What is the treatment for Helicobacter pylori (H. pylori) infection in a child?

From the Guidelines

For H. pylori treatment in children, a triple therapy regimen is typically recommended, consisting of a proton pump inhibitor (PPI) such as omeprazole (1 mg/kg/day divided twice daily, maximum 20 mg twice daily) plus two antibiotics - usually amoxicillin (50 mg/kg/day divided twice daily, maximum 1g twice daily) and clarithromycin (15 mg/kg/day divided twice daily, maximum 500 mg twice daily) for 14 days, as supported by the most recent guidelines 1.

Key Considerations

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, with standard triple therapy recommended if low clarithromycin resistance is present 1.
• For penicillin-allergic children, metronidazole (20 mg/kg/day divided twice daily, maximum 500 mg twice daily) can replace amoxicillin.
• Treatment duration should be 14 days as shorter courses have lower eradication rates.
• Side effects may include diarrhea, nausea, or metallic taste, and probiotics given during treatment may help reduce side effects 1.

Important Notes

• Testing for eradication should be performed at least 4 weeks after completing therapy.
• H. pylori eradication is particularly important in children with peptic ulcer disease, chronic gastritis, or family history of gastric cancer, as the infection can lead to chronic inflammation and potentially serious complications if left untreated 1.
• The worldwide prevalence of H. pylori infections is approximately 50%, with the highest being in developing countries, and standard treatments have been endorsed by Western scientific societies and regulatory authorities 1.

From the FDA Drug Label

The combination of omeprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori. H. pylori eradication was defined as no positive test (culture or histology) at 4 weeks following the end of treatment, and two negative tests were required to be considered eradicated of H. pylori. The combination of omeprazole and clarithromycin was effective in eradicating H. pylori and reduced duodenal ulcer recurrence.

The treatment for Helicobacter pylori (H. pylori) infection in a child is:

• A combination of omeprazole, clarithromycin, and amoxicillin.
• Alternatively, a combination of omeprazole and clarithromycin can be used, but the triple therapy is more effective. Note that the studies provided do not specifically address the treatment of H. pylori infection in children, but rather in adults with duodenal ulcers. However, based on the available information, the above treatment regimens can be considered. 2

From the Research

Treatment Options for H. pylori Infection in Children

• The treatment of H. pylori infection in children should consider factors such as long-term eradication of the organism, cost, compliance, and adverse event profile 3.
• Triple therapy with bismuth, tetracycline, and metronidazole is not recommended for children due to the potential for tooth discoloration and alterations in bone growth associated with tetracyclines 3.
• Dual therapy with omeprazole and clarithromycin may be considered as an alternative for children, but the dosage of omeprazole in pediatric patients has not been established 3.
• Aminopenicillin/bismuth or aminopenicillin/tinidazole combinations appear to be effective in eradicating H. pylori in children, with amoxicillin 50 mg/kg/d plus bismuth subsalicylate or bismuth subcitrate for 6 weeks being a possible treatment option 3.

Treatment Regimens for Resistant H. pylori Strains

• High-dose triple therapy with amoxicillin, metronidazole, and esomeprazole for 2 weeks may be effective in treating children infected with a double-resistant H. pylori strain 4.
• The eradication rate of this regimen was 66% (intention to treat) and 73% (per protocol), with mild to moderate adverse events reported by 21 patients 4.
• A comparative study of amoxicillin and metronidazole in a three-drug regimen for the treatment of H. pylori infection in children found no significant difference in eradication rate between the two regimens 5.

Other Treatment Considerations

• Dual therapy with omeprazole or ranitidine bismuth citrate and either amoxycillin or clarithromycin may eradicate H. pylori in 50-80% of patients 6.
• One week, twice daily, proton pump inhibitor (PPI)-based triple therapy regimens may eradicate about 90% of H. pylori and are associated with mild side effects 6.
• A combination therapy consisting of metronidazole, omeprazole, and clarithromycin for 2 weeks may be effective in treating H. pylori infection, with a cure rate of 88% 7.