What is the recommended treatment for a 14-year-old patient with a suspected H. pylori infection?

Treatment of H. pylori in a 14-Year-Old Patient

A 14-year-old with suspected H. pylori infection should undergo non-invasive testing (urea breath test or stool antigen test) and, if positive, receive empiric eradication therapy with either 14-day bismuth quadruple therapy or 14-day concomitant therapy (non-bismuth quadruple therapy), without requiring endoscopy unless alarm symptoms are present. 1, 2

Diagnostic Approach for Adolescents

• Non-invasive testing is the appropriate first step for a 14-year-old patient, as this age group falls well below the 45-year threshold that triggers automatic endoscopy referral 1, 3

• Recommended non-invasive tests include:

  • 13C-urea breath test (highest accuracy) 1
  • Stool antigen test (90-95% accuracy) 1
  • Laboratory serology only if locally validated 1

• Endoscopy is NOT indicated unless the patient presents with alarm symptoms such as anemia, unintentional weight loss (≥5% in previous 6 months), dysphagia, palpable abdominal mass, malabsorption, or persistent vomiting 1, 3

First-Line Treatment Regimens

Due to increasing clarithromycin resistance worldwide, traditional triple therapy should be abandoned in favor of more effective regimens: 4, 2

Preferred Option 1: Bismuth Quadruple Therapy (14 days)

• Proton pump inhibitor (PPI) + bismuth salt + tetracycline + metronidazole 5, 2
• Important caveat: Tetracycline dosing in pediatric patients requires careful consideration, as the FDA label for amoxicillin notes that tetracycline is an alternative antibiotic but doesn't specify pediatric dosing 6

Preferred Option 2: Concomitant Therapy (14 days)

• PPI + amoxicillin + clarithromycin + metronidazole (all given simultaneously) 2
• This non-bismuth quadruple therapy is effective in areas of high clarithromycin resistance 2

Alternative if Above Not Feasible: Triple Therapy (14 days)

• Only in areas with documented low clarithromycin resistance (<15%): 2
• PPI + amoxicillin + clarithromycin 2
• The FDA-approved dosing for H. pylori in adults uses 1 gram amoxicillin with 500 mg clarithromycin and 30 mg lansoprazole, all twice daily for 14 days 6
• For a 14-year-old, weight-based dosing applies: If weight >40 kg, use adult dosing; if <40 kg, calculate based on 45 mg/kg/day amoxicillin divided every 12 hours 6

Critical Treatment Considerations

• Treatment duration should be 14 days, not 7 days, as longer duration improves eradication rates 2

• High-dose potent PPI or vonoprazan is recommended to achieve adequate acid suppression, which enhances antibiotic effectiveness 2

• Probiotics can be added as adjuvant treatment to reduce antibiotic side effects and potentially enhance eradication rates 2

• Amoxicillin should be taken at the start of meals to minimize gastrointestinal intolerance 6

Post-Treatment Follow-Up

• Confirmation of eradication is strongly recommended if the patient had complicated peptic ulcer disease or gastric ulcer 1

• For uncomplicated cases with symptom resolution, follow-up testing may not be necessary, though regional centers should monitor treatment efficacy 4, 1

• If follow-up testing is performed:

  • Wait at least 4 weeks after treatment cessation 1
  • Stop antibiotics, bismuth, or PPIs at least 2 weeks before testing to avoid false negatives 1
  • Use urea breath test or stool antigen test (not serology, which remains positive long-term) 1

When to Refer to Specialist

Immediate referral is indicated if: 3

• Alarm symptoms present (anemia, weight loss, dysphagia, palpable mass, malabsorption, persistent vomiting)
• Known history of gastric ulcer (requires repeat endoscopy with biopsy until healed)
• Symptoms severe or refractory to first-line treatment
• Family history of gastric cancer (increases risk even in young patients)

Second-Line Therapy if First-Line Fails

• 14-day levofloxacin triple therapy (PPI + amoxicillin + levofloxacin) OR 2
• 14-day bismuth quadruple therapy if not previously used 2
• Avoid using the same antibiotics that failed in first-line treatment 2