What are the ESPGHAN/NASPGH treatment guidelines for pediatric Helicobacter pylori (Hp) infection?

Updated: Nov 16, 2018
  • Author: Mutaz I Sultan, MBChB, MD; Chief Editor: Carmen Cuffari, MD  more...
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The European Society for Paediatric Gastroenterology Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition made the following recommendations in 2017 for the Management of Helicobacter pylori in Children and Adolescents [31] :

1. Antimicrobial sensitivity should be obtained for the infecting H pylori strain (s), and eradication therapy tailored accordingly.

2. The effectiveness of first-line therapy should be evaluated in national/regional centers.

3. The physician should explain to the patient/family the importance of adherence to the anti–H pylori therapy to enhance successful eradication.

The recommendations also included practice points for the first-line therapy for H pylori infection:

  • If the strain is susceptible to clarithromycin (CLA) and to metronidazole (MET), triple therapy (PPI, amoxicillin [AMO], CLA) for 14 days is the preferred choice.
  • Sequential therapy for 10 days (proton pump inhibitor (PPI) with amoxicillin for 5 days followed by proton pump inhibitor with clarithromycin and metronidazole for 5 days) is equally effective in patients infected with fully susceptible strains. However, sequential therapy has the disadvantage of exposing the child to 3 different antibiotics. Sequential therapy should not be given if the strain is resistant to metronidazole (MET) or clarithromycin (CLA), or if susceptibility testing is not available. The most recent adult guidelines recommend against the use of sequential therapy as first- or second-line therapy.
  • Doses of proton pump inhibitor and antibiotics should be calculated based on the bodyweight.
  • A higher degree of acid suppression improves the success rate of amoxicillin- and clarithromycin-based therapy. Younger children need a higher PPI dose per kg bodyweight compared to adolescents and adults to obtain sufficient acid suppression.
  • Esomeprazole and rabeprazole are less susceptible to degradation by rapid metabolizers with CYP2C19 genetic polymorphism, and therefore, may be preferred when available.
  • For children younger than 8 years, bismuth quadruple therapy refers to bismuth, PPI, AMO, and MET. In children older than 8 years, bismuth quadruple therapy refers to bismuth, PPI, MET, and tetracycline.
  • Current evidence does not support the routine addition of either single or combination probiotics to eradication therapy to reduce side effects and/or improve eradication rates.
  • The outcome of anti–H pylori therapy should be assessed at least 4 weeks after completion of therapy using one of the following tests:
    • (a) The 13C-urea breath (13C-UBT) test or (b) a 2-step monoclonal stool antigen test.
  • When H pylori treatment fails, rescue therapy should be individualized considering antibiotic susceptibility, the age of the child, and available antimicrobial options.

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