Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016)

Diagnostic immunohistochemistry use in Belgian laboratories

OBJECTIVES

In Belgium, the use of IHC testing has grown in the last decade. However, there is a lack of information on the specific indications for which it is reimbursed. The aim of the study is to offer an overview on the use of diagnostic inmunohistochemistry (IHC) testing and its recent trends.

METHODS

Our analysis is limited to reimbursed use, which in Belgium is restricted to a maximum of 4 different IHC stains per sampling session for diagnostic IHC. Consulted sources included data from the compulsory health insurance, and data extracted from a sample of pathology reports gathered from Belgian laboratories for the year 2019.

RESULTS

Over the last 10 years, the use of IHC in Belgium grew from 729 030 stains in 2012 to 1,194,331 in 2019, an increase of 63.8 % while the increase in the number of histological or cytological examinations was 13.3 %. The main stains used in 2019 were H. pylori, Ki-67 and broad spectrum CK, which were used in multiple body sites, reflecting the difficulties to identify specific indications. The gastro-intestinal tract is the body site with the highest number of IHC stains (38.2 % of all stains performed), and the most frequently used stain in gastro intestinal biopsies were H. pylori (43.1 %), and CD3 (6.8 %).

CONCLUSION

This study offers an overview of the most frequent indications for which diagnostic IHC staining is used in Belgium, and reflects the evolving nature of this field, highlighting the importance to increase clarity and improve data collection.

Recurrent abdominal pain in children in Wuhu, China was not associated with Helicobacter pylori infection, but associated with <1 h/day physical activity and academic stress

Background

Recurrent abdominal pain (RAP) is one of the most common gastrointestinal disorders in children. The aim of this study was to investigate the relationship between RAP and Helicobacter pylori infection in children in Wuhu, China as well as the risk factors for Helicobacter pylori infection in this region.

Materials and methods

In this cross-sectional survey, we randomly selected children aged 6-17 years who underwent health examinations at three public hospital examination centers in Wuhu city, Anhui Province, China. Helicobacter pylori infection was assessed by a 13C-urea breath test (UBT) kit. Questionnaires were custom designed to obtain data on behavioral, sociodemographic, and environmental characteristics, and to investigate the relationship between RAP and Helicobacter pylori infection in children.

Results

A total of 1,187 children aged 6-17 years were enrolled, among these children, 182 were diagnosed with RAP, with an incidence rate of 15.3%. A total of 266 children were infected with Helicobacter pylori, with an infection rate of 22.4%. Multivariate regression analysis revealed that physical activity for <1 h/day and academic stress are associated with RAP in children, whereas Helicobacter pylori infection, age, sex, body mass index (BMI), and fast-food consumption are not associated with RAP in children. Our research also found that the risk of Helicobacter pylori infection increases with age in children. Risk factors for Helicobacter pylori infection in children include left-behind children, poor hygiene habits, family history of Helicobacter pylori infection, and mother with low cultural levels.

Conclusions

Recurrent abdominal pain in children in Wuhu, China was not associated with Helicobacter pylori infection, but strongly associated with <1 h/day physical activity and academic stress.

Causal relationship between Helicobacter pylori infection and IgA nephropathy: a bidirectional two-sample mendelian randomization study

IgA nephropathy (IgAN) is one of the most common primary glomerulonephritis, and serum Helicobacter pylori (H. pylori) antibody levels are increased in patients with IgA N, but the role of H. pylori infection in the pathogenesis of IgAN is unclear. In this study, we investigated whether there is a causal relationship and reverse causality between IgAN and H. pylori infection by using a bidirectional two-sample Mendelian randomization (MR) analysis. This study was estimated using inverse variance weighted (IVW), MR-Egger and weighted median methods, with the IVW method having the strongest statistical efficacy. Seven common serum H. pylori antibodies were selected as exposure factors for positive MR analysis. The results showed that there was no evidence of a causal relationship between H. pylori infection and IgAN. Reverse MR analysis showed that there was also no evidence that the occurrence of IgAN leads to an increased risk of H. pylori infection.

Efficacy of B - mode and elastography ultrasound technique in the prediction of Helicobacter pylori: a prospective study

BACKGROUND

Helicobacter pylori (HP) affect nearly 50% of the world's population and can colonize the submucosal and mucosal layers of the stomach wall, causing inflammation leading to a thickening of these layers. The study aimed to evaluate the application value of transabdominal ultrasonography combined with elastography in the prediction of HP using HP Fecal Antigen Test as gold standard.

METHOD

This prospective case-control study was conducted in 174 participants classified into three groups: Group A: Symptomatic patients with thickened stomach antral and evident HP infection on fecal antigen test results, Group B: Symptomatic patients with thickened antral and no evident HP infection on fecal antigen test results, and Group C: control group of asymptomatic individuals with negative HP screening to predict the diagnostic accuracy of B-mode ultrasound and elastography in the prediction of HP pylori.

RESULTS

Positive HP patients had higher values of antral wall thickness (AWT), mucosal layer thickness (MLT), MLT/AWT ratio, SR (strain ratio), and a combination of AWT and SR: 5.57 ± 0.55 mm, 2.96 ± 0.45 mm, 0.53 ± 0.06 mm, 3.21 ± 0.43, and 8.79 ± 0.68 mm, respectively. In comparison, negative HP patients had values of 4.61 ± 0.47 mm, 2.05 ± 0.42 mm, 0.41 ± 0.08 mm, 2.51 ± 0.42 mm, and 7.13 ± 0.62 mm, respectively, and the control groups had values of 3.53 ± 0.36 mm, 1.47 ± 0.25 mm, 0.40 ± 0.06 mm, 1.81 ± 0.41, and 5.35 ± 0.55 mm, respectively (p < 0.001). The sensitivity of B-mode ultrasonography, elastography, and the combination of the two was 98%, 95.1%, and 98.4%, respectively, and the diagnostic accuracy was 98.4%, 98.3%, and 100%, respectively.

CONCLUSION

B-mode ultrasonography and elastography exhibit high discriminatory power in distinguishing symptomatic HP patients from normal individuals and differentiating + HP from - HP, with greater discriminatory power when combined both modes.

Different regimens for eradication of Helicobacter pylori infection in children: a randomized controlled trial

Eradication of Helicobacter pylori (H. pylori) infection in children is challenging due to increased antibiotic resistance and decreased effectiveness of the current therapeutic choices, especially in developing countries. The purpose of this study is to compare the efficacy and safety of triple therapy (TT), sequential therapy (ST), hybrid therapy (HT), concomitant therapy (CT), and ciprofloxacin-based triple therapy (CTT) as an empirical therapy for H. pylori eradication in children. In this randomized controlled trial, 200 children (aged between 3 and 16 years) with both positive rapid urease test and histopathology for H. pylori infection were included. Patients were randomly assigned to receive either TT, ST, HT, CT, or CTT. The eradication status was evaluated using a stool antigen test (SAT) 4 weeks after stoppage of antibiotic therapy and 2 weeks after stoppage of proton pump inhibitors. SAT was performed using an ELISA monoclonal antibody-based kit. The most common presenting symptom was epigastric pain (79%). The most common endoscopic findings were gastric antral erythema (98%) and antral nodularity (54.5%). All gastric biopsies showed superficial lamina propria infiltration with plasma cells and lymphocytes. Active gastritis with neutrophils infiltration was seen in 75% of the cases. Gastric atrophy and intestinal metaplasia were uncommon histopathological findings (8.5% and 1%, respectively). The eradication rates for TT, ST, HT, CT, and CTT were 70%, 77.5%, 80%, 85%, and 90%, respectively, with the latter achieving a statistically significant difference when compared with TT (p = 0.025). The rate of occurrence of adverse effects among different regimens was not statistically different.

CONCLUSION

As an empirical treatment for children with H. pylori infection, CTT is safe and provides the highest eradication rate. HT, ST, and CT might not be superior to TT.

TRIAL REGISTRATION

This study was registered at the Pan African Clinical Trials Registry, Cochrane South Africa, under the identifier PACTR202201686010590. Date of registration: 04 January 2022.

WHAT IS KNOWN

• Triple therapy has been the standard eradication regimen for pediatric H. pylori infection. The efficacy of triple therapy has decreased in many countries due to increased antibiotic resistance.

WHAT IS NEW

• This randomized controlled trial is the first to compare triple therapy, sequential therapy, hybrid therapy, concomitant therapy, and ciprofloxacin-based triple therapy for the eradication of pediatric H. pylori infection. Triple therapy exhibited the lowest eradication rate among the studied regimens, suggesting it may not be an adequate therapeutic option for infected children. Ciprofloxacin-based triple therapy appears to be a safe and effective therapeutic choice for pediatric H. pylori infection. Additionally, this study provides the first reported eradication rate of hybrid therapy in pediatric H. pylori infection.

