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pylori antigen in stool is a reliable noninvasive test to determine whether H pylori has been eradicated. Agree: 86% (AR 21%, A 29%, AS 36%, D 7%, DR 7%). Grade of evidence: moderate. Comment on Recommendation 9: Detection of H pylori antigen in stool is an attractive noninvasive method that seems suitable for both clinical use and epidemiological studies. Several methods are available for the detection of H pylori antigen in stool, such as enzyme immunoassay (EIA) based on polyclonal or monoclonal antibodies, and immuno- chromatographic tests (so-called rapid or quick tests). Stool tests are generally more convenient in pediatric patients than the UBT. Stool samples can be obtained from children without their active collaboration and are transportable by mail for analysis. Neither keeping the samples at room temperature for up to 5 days nor freezing for months or even years seems to influence the accuracy of the stool tests (86–89). In most countries, an EIA would be less costly than the UBT. In addition, the EIA stool test is the only diagnostic noninvasive test that has not shown an age dependence on the accuracy of the test results (64,87). Therefore, validation studies in adults may be extrapolated to children. The first commercial EIA test to detect H pylori antigen in stool was the Premier Platinum HpSA (Meridian Diagnostics, Cincinatti, OH). This test is based on polyclonal antibodies. There is a wide range for sensitivity and specificity of the test in children, both pretreatment (86,90–98) and posttreatment (89,91,92,95). Testing the same stool samples with different production lots of the polyclonal test indicated interassay variation (99). This may explain the wider range reported for the sensitivity and specificity of the polyclonal stool tests. A different polyclonal EIA (Equipar Diagnostici, Saronno, Italy) was recently evaluated against invasive methods, but the present study included only 33 children with a biopsy-proven H pylori status (100). So far, only the EIA based on monoclonal antibodies has achieved the accuracy of the UBT, which is considered the reference standard of the noninvasive tests (87,99,101–103). A systematic review and meta-analysis of the 8 studies directly comparing the polyclonal with the monoclonal EIA, including pediatric and adult patients, confirmed the significantly better performance with respect to sensitivity of the monoclonal test, both before and after therapy (104). No difference in accuracy has been observed between studies in adults and children, and within the pediatric studies, young age did not influence the performance of the tests (87,99,101–103). So-called rapid or office-based fecal tests based on an immunochromography using monoclonal antibodies have been evaluated in children (102,105). The accuracy was lower compared with EIA, even though the tests were based on the same antigens. Although these tests have improved over time, the problem of interobserver variability in weakly positive tests remains unresolved (102,106). Additional ELISA tests for the detection of H pylori antigen in stool will be developed and evaluated in the near future. There- fore, this statement applies only to the tests that have been evaluated in pediatric populations and have shown an equal or better performance as the UBT or validated stool tests (87,104). Recommendation 10 Tests based on the detection of anti- bodies (IgG, IgA) against H pylori in serum, whole blood, urine, and saliva are not reliable for use in the clinical setting. Agree: 87% (AR53%, A 20%, AS 13%, DS 7%, D 7%). Grade of evidence: high. Comment on Recommendation 10: H pylori infection induces an early increase of specific IgM and a later and persistent increase of specific IgA and IgG anti- bodies. These antibodies can be detected in whole blood, serum, urine, and saliva (63). In general, serologic assays cannot be used on their own to perform the diagnosis of H pylori infection or to monitor the success of therapy because the sensitivity and specificity for detection of antibodies (IgG or IgA) against H pylori in children vary widely. Specific IgG may remain positive for several months or even years after the infection resolves. Thus, the tests cannot be used reliably for treatment outcomes. Many tests based on the detection of antibodies are commer- cially available, easy to perform, and inexpensive. In spite of these advantages, they have not been recommended for clinical practice in pediatric patients by previous American, Canadian, or European consensus statements (6,14,15). The main problems are age dependence, particularly with respect to sensitivity in younger children, and test-to-test varia- bility. IgA-based tests detect only 20% to 50% of H pylori–infected children, and are not suitable for diagnosis. IgG-based tests offer a Koletzko et al JPGN
