Evidence-based Guidelines From ESPGHAN and NASPGHAN for Helicobacter pylori Infection in Children
01 Aug 2011-Journal of Pediatric Gastroenterology and Nutrition (J Pediatr Gastroenterol Nutr)-Vol. 53, Iss: 2, pp 230-243
TL;DR: These clinical practice guidelines represent updated, best-available evidence and are meant for children and adolescents living in Europe and North America, but they may not apply to those living on other continents, particularly in developing countries with a high H pylori infection rate and limited health care resources.
Abstract: Objective: As the clinical implications of Helicobacter pylori infection in children and adolescents continue to evolve, ESPGHAN and NASPGHAN jointly renewed clinical guidelines using a standardized evidence-based approach to develop updated recommendations for children and adolescents in North America and Europe. Methods: An international panel of 11 pediatric gastroenterologists, 2 epidemiologists, 1 microbiologist, and 1 pathologist was selected by societies that developed evidence-based guidelines based on the Delphi process with anonymous voting in a final face-to-face meeting. A systematic literature search was performed on 8 databases of relevance including publications from January 2000 to December 2009. After excluding nonrelevant publications, tables of evidence were constructed for different focus areas according to the Oxford classification. Statements and recommendations were formulated in the following areas: whom to test, how to test, whom to treat, and how to treat. Grades of evidence were assigned to each recommendation based on the GRADE system. Results: A total of 2290 publications were identified, from which 738 were finally reviewed. A total of 21 recommendations were generated, and an algorithm was proposed by the joint committee providing evidence-based guidelines on the diagnostic workup and treatment of children with H pylori infection. Conclusions: These clinical practice guidelines represent updated, bestavailable evidence and are meant for children and adolescents living in Europe and North America, but they may not apply to those living on other continents, particularly in developing countries with a high H pylori infection rate and limited health care resources.
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TL;DR: The primary goal of clinical investigation is to identify the cause of upper gastrointestinal symptoms rather than H pylori infection, and it is recommended against a test and treat strategy.
Abstract: Background Because of the changing epidemiology of Helicobacter pylori infection and low efficacy of currently recommended therapies, an update of the European Society for Paediatric Gastroenterology Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommendations for the diagnosis and management of H pylori infection in children and adolescents is required. Methods A systematic review of the literature (time period: 2009-2014) was performed. Representatives of both societies evaluated the quality of evidence using GRADE (Grading of Recommendation Assessment, Development, and Evaluation) to formulate recommendations, which were voted upon and finalized using a Delphi process and face-to-face meeting. Results The consensus group recommended that invasive diagnostic testing for H pylori be performed only when treatment will be offered if tests are positive. To reach the aim of a 90% eradication rate with initial therapy, antibiotics should be tailored according to susceptibility testing. Therapy should be administered for 14 days, emphasizing strict adherence. Clarithromycin-containing regimens should be restricted to children infected with susceptible strains. When antibiotic susceptibility profiles are not known, high-dose triple therapy with proton pump inhibitor, amoxicillin, and metronidazole for 14 days or bismuth-based quadruple therapy is recommended. Success of therapy should be monitored after 4 to 8 weeks by reliable noninvasive tests. Conclusions The primary goal of clinical investigation is to identify the cause of upper gastrointestinal symptoms rather than H pylori infection. Therefore, we recommend against a test and treat strategy. Decreasing eradication rates with previously recommended treatments call for changes to first-line therapies and broader availability of culture or molecular-based testing to tailor treatment to the individual child.
287 citations
Cites background or methods from "Evidence-based Guidelines From ESPG..."
...Scope and Purpose Joint ESPGHAN/NASPGHAN guidelines were developed for the management of H pylori infection in children and adolescents in 2009 and published in 2011 (6)....
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...First-line therapies recommended in previous guidelines have unacceptable treatment failures rates (6)....
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...Lack of adherence is a significant risk factor for failure of therapy (6)....
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...In the previous joint guidelines, a weak recommendation for testing for H pylori infection in the setting of a first-degree relative with gastric cancer was included (6)....
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...COMMENT: Since the last guidelines in 2009 (6), no new data support a role for H pylori infection as a cause of symptoms in the absence of PUD....
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TL;DR: Since the ‘Fourth Chinese National Consensus Report on the management of H. pylori infection’ was published in 2012, three important consensuses (Kyoto global consensus report on H.pylori gastritis, The Toronto Consensus for the Treatment ofH. pylonori infection and the Maastