What is the recommended first‑line therapy and dosing for a 10‑year‑old child with confirmed Helicobacter pylori infection?

First-Line Treatment for H. pylori in a 10-Year-Old Child

For a 10-year-old child with confirmed H. pylori infection, bismuth quadruple therapy for 14 days is the recommended first-line treatment, consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate 262 mg (or bismuth subcitrate 120 mg) four times daily, metronidazole 500 mg three times daily, and tetracycline 500 mg four times daily. 1, 2

Rationale for Bismuth Quadruple Therapy in Children

• Bismuth quadruple therapy achieves 80-90% eradication rates even in areas with high clarithromycin and metronidazole resistance, making it superior to traditional triple therapy in most clinical scenarios. 1, 2

• No bacterial resistance to bismuth has been described, and tetracycline resistance remains rare (<5%), preserving the efficacy of this regimen. 1

• Bismuth's synergistic effect overcomes metronidazole resistance in vitro, allowing successful eradication even when metronidazole-resistant strains are present. 1, 3

Specific Dosing for a 10-Year-Old

• PPI twice daily: Standard pediatric dosing includes omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 20 mg, or rabeprazole 20 mg, taken 30 minutes before meals on an empty stomach. 1, 2

• Bismuth subsalicylate 262 mg (two tablets) four times daily or bismuth subcitrate 120 mg four times daily, taken 30 minutes before meals and at bedtime. 1, 2

• Metronidazole 500 mg three times daily (total 1.5 g/day), taken 30 minutes after meals. 1, 2, 3

• Tetracycline 500 mg four times daily; do not substitute with doxycycline as it yields significantly inferior eradication rates. 1

Treatment Duration

• A 14-day course is mandatory, as extending therapy from 7 to 14 days improves eradication success by approximately 5%. 1, 2, 3

• All major gastroenterology guidelines endorse 14 days as the standard duration to maximize first-attempt success. 1

Why Traditional Triple Therapy Is Not Recommended

• Traditional triple therapy (PPI + clarithromycin + amoxicillin) achieves only 54-68% eradication in North American children, well below the 80% minimum target. 4, 5

• Clarithromycin resistance now exceeds 15-20% in most regions, making empiric clarithromycin-based therapy unacceptable without susceptibility testing. 1

• When H. pylori strains are clarithromycin-resistant, eradication rates drop from approximately 90% to 20%. 1

Alternative First-Line Option (If Bismuth Is Unavailable)

• Concomitant non-bismuth quadruple therapy: PPI twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily for 14 days. 1

• This regimen should only be used in areas with documented clarithromycin resistance <15% and when bismuth is truly unavailable. 1, 2

Critical Optimization Factors

• High-dose PPI twice daily is mandatory; once-daily dosing markedly reduces treatment efficacy. 1, 3

• PPI should be taken 30 minutes before meals on an empty stomach, without concomitant use of other antacids. 1, 2

• Complete the full 14-day course; shorter durations reduce eradication success. 1, 2, 3

Expected Side Effects and Management

• Diarrhea occurs in 21-41% of patients during the first week due to disruption of normal gut microbiota; this does not indicate treatment failure. 1

• Consider adjunctive probiotics to reduce the risk of diarrhea and improve patient compliance. 1

• Minor adverse effects occur in approximately 25% of pediatric patients but are generally well-tolerated. 4

Confirmation of Eradication

• Test for eradication success at least 4 weeks after completing therapy using urea breath test or validated monoclonal stool antigen test. 1, 2

• Discontinue PPI at least 2 weeks before testing to avoid false-negative results. 1, 2

• Never use serology to confirm eradication, as antibodies persist long after successful treatment. 1

Second-Line Treatment (If First-Line Fails)

• Levofloxacin triple therapy: PPI twice daily + amoxicillin 1000 mg twice daily + levofloxacin 500 mg once daily for 14 days (only if no prior fluoroquinolone exposure). 1, 2

• After two failed eradication attempts, antibiotic susceptibility testing should guide further treatment. 1, 2

Common Pitfalls to Avoid

• Do not use clarithromycin-based triple therapy as first-line in North American children; eradication rates are unacceptably low at 54-68%. 4, 5

• Do not shorten treatment duration below 14 days; this reduces eradication by approximately 5%. 1, 2, 3

• Do not use standard-dose PPI once daily; twice-daily high-dose dosing is essential for optimal efficacy. 1, 3

• Do not substitute doxycycline for tetracycline; doxycycline yields significantly inferior results. 1