Multiple cross displacement amplification-based lateral flow biosensor for rapid and sensitive detection of Helicobacter pylori

Helicobacter pylori (H. pylori, HP), recognized globally as one of the most widespread bacteria, serves as primary etiological agent for numerous gastroduodenal diseases, highlighting the urgent need to develop rapid and sensitive diagnostic method for H. pylori infection. Here, we devised a new diagnostic test that merged multiple cross displacement amplification (MCDA) with nanoparticle-based lateral flow biosensor (LFB), termed HP-MCDA-LFB, to facilitate the rapid and sensitive detection of H. pylori. The whole detection workflow, which includes stages such as DNA template extraction (~15 min), MCDA pre-amplification (~40 min), and result readout (~2 min), was efficiently completed within 1 h. After optimization, the HP-MCDA-LFB assay demonstrated remarkable sensitivity in detecting H. pylori, with a detection threshold as low as 60 fg of genomic DNA (~56 copies) per microliter. Furthermore, the HP-MCDA-LFB assay also achieved a perfect specificity rate of 100%, exhibiting no cross-reactivity with non-Helicobacter isolates. Particularly, the clinical feasibility of HP-MCDA-LFB assay was validated using 40 antral mucosa samples, among which 17 tested positive for H. pylori, which was in complete agreement with the results obtained from the rapid urease test. In conclusion, the HP-MCDA-LFB method developed in this study is a rapid, sensitive, and specific method for diagnosing H. pylori infection, indicating great potential for H. pylori eradication therapy.

Prevalence, Management, and Outcomes of Non-Invasive Helicobacter pylori Testing in Children at a Tertiary Paediatric Hospital in Singapore

Purpose

Helicobacter pylori infections differ between children and adults. The Pediatric society practice guidelines recommend against a test-and-treat approach, characterized by the use of non-invasive tests for diagnosis (e.g. urea breath test [UBT] or stool antigen test). However, significant variations exist in clinical practice. This study examined the use of non-invasive testing for the screening and diagnosis of H. pylori infection in children at a tertiary pediatric hospital in Singapore, reviewing both management decisions and patient outcomes.

Methods

A retrospective review was conducted on children between the ages of 0 and 18 years who were tested for H. pylori infection using either a stool antigen test or UBT between January 2018 and June 2020.

Results

Among the 1,397 children tested, 117 (8.4%) had a positive stool H. pylori antigen result, and 5 out of 85 tested (5.9%) had a positive UBT. Abdominal pain was the predominant symptom (n=98; 80.3%). Only 7 treatment-naïve children had biopsy-proven disease. Tissue biopsies for H. pylori culture were sent to 2 children, with 1 negative result. A total of 111 children (91.0%) received treatment, wherein proton pump inhibitor, amoxicillin, and clarithromycin for 14 days was the most common therapeutic regimen. Symptom resolution was observed in 62 children (50.8%).

Conclusion

A test-and-treat strategy was more widely utilized than endoscopy-based testing, showing a low compliance to existing guidelines for the management of H. pylori infections in children at our center and significant false-positive rates.

Effect of Helicobacter pylori Eradication on Serum Level of Valproic Acid in Children with Idiopathic Generalized Epilepsy

BACKGROUND/OBJECTIVES

The purpose of this study was to determine the influence of H. pylori eradication on the serum level of the orally administered valproic acid (VPA) in children with idiopathic generalized epilepsy; Methods: This prospective cohort observational study included 100 children with idiopathic generalized epilepsy, recruited from a neurology clinic from May 2021 to December 2021. The patients were divided into two groups, each containing 50 children. The first group had a positive H. pylori stool antigen and H. pylori-related symptoms, while the second group had a negative antigen. H. pylori Eradication therapy was given to the positive H. pylori group. The serum level of VPA was obtained at baseline and 4 weeks after eradication therapy.

RESULTS

Despite there being no significant difference between the H. pylori-positive and H. pylori-negative groups regarding the baseline VPA serum level (79.9 ± 13.9 and 77.9 ± 13.1 mcg/mL), respectively, the serum VPA level had significantly increased after H. pylori eradication therapy (99.4 ± 11 mcg/mL) (p value = 0.000), as opposed to the H. pylori-negative group (85.3 ± 10.9 mcg/mL) (p value = 0.142). Furthermore, there was a statistically significant association with a negative correlation between the VPA serum level after eradication and the number of epileptic attacks per month (p value = 0.033, R value = -0.301) and the dose of VPA (p value = 0.046, R value = -0.284).

CONCLUSIONS

The eradication of H. pylori resulted in a highly significant improvement in the serum level of the orally given VPA in children with idiopathic generalized epilepsy, as well as an indirect decrease in the frequency of epileptic events per month, allowing for dose reduction. Eradication therapy may have anticonvulsant properties and might indirectly aid in the management of epileptic activity. H. pylori screening for children with idiopathic generalized epilepsy can optimize serum VPA levels, potentially leading to better seizure control. To our knowledge, this is the first study in the literature to describe the effect of H. pylori eradication on the serum level of the orally administered VPA in children with idiopathic generalized epilepsy.

Efficacy of Bismuth Therapy in Eradicating Helicobacter pylori in Children-Data From the RENIHp Registry

OBJECTIVES

To evaluate the efficacy of colloidal bismuth subcitrate (CBS) therapy for the eradication of H. pylori in patients from a national pediatric registry of H. pylori infection.

METHODS

The Spanish Registry of Children with H. pylori Infection (RENIHp) is a national, multi-center, prospective, non-interventional registry that includes children aged 5-18 years with H. pylori infection diagnosed by endoscopy. All patients in the registry who were treated with CBS between the period 2020 and 2023 were included in this study. The primary outcome was the eradication rate, which was assessed using a 13C-urea breath test or monoclonal antigen in the stool 6-8 weeks post-treatment.

RESULTS

The registry included 682 patients, 38 (5.6%) of whom underwent treatment with CBS. Fifty percent (19/38) of patients had previously undergone unsuccessful eradication treatment. In 78.9% (30/38) of patients, treatment was guided by an antibiotic sensitivity test. In the remaining patients, an empirical approach was employed. The CBS therapies used were as follows: quadruple therapy with proton pump inhibitors (PPIs), CBS, amoxicillin, and metronidazole (MET) [18/38 (47.3%)]; quadruple therapy with PPIs, CBS, tetracycline, and MET [13/38 (34.2%)]; and other therapies [7/38 (18.4%)]. Thirty-two patients (84.2%) treated with CBS were followed-up with eradication monitoring. The overall eradication rate in patients treated with CBS was 93.8% (30/32, [95% CI: 85.4%-100%]), whereas it was 86.7% in patients in the registry who were not on CBS treatment (430/496, [95% CI: 83.3%-89.5%], p = 0.208). In the six patients with dual resistance to clarithromycin (CLA) and MET who were treated with quadruple therapy with CBS, the eradication rate was 100% (n = 6/6, [95% CI: 61.0%-100%]).

CONCLUSION

CBS therapies in our registry, although only used in selected cases and at lower than recommended levels, were very effective and showed an eradication rate of > 90%.

Factors Associated With Decision to Treat or Not to Treat Helicobacter pylori Infection in Children: Data From the EuroPedHp Registry

BACKGROUND

European and North-American guidelines on management of H. pylori infection in children provide the option not to treat even if the infection is endoscopically confirmed. We used data from the EuroPedHp Registry to identify factors associated with therapy decisions.

METHODS

We included treatment-naïve patients reported between 2017 and 2020 from 30 centers in 17 European countries. Multivariable logistic regression identified factors including comorbidities within and outside the gastrointestinal (GI) tract influencing the decision for or against therapy.

RESULTS

Of 1165 patients (52% females, median age 12.8), 28% (321/1165) reported any alarm symptom, 26% (307/1165) comorbidities, and 16% (192/1165) did not receive eradication treatment. Therapy was initiated less often in children having any GI comorbidity (57%, n = 181), particularly in those with eosinophilic esophagitis (60%, n = 35), inflammatory bowel disease (54%, n = 28), and celiac disease (43%, n = 58), compared to those with non-GI (86%, n = 126) or no comorbidity (89%, n = 858), despite similar frequencies of alarm and non-alarm symptoms, ulcers, erosions, and nodular gastritis. Patients with GI and without comorbidities remained more likely untreated in high versus low H. pylori prevalence countries (p < 0.0001). In children without comorbidities, factors favoring therapy included older age, being overweight, having symptoms, erosions, antral nodularity, and available antibiotic susceptibility results.

