Comparison of sequential and classical therapy for helicobacter pylori eradication in children and investigation of clarithromycin resistance

OBJECTIVES: The aim of this study was to compare the efficacy of sequential and standart triple-drug regimen for Helicobacter pylori (H. pylori) eradication in children and to provide more efficient use of antibiotics in the first-line therapy for H. pylori eradication in children by determination of clarithromycin resistance rate.PATIENTS AND METHODS: Patients who underwent upper gastrointestinal endoscopy for different indications in Dokuz Eylul University School of Medicine Unit of Pediatric Gastroenterology, Nutrition and Metabolism between 1 April 2008 and 1 October 2010 and who were found to be positive for Helicobacter pylori (H. pylori) infection by rapid urease test and/or histopathologic evaluation of the antrum and/or corpus biopsies were included in the study. Helicobacter pylori positive patients were randomized into two groups. The first group was administered standart regimen consisting of lansoprazole 2 mg/kg/day for 30 days, amoxcicilin 50 mg/kg/day and clarithromycin 15 mg/kg/day for 14 days. The second group was administered a sequential regimen consisting of lansoprazole 2 mg/kg/day for 30 days, amoxcicilin 50 mg/kg/day for seven days, followed by clarithromycin 15 mg/kg/day and metronidazole 30 mg/kg/day for the next seven days. Groups were compared for eradication rate, adverse drug reactions and compliance to the treatment. In this study, detection of H. pylori and determination of clarithromycin susceptibility using formalin-fixed, parafin- embedded gastric biopsy specimens by fluorescence in-situ hybridization were also investigated.RESULTS: Forty-four patients, 19 (43.2%) of them male and 25 of them (56.8%) female, 28 of them in the standart and 16 of them in the sequential therapy group, with the mean age of 13.7 ? 3.5 years were included into the study. Age and gender distrubution of the patients were similar in the groups. Helicobacter pylori eradication rate was higher in the sequential therapy group (93.7%) than in the standart therapy group (46.4%) (p=0.002). There was no difference between the groups in adverse drug reactions and compliance to the treatment. In 83.3% of the patients H. pylori could be detected by FISH method. Primary clarithromycin resistance rate for H. pylori was found as 25.7% (n=9). All of the nine patients having clarithromycin resistance were coincidentally in the standart therapy group. After the exclusion of these nine patients, the eradication rate of the standart therapy was calculated to be 57.8%. A new comparison was performed and sequential therapy was again found to be more effective than the standart therapy (p=0.02).CONCLUSION: The eradication rate of H. pylori in children, treated with standart eradication therapy are below the acceptable levels. In our region we found that primary clarithromycin resistance rate was 25.7% for H. pylori in children. However, because amoxicilin and proton pump inhibitor given in the first week of the sequential therapy reduce clarithromycin and metronidazole resistant strains markedly, eradication can be achieved by clarithromycin and metronidazole administered in the second week even in the resistant cases. At the present time sequential therapy can be suggested to improve the eradication rate and to overcome clarithromycin resistance in H. pylori eradication.Key words: Children, Helicobacter pylori, sequential therapy, clarithromycin resistance, flıorescent in situ hybridization (FISH) method, gastritis, Turkey, Turkish