What is the dosing for triple therapy to treat Helicobacter pylori (H. pylori) in a child weighing 25 kilograms (kg)?

H. pylori Triple Therapy Dosing for a 25 kg Child

For a 25 kg child, administer triple therapy with amoxicillin 1000 mg twice daily, clarithromycin 250 mg twice daily, and a proton pump inhibitor (esomeprazole 10-20 mg or omeprazole 10-15 mg twice daily) for 14 days. 1, 2

Weight-Based Dosing Calculations

For this 25 kg child, the specific doses are:

• Amoxicillin: 40 mg/kg/day divided twice daily = 1000 mg twice daily (maximum adult dose already reached at this weight) 3, 4
• Clarithromycin: 15-30 mg/kg/day divided twice daily = 250 mg twice daily (use 250 mg for children <10 years or <40 kg; 500 mg for older/heavier children) 3, 5
• Proton pump inhibitor:
  • Esomeprazole 0.6-1.5 mg/kg/day divided twice daily = 10-20 mg twice daily 6
  • OR Omeprazole 0.6 mg/kg/day divided twice daily = 10-15 mg twice daily 3, 5

Treatment Duration and Optimization

• Administer for 14 days rather than 7 days, as this improves eradication rates from approximately 50% to 73% in pediatric populations 4, 1
• Give all medications 30 minutes before meals to maximize absorption and efficacy 7
• High-dose PPI twice daily is critical—single daily dosing significantly reduces treatment success 1, 2

Critical Considerations for Pediatric Patients

• This regimen should only be used in areas with documented low clarithromycin resistance (<15%), as resistance rates now exceed 15-20% in most regions, making this triple therapy achieve only 50-70% eradication rates 7, 1
• In regions with high clarithromycin resistance, bismuth quadruple therapy is preferred, but tetracycline is contraindicated in children, creating a therapeutic dilemma 1
• For children with double-resistant H. pylori (clarithromycin and metronidazole resistant), consider high-dose triple therapy with amoxicillin (75 mg/kg/day), metronidazole (25 mg/kg/day), and esomeprazole (~1.5 mg/kg/day) for 14 days, which achieves 73% eradication in per-protocol analysis 6

Expected Adverse Effects and Management

• Mild adverse effects occur in 16-25% of pediatric patients, including diarrhea (8.9%), nausea (10.8%), vomiting (7.1%), altered taste, and headache 3, 6, 8
• These side effects rarely require discontinuation (<5% of cases) 6, 5
• Consider adjunctive probiotics to reduce antibiotic-associated diarrhea and improve compliance 9, 2

Verification of Eradication

• Confirm eradication with C13-urea breath test at least 4-6 weeks after completing therapy and at least 2 weeks after stopping the PPI 6, 1
• Do not use serology for confirmation, as antibody titers persist for months after successful treatment 2

Common Pitfalls to Avoid

• Never use fluoroquinolones (levofloxacin) in children—they are not licensed for pediatric use and carry risks of musculoskeletal adverse effects 7, 1
• Do not underdose the PPI—inadequate acid suppression is a major cause of treatment failure 1, 2
• Ensure compliance by using a medication diary, as adherence rates average 95% but non-adherence accounts for significant treatment failures 6
• If this first-line therapy fails and the child weighs >15 kg, consider the high-dose metronidazole-based regimen for double-resistant strains rather than immediately resorting to adult rescue therapies 6