CONCLUSION

In this cohort, H. pylori-infected children with GI comorbidities compared to no comorbidity showed 75% reduced chance of receiving eradication therapy. We found no evidence supporting different management strategies in infected patients with GI comorbidities compared to all pediatric patients with endoscopically proven H. pylori infection.

Updated joint ESPGHAN/NASPGHAN guidelines for management of Helicobacter pylori infection in children and adolescents (2023)

BACKGROUND

Evolving epidemiological data and increasing antibiotic resistance mandate an update of the European and North American Societies of Pediatric Gastroenterology, Hepatology and Nutrition guidelines.

METHODS

Certainty of evidence and strength of recommendations were rated by experts according to the Grading of Recommendation Assessment, Development, and Evaluation approach. PICO (patient population, intervention, comparator, and outcome) questions were developed and voted on by the group. Recommendations were formulated using the Evidence to Decision framework.

RESULTS

The current literature supports many of the previous recommendations and several new recommendations. Invasive testing with strain antimicrobial susceptibility analysis is recommended for the diagnosis and selection of eradication therapy for H. pylori infection. Molecular methods are acceptable for detection of infection and of antibiotic resistance in gastric biopsy specimens. Reliable, noninvasive tests can be used as a screening method for children with history of gastric cancer in a first-degree relative. When investigating causes of chronic immune thrombocytopenic purpura, testing for H. pylori is no longer recommended. When investigating other diseases such as inflammatory bowel disease, celiac disease, or eosinophilic esophagitis, specific diagnostic biopsies for H. pylori infection are not indicated. However, if H. pylori is an incidental finding, treatment may be considered after discussing the risks and benefits. Treatment should be based on antibiotic antimicrobial susceptibility testing and, if unavailable, regimens containing clarithromycin should be avoided.

CONCLUSIONS

Due to decreasing prevalence of infection, increasing challenges with antibiotic resistance, and emerging evidence regarding complications of infection, clinicians must be aware of these recommended changes to appropriately manage H. pylori infection and its clinical sequelae in children.

Clinical Dilemmas for the Diagnosis and Treatment of Helicobacter pylori Infection in Children: From Guideline to Practice

Helicobacter pylori infection is often acquired in early childhood. While most infected children remain asymptomatic, H. pylori can cause chronic gastritis, gastric ulceration, and, in the long term, gastric cancer. This article aimed to review different diagnostic and treatment options and discuss the challenges associated with applying the current guidelines in the real world. Relevant articles published from 2015 to August 2023 in the English language in PubMed and Medline electronic databases were extracted using subject headings and keywords of interest to the topic. References of interest in the selected articles were also considered. Invasive and noninvasive diagnostic tests have advantages but also disadvantages and limitations according to the clinical setting and age of the child. Guidelines recommend not performing diagnostic testing in children with long-lasting or recurrent abdominal complaints or cases of a family history of severe disease caused by H. pylori. However, parents regularly consult with the explicit demand to test for H. pylori because of them or a close family member experiencing severe gastric disease caused by H. pylori. In some situations, it may be challenging for the healthcare professional to stick to evidence-based guidelines and not consider "patient-centered care," with the risk of putting a trustful relationship in danger. Physicians may find it challenging not to perform diagnostic tests for H. pylori and prescribe eradication treatment in specific clinical settings when maintaining a trusting patient-physician relationship by applying this "patient-centered care" method when evidence-based guidelines recommend differently.

A randomised controlled clinical study of standard triple therapy, bismuth-based quadruple therapy and sequential therapy for Helicobacter pylori infection in children

BACKGROUND AND AIM

Bismuth and non-bismuth quadruple therapy are the guideline-recommended first-line therapy in children with Helicobacter pylori infection in areas with high antibiotic resistance. However, their efficacy in children is uncertain and there are few well-designed studies. Here, we evaluated the eradication rates of standard triple therapy, bismuth-based quadruple therapy and sequential therapy in children with H. pylori infection.

METHODS

A randomised controlled trial was conducted in children infected with H. pylori in West China Second Hospital. They were randomly assigned to 14-day standard triple therapy (omeprazole + amoxicillin + clarithromycin), 14-day bismuth quadruple therapy (bismuth + omeprazole + amoxicillin + clarithromycin) and 10-day sequential therapy (omeprazole + amoxicillin for 5 days followed by omeprazole + clarithromycin + metronidazole for 5 days). The eradication rate was assessed by a 13C-urea breath test 4 to 6 weeks after therapy completion. Symptom improvement and adverse events were compared among the groups.

RESULTS

In total, 132 patients were enrolled. The eradication rates of 14-day standard triple therapy, 14-day bismuth quadruple therapy and 10-day sequential therapy were 70.0%, 78.9% and 50.0% in per-protocol analysis and 63.6%, 68.2% and 43.2% in intention-to-treat analysis, respectively. Symptom improvement and adverse drug event rates were similar in the three groups.

CONCLUSION

The three therapeutic regimens evaluated in this study are equally not recommendable for H. pylori infection treatment due to unsatisfactory eradication rates. The high prevalence of clarithromycin resistance makes the use of clarithromycin-based quadruple therapy not advisable, even in combination with amoxicillin and bismuth salts.

Antibiotic resistance in Helicobacter pylori among children and adolescents in East Asia: A systematic review and meta-analysis

BACKGROUND

In East Asia, Helicobacter pylori ( H. pylori ) infection and related diseases are common, primarily during childhood and adolescence. The rates of primary antibiotic resistance in H. pylori among East Asian children and adolescents have not been extensively explored; few relevant systematic reviews or meta-analyses have been conducted. We evaluated the rates of antibiotic resistance in H. pylori among East Asian children and adolescents, with the goal of facilitating individualized treatment recommendations.

METHODS

We searched PubMed, Embase, and the Cochrane Library for studies in any language published up to February 2023 that explored antibiotic resistance in H. pylori among East Asian children and adolescents. We used MeSH and non-MeSH terms related to the topic, including terms related to children, adolescents, antibiotic resistance, H. pylori , and nations or regions. Additionally, we reviewed the reference lists of relevant articles. Studies that matched our strict predefined eligibility criteria were included in the screening process. Using established assessment methods, we evaluated the quality of the included studies.

RESULTS

We identified 15 observational studies involving 4831 H. pylori isolates, all published between 2001 and 2022. There was substantial primary antibiotic resistance in H. pylori isolates from East Asian children and adolescents. The rates of primary resistance were 51% (95% confidence interval [CI]: 40-62%) for metronidazole; 37% (95% CI: 20-53%) for clarithromycin; 19% (95% CI: 11-28%) for levofloxacin; and less than 3% each for amoxicillin, tetracycline, and furazolidone. Subgroup analysis revealed a prominent increase in metronidazole resistance over time. Clarithromycin and levofloxacin resistance rates fluctuated between 2005 and 2015, then remained stable; other antibiotic resistance rates were generally stable. Metronidazole, clarithromycin, and levofloxacin resistance rates were significantly higher in the Chinese mainland than in other East Asian regions. The rates of dual and multiple antibiotic resistance were 28% (95% CI: 21-36%) and 10% (95% CI: 7-14%), highlighting the potential for diverse resistance patterns.

CONCLUSIONS

H. pylori isolates from East Asian children and adolescents exhibit high levels of metronidazole and clarithromycin resistance, particularly in the Chinese mainland. The non-negligible rates of dual and multiple resistance highlight the complexity of this problem.

REGISTRATION

PROSPERO, No. CRD42023402510.

Effect of MDR1 C3435T and CYP2C19 genetic polymorphisms on the outcome of Helicobacter pylori eradication treatment in children with gastritis and peptic ulcer, Vietnam

BACKGROUND

Helicobacter pylori eradication therapy based on antimicrobial susceptibility in Vietnamese children currently get low efficiency. There are causes of treatment failure, among host genetic factors namely MDR1 C3435T and CYP2C19 affect the absorption and metabolism of proton pump inhibitors - a crucial component of eradication therapy. The study aimed to investigate the effect of MDR1 C3435T and CYP2C19 genetic polymorphisms on the cure rate.

METHODS

207 pediatric patients with gastritis and peptic ulcer infecting Helicobacter pylori completed the eradication therapy based on antimicrobial susceptibility with proton pump inhibitor esomeprazole. Eradication efficacy was assessed after at least 4 weeks by the urease breath test. MDR1 C3435T genetic polymorphism and CYP2C19 genotype were determined using a sequencing method based on Sanger's principle.

