Helicobacter pylori infection in pediatrics

Child With Extranodal Marginal Zone B-cell Lymphoma of Mucosa-associated Lymphoid Tissue

Many patients present to our clinic with Helicobacter pylori (H. pylori) infection. Most have nonspecific symptoms that cannot be immediately attributed to H. pylori. The joint European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)/North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines recommend upper gastroscopy to detect the cause of such symptoms. Herein, we present the case of a 9-year-old girl diagnosed with gastric mucosa-associated lymphoid tissue lymphoma associated with H. pylori infection using upper gastroscopy. We believe that a patient of such a young age with this serious condition secondary to H. pylori will highlight the importance of upper gastrointestinal endoscopy in such cases.

Helicobacter pylori infection in children: an overview of diagnostic methods

Children differ from adults regarding Helicobacter pylori (H. pylori) infection in many terms. H. pylori infection represents a key factor in the pathogenesis of duodenal ulcer and chronic gastritis in children. H. pylori infection causes some extraintestinal diseases as well as gastrointestinal diseases. Although, among these illnesses in children, symptoms like recurrent abdominal pain are not specific. Moreover, the role of the pathogen in the growth faltering, iron deficiency anemia, and asthma still remains controversial. A reliable method to detect H. pylori infection is a crucial issue, sand is still a matter of active debate. The tests applied for H. pylori diagnosis are grouped as either invasive or non-invasive methods. Invasive methods consist of endoscopic evaluation, the rapid urease test (RUT), histology, and bacterial culture. Non-invasive tests include the urea breath test (UBT), stool antigen test (SAT), serology, and molecular diagnostic approaches. Use of endoscopy is a pre-requisite for all invasive methods and poses difficulties in children as it is a difficult procedure and requires patient's cooperation. For this reason, the non-invasive tests have been commonly used in children, although their accuracy is not very reliable in some cases. Invasive tests may be opted to confirm the diagnosis as and when needed. This review presents the diagnostic tests used to detect H. pylori infection in children.

Antibiotic Resistance of Helicobacter pylori in Iranian Children: A Systematic Review and Meta-Analysis

Antibiotic therapy for children infected with Helicobacter pylori is important. However, resistance to antibiotics is one of the main causes of treatment failure. This study was designed to evaluate the prevalence pattern of antibiotic resistance of H. pylori in Iranian children using a systematic review and meta-analysis of literature. A computerized search (until June 10, 2017) using related keywords in the national and international databases was performed. A total of 261 original articles on antibiotic resistance of H. pylori in Iranian children were collected. After screening for inclusion and exclusion criteria, six eligible articles were included in the meta-analysis. Resistance rates of H. pylori to different antibiotics were as follows: metronidazole: 71%, clarithromycin: 12.2%, amoxicillin: 20.4%, tetracycline: 8.4%, ampicillin: 21.4%, rifampin: 28.6%, furazolidone: 8.4%, ciprofloxacin: 16.2%, azithromycin: 19%, erythromycin: 15.3%, and nitrofurantoin: 0%. The prevalence of H. pylori resistance to metronidazole, amoxicillin, ampicillin, and rifampin among Iranian children was high. Therefore, a careful monitoring of antibiotic resistance to select the best treatment options and prevent treatment failure is required. Although resistance to some antibiotics such as clarithromycin, tetracycline, furazolidone, and ciprofloxacin was less prevalent, frequent consumption of these drugs in children should be controlled owing to their known adverse events.

Antibacterial resistance and the success of tailored triple therapy in Helicobacter pylori strains isolated from Slovenian children

BACKGROUND

Primary Helicobacter pylori (H. pylori) infection occurs predominantly in childhood. Antimicrobial resistance is the leading cause for H. pylori eradication failure. The aims of this study were (i) to establish for the first time the antimicrobial resistance of H. pylori strains in infected Slovenian children not previously treated for H. pylori infection and (ii) to evaluate the effectiveness of tailored triple therapy, assuming that eradication rate with tailored triple therapy will be >90%.

