Unfortunately, there have not been many randomized placebo-controlled studies in the pediatric population looking at eradication of H. pylori. One study involving 73 children with dyspeptic symptoms demonstrated an eradication rate of 74% using Amoxicillin and Clarithromycin with a PPI, and 9.4% using dual therapy of Amoxicillin and Clarithromycin for 7 days using intention to treat analysis [83]. Another study by Oderda et al. [84] used Lansoprazole, Amoxicillin and Tinidazole triple therapy versus placebo plus Amoxicillin and Tinidazole dual therapy for 1 week; after 6 months the eradication rate was 72% for triple therapy and remained at 71% for dual therapy, showing no difference between the two treatments. A recently developed 10-day sequential treatment for H. pylori eradication was studied in 78 children. They were either randomized to receiving Omeprazole plus Amoxicillin for 5 days, followed by Omeprazole plus Clarithromycin and Tinidazole for another 5 days, compared to triple therapy of Omeprazole plus Amoxicilline and Tinidazole for 1 week. Sequential treatment had an eradication rate of 97.3% and triple therapy an eradication rate of 75.7%, demonstrating that sequential treatment is superior to triple therapy, consistent with results from adult studies [85, 86]. This sequential treatment needs to be further studied in different populations to determine its efficacy and safety, and to confirm its higher eradication rate in comparison to a 2-week course of triple therapy.

A recent Canadian Helicobacter Study Group Consensus Conference still recommends the use of triple therapy for 2 weeks using a PPI with Clarithromycin and Amoxicillin or Metronidazole given for 14 days. The duration of treatment of 2 weeks is likely to be optimal, but not conclusive; there is a 7-9% increase in the eradication rate with 14 days of treatment versus 7 days [87]. Tetracycline should be avoided in children under the age of 12 because it may cause staining of the children's enamel. In addition, treatment failure is increased with antibiotic resistance [88]. A recent Russian study by Nijevitch et al. [89] treated 76 children, who had failed triple therapy, using quadruple therapy. These children were randomized to receive a 2-week course of bismuth subcitrate, Amoxicillin with Nifuratel or Furazolidone plus Omeprazole. The eradication rate was 89% for Nifuratel and 87% for Furazolidone. Nifuratel is preferred because of a lower frequency of side effects. Potentially, this could be a treatment of choice for those who have failed eradication. It is vital that reference laboratories are available to monitor the population H. pylori antibiotic sensitivity and test those with treatment failure.

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