RESULTS

Among 207 children recruited in this study, the ratio of CYP2C19 EM, IM, and PM phenotypes was 40.1%, 46.4%, and 16.9%, respectively. The patient with MDR1 3435 C/C polymorphism accounted for 43.0%, MDR1 3435 C/T was 40.1%, and MDR1 3435T/T was 16.9%. The cure rate of Helicobacter pylori infection in patients with CYP2C19 EM genotype was 78.3%; 83.3% of those with the IM genotype, and PM genotype was 96,4% (p = 0.07). Successful eradication rates for Helicobacter pylori were 85.4%, 86.7%, and 68.6% in patients with the MDR1 3435 C/C, C/T, and T/T, respectively (p = 0.02). Multiple logistic regression analysis found that MDR1 C3435T genetic polymorphisms of patients were significant independent risk factors for treatment failure, and CYP2C19 genotype did not affect Helicobacter pylori eradication.

CONCLUSIONS

The Helicobacter pylori eradication rates by regimens based on antibiotic susceptibility and esomeprazole were not significantly different between the CYP2C19 phenotypes. The MDR1 C3435T polymorphism is one of the factors impacting Helicobacter pylori eradication results in children.

Clinical evaluation of a real-time PCR assay for diagnosis of Helicobacter pylori infection and antibiotic resistance

OBJECTIVES

Helicobacter pylori (H. pylori) is a globally prevalent bacterium that increases the risk of developing various gastrointestinal diseases, including gastric adenocarcinoma. This study aimed to evaluate the performances of real-time PCR assay in detecting H. pylori infection, as well as clarithromycin and levofloxacin resistance, in both stool and gastric biopsy specimens.

METHODS

Stool and gastric biopsy specimens were collected from patients within one to three days post-hospitalization. All patients were analyzed for H. pylori infection and resistance to clarithromycin and levofloxacin using a real-time PCR based molecular assay.

RESULTS

169 patients (83 males) with a mean age of 43.6±13.1 years were included in the study. The prevalence of H. pylori was 89.9% (152/169) in stool and 90.5% (153/169) in gastric biopsy samples. The molecular diagnostics employed in this study exhibited a sensitivity of 99.3% and a specificity of 100%, resulting in a diagnostic accuracy rate of 99.6%. Resistance to clarithromycin was 36.1% (61/169) in stool and 44.4% (75/169) in gastric biopsy samples. The molecular tests for clarithromycin resistance demonstrated a sensitivity of 96.8% and a specificity of 86.8%, with an overall diagnostic accuracy of 90.5%. Furthermore, resistance to levofloxacin was 22.5% (38/169) and 26.6% (45/169) in stool and gastric biopsy samples, respectively. The molecular test demonstrated a sensitivity of 80.9% and a specificity of 94.3%, resulting in a diagnostic accuracy of 90.5%.

CONCLUSION

The implementation of real-time PCR-based screening for H. pylori infection and resistance to clarithromycin and levofloxacin in the stool may enhance the success rate of eradication therapy.

Navigating through 65 years of insights: lessons learned on functional abdominal pain in children

In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.

Prevalence of metronidazole resistance and Helicobacter pylori infection in Moroccan children: a cross-sectional study

Introduction

the prevalence of Helicobacter pylori (H. pylori) infection in children is very high in Morocco. Eradication rates of H. pylori infection decrease due to the emergence of resistance to antibiotics. Data on the antimicrobial susceptibility of H. pylori in Moroccan children are not available. This study aims to assess the prevalence of H. pylori infection and the metronidazole resistance rate of H. pylori in Moroccan pediatric patients, and their association with epidemiologic factors.

Methods

a cross-sectional study was conducted on 132 pediatric patients who had an indication for upper gastrointestinal endoscopy and attended pediatric hospital Abderrahim Harouchi of the University Hospital Ibn Rochd, Casablanca, Morocco. Detection of H. pylori infection and the susceptibility to metronidazole was performed by classic PCR. Statistical analysis was performed using R Studio software.

Results

the overall prevalence of H. pylori infection was 80.3%. vomiting was significantly associated with H. pylori infection (p-value=0.01). Regarding the resistance rate of metronidazole, we found that the prevalence of H. pylori resistance to metronidazole was high (70.8%) and it significantly increased, especially in pediatric patients living in urban areas (p-value=0.01).

Conclusion

the prevalence of H. pylori infection and resistance rate of metronidazole were very high in Moroccan children. Therefore, triple therapy with metronidazole must be preceded by a study of the bacterium's susceptibility to the prescribed antibiotics, in particular to metronidazole.

Antimicrobial Resistance of Helicobacter pylori Isolated From Latin American Children and Adolescents (2008-2023): A Systematic Review

BACKGROUND

Latin America has a high prevalence of Helicobacter pylori in children that may lead to peptic ulcer disease and eventually gastric cancer in adulthood. Successful eradication is hindered by rising antimicrobial resistance. We summarize H. pylori resistance rates in Latin American children from 2008 to 2023.

MATERIAL AND METHODS

Systematic review following PRISMA guidelines and National Heart, Lung, and Blood Institute checklist to assess risk of bias (PROSPERO CRD42024517108) that included original cross-sectional observational studies reporting resistance to commonly used antibiotics in Latin American children and adolescents. We searched in PubMed, LILACS, and SciELO databases.

RESULTS

Of 51 studies, 45 were excluded. The quality of the six analyzed studies (297 H. pylori-positive samples) was satisfactory. Phenotypic methods (N = 3) reported higher resistance rates than genotypic studies (N = 3). Clarithromycin resistance ranged from 8.0% to 26.7% (6 studies; 297 samples), metronidazole from 1.9% to 40.2% (4 studies; 211 samples), amoxicillin from 0% to 10.4% (3 studies; 158 samples), tetracycline resistance was not detected (3 studies; 158 samples), and levofloxacin resistance was 2.8% (1 study; 36 samples).

CONCLUSION

Scarce Latin American studies on H. pylori resistance, along with methodological heterogeneity, hinder conclusive findings. Clarithromycin and metronidazole (first-line drugs) resistance is worrisome, likely impacting lower eradication rates. Urgent systematic surveillance or individual testing before treatment is necessary to enhance eradication.

Impact of medication dosage on Helicobacter pylori eradication rates among pediatric patients

OBJECTIVES

Helicobacter pylori rates of eradication to common first-line regimens continue to decline globally. Prescription of the appropriate medication dosage is an important consideration, particularly in the pediatric population due to medication weight-based dosing. Limited data is available on the impact of guideline-recommended weight-based dosing on the successful eradication of H. pylori in children.

METHODS

Retrospective study of patients with histologic evidence of H. pylori from two pediatric tertiary care centers in New England. We excluded patients who were not treated or those missing eradication data. We compared the eradication rates of patients prescribed recommended weight-based dosages, duration, and frequency of treatment with those who were not.

RESULTS

One hundred forty-four patients were included. The overall eradication rate was 73.6% (106/144). All treatment regimens were properly prescribed for 14 days. There was a high rate of improper weight-based dosing: proton pump inhibitor (PPI) 31.2% (45/144), amoxicillin 31.7% (39/123), metronidazole (MET) 19.4% (12/62), clarithromycin (CLA) 23.9% (22/70), tetracycline 50% (6/12), bismuth 26.1% (6/23). When PPIs were properly weight-dosed, there was a 78.8% eradication rate that dropped to 62.2% with suboptimal dosing (p = 0.036, odds ratio [OR]: 2.26, confidence interval [CI]: 1.04-4.87). When amoxicillin was properly weight-dosed, successful eradication was achieved in 81% versus only 53.8% when improperly dosed (p = 0.002; OR: 3.64, CI: 1.58-8.37). There was no statistically significant impact on eradication rates with improper weight-based dosing of MET, CLA, tetracycline, or bismuth.

CONCLUSION

Proper weight-based dosing of amoxicillin and PPI is important for the successful eradication of H. pylori among children in the New England area.

Helicobacter pylori-Associated Extranodal Marginal Zone Lymphoma of Mucosa-Associated Tissue in Children: A Multicenter Case Series

OBJECTIVE

Data regarding Helicobacter pylori (H. pylori)-associated mucosa-associated lymphoid tissue (MALT) lymphoma in children are lacking. We aimed to characterize the diagnosis, management, and outcome of H. pylori-associated MALT lymphoma in pediatric patients.

STUDY DESIGN

A retrospective multicenter case series of the pediatric patients with H. pylori-associated MALT lymphoma who were diagnosed during 2010-2022.