METHODS

Data on all treatment-naive children 1-18 years old and treated for H. pylori infection according to susceptibility testing were retrospectively analyzed. All relevant clinical information and demographical information were retrospectively collected from the hospital information systems and/or patients' medical documentation.

RESULTS

The inclusion criteria were met by 107 children (64.5% girls) with a median age of 12.0 years (range 2.0-17.6 years). Primary antimicrobial resistance rates of H. pylori were 1.0% to amoxicillin (AMO), 23.4% to clarithromycin (CLA), 20.2% to metronidazole (MET), 2.8% to levofloxacin (LEV), and 0.0% to tetracycline (TET). Dual resistances were detected to CLA and MET in 11.5% (n=12) of strains, to CLA and LEV in 2.8% (n=3), and to MET and LEV in 2.9% (n=3). Results of treatment success were available for 71 patients (66.2% girls). Eradication of H. pylori was evaluated using the 13C-urea breath test, monoclonal stool antigen test or in some cases with repeated upper GI endoscopy with histology and cultivation/molecular tests. Eradication was achieved in 61 of 71 (85.9%) patients.

CONCLUSIONS

The primary resistance rates of H. pylori to CLA and MET in Slovenia are high. Our data strongly support the fact that in countries with high prevalence of resistant H. pylori strains susceptibility testing and tailored therapy is essential.

Investigation of Helicobacter pylori infection among symptomatic children in Hangzhou from 2007 to 2014: a retrospective study with 12,796 cases

Background and Aim

The infection of Helicobacter pylori (H. pylori) is acquired in childhood and the prevalence vary greatly in different countries and regions. The study aimed to investigate the characteristics of H. pylori infection among children with gastrointestinal symptoms in Hangzhou, a representative city of eastern China.

Methods

A systematic surveillance of H. pylori infection according to the ¹³C-urea breath test was conducted from January 2007 to December 2014 in the Children’s hospital, Zhejiang University School of Medicine. The demographic information and main symptoms of every subject were recorded.

Results

A total of 12,796 subjects were recruited and 18.6% children evaluated as H. pylori positive. The annual positive rates decreased from 2007 to 2014 (χ² = 20.461, p < 0.01). The positive rates were 14.8%, 20.2% and 25.8% in 3–6, 7–11 and 12–17 years age group respectively, which increased with age (χ² = 116.002, p < 0.01). And it was significantly higher in boys than girls (χ² = 15.090, p < 0.01). Multivariate logistic regression identified possible risk factors for H. pylori infection. Age, gender, gastrointestinal symptoms and history of H. pylori infected family member were all significantly associated with H. pylori infection (all p < 0.05).

Conclusions

H. pylori infection rates in children with gastrointestinal symptoms were lower than most of those reported in mainland China. Further studies are required to determine the prevalence in the general population. Comprehensively understanding of the characteristics and the possible risk factors of H. pylori infection will be helpful to its management strategies in children in China.

Gastric cancer incidence in the Romagna Region of Italy: A spatial and temporal analysis

BACKGROUND

The worldwide decrease in gastric cancer incidence is due to a birth-cohort-dependent decrease in exposure to major risk factors.

METHODS

In an area of northern Italy with a historically strong internal geographical gradient in gastric cancer incidence, variations in rates by municipality and age group between 1987 and 2008 were evaluated. The study period was divided into three nonadjacent periods. End points included: age- and sex-standardised incidence rates; incidence rate ratio between age- and sex-standardised incidence rates; smoothed relative risks of gastric cancer incidence, and posterior probabilities of the relative risk being >1.

RESULTS

In 1987-1990, the estimate of posterior probabilities of relative risk being >1 showed a higher incidence in hilly/mountainous areas. Between 1987-1990 and 2005-2008, a uniform decrease of more than 50% was observed (incidence rate ratio: plain, 0.45 (95% confidence interval 0.40-0.51); hill, 0.44 (0.34-0.58); mountain, 0.48 (0.22-1.02)). The decrease in the mountainous area was weak in the middle time period, with an incidence rate ratio of 0.92 (0.46-1.84), and intensified afterwards. The decrease occurred earlier and was more pronounced among younger people. In 2005-2008, gastric cancer risk was uniform across ages and municipalities.

CONCLUSIONS

The observed changes in gastric cancer incidence is the epilogue of a birth-cohort-dependent decrease in exposure to major risk factors.

Antibiotic resistance of Helicobacter pylori clinical isolates from children in Guiyang area

AIM: To investigate the antibiotic resistance of Helicobacter pylori (H. pylori) clinical isolates from children in Guiyang area.

METHODS: H. pylori strains were isolated from children who underwent gastroduodenoscopy at Guiyang Children's Hospital from October 2011 to June 2014, and were further incubated in microaerobic condition. The susceptibility of H. pylori to metronidazole, elarithromycin, amoxicillin and levofloxacin was tested by the breakpoint method.

RESULTS: A total of 63 H. pylori strains were isolated from 434 children. Sixty isolates were drug resistant, and only 3 were sensitive strains. Of all isolates, 57.1% were resistant to metronidazole, 85.7% resistant to clarithromycin, 38.1% to amoxicillin and 90.5% to levofloxacin. The dual, triple and quadruple resistance percentages were 90.5% (57/63), 57.1% (36/63) and 38.1% (24/63), respectively.

CONCLUSION: Resistance rate against amoxicillin is lower than those against other antibiotics. Resistance rate to levofloxacin is higher. Multi-drug resistance is serious in Guiyang area.

Prevalence of the Helicobacter pylori babA2 gene and correlation with the degree of gastritis in infected Slovenian children

The aims of our study were to determine the prevalence of the babA2 gene within Helicobacter pylori strains circulating in the Slovenian pediatric population, to further clarify its significance in causing inflammation of gastric mucosa in children and to verify whether cagA, vacA, iceA and babA genes work independently or synergistically in causing gastritis. A total of 163 H. pylori isolates obtained from the same number of children were tested for the presence of cagA, vacA and iceA genes using previously established methods, while the babA2 gene was determined using novel polymerase chain reaction assay targeting a 139-bp fragment of the central region of babA2. The babA2 gene was detected in 47.9% of H. pylori samples. The presence of the babA2 gene was strongly associated with cagA, vacA s1 and vacA m1 genotype. The babA2 status correlated positively with bacterial density score, activity of inflammation and chronic inflammation of gastric mucosa. No significant correlation was found between the babA2 status and the presence of atrophy or intestinal metaplasia. In addition, the activity of gastric inflammation and density score were significantly associated with the coexpression of the cagA, vacA s1, vacA m1 and babA2 genes. The study, which included the largest number of pediatric H. pylori samples to date, confirmed that babA2 gene plays an important role in the pathogenesis of H. pylori gastritis in children. Furthermore, our results suggest that babA2, cagA and vacA s1 and m1 gene products may work synergistically in worsening the inflammation of gastric mucosa.

Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study

Background

The treatment for the eradication of Helicobacter pylori (H. pylori) is complex; full effectiveness is rarely achieved and it has many adverse effects. In developing countries, increased resistance to antibiotics and its cost make eradication more difficult. Probiotics can reduce adverse effects and improve the infection treatment efficacy.

If the first-line therapy fails a second-line treatment using tetracycline, furazolidone and proton-pump inhibitors has been effective and low cost in Brazil; however it implies in a lot of adverse effects. The aim of this study was to minimize the adverse effects and increase the eradication rate applying the association of a probiotic compound to second-line therapy regimen.

Methods

Patients with peptic ulcer or functional dyspepsia infected by H. pylori were randomized to treatment with the furazolidone, tetracycline and lansoprazole regimen, twice a day for 7 days. In a double-blind study, patients received placebo or a probiotic compound (Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum and Streptococcus faecium) in capsules, twice a day for 30 days. A symptom questionnaire was administered in day zero, after completion of antibiotic therapy, after the probiotic use and eight weeks after the end of the treatment. Upper digestive endoscopy, histological assessment, rapid urease test and breath test were performed before and eight weeks after eradication treatment.

Results

One hundred and seven patients were enrolled: 21 men with active probiotic and 19 with placebo plus 34 women with active probiotic and 33 with placebo comprising a total of 55 patients with active probiotic and 52 with placebo. Fifty-one patients had peptic ulcer and 56 were diagnosed as functional dyspepsia. The per-protocol eradication rate with active probiotic was 89.8% and with placebo, 85.1% (p = 0.49); per intention to treat, 81.8% and 79.6%, respectively (p = 0.53). The rate of adverse effects at 7 days with the active probiotic was 59.3% and 71.2% with placebo (p = 0.20). At 30 days, it was 44.9% and 60.4%, respectively (p = 0.08).

Conclusions

The use of this probiotic compound compared to placebo in the proposed regimen in Brazilian patients with peptic ulcer or functional dyspepsia showed no significant difference in efficacy or adverse effects.

Trial registration

Current Controlled Trials ISRCTN04714018

Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study

Internet websites are a resource for patients seeking information about probiotics. We examined a sample of 71 websites presenting probiotic information. We found that descriptions of benefits far outnumbered descriptions of risks and commercial websites presented significantly fewer risks than noncommercial websites. The bias towards the presentation of therapeutic benefits in online content suggests that patients are likely interested in using probiotics and may have unrealistic expectations for therapeutic benefit. Gastroenterologists may find it useful to initiate conversations about probiotics within the context of a comprehensive health management plan and should seek to establish realistic therapeutic expectations with their patients.

Helicobacter pylori persistence in children: distinguishing inadequate treatment, resistant organisms, and reinfection

Helicobacter pylori is a worldwide infection that causes chronic gastritis, duodenal ulcers, and malignancy. Transmission of Helicobacter pylori within a family appears to be the predominant mode of contamination. Recurrence of the infection is frequently seen following treatment. Lack of eradication due to either inadequate treatment or resistant bacteria vs. reinfection have been explanations for detection of H. pylori following treatment. In this article we will discuss the concepts of inadequate treatment vs. resistant infection and reinfection as causes of persistent H. pylori infection.

Primary antibiotic resistance of Helicobacter pylori isolated from Beijing children

BACKGROUND

The antimicrobials resistance of Helicobacter pylori (H. pylori) was able to sharply decline the eradication rate of H. pylori both in adults and children, but there are limited studies about the primary antibiotic resistance and the related gene mutations, specifically in China.

MATERIALS AND METHODS

The primary resistance to 9 antibiotics of 73 H. pylori strains isolated from gastric biopsies of children recruited at Beijing Children's Hospital was assessed, and the mutations in 23S rRNA gene of 65 macrolide-resistant strains and in gyrA and gyrB of 12 quinolone-resistant strains were investigated.

RESULTS

The resistance rate to clarithromycin, azithromycin, metronidazole, levofloxacin, moxifloxacin, and rifampicin was 84.9%, 87.7%, 61.6%, 13.7%, 15.1%, and 6.8%, respectively. No resistance to amoxicillin, gentamicin, and tetracycline was observed. Dual, triple, and quadruple antibacterial resistant percentage was 46.6% (34/73), 15.1% (11/73), and 2.7% (2/73), respectively. The gene mutation rate of A2142C, A2142G, and A2143G in 23S rRNA gene was 1.5% (1/65), 6.2% (4/65), and 84.6% (55/65), respectively. The detection rate of mutations of Asn87, Asp91, and Met191 in GyrA was 41.7% (5/12), 25% (3/12), and 25% (3/12), respectively.

