies (2 per patient). Clinical and demographic data were obtained by questionnaire.

RESULTS

Cultures for H. pylori yielded 55 isolates from 53 children. In treatment-naïve children, the prevalence rate of primary resistance to clarithromycin was 25% and to metronidazole, 19%. Respective rates in children previously treated for H. pylori infection were 42% (p = 0.22) and 52% (p = 0.016). Simultaneous resistance to both drugs was found in 13% of isolates (n = 7), all from children with previous treatment failure. No resistance was found to amoxicillin, tetracycline or levofloxacin. Clarithromycin resistance was associated with macrolide use for any indication during the previous year (p = 0.033). In 2 patients (3.8%), a different H. pylori strain was cultured from each biopsy.

CONCLUSIONS

H. pylori resistance to clarithromycin and metronidazole is high in Israeli children, particularly in those previously treated for H. pylori infection, in whom culture-based treatment should be considered. The simultaneous colonization of multiple strains in a minority of patients needs to be further characterized.

Is antimicrobial susceptibility testing necessary before first-line treatment for Helicobacter pylori infection? Meta-analysis of randomized controlled trials

BACKGROUND

With the wide use of antibiotics, antibiotic-resistant Helicobacter pylori strains are becoming increasingly prevalent. It has been hypothesized that culture-guided therapy might help to increase treatment success. But the effects and the costs still remain controversial.

AIMS

To systematically review the efficacy and the cost of culture-guided triple therapy, compared to standard triple regimen for first-line treatment of Helicobacter pylori infection.

METHODS

A search of the Cochrane Library, PubMed, EMBASE, Science Citation Index Expanded and CBM was performed. Randomized controlled trials comparing culture-guided triple therapy to standard triple therapy in the first-line treatment of Helicobacter pylori infection were selected for meta-analysis. Relative risk was used as a measure of the effect of two regimens mentioned above with a fixed-effects model using the methods of DerSimonian and Laird.

RESULTS

Five randomized controlled trials totaling 701 patients were included. The meta-analysis showed that culture-guided triple therapy was superior referring to a higher eradication rate from intention-to-treat analyses (RR, 0.84; 95% CI,0.77, 0.90; p<0.00001) and a lower overall cost.

CONCLUSION

Culture-guided triple therapy was more effective than standard triple therapy for first-line treatment of Helicobacter pylori infection. Based on the only paper focused on the overall cost, the culture-guided triple therapy was also more cost saving. Antimicrobial susceptibility testing is necessary before first-line treatment for Helicobacter pylori infection.

Efficacy of the standard quadruple therapy versus triple therapies containing proton pump inhibitor plus amoxicillin and clarithromycin or amoxicillin-clavulanic acid and metronidazole for Helicobacter pylori eradication in children

OBJECTIVES

Helicobacter pylori (H. pylori) cure rates vary in different geographical regions because of differences in hosts as well as in H. pylori strains. In this study we evaluated the efficacy of different treatment regimens for eradication of H. pylori infection in children, in order to select a treatment regimen that is most effective with the least adverse effects and cost.

METHOD

Through a randomized clinical trial study we enrolled 120 pediatric patients (age <or= 18 years) with H. pylori infection confirmed through histopathological examination of their upper endoscopic findings and positive rapid urease test. Patients were randomized into three groups: group A received omeprazole, amoxicillin, metronidazole, and bismuth subcitrate; group B received omeprazole, amoxicillin, and clarithromycin; and group C the most recent regime of omeprazole, amoxicillin-clavulanic acid, and metronidazole. Subjects were followed 6 weeks after completing the antimicrobial therapy and H. pylori eradication was assessed with urea breath test.

RESULTS

A total of 117 patients with a mean age of 12 +/- 4 years completed the study. Eradication rate was 91.9% in group A, compared with 82.1% in group B, and 80.5% in group C (P = 0.33).

CONCLUSION

Considering these data we suggest quadruple therapy as the first line of therapy for eradication of H. pylori infection in children in our geographic area (Iran).

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.

Helicobacter pylori infection in children: management and pharmacotherapy

Helicobacter pylori infection is mainly acquired during childhood: it is recognised as a cause of gastritis and peptic ulcer and it has been classified as a group A carcinogen by the World Health Organisation. The exact mode of transmission is as yet unknown. The aim of this review was to analyse the literature about H. pylori infection in paediatric patients. The large diffusion of H. pylori infection in paediatric patients, the absence of a specific clinical feature, the new non-invasive methods for diagnosis and follow-up, which are still not validated and the different therapeutic schedules have led to the necessity of determining the real clinical outcome in affected children and adolescents. The scope of the review was to identify better eradication therapy and the most important factors in treatment failure. The international literature has shown the importance of culture, antibiograms, the compliance of families and patients and the use of probiotics during triple eradication therapy. The review paid attention to the management, diagnostic techniques and therapy of this infection in paediatric patients.

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.

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.

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.