RESULTS

Five children, of them three females, were identified. The mean age at diagnosis was 14.6 ± 2.4 years. The clinical presentation included abdominal pain (5/5), nausea (3/5), weight loss, night sweats, recurrent fever (1/5), and iron deficiency anemia (2/5). Endoscopic findings in both the stomach antrum and body included a fragile and hyperemic mucosa, large ulcers, extensive nodularity, and exudate. All the biopsies from the gastric mucosa were consistent with MALT lymphoma, and positive for H. pylori (by Giemsa stain). All the patients received triple therapy (amoxicillin, nitroimidazole, or a macrolide, and a proton pump inhibitor, for 14 days), and achieved H. pylori eradication. All had complete resolution of histological findings at the last follow-up. In one patient, the histology of MALT lymphoma persisted 12 months after H. pylori eradication, and only the 18-month-biopsy was free of residual disease.

CONCLUSIONS

In this series of pediatric MALT lymphoma, complete resolution of disease occurred in all the patients, yet histological remission was delayed in one. This supports the importance of endoscopic follow-up.

Helicobacter pylori Infection in Children With Cerebral Palsy: A Cross-Sectional Study

BACKGROUND

Children with cerebral palsy (CP) frequently have associated disorders and complications, including gastrointestinal problems. Helicobacter pylori is a common infection worldwide, frequently associated with gastrointestinal manifestations.

METHODS

To estimate the prevalence of H. pylori infection in children with CP, a cross-sectional study over an eight-month period was performed in the pediatric neurology outpatient clinic of Tanta University Hospital. The study included 100 patients with CP aged two to 17 years. All patients were tested for H. pylori antigen in stool by enzyme-linked immunosorbent assay.

RESULTS

The mean age of studied children with CP was 7.03 ± 4.1 years; there were 57 males and 43 females. Spastic quadriplegic CP was the most common type of CP (34%). Forty-five children with CP were positive for H. pylori antigen in stool. Intellectual disability (ID), low sociodemographic scoring system, semisolid diet, and Eating and Drinking Ability Classification System (EDACS) levels 4 and 5 were significant predictors of H. pylori infection (odds ratio of 1.86, 2.63, 12, and 1.77, respectively, P < 0.05). Vomiting, abdominal pain, and gastrointestinal tract bleeding were significantly more frequent in H. pylori-infected children with CP than noninfected children with CP (P value < 0.05) CONCLUSION: H. pylori is a relatively common infection among children with CP. The main risk factors for H. pylori infection were low socioeconomic level, ID, semisolid diet, and EDACS levels 4 and 5.

Helicobacter Pylori infection in children with inflammatory bowel disease: a prospective multicenter study

BACKGROUND

The relationship between Helicobacter-pylori(Hp)infection and inflammatory-bowel-disease(IBD) in pediatric-patients remains controversial. We aimed to assess the Hp-infection occurrence in newly-diagnosed pediatric-patients with IBD compared to no-IBD patients. Additionally, we aimed to examine differences in clinical-activity-index(CAI) and endoscopic-severity-score(ESS)between IBD-patients with and without Hp-infection, at baseline and at 1-year-follow-up(FU), after eradication-therapy(ET).

METHODS

IBD diagnosis was based on Porto-criteria, and all patients underwent gastroscopy at baseline and 1-year FU. For Crohn's-disease(CD) and ulcerative colitis(UC), IBD-CAI and -ESS were classified using PCDAI/SES-CD and PUCAI/UCEIS, respectively.

RESULTS

76 IBD-patients were included in the study[35 F(46.1%),median-age 12(range 2-17)]. CD and UC were diagnosed in 29(38.2%) and 45(59.2%)patients, respectively, and unclassified-IBD in two(2.6%)patients. Non-IBD patients were 148[71 F(48.0%),median-age 12(range 1-17)]. Hp-infection at baseline was reported in 7(9.2%) and 18(12.2%)IBD and non-IBD patients, respectively(p = 0.5065). The 7 IBD patients with Hp infection were compared to 69 IBD patients without Hp-infection at baseline evaluation, and no significant differences were reported considering CAI and ESS in these two groups. At 1-year FU, after ET, IBD patients with Hp infection improved, both for CAI and ESS, but statistical significance was not reached.

CONCLUSION

The occurrence of Hp-infection did not differ between IBD and no-IBD patients. No differences in CAI or ESS were observed at the diagnosis, and after ET no worsening of CAI or ESS was noted at one-year FU, between Hp-positive and -negative IBD patients.

Physician perspectives of Helicobacter pylori diagnostic and treatment practices in Canada: results of a Canadian survey

BACKGROUND

Helicobacter pylori infection is prevalent worldwide and can lead to peptic ulcer disease (PUD) and gastric cancer. Effective diagnosis and treatment of H. pylori infection by gastroenterologists and family physicians is crucial. However, there are differing views on optimal diagnosis and treatment. The objective of this study is to understand the impressions of Canadian physicians regarding H. pylori diagnosis and treatment and whether impressions differ between gastroenterologists and family physicians. A second objective is to understand physician perspectives on rising antibiotic resistance and how that guides empiric management.

METHODS

A survey facilitated via REDCap was administered to Canadian gastroenterologists and family physicians. A total of 105 participants completed the survey, including 43 gastroenterologists and 62 family physicians. Gastroenterologists were recruited from across the country and family physicians were recruited from Manitoba.

RESULTS

For diagnosis of H. pylori, 67% of gastroenterologists reported endoscopic biopsies for histology assessment as most common and 73% of family physicians reported serology as their main diagnostic test. While nearly all gastroenterologists believed antibiotic resistance to be a problem, nearly one quarter of family physicians did not believe it was a problem.

CONCLUSIONS

There is variability in practices among both gastroenterologists and family physicians regarding diagnosis of H. pylori infection. There was consensus that local antibiotic resistance patterns should guide management. If known, the degree and patterns of antibiotic resistance could bring a more uniform consensus to H. pylori management. Greater education of physicians, especially family physicians regarding management of H pylori is needed.

Helicobacter pylori antibiotic resistance profile in Chinese children with upper gastrointestinal symptoms and a literature review for developing personalized eradicating strategies

Background: H. pylori (Helicobacter pylori) infections typically occur in early childhood. Although the prevalence of H. pylori in children is lower than that in adults, the eradication rate of this infection in children is relatively low because of resistance. In this study, we analyzed personalized treatment strategies to achieve treatment goals based on H. pylori resistance characteristics. This retrospective single-center study was conducted between January 2019 and December 2022 and enrolled 1,587 children who presented with upper gastrointestinal symptoms and underwent endoscopy. H. pylori culturing and antimicrobial susceptibility testing were performed. Results: Culture-positive results for H. pylori were obtained in 535 children. The resistance rates to clarithromycin (CLA), metronidazole (MET), and levofloxacin (LEV) were 39.8%, 78.1%, and 20.2%, respectively. None of the isolates were resistant to tetracycline (TET), amoxicillin (AMO), or furazolidone (FZD). Double resistance rates to CLA + MET, CLA + LEV, and MET + LEV were 19.1%, 3.0%, and 5.8%, respectively. Notably, triple-resistant to CLA + MET + LEV was 9.7%. Based on susceptibility tests, individualized triple therapy [proton pump inhibitor (PPI) +AMO + CLA/MET] was selected for 380 children with H. pylori sensitive to MET and/or CLA. In 155 children resistant to CLA and MET, bismuth-based quadruple therapy was recommended; for unable to receive bismuth, concomitant therapy was recommended for 14 children (<8 years of age); triple therapy with TET was recommended for 141 children (>8 years of age), with 43 children (>14 years of age) requiring FZD rather than TET. Conclusion: Resistance to H. pylori in Chinese children was relatively poor. Personalized therapy regimens should be based on susceptibility tests and avoided factors associated with treatment failure.

Helicobacter pylori eradication therapy for children

OBJECTIVES

The research aims to investigate the effect of vitamin D supplementation on the efficacy of Helicobacter pylori eradication therapy and to find new drug combinations for the eradication of the bacterium.

METHODS

A total of 128 children participated in the research. They were distributed under the following criteria: group A were children who tested positive for H. pylori and were treated with the standard so-called triple therapy including vitamin D; group B were children who tested positive for H. pylori and received the standard triple therapy without including vitamin D in the treatment; and group C were children who tested negative for H. pylori. After endoscopic examination, additional venous blood samples were taken from the children to determine vitamin D levels. A controlled study was carried out 45 days after the initial treatment.

RESULTS

The overall success rate of eradication therapy was 84.1 %. In group A, the success rate of treatment was 93.5 %, contrary to group B, where the success rate was 75 %. Although there was a difference in the percentage of H. pylori eradication therapy in the main group compared to the control group, there was no significant difference in group B. The success rate of eradication is p=0.082.

CONCLUSIONS

Following the research results, the addition of vitamin D to the standard triple therapy regimen for H. pylori had no effect. It can therefore be concluded that vitamin D does not significantly increase the efficacy of eradication therapy.

Assessment of the quality, diagnosis, and therapeutic recommendations of clinical practice guidelines on patients with Helicobacter pylori infection: A systematic review

We conducted this study to systematically review and assess the current clinical practice guidelines (CPGs) related to the diagnosis and treatment of Helicobacter pylori (H. pylori) infection. The aim was to evaluate the quality of these included CPGs and provide clinicians with a convenient and comprehensive reference for updating their own CPGs. We searched four databases to identify eligible CPGs focusing on H. pylori diagnosis and treatment recommendations. The results were presented using evidence mappings. Quality and clinical applicability were assessed comprehensively using AGREE-II and AGREE-REX. Statistical tests, specifically Bonferroni tests, were employed to compare the quality between evidence-based guidelines and consensus. A total of 30 eligible CPGs were included, comprising 17 consensuses and 13 guidelines. The quality showed no statistical significance between consensuses and guidelines, mainly within the moderate to low range. Notably, recommendations across CPGs exhibited inconsistency. Nevertheless, concerning diagnosis, the urea breath test emerged as the most frequently recommended method for testing H. pylori. Regarding treatment, bismuth quadruple therapy stood out as the predominantly recommended eradication strategy, with high-dose dual therapy being a newly recommended option. Our findings suggest the need for specific organizations to update their CPGs on H. pylori or refer to recently published CPGs. Specifically, CPGs for pediatric cases require improvement and updating, while a notable absence of CPGs for the elderly was observed. Furthermore, there is a pressing need to improve the overall quality of CPGs related to H. pylori. Regarding recommendations, additional evidence is essential to elucidate the relationship between H. pylori infection and other diseases and refine test indications. Clinicians are encouraged to consider bismuth quadruple or high-dose dual therapy, incorporating locally sensitive antibiotics, as empirical radical therapy. .

Recommendations for the management of gastrointestinal comorbidities with or without trofinetide use in Rett syndrome

INTRODUCTION

Although gastrointestinal (GI) comorbidities are experienced by over 90% of individuals with Rett syndrome (RTT), a neurodevelopmental disorder associated with mutations in the MECP2 gene, many neurologists and pediatricians do not rank the management of these comorbidities among the most important treatment goals for RTT. Trofinetide, the first approved pharmacologic treatment for RTT, confers improvements in RTT symptoms but is associated with adverse GI events, primarily diarrhea and vomiting. Treatment strategies for GI comorbidities and drug-associated symptoms in RTT represent an unmet clinical need.

AREAS COVERED

This perspective covers GI comorbidities experienced by those with RTT, either with or without trofinetide treatment. PubMed literature searches were undertaken on treatment recommendations for the following conditions: constipation, diarrhea, vomiting, aspiration, dysphagia, gastroesophageal reflux, nausea, gastroparesis, gastritis, and abdominal bloating.

EXPERT OPINION

The authors recommend a proactive approach to management of symptomatic GI comorbidities and drug-associated symptoms in RTT to enhance drug tolerance and improve the quality of life of affected individuals. Management strategies for common GI comorbidities associated with RTT are reviewed based on authors' clinical experience and augmented by recommendations from the literature.

Leading Paediatric Infectious Diseases-Current Trends, Gaps, and Future Prospects in Oral Pharmacotherapeutic Interventions

Paediatric infectious diseases contribute significantly to global health challenges. Conventional therapeutic interventions are not always suitable for children, as they are regularly accompanied with long-standing disadvantages that negatively impact efficacy, thus necessitating the need for effective and child-friendly pharmacotherapeutic interventions. Recent advancements in drug delivery technologies, particularly oral formulations, have shown tremendous progress in enhancing the effectiveness of paediatric medicines. Generally, these delivery methods target, and address challenges associated with palatability, dosing accuracy, stability, bioavailability, patient compliance, and caregiver convenience, which are important factors that can influence successful treatment outcomes in children. Some of the emerging trends include moving away from creating liquid delivery systems to developing oral solid formulations, with the most explored being orodispersible tablets, multiparticulate dosage forms using film-coating technologies, and chewable drug products. Other ongoing innovations include gastro-retentive, 3D-printed, nipple-shield, milk-based, and nanoparticulate (e.g., lipid-, polymeric-based templates) drug delivery systems, possessing the potential to improve therapeutic effectiveness, age appropriateness, pharmacokinetics, and safety profiles as they relate to the paediatric population. This manuscript therefore highlights the evolving landscape of oral pharmacotherapeutic interventions for leading paediatric infectious diseases, crediting the role of innovative drug delivery technologies. By focusing on the current trends, pointing out gaps, and identifying future possibilities, this review aims to contribute towards ongoing efforts directed at improving paediatric health outcomes associated with the management of these infectious ailments through accessible and efficacious drug treatments.

Helicobacter pylori infection found during upper endoscopy performed for the diagnosis of celiac, inflammatory bowel diseases, and eosinophilic esophagitis: A multicenter pediatric European study

BACKGROUND

Helicobacter pylori may be found during upper gastrointestinal endoscopy (UGE) performed to diagnose celiac disease (CeD), inflammatory bowel disease (IBD), and eosinophilic esophagitis (EoE). We aimed to describe the frequency of H. pylori in children undergoing UGE for CeD, IBD, and EoE and the number of children receiving eradication treatment.

MATERIALS AND METHODS

A retrospective multicenter study from 14 countries included pediatric patients diagnosed with CeD, IBD, and EoE between January 2019 and December 2021.

DATA COLLECTED

age, gender, hematologic parameters, endoscopic, histologic, and H. pylori culture results, and information on eradication treatment.

RESULTS

H. pylori was identified in 349/3890 (9%) children [167 (48%) male, median 12 years (interquartile range 8.1-14.6)]. H. pylori was present in 10% (173/1733) CeD, 8.5% (110/1292) IBD and 7.6% (66/865) EoE patients (p = NS). The prevalence differed significantly between Europe (Eastern 5.2% (28/536), Southern 3.8% (78/2032), Western 5.6% (28/513)) and the Middle East 26.6% (215/809) [odds ratio (OR) 7.96 95% confidence interval (CI) (6.31-10.1) p < 0.0001]. Eradication treatment was prescribed in 131/349 (37.5%) patients, 34.6% CeD, 35.8% IBD, and 56.1% EoE. Predictors for recommending treatment included erosions/ulcers [OR 6.45 95% CI 3.62-11.47, p < 0.0001] and nodular gastritis [OR 2.25 95% CI 1.33-3.81, p 0.003]. Treatment rates were higher in centers with a low H. pylori prevalence (<20%) [OR 3.36 95% CI 1.47-7.66 p 0.004].

CONCLUSIONS

Identifying H. pylori incidentally during UGE performed for the most common gastrointestinal diseases varies significantly among regions but not among diseases. The indications for recommending treatment are not well defined, and less than 40% of children received treatment.

Global Primary Antibiotic Resistance Rate of Helicobacter pylori in Recent 10 years: A Systematic Review and Meta-Analysis

INTRODUCTION

Due to irregular antibiotic use, the rate of antibiotic resistance to Helicobacter pylori (H. pylori) is increasing and varies from region to region. Therefore, for the purpose of further clarifying the changes in antibiotic resistance rates nowadays, we conducted a systematic review and meta-analysis to update and assess the 10-year trend of primary H. pylori antibiotic resistance rate to the commonly prescribed antibiotics worldwide.

MATERIALS AND METHODS

According to the PRISMA statement, we systematically searched electronic databases for studies that assessed rates of H. pylori resistance to clarithromycin, metronidazole, levofloxacin, amoxicillin, or tetracycline published from 2013 to 2023. AHRQ was adopted to estimate methodological quality and publication bias in the included studies, and statistical analysis was performed using Stata 17.0.

RESULTS

We identified 163 studies, comprising 47,002 isolates from 36 countries. The meta-analysis showed that the primary antibiotic resistance rate of H. pylori varied widely among antibiotics. Subgroup analysis showed higher rates of antibiotic resistance in the adult population than in children, and a general trend of increased resistance was observed from 2013 to 2023. There was considerable heterogeneity (I2 > 75%) among all analyses, which may be due to high variability in resistance rates across the global regions.

CONCLUSIONS

Resistance of H. pylori to antibiotics has reached alarming levels worldwide, which has a great effect on the efficacy of treatment. Local surveillance networks are required to select appropriate eradication regimens for each region.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Quality appraisal of clinical guidelines for Helicobacter pylori infection and systematic analysis of the level of evidence for recommendations

OBJECTIVES

To systematically assess the quality of clinical practice guidelines (CPGs) for Helicobacter pylori (HP) infection and identify gaps that limit their development.