CONCLUSION

The high prevalence of primary antibiotic resistance was out of expectation in H. pylori strains isolated from the children in Beijing. Antibiotic susceptibility should be made clear before the antibiotic was used in the anti-H. pylori therapy in this population. The A2143G was the most populated mutation in macrolide-resistant strains, and Asn87 and Asp91 of GyrA were the most common mutation points in quinolone resistance strains.

Prevalence of Helicobacter pylori in HIV-infected, HAART-naïve Ugandan children: a hospital-based survey

BACKGROUND

The aim of this survey was to determine the prevalence of and factors associated with Helicobacter pylori (H. pylori) colonization in HIV-infected, highly active antiretroviral therapy-naïve Ugandan children aged 0-12 years.

METHODS

In a hospital-based survey, 236 HIV-infected children were tested for H. pylori colonization using a faecal antigen test. A standardized interview with socio-demographic information and medical history was used to assess risk factors. A cluster of differentiation 4 (CD4) cell percentage was prevalent in most children.

RESULTS

The overall prevalence of H. pylori in the HIV-infected children was 22.5%. Age-specific prevalence was as follows: up to one year, 14.7%; 1-3 years, 30.9%; and 3-12 years, 20.7%. HIV-infected children who were more seriously affected by their disease (low CD4 cell percentage or WHO clinical stage II-IV) were less likely to be colonized with H. pylori. There was a trend for a lower prevalence of H. pylori in children who had taken antibiotics for the preceding two weeks (21.6%) than in those who had not taken antibiotics (35.7%). There was no statistically significant difference in prevalence by gender, housing, congested living, education of the female caretaker, drinking water or toilet facilities.

CONCLUSIONS

HIV-infected, HAART-naïve Ugandan children had a lower prevalence of H. pylori colonization compared with apparently healthy Ugandan children (44.3%). Children with a low CD4 cell percentage and an advanced clinical stage of HIV had an even lower risk of H. pylori colonization. Treatment with antibiotics due to co-morbidity with infectious diseases is a possible explanation for the relatively low prevalence.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Helicobacter pylori in apparently healthy children aged 0-12 years in urban Kampala, Uganda: a community-based cross sectional survey

Background

Helicobacter pylori is one of the most common causes of bacterial infection in human beings. Studies have showed a high prevalence of Helicobacter pylori among people in low-income countries and colonization early in life. A monoclonal antigen test, performed on faeces, HpSA^®ImmunoCardSTAT, has a high sensitivity, specificity and accuracy and the faecal test can be performed in all ages, also in resource-limited settings. The main objective of this study was to determine the prevalence and factors associated with Helicobacter pylori colonization in apparently healthy children aged 0-12 years in urban Kampala, Uganda.

Method

We tested 427 apparently healthy children, age 0-12 years (211 males, 216 females), in a cross sectional survey for Helicobacter pylori colonization using HpSA ^®ImmunoCardSTAT. A short standardized interview with socio-demographic information and medical history was used to assess risk factors.

Results

The overall prevalence of Helicobacter pylori in the 427 children was 44.3% (189 out of 427). Early colonization was common, 28.7%, in children younger than 1 year of age. The age specific rates were 46.0% in children age 1- < 3 years, 51.7% in children age 3- < 6 years, 54.8% in children age 6- < 9 years and 40.0% in children age 9- < 12 years. There was a significant difference in prevalence by gender; female 38.5% versus male 49.8% and by type of housing; permanent house 38.5% versus semi-permanent house 48.6%. Congestive living and education level of the female caretaker showed a clear trend for a difference in prevalence. Factors independently associated with Helicobacter pylori colonization included: drugs taken last three months, using a pit latrine, sources of drinking water and wealth index.

Conclusion

The prevalence of Helicobacter pylori colonization among urban Ugandan children is high at an early age and increases with age. The impact of Helicobacter pylori colonization on children's health in Uganda needs to be further clarified.