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Pediatric Helicobacter Pylori Infection Treatment & Management

  • Author: Mutaz I Sultan, MBChB, MD; Chief Editor: Carmen Cuffari, MD  more...
Updated: May 02, 2016

Medical Care

Antibiotic resistance is the major cause of failure in the treatment of H pylori infection. Most of the studies worldwide confirmed an increase in macrolide resistance, while metronidazole resistance either decreased or remained stable. In a prospective multicenter European study, primarily comprised of adults, Megraud et al found a 31.8% resistance rate to clarithromycin and 25.7% to metronidazole in the 311 H pylori isolates from children from the 8 countries included in the study.[32]

The most recent ESPGHAN and NASPGHAN guidelines recommended treatment for the following group of patients[30] :

  • In the presence of H pylori –positive PUD, eradication of the organism is recommended.
  • When H pylori infection is detected by biopsy-based methods in the absence of PUD, H pylori treatment may be considered. The decision to treat H pylori –associated gastritis without duodenal or gastric ulcer is subject to the judgment of the clinician and deliberations with the patient and family, taking into consideration the potential risks and benefits of the treatment in the individual patient.
  • In children who are infected with H pylori and whose first-degree relative has gastric cancer, treatment can be offered.
  • A ‘test-and-treat’ strategy is not recommended in children. The primary goal of testing is to diagnose the cause of clinical symptoms

The following treatments should be applied[30] :

  • First-line eradication regimens are the following: triple therapy with a PPI + amoxicillin + imidazole; or PPI + amoxicillin + clarithromycin; or bismuth salts + amoxicillin + imidazole; or sequential therapy. Sequential therapy involves dual therapy with a PPI and amoxicillin for 5 days followed sequentially by 5 days of triple therapy (a PPI with clarithromycin and metronidazole/tinidazole). In fact, this regimen can be considered as quadruple therapy provided in a sequential manner. It is speculated that the initial use of amoxicillin reduces the bacterial load and provides protection against clarithromycin resistance.
  • In a review of 10 randomized trials performed in different countries, Zullo et al found that sequential therapy achieved significantly higher eradication rates compared with the 7- and 10-day standard triple therapies, even in clarithromycin and metronidazole resistance H pylori strains.[33]
  • Antibiotic susceptibility testing for clarithromycin is recommended before initial clarithromycin-based triple therapy in areas/populations with a known high resistance rate (>20%) of H pylori to clarithromycin.
  • It is recommended that the duration of triple therapy be 7-14 days. Costs, compliance, and adverse effects should be taken into account.
  • A reliable noninvasive test for eradication is recommended at least 4-8 weeks following completion of therapy

If treatment has failed, the following 3 options are recommended:

  • EGD, with culture and susceptibility testing, including alternate antibiotics if not performed before guide therapy.
  • Fluorescence in situ hybridization (FISH) on previous paraffin-embedded biopsies if clarithromycin susceptibility testing has not been performed before to guide therapy.
  • Modify therapy by adding an antibiotic, using different antibiotics, adding bismuth, and/or increasing dose and/or duration of therapy.

If it is not possible to perform a primary culture, then the following therapeutic regimens are suggested as second-line or salvage therapy[30] :

  • Quadruple therapy is with PPI + metronidazole + amoxicillin + bismuth. Quadruple therapy is the recommended second-line therapy in most guidelines; however, this regimen is complicated to administer. Furthermore, bismuth salts are not universally available.
  • Triple therapy is with PPI + levofloxacin (moxifloxacin) + amoxicillin. Evaluation of regimens using fluoroquinolones, including levofloxacin, as second-line therapy in children is limited. In adult studies, this regimen appears to be effective.

Although the studies on the ideal duration of therapy for second-line treatment are not conclusive, a longer duration of therapy of up to 14 days is recommended.


Surgical Care

See the list below:

  • Surgical procedures are rarely necessary in the treatment of patients with H pylori infection. However, in ulcer disease, surgery may be necessary for certain complications unresponsive to medical therapies, including intractable abdominal pain, gastric outlet obstruction, perforation, and severe bleeding.


See the list below:

  • Pediatric gastroenterologist - For evaluation, endoscopy, and biopsy testing to confirm H pylori infection and exclude other causes of abdominal pain or bleeding
  • Surgeon - For intervention in patients with severe or intractable pain or bleeding or in patients with GI tract perforation or obstruction
  • Radiologist - For patients who require upper-GI imaging with contrast-enhanced studies


See the list below:

  • Foods such as berry juice and some dairy products may have modest bacteriostatic effect on H pylori.
  • Two randomized, placebo-controlled trials evaluated the effect of probiotic food as an adjuvant to the standard triple therapy for eradication of H pylori infection in children and showed conflicting results.[34, 35]
  • In a recent prospective study in adults, addition of vitamin C to an H pylori treatment regimen of amoxicillin, metronidazole, and bismuth can significantly increase H pylori eradication rate.[36]


See the list below:

  • No specific restrictions of activities are necessary for the child with H pylori infection.


A study by Zeng et al aimed to assess the efficacy, safety, and immunogenicity of a three-dose oral recombinant H pylori vaccine in children in China. The study tested the effectiveness of the vaccine on 4,446 children with a three-dose vaccination schedule. The study recorded 64 events of H pylori infection within the first year which resulted in a vaccine efficacy of 71.8%. 157 (7%) participants in the vaccine group and 161 (7%) participants in the placebo group reported at least one adverse reaction that were reported as mild.[37, 38]

Contributor Information and Disclosures

Mutaz I Sultan, MBChB, MD Assistant Professor of Pediatrics, Al-Quds University Medical College; Pediatric Gastroenterologist and Hepatologist, Division of Pediatrics, Makassed Hospital, Palestine

Mutaz I Sultan, MBChB, MD is a member of the following medical societies: American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.


B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Maria Triantafyllopoulou Greene, MD Assistant Professor of Pediatrics, Northwestern University Feinberg School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology, and Nutrition, Children's Memorial Hospital

Maria Triantafyllopoulou Greene, MD is a member of the following medical societies: American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Stefano Guandalini, MD Founder and Medical Director, Celiac Disease Center, Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medical Center; Professor, Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, North American Society for the Study of Celiac Disease

Disclosure: Received consulting fee from AbbVie for consulting.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

Hisham Nazer, MB, BCh, FRCP, , DTM&H Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, University of Jordan Faculty of Medicine, Jordan

Hisham Nazer, MB, BCh, FRCP, , DTM&H is a member of the following medical societies: American Association for Physician Leadership, Royal College of Paediatrics and Child Health, Royal College of Surgeons in Ireland, Royal Society of Tropical Medicine and Hygiene, Royal College of Physicians and Surgeons of the United Kingdom

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Meta Carroll, MD, to the development and writing of this article.

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Helicobacter pylori infection revealed by endoscopy (nodular gastropathy).
Helicobacter pylori–associated peptic ulcer in the duodenal bulb.
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