Pediatric Helicobacter Pylori Infection Treatment & Management

Updated: Nov 16, 2018
  • Author: Mutaz I Sultan, MD, MBChB; Chief Editor: Carmen Cuffari, MD  more...
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Medical Care

Antibiotic resistance is the major cause of failure in the treatment of H pylori infection. [44, 45] 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. [33]

If the strain is resistant to one of the antibiotics used, treatment success will be compromised. As a result therapies that are recommended should be based on antibiotic susceptibility testing. If this testing is not available, then clarithromycin-based triple therapy should not be used as part of first-line therapy due to high rates of clarithromycin resistance rates. [31]

The European Society for Paediatric Gastroenterology Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition made the following recommendations in 2017 for the Management of Helicobacter pylori in Children and Adolescents [31] :

1. Antimicrobial sensitivity should be obtained for the infecting H pylori strain (s), and eradication therapy tailored accordingly.

2. The effectiveness of first-line therapy should be evaluated in national/regional centers.

3. The physician should explain to the patient/family the importance of adherence to the anti–H pylori therapy to enhance successful eradication.

The recommendations also included practice points for the first-line therapy for H pylori infection:

  • If the strain is susceptible to clarithromycin (CLA) and to metronidazole (MET), triple therapy (PPI, amoxicillin [AMO], CLA) for 14 days is the preferred choice.
  • Sequential therapy for 10 days (proton pump inhibitor (PPI) with amoxicillin for 5 days followed by proton pump inhibitor with clarithromycin and metronidazole for 5 days) is equally effective in patients infected with fully susceptible strains. However, sequential therapy has the disadvantage of exposing the child to 3 different antibiotics. Sequential therapy should not be given if the strain is resistant to metronidazole (MET) or clarithromycin (CLA), or if susceptibility testing is not available. The most recent adult guidelines recommend against the use of sequential therapy as first- or second-line therapy.
  • Doses of proton pump inhibitor and antibiotics should be calculated based on the bodyweight.
  • A higher degree of acid suppression improves the success rate of amoxicillin- and clarithromycin-based therapy. Younger children need a higher PPI dose per kg bodyweight compared to adolescents and adults to obtain sufficient acid suppression.
  • Esomeprazole and rabeprazole are less susceptible to degradation by rapid metabolizers with CYP2C19 genetic polymorphism, and therefore, may be preferred when available.
  • For children younger than 8 years, bismuth quadruple therapy refers to bismuth, PPI, AMO, and MET. In children older than 8 years, bismuth quadruple therapy refers to bismuth, PPI, MET, and tetracycline.
  • Current evidence does not support the routine addition of either single or combination probiotics to eradication therapy to reduce side effects and/or improve eradication rates.
  • The outcome of anti–H pylori therapy should be assessed at least 4 weeks after completion of therapy using one of the following tests:
    • (a) The 13C-urea breath (13C-UBT) test or (b) a 2-step monoclonal stool antigen test.
  • When H pylori treatment fails, rescue therapy should be individualized considering antibiotic susceptibility, the age of the child, and available antimicrobial options.

Rescue therapy should be based on antibiotic resistance profiles when it is possible. Studies in adults suggest that increasing acid suppression and metronidazole dose may improve efficacy of eradication therapy. One study showed that in children infected with clarithromycin- and metronidazole-resistant strains, the eradication rate using high dose amoxicillin and PPI with metronidazole was 66% in intention to treat analysis. [31]

In a recent multicenter, open-label, single-arm, clinical trial of H pylori–positive adults who had failed more than one previous course of omeprazole-amoxicillin-clarithromycin therapy, a quadruple regimen of bismuth, metronidazole, and tetracycline plus omeprazole produced a high eradication rate (up to 95.8%). [34]




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. [35, 36]

  • 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. [37]



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. [38, 39]