STUDY DESIGN AND SETTING

CPGs for HP infection were systematically collected from PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and six online guideline repositories. Three researchers independently used the AGREE Ⅱ tool to evaluate the methodological quality of the eligible CPGs. In addition, the reporting and recommendation qualities were appraised by using the RIGHT and AGREE-REX tools, respectively. The distribution of the level of evidence and strength of recommendation among evidence-based CPGs was determined.

RESULTS

A total of 7,019 records were identified, and 24 CPGs met the eligibility criteria. Of the eligible CPGs, 19 were evidence-based and 5 were consensus-based. The mean overall rating score of AGREE II was 50.7% (SD = 17.2%). Among six domains, the highest mean score was for scope and purpose (74.4%, SD = 17.7%) and the lowest mean score was for applicability (24.3%, SD = 8.9). Only three of 24 CPGs were high-quality. The mean overall score of recommendation quality was 35.5% (SD = 12.2%), and the mean scores in each domain of AGREE-REX and RIGHT were all ≤ 60%, with values and preferences scoring the lowest (16.6%, SD = 11.9%). A total of 505 recommendations were identified. Strong recommendations accounted for 64.1%, and only 34.3% of strong recommendations were based on high-quality evidence.

CONCLUSION

The overall quality of CPGs for HP infection is poor, and CPG developers tend to neglect some domains, resulting in a wide variability in the quality of the CPGs. Additionally, CPGs for HP infection lack sufficient high-quality evidence, and the grading of recommendation strength should be based on the quality of evidence. The CPGs for HP infection have much room for improvement and further researches are required to minimize the evidence gap.

H. Pylori Treatment in the COVID-19 Era. What Have We Learned So Far?

PURPOSE OF REVIEW

CoronaVirus Disease of 2019 (COVID-19) has negatively influenced the management of multiple conditions in regards to the gastroenterology patient. An equivalent change in the management of Helicobacter pylori (H. pylori)-related diseases was reported, as practically no eradication treatment was offered during most of the pandemic. Given the scarcity of published data, we performed a literature review trying to elucidate the effect of COVID-19 on H. pylori treatment.

RECENT FINDINGS

COVID-19 has produced more questions than answers as to the outcome of COVID-19 in H. Pylori infected patients, post-COVID-19 patients treated for H. pylori, acid suppression and COVID-19 incidence and outcomes, and H. pylori eradication treatment in patients having recovered from COVID-19. We strongly believe that this scientific uncertainty produced by the COVID-19 pandemic has set up the stage for an incremental change in H. pylori treatment as COVID-19 has offered us the chance to speed up how we will, in the near future, approach patients with a possible Η. pylori infection.

Accuracy of gastric nodule combined with rapid urease test prediction in diagnosing Helicobacter pylori infection in children

BACKGROUND

The diagnosis of Helicobacter pylori (H. pylori) infection in children remains challenging with the lack of a rapid, cost-effective, and highly accurate diagnostic method. Consequently, this study aimed to investigate the accuracy of the combination of gastric nodule and rapid urease test (RUT) as a diagnostic method for H. pylori infection in children.

METHODS

The study included participants who underwent a thorough examination, including gastroscopy, a 13C breath test, RUT, and pathological methylene blue staining, with the gold standard for diagnosing of H. pylori infection being a positive result from both pathological methylene blue staining and 13C breath test. The sensitivity, specificity, positive and negative predictive values, and accuracy of the diagnostic methods were calculated.

RESULTS

The accuracy of the different tests for H. pylori infection was evaluated in 2202 participants. A total of 730 (33.2%) children were diagnosed with H. pylori infection (pathological methylene blue staining and 13C breath test, both positive). Gastric nodule had a sensitivity of 87.1% and a specificity of 93.1%, whereas combining gastric nodule and RUT in parallel had the higher accuracy of 95.4%. The accuracy of gastric nodule diagnosis was higher in younger age groups and increased after excluding patients with a history of anti-H. pylori treatment.

CONCLUSIONS

The findings of this study suggest that gastric nodules, particularly when combined with RUT, can be a valuable predictor of H. pylori infection in children, offering a simple and feasible alternative to other invasive methods.

Testing for Helicobacter pylori in an era of antimicrobial resistance

Antimicrobial resistance in Helicobacter pylori has reached alarming levels and is compromising traditional empiric treatment of H. pylori. Antimicrobial susceptibility testing is routinely performed for infectious diseases when there is a risk of resistance and is now recommended to guide therapy for H. pylori. This mini-review overviews the current diagnostics for H. pylori with a focus on tests that enable susceptibility-guided treatment, including molecular tests performed directly on stool and endoscopically collected specimens.

Clinical presentation and outcomes of Helicobacter heilmannii gastritis in children in the New England region of the United States

OBJECTIVE

To describe the clinical, endoscopic, histologic, and treatment outcomes of Helicobacter heilmannii (H. heilmannii) associated gastritis in children in the New England region of the United States.

METHODS

Retrospective study of children (1-18 years) with H. heilmannii identified on gastric mucosal biopsies from two pediatric centers over a 21-year period, January 2000-December 2021. Cases were identified by querying pathology databases at each institution. Demographic and clinical data were obtained from the medical record. Endoscopic and histologic findings were extracted from endoscopy and pathology reports, respectively.

RESULTS

Thirty-eight children were diagnosed with H. heilmannii-associated gastritis during the study period. The mean age at diagnosis was 10.1 ± 5.3 years, and 25/38 (66%) cases were male. Abdominal pain (32%) and nausea with or without vomiting (26%) were the most common symptoms. Thirty-two children (84%) had endoscopic findings including gastric nodularity (55%) and erythema (26%). All children had histologic signs of chronic gastritis, including those with normal endoscopic exams. Antibiotic regimens used for treating Helicobacter pylori were frequently prescribed. Of the 17 children who underwent a follow-up endoscopy (range 2-68 months), 15 (88%) did not have H. heilmannii identified on gastric biopsies.

CONCLUSION

H. heilmannii was an infrequent but potential cause of epigastric abdominal pain and nausea in our cohort of New England children. While morphologically distinct from H. pylori, the bacteria can result in similar endoscopic and histologic findings of nodularity and chronic gastritis, respectively. The rate of eradication, as assessed by histology following treatment with H. pylori therapies, was below the 90% recommended goal for antimicrobial therapies.

Validation of the PyloPlus Urea Breath Test System in pediatric patients

IMPORTANCE

For the diagnosis and post-treatment monitoring of H. pylori infection, non-invasive testing methodologies improve patient comfort, particularly for children. Previously, only the BreathTek UBT had FDA approval for use in pediatric patients and required an adjustment calculation based on age, height, and weight of the patient. The purpose of this study was to evaluate the performance of the PyloPlus UBT assay in a pediatric population.

Are alarm symptoms of the Rome IV criteria enough to rule out organic pathology?

BACKGROUND

The Rome IV criteria offer symptom-based recommendations for diagnosing functional gastrointestinal diseases (FGID) in children and adolescents without esophagogastroduodenoscopy (EGD). The aim of this study is to evaluate the usefulness of Rome IV criteria for ruling out organic disease in patients with and without alarm symptoms.

METHODS

Retrospective research was conducted on children and adolescents who had dyspepsia and underwent EGD. The patients were categorized into groups according to the Rome IV criteria, based on the presence or absence of alarm signs. The esophagogastroduodenoscopy findings in these groups were then compared and classified as either altered or normal.

RESULTS

Seventy-seven of 124 cases (62%) had altered EGD findings, and 97.2% (75/77) of altered EGD patients had histopathological findings. In the study population, the prevalence of Helicobacter pylori was 46.7%. Seventy-four of 124 cases (59.7%) had no alarm symptoms and were diagnosed with FGID according to Rome IV criteria. Thirty-six (48%) of these patients had altered EGD, and five of these patients had duodenal ulcers. Patients without alarm symptoms were compared based on altered versus normal EGD findings. Helicobacter pylori was significantly more abundant in the altered EGD group. Fifty (40.3%) of 124 patients had one or more alarm symptoms and 41 of 50 (82%) cases with alarm symptoms had altered EGD. When patients with altered and normal EGD findings were compared, alarm symptoms, H. pylori, and histopathological findings were higher in the altered EGD group.

CONCLUSION

The Rome IV criteria are effective for alarm-symptom-positive patients. However, in patients lacking alarm symptoms, the Rome IV criteria are insufficient to rule out organic causes.