Volume 53, Number 2, August 2011 236 www.jpgn.org Copyright 2011 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. better sensitivity than IgA-based tests, but the sensitivity of most tests is much lower when used in children compared with adults from the same geographic region. The use of cutoff values obtained in validation studies in adults results in a failure to detect a large proportion of infected children, especially in children younger than 6 to 8 years. Oliveira et al (107) used a second-generation EIA in comparison with biopsy-based methods and found a low sensitivity of 44% in children ages 2 to 6 years. Sensitivity increased to 77% in children ages 7 to 11 years and to 93% in adolescents, which is comparable with results in adults. When 2 IgG-based EIAs were applied to sera of 175 children with biopsy-proven H pylori status, a remarkable difference of sensi- tivity was observed, mainly in the younger age groups (108). Immunoblotting was found to be superior to serology for diagnosis of H pylori infection in children (109). In a European multicenter study, however, a more recent third-generation EIA seems to perform better, with sensitivity just less than the UBT (76). Tests based on the detection of H pylori antibodies in saliva or office-based tests on whole blood or serum display even worse performance characteristics than laboratory-based serologic EIAs. Therefore, these tests cannot be recommended in children of any age group (63). Recommendation 11 It is recommended that clinicians wait at least 2 weeks after stopping PPI therapy and 4 weeks after stopping antibiotics to perform biopsy-based and noninvasive tests (UBT, stool test) for H pylori . Agree: 100% (AR 47%, A 40%, AS 13%). Grade of evidence: high. Comment on Recommendation 11: Studies in adults suggest that antibiotic or PPI therapy can cause false-negative test results because of a reduction in bacterial load without eradication of the bacterium (69,110,111). Therefore, it is recommended that testing be performed at least 4 weeks after completion of antibiotic treatment and 2 weeks following cessation of PPI therapy. 3.4. Who Should Be Treated? Recommendation 12 In the presence of H pylori–positive PUD, eradication of the organism is recommended. Agree: 100% (AR 79%, A, 13%, AS 7%). Grade of evidence: high. Comment on Recommendation 12: Several meta-analyses in adults consistently demonstrate that eradication of H pylori in patients with PUD significantly reduces the relapse rate for ulcer disease and for recurrent bleeding ulcers (112,113). Previous pediatric studies in children with PUD indicated that the relapse rate is high without treatment of H pylori infection (114). Only 1 randomized controlled pediatric trial in H pylori – infected children with PUD (n ¼ 106) has been published. This trial compared the eradication rate of H pylori and the cure rate of PUD with 3 different treatment regimens, but did not report the recurrence of ulcer or bleeding ulcer in those who failed bacterial eradication (115). Although there are differences in the etiologies and clinical presentation and frequency of PUD in children compared with adults (1,116), it can be assumed that recurrence of H pylori – related PUD can be prevented in children by eradication of the infection. Therefore, eradication of the infection is recommended in a child with H pylori infection and PUD. The indication applies also for healed ulcers or a history of PUD.
Recommendation 13 When H pylori infection is detected by biopsy-based methods in the absence of PUD, H pylori treatment may be considered. Agree: 79% (AR 29%, A 50%, DS 21%). Grade of evidence: low. Comment on Recommendation 13: The finding of H pylori–associated gastritis in the absence of PUD during diagnostic endoscopy poses a dilemma for the endo- scopist (see comment for recommendations 1, 2, and 3). As outlined in the comments for recommendations 1 and 2, there is inadequate evidence supporting a causal relation between H pylori gastritis and abdominal symptoms in the absence of ulcer disease. Therefore, eradication of the organism in the absence of ulcers may not result in improvement of symptoms. As reviewed in the comment for recommendation 3, H pylori is a risk factor for the development of gastric malignancies; however, only a fraction of infected individuals develop cancer. The carcinogenic risk is modified by strain-specific bacterial factors, host responses, and/or specific host–microbe interactions. (117). Current evidence suggests that in high-risk populations such as in China, the eradication of H pylori may have the potential to decrease the risk of gastric cancer in a subset of individuals without precancerous lesions (39). Prospective intervention trials are of variable quality and results may not be generalizable from 1 population to another. As noted in the comment to recommendation 12, eradication of H pylori can prevent recurrence of PUD. In adults with nonulcer dyspepsia, eradication of H pylori may reduce the development of peptic ulcers (118). A potential benefit of chronic infection with certain H pylori strains cannot be excluded (119). Therefore, 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. Recommendation 14 A ‘‘test and treat’’ strategy is not recommended in children. Agree: 80% (AR 47%, A 20%, AS 13%, DS 13%, D 7%). Grade of evidence: moderate. Comment on Recommendation 14: The primary goal of testing is to diagnose the cause of clinical symptoms. By definition, a ‘‘test and treat’’ strategy (the detection of the presence of H pylori infection by a noninvasive test followed by treatment in the case of a positive test) will not provide this information in children (see comments on recommendations 1 and 2). Therefore, in contrast to current guidelines for adults (8,120), current evidence does not support this practice in children. 3.5. Which Treatment Should Be Applied in Which Situation? Recommendation 15 In children who are infected with H pylori and whose first-degree relative has gastric cancer, treatment can be offered. Agree: 93% (AR 20%, A 47%, AS 27%, DR 6%). Grade of evidence: low. Comment on Recommendation 15: Please refer to the comment on recommendation 3. Recommendation 16 Surveillance of antibiotic resistance rates of H pylori strains in children and adolescents is recommended in different countries and geographic areas. JPGN
Recommendations for H pylori Infection in Children www.jpgn.org 237
Copyright 2011 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Agree: 100% (AR 60%, A 20%, AS 20%). Grade of evidence: not applicable. Comment on Recommendation 16: Several European studies have documented high resistance rates to clarithromycin and metronidazole in pediatric and adult populations (1,121 – 123). Increasing rates of primary clarithromycin resistance have been reported from several countries (124 – 126). A prospective US multicenter study in adults and children also documented similar high resistance rates (127). In 2 small studies from the United States (Michigan and West Virginia), a high proportion of isolates were resistant to clarithromycin (128,129). Antibiotic resistance is an important factor in treatment success (130). Indeed, eradication rates in children treated with standard therapy are also decreasing over time, in part related to increased antibiotic resistance. H pylori antibiotic susceptibility data are not available for most geo- graphic regions. Therefore, it is recommended that continuous surveillance of resistance rates be undertaken to effectively guide initial empiric therapy with the aim of improving treatment outcomes. Recommendation 17 First-line eradication regimens are the following: triple therapy with a PPI R amoxicillin R imidazole; or PPI R amoxicillin R clarithromycin; or bismuth salts R amoxicillin R imidazole; or sequential therapy. Agree: 100% (AR 36%, A 40%, AS 14%). Grade of evidence: moderate. Recommendation 18 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. Agree: 93% (AR 33%, A 40%, AS 20%, DS 7%). Grade of evidence: moderate. Recommendation 19 It is recommended that the duration of triple therapy be 7 to 14 days. Costs, compliance, and adverse effects should be taken into account. Agree: 93% (AR 27%, A 40%, AS 27%, DS 6%). Grade of evidence: moderate. Comment on Recommendations 17–19: The goal of treatment is at least a 90% eradication rate on a per-protocol basis at the first attempt. A high initial eradication rate will prevent the development of antibiotic resistance and spread of resistant H pylori strains in the population. For individual patients, a high initial success rate will reduce the need for further treatments and procedures, including endoscopies. The combination of 2 antibiotics and a PPI has been the recommended first-line therapy since the first published pediatric guidelines (6,14,15). Studies comparing the various treatment options in the pediatric population remain limited. In 2000, Oderda et al (131) performed a systematic review of the published eradication treatment studies in children. Because of the marked heterogeneity and the limited number of well-designed studies, it was difficult to make definitive recommendations. In 2001, the first randomized double-blind trial comparing dual therapy of amoxicillin and clarithromycin with triple therapy including omeprazole in children confirmed that in intention-to-treat analysis, triple therapy was far superior to dual therapy with eradication rates of 74.2% versus 9.4% (132). A recent meta-analysis of eradication treatment efficacy in children concluded that, in general, the methodological quality of the studies was poor and that additional well-designed randomized trials are needed (7). Thus, current recommendations remain mainly extrapolated from adult studies. Recent data indicate a falling rate of H pylori eradication in response to treatment. For example, the European pediatric treatment registry reported results from the use of 27 different regimens in 518 children with H pylori (133). The overall eradica- tion rate was 65.6%, lower than previously reported, but was higher in children with peptic ulcers (79.7%). One potential reason for this decline is antibiotic resistance (134). Based on the negative effect of antibiotic resistance on treatment outcomes, the rates of resistance in the area where the child lives or comes from should be taken into account when deciding on the initial therapeutic regimen for eradication (1). Clarithromycin resistance adversely affects eradication rates in children (135,136). Studies in children addressing the role of susceptibility testing to target initial therapy are limited; however, 3 studies in children suggest that tailoring therapy based on antibiotic susceptibility testing can enhance eradication rates (137–139). In a study of 58 German children, clarithromycin and metronidazole susceptibility testing was used to guide standard triple therapy and resulted in a high eradication rate of 93% (137). An earlier study of 2 consecutive groups of 75 H pylori –infected children treated with either triple therapy, including amoxicillin and clarithromycin (group 1), or antibiotic therapy, guided by suscepti- bility testing (group 2), demonstrated enhanced eradication in the group with susceptibility-guided therapy (93% vs 81%) (138). Therefore, clarithromycin-based triple therapy can only be recom- mended as first-line therapy if susceptibility testing in the individual patient revealed a clarithromycin-susceptible strain or if the clarithromycin resistance rate in this area is known to be low. In the absence of these conditions, clarithromycin-based triple therapy cannot be recommended as first-line therapy. Declining eradication rates with these standard triple regimens have led to the development of alternate treatment options (134). 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 metronidazol/tinidazol). 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 2005, 74 children were randomized to receive either sequential treatment (omeprazole þ amoxicillin for 5 days, followed by omeprazole þ clarithromycin þ tinidazole for another 5 days) or triple therapy for 1 week (140). Successful eradication was achieved in 97.3% of children receiving sequential therapy compared with 75.7% on standard triple therapy. In a subsequent study evaluating adjunctive probiotic supplement- ation, eradication of 82.5% was obtained from a group of 40 children receiving sequential therapy (141). Based on these studies suggesting that sequential therapy is at least as effective as standard therapy, sequential therapy was recommended as a first- line treatment option. It is important to note that the data in children are mostly limited to Italian studies, and therefore additional studies in North America and different European countries are needed to confirm that the findings apply to other locations. Furthermore, clarithromycin resistance has a negative effect on eradication success even with this regimen, although less so compared with standard triple therapy (136,142,143). Bismuth-based triple therapy is also recommended as an alternate first-line therapy. Although there are no well-designed randomized studies directly comparing this regimen with the alternate recommended first-line therapies, in a study reported by the European pediatric treatment registry, bismuth-containing triple therapies were more efficacious than PPI-containing ones (77% versus 64%) when used as first-line treatment (133). Koletzko et al JPGN
238 www.jpgn.org Copyright 2011 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. In addition, bismuth-based triple therapy may be less costly than the other options; however, concerns regarding the palatability of bismuth potentially affecting adherence should also be considered. Conflicting data exist regarding the benefit of longer duration of therapy for first-line regimens in adults (142,144). A systematic review of therapy in children found no benefit from longer duration of therapy (131). In contrast, a recent meta-analysis of studies in children suggested that longer duration of therapy was associated with improved eradication rates (7). Similarly, a meta- analysis comparing sequential therapy with standard triple therapy showed higher eradication rates with longer duration of triple therapy up to 14 days (142). Therefore, based on these data, recommended duration of therapy is 7 to 14 days, taking into consideration cost, compliance, and side effects. Suggested doses are given in Table 1. Recommendation 20 A reliable noninvasive test for eradica- tion is recommended at least 4 to 8 weeks following completion of therapy. Agree: 93% (AR 53%, A 27%, AS 13%, DS 7%). Grade of evidence: low. Comment on Recommendation 20: Even when children become asymptomatic after treatment, it is recommended that the success of treatment regardless of the initial endoscopic findings be evaluated. The absence of symptoms does not necessarily mean the infection has been eradicated (30). Particularly in children who had PUD, persistence of infection would warrant additional treatment. Reliable tests to monitor successful eradication include the 13 C-UBT and a monoclonal ELISA for detection of H pylori antigen in stool. A follow-up endoscopy is not routinely indicated unless other causes of ulceration (eg, eosinophilic gastroenteropathy, Crohn disease) are suspected or if biopsies are needed for culture and antibiotic susceptibility testing. Recommendation 21 If treatment has failed, there are 3 options recommended: 1. EGD, with culture and susceptibility testing, including alternate antibiotics if not performed before guide therapy. 2. FISH on previous paraffin-embedded biopsies if clarithro- mycin susceptibility testing has not been performed before guide therapy. 3. Modify therapy by adding an antibiotic, using different antibiotics, adding bismuth, and/or increasing dose and/or duration of therapy. Agree: 100% (AR 29%, A 43%, AS 28%) Grade of evidence: not applicable . Comment on Recommendation 21: Primary antibiotic resistance adversely affects treatment outcomes (see comment for recommendation 20). In addition, a 12-year observational study from Belgium demonstrated secondary resistance following treatment in 39 of 87 strains obtained from children who had failed initial therapy (122). The present study suggests that development of secondary antibiotic resistance may be common in children. Thus, if possible, primary culture with antibiotic sensitivity testing should be performed to guide second-line therapy in an H pylori–infected child who has failed initial therapy. If primary culture and sensitivity testing is not available, then the choice of second-line therapy must take into account the initial therapy administered and avoid readministering an antibiotic that was previously provided (145). Another option available at some centers is FISH to detect primary clarithromycin resistance on previously obtained biopsies (65,129,146). Clarithromycin should only be used as part of second-line therapy if the strain is found to be sensitive. If it is not possible to perform a primary culture, then the following therapeutic regimens are suggested as second-line or salvage therapy.
Quadruple therapy: PPI
þ metronidazole þ amoxicillin þ bismuth. Quadruple therapy is the recommended second- line therapy in most guidelines (8,15); however, this regimen is complicated to administer. Furthermore, bismuth salts are not universally available.
Triple therapy: PPI þ levofloxacin (moxifloxacin) þ amoxi- cillin. Evaluation of regimens using fluoroquinolones, including levofloxacin, as second-line therapy in children is limited. In adult studies, this regimen appears to be effective. In a recent meta-analysis of studies in adults (147), triple therapy with levofloxacin appeared to be as efficacious as quadruple therapy for second-line treatment; however, there are concerns regarding increasing rates of quinolone resistance (145). Therefore, this regimen should not be used if the child has received fluoroquinolones previously. 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. 4. CONCLUSIONS These clinical guidelines represent updated, best-available evidence, and expert opinion regarding the management of H pylori infection in children in Europe and North America developed through a rigorous standardized process. The goal of these recommendations is to improve the care of children and adolescents with H pylori infection. As the clinical implications of H pylori infection in the pediatric setting continue to evolve, these guidelines will need to be updated. Acknowledgments: We thank Kathleen Ismond, library
scientist, who conducted searches and helped prepare tables; Stephanie Joyce and Monica Sierra, student research assistants, who helped prepare tables; and Andrea Schwarzer, MD, who assisted during the consensus meeting and helped with the voting system. We also thank Stephen Czinn, Mark Gilger, TABLE 1. First-line treatment recommendations for H pylori eradication in children PPI (1–2 mg Á kg À1
À1 ) þ amoxicillin (50 mg Á kg À1 Á day
À1 ) þ metronidazole (20 mg kg day) Ã PPI (1–2 mg Á kg À1
À1 ) þ amoxicillin (50 mg Á kg À1 Á day
À1 ) þ clarithromycin (20 mg Á kg À1 Á day
À1) Ã Bismuth salts (bismuth subsalicylate or subcitrate 8 mg Á kg À1 Á day À1 ) þ amoxicillin (50 mg Á kg À1 Á day À1 ) þ metronidazole (20 mg Á kg
À1 Á day
À1 ) Ã PPI (1–2 mg Á kg
À1 Á day
À1 ) þ amoxicillin (50 mg Á kg À1 Á day
À1 ) for 5 days then PPI (1–2 mg Á kg À1 Á day À1 ) þ clarithromycin (20 mg Á kg
À1 Á day
À1 ) þ metronidazole (20 mg Á kg À1 Á day
À1 ) for 5 days Maximum daily dose for amoxicillin 2000 mg, for metronidazole 1000 mg, for clarithromycin 1000 mg/day. PPI ¼ proton pump inhibitor. Ã Administered twice daily for 10 to 14 days. JPGN
Volume 53, Number 2, August 2011 Recommendations for H pylori Infection in Children www.jpgn.org 239
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