Comment traiter aujourd’hui !

Based on the join ESPGHAN/NASPGHAN

guidelines on the Management of

Helicobacter pylori infection in children

Koletzko et al. JPGN 2011

Tri-thérapie 7j adaptée à la sensibilité des souches

o Arenz et al. JPGN 2006

 54/58 (93%, 95%CI 83-98%) enfants éradiqués (PP = ITT)

 49/53 (92%) avec EAC 7j

 5/5 avec EAM 7j

Tri-thérapie 7j adaptée à la sensibilité des souches vs séquentiel

Bontems et al. JPGN 2011

Traitement séquentiel

Deux périodes successives de 5 jours combinant:

Inhibiteur de la pompe à proton avec de l’Amoxicilline 5j

Suivi trithérapie (IPP, Clarithromycine, Métronidazole) 5j

Meta-analyse (Gatta 2009)

260 enfants et adolescents

3 études randomisées controlées

OR traitement séquentiel vs tri-thérapie 1.98

95% CI 0.96–4.07

sensibilité aux antibiotiques non disponibles

o 2009: Sequential treatment superior to standard triple

therapy in adults but not significantly advantage

 Gatta et al. Am J Gastroenterol

o 2013: Sequential treatment 10d superior to standard triple

therapy 7d but not to STT 10 or 14d

o Horvath et al. APT

o 2015: Sequential treatment 10d superior to standard triple

therapy given 7 or 10 d but not for 14d (number to treat =

16 !)

o Huang et al. 2015

However, eradication rate still less than desired

Meta-analysis in children

Sequential versus triple therapy for H. pylori eradication

in children

• No antimicrobial susceptibility testing in most studies

• Adherence to therapy not assessed

• Small number of patients

• Insufficient eradication rates

Horvath et al. APT 2013

77%72%

Recommendation 12/16

o We recommend that the effectiveness of first-

line therapy be evaluated in national/regional

centers.

 Practice Points:

1. To avoid further investigations, and induction of

secondary resist- ance in the infecting H. pylori strains, a

primary success rate for eradication should be more

than 90% in per-protocol analysis.

2. Improvement care strategy needed locally to obtain the

recommended target of 90% of efficacy.

Jones et al. JPGN 2017

Quality control circle of Deming

Taux d’éradication chez l’enfant

Traitement

(1-2 semaines)

enfant (n)

Eradication PP

(%)

95% CI

Ome-Amo-Clar 175 61 53-68

Ome-Amo-Metro 83 66 55-76

Bis-Amo-Metro 56 80 68-90

Bis-Clar-Metro 45 73 58-85

Lan-Amo-Metro 28 57 37-75

Ome-Clar-Metro 20 95 75-100

(Oderda et al. Helicobacter 2007)

Possibility to improve the eradication rates in children

o Increase the duration of the tailored triple

therapy to 14d

o Double check the dosage prescribed, must be

superior to:

 > 50 mg/kg for AMO

 > 25 mg/kg for CLA

 > 20 mg/kg for MET

 > 1-2 mg/kg for PPI

o Amoxicillin in tid

o Probiotic to prevent side effects

o Use concomitant quadruple therapy

o Statement 10: Extending the duration of PPI-

clarithromycin-containing triple therapies from 7 to

10 or 14 days improves the eradication success by

about 5% and may be considered.

Evidence level: 1a

Malfertheiner et al. Gut 2012

Fuccio et al. Ann Intern Med 2007

Effect of triple therapy duration on efficacy in adults

Fallone et al. Gastroenterology 2016

Tailored triple therapy 7d

Kato et al. J Gastroenterol 2004

Tailored Sequential vs tailored triple therapy 10 days

Kotilea et al. Helicobacter 2016

After adjustment for adherence and adverse events