Gastrocolic fistula as a complication of a gastric ulcer related to Helicobacter pylori in a child

Gastrocolic fistulas are very rare in children and their association with Helicobacter pylori is poorly described. We present the case of a 10-year-old boy with a history of chronic abdominal pain, diarrhea, halitosis, and growth delay diagnosed with H. pylori-associated gastritis and gastrocolic fistula. The boy recovered with resection surgery and antibiotic therapy for eradication of the pathogen. This is the first description of a gastrocolic fistula in pediatrics related to H. pylori.

Role of Probiotics in the Treatment and Prevention of Common Gastrointestinal Conditions in Children

Probiotics are live microorganisms that confer health benefits to the host when administered in adequate amounts. Although recommendations for probiotic use should be strain-specific, many systematic reviews, including recommendations from different societies, recommend probiotic use in general, providing no relevant information for healthcare professionals regarding which probiotic to recommend for which clinical indication, at what dose, and for how long. This narrative review aimed to present the available evidence on the use of probiotics in the prevention and treatment of common gastrointestinal diseases in children, considering the strain and dose used. Furthermore, this study summarizes the evidence on the possible side effects and quality of products containing probiotics.

Important Recommendations Regarding the Test-and-Treat Strategy for Helicobacter pylori Infection in Children

Helicobacter pylori is a commonly encountered pathogen in medical practice. It causes chronic gastritis in patients of different ages. Many published papers have provided different opinions on whether the test-and-treat strategy for H. pylori infection should be implemented in children. It is critical that the opinion in favor of this strategy was published in Europe, where ESPGHAN/NASPGHAN guidelines have not recommended the use of test-and-treat strategy for H. pylori in children. Herein, I propose my opinion regarding this debate using 4 main points. First, this strategy should be implemented in areas where its benefits outweigh the associated risks. Thus, if it is not tailored to the locality, the results of the test-and-treat strategy for H. pylori in children may be erroneous. Second, the association between H. pylori infection and other diseases such as asthma and other allergic diseases should not be factored in when considering the test-and-treat strategy. This is because these diseases are associated with H. pylori noninfection and not with its posteradication status. Third, there is evidence that H. pylori infection can significantly alter children's intestinal microbiota. Finally, gastroscopy should not be performed in all H. pylori-positive children, particularly if the drug susceptibility test is not available. In the near future, it will be possible to easily conduct drug susceptibility tests for H. pylori using fecal samples. I believe that this report may expand the test-and-treat strategy for children infected with asymptomatic H. pylori outside of Japan and prevent not only gastric cancer but also minor diseases such as iron deficiency anemia, chronic idiopathic thrombocytopenic purpura, and failure to thrive. Pediatricians are responsible for keeping children healthy not only during childhood but also in adulthood. Thus, even if there are only a few H. pylori-related diseases and no severe cases in children, it is necessary to take early measures to prevent problems (eg, incidence of gastric cancer) in adulthood.

Profile of Helicobacter pylori infections among children in the South Island of New Zealand (2010-2021)

BACKGROUND

Helicobacter pylori is a gram-negative gut bacterium most often acquired during childhood. International guidelines state that children with suspected H. pylori infection should be referred to a gastroenterologist for investigation via gastroscopy and biopsy. Eradication therapy should be prescribed for children with peptic ulcer disease or following a treatment risk/benefit discussion for those with an incidental gastroscopy finding. Guidelines state that for children a "test-and-treat" approach is not warranted, contrasting recommendations for adults. The aim of this study was to profile pediatric H. pylori infections in the South Island of New Zealand (NZ) to determine diagnostic and management strategies, and adherence to international guidelines.

MATERIALS AND METHODS

Retrospective data for positive H. pylori tests between 2010 and 2021 were retrieved from hospitals and regional testing laboratories throughout the South Island (NZ) for children ≤18 years. Outcome data were retrieved from tertiary care hospital records; sociodemographic, testing methods, eradication therapy, and symptoms.

RESULTS

Two-hundred and forty children were identified: 105 (44%) male, mean age 13.2 years (SD 4.3). Participants of Pasifika, Asian, and Middle Eastern/Latin American/African heritage were overrepresented compared to the NZ census data. Overall, 138 (58%) children were diagnosed via stool antigen tests, 78 (32%) serum, and only 24 (10%) adhered to international guidelines in being confirmed via gastroscopy. Only 59 (25%) had a record of eradication therapy, and 39/59 (66%) were retested to determine eradication success, with 32 (82%) negative tests and seven (18%) remaining positive. Of the 181 (75%) that had eradication status unknown, 66 (28%) had a retest result available with 48 (73%) testing negative and 18 (27%) positive, suggesting a substantial proportion had received eradication therapy without adhering to international guidelines.

CONCLUSIONS

International guidelines were not adhered to for most children in the study cohort. Implications of this include cost, unnecessary venipuncture, and unjustified antibiotic exposure.

Antibiotic resistance of Helicobacter pylori in Chinese children: A multicenter study from 2016 to 2023

BACKGROUND

To investigate the antibiotic resistance of Helicobacter pylori (H. pylori) strains to clarithromycin, metronidazole, amoxicillin, levofloxacin, furazolidone, and tetracycline in Chinese children.

MATERIALS AND METHODS

This multicenter, retrospective study was conducted from January 2016 through May 2023. Gastric mucosa biopsies were obtained from pediatric participants who underwent upper gastrointestinal endoscopy at 96 hospitals in northern, southwestern, and southeastern China. The susceptibility of H. pylori to six commonly used antibiotics was determined by agar dilution method.

RESULTS

Among the 3074 H. pylori isolates, 36.7% were resistant to clarithromycin, 77.3% to metronidazole, 16.6% to levofloxacin, and 0.3% to amoxicillin. No strains were detected to be resistant to furazolidone or tetracycline. During the 8-year study period, resistance to clarithromycin and metronidazole showed a significant upward trend, while the resistance pattern of the other antibiotics demonstrated a slight but nonsignificant fluctuation. Significant regional differences were found in the distribution of clarithromycin resistance among the northern (66.0%), southwestern (48.2%), and southeastern (34.6%) regions. The metronidazole resistance rate was significantly lower in the southeastern coastal region (76.3%) than in the other two regions (88.2% in the north and 87.7% in the southwest). Multi-drug resistance for two or more antibiotics was detected in 36.3% of the H. pylori strains, and the predominant multi-resistance pattern was the dual resistance to clarithromycin and metronidazole.

CONCLUSIONS

The prevalence of H. pylori resistance to clarithromycin and metronidazole is rather high in Chinese children and has been increasing over time. A relatively high resistance rate to levofloxacin was also noticed in children, while almost all strains were susceptible to amoxicillin, furazolidone, and tetracycline. It will be of great clinical significance to continuously monitor the antibiotic-resistance patterns of H. pylori in the pediatric population.

Age-specific causes of upper gastrointestinal bleeding in children

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

The effect of Saccharomyces boulardii supplementation on Helicobacter pylori eradication in children: a systematic review and meta-analysis of Randomized controlled trials

BACKGROUND

It is unclear whether Saccharomyces boulardii (S. boulardii) supplementation in standard triple therapy (STT) is effective in eradicating Helicobacter pylori (H. pylori) infection in children. We therefore conducted a meta-analysis of randomized controlled trials (RCTs) to assess the effect of S. boulardii supplementation on H. pylori eradication in children.

METHODS

We conducted electronic searches in PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure and Wanfang database from the beginning up to September 2023. A random-effects model was employed to calculate the pooled relative risk (RR) with 95% confidence intervals (CI) through a meta-analysis.

RESULTS

Fifteen RCTs (involving 2156 patients) were included in our meta-analysis. Results of the meta-analysis indicated that S. boulardii in combination with STT was more effective than STT alone (intention-to-treat analysis : 87.7% vs. 75.9%, RR = 1.14, 95% CI: 1.10-1.19, P < 0.00001; per-protocol analysis : 88.5% vs. 76.3%, RR = 1.15, 95% CI: 1.10-1.19, P < 0.00001). The S. boulardii supplementation group had a significantly lower incidence of total adverse events (n = 6 RCTs, 9.2% vs. 29.2%, RR = 0.32, 95% CI: 0.21-0.48, P < 0.00001), diarrhea (n = 13 RCTs, 14.7% vs. 32.4%, RR = 0.46, 95% CI: 0.37-0.56, P < 0.00001), and nausea (n = 11 RCTs, 12.7% vs. 21.3%, RR = 0.53, 95% CI: 0.40-0.72, P < 0.0001) than STT group alone. Similar results were also observed in the incidence of vomiting, constipation, abdominal pain, abdominal distention, epigastric discomfort, poor appetite and stomatitis.

CONCLUSIONS

Current evidence indicated that S. boulardii supplementing with STT could improve the eradication rate of H. pylori, and concurrently decrease the incidence of total adverse events and gastrointestinal adverse events in children.