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

H. pylori Treatment for Children

For children with H. pylori infection, the recommended first-line treatment is a proton pump inhibitor (PPI) with amoxicillin and either clarithromycin or metronidazole for 14 days, with antibiotic selection based on local resistance patterns. 1, 2

Recommended Treatment Regimens

First-line Treatment Options:

1. Triple Therapy:

   • PPI (standard dose twice daily)
   • Amoxicillin (50 mg/kg/day divided twice daily, max 1g twice daily)
   • Clarithromycin (15 mg/kg/day divided twice daily, max 500mg twice daily)
   • Duration: 14 days

2. Alternative Triple Therapy (in areas with high clarithromycin resistance):

   • PPI (standard dose twice daily)
   • Amoxicillin (50 mg/kg/day divided twice daily, max 1g twice daily)
   • Metronidazole (20 mg/kg/day divided twice daily, max 500mg twice daily)
   • Duration: 14 days

3. Bismuth-based Quadruple Therapy (for areas with high dual resistance):

   • PPI (standard dose twice daily)
   • Bismuth salts (dosage based on weight)
   • Amoxicillin (50 mg/kg/day divided twice daily)
   • Metronidazole (20 mg/kg/day divided twice daily)
   • Duration: 14 days

Antibiotic Selection Considerations

The choice of antibiotics should be guided by:

• Local resistance patterns: Clarithromycin should only be used in areas with <15-20% resistance 1, 3
• Prior antibiotic exposure: Avoid antibiotics the child has recently received
• Antimicrobial stewardship principles: Consider using "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) when possible 1

Important Treatment Considerations

• Duration: 14-day regimens are preferred over 7-10 day regimens to improve eradication rates 1, 3
• Medication restrictions: Tetracyclines and fluoroquinolones are contraindicated in children 1
• Confirmation of eradication: Test for cure should be performed at least 4 weeks after completion of therapy using urea breath test or stool antigen test 2
• Susceptibility testing: Consider antimicrobial susceptibility testing before using clarithromycin, especially in areas with high resistance or after treatment failure 1

Treatment Failures

For children who fail initial therapy:

1. Avoid repeating antibiotics used in the first treatment course
2. Consider bismuth-based quadruple therapy if not used initially
3. Perform susceptibility testing when available to guide antibiotic selection
4. Extend treatment duration to 14 days if shorter duration was initially used

Common Pitfalls to Avoid

• Inadequate duration: Using 7-day regimens instead of 14-day regimens
• Poor adherence: Not emphasizing the importance of completing the full course of treatment
• Inappropriate antibiotic selection: Using clarithromycin in areas with high resistance
• Failure to confirm eradication: Not performing test of cure after treatment
• Inadequate acid suppression: Using insufficient PPI dosing

By following these evidence-based recommendations and considering local antibiotic resistance patterns, clinicians can optimize H. pylori eradication rates in children while practicing good antimicrobial stewardship.