Rescue therapies for children with persistent Helicobacter pylori after initial treatment

Rescue therapies for children with persistent Helicobacter pylori after initial treatment

Initial antibiotic susceptibility	Previous treatment regimen	Rescue treatment
CLA and MET resistant or initial antimicrobial susceptibility unknown	Triple therapy	Perform a second endoscopy to assess secondary antimicrobial susceptibility (preferred) or treat empirically with: Bismuth-PPI-MET-TET (if ≥8 years)* or Bismuth-PPI-AMO-MET (if <8 years)* or PPI-AMO-MET with high-dose AMO*^¶
	Quadruple therapy (bismuth-based)	Perform a second endoscopy to assess secondary antimicrobial susceptibility*^Δ
CLA and MET susceptible	PPI-AMO-CLA	PPI-AMO-MET
CLA and MET susceptible	PPI-AMO-MET	PPI-AMO-CLA
CLA resistant, MET susceptible	PPI-AMO-MET	Bismuth-PPI-MET-TET (if ≥8 years)* or Bismuth-PPI-AMO-MET (if <8 years)* or PPI-AMO-MET with high-dose AMO*^¶
CLA susceptible, MET resistant	PPI-AMO-CLA	Perform a second endoscopy to assess secondary antimicrobial susceptibility (preferred) or treat empirically with 1 of the following: Bismuth-PPI-MET-TET (if ≥8 years) or Bismuth-PPI-AMO-MET (if <8 years) or PPI-AMO-MET with high-dose AMO^¶

The above regimens should be given for 14 days. For rescue therapy, we typically use higher doses of metronidazole (50 mg/kg/day divided 3 times daily) and amoxicillin (75 mg/kg/day divided 3 or 4 times daily to avoid low trough levels). For doses of other medications, refer to UpToDate table on antibiotic dosing for H. pylori in children.

CLA: clarithromycin; MET: metronidazole; PPI: proton pump inhibitor; TET: tetracycline; AMO: amoxicillin.

* Consider substituting levofloxacin instead of MET if the patient had difficulty tolerating MET in the previous eradication attempt.

¶ Where bismuth is available, bismuth-based quadruple therapy is preferred due to better eradication rates compared with high-dose AMO. We use bismuth-based regimens when indicated. In the United States, bismuth is available only as bismuth subsalicylate, so we avoid it if the child has any flu-like illness because of theoretical concerns about Reye syndrome due to the subsalicylate component.

Δ If bismuth-based quadruple therapy was used initially, options for rescue therapy include an alternative bismuth-based quadruple therapy (eg, with high-dose PPI and amoxicillin) or a levofloxacin based triple regimen.

Adapted from: Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr 2017; 64:991.

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Rescue therapies for children with persistent Helicobacter pylori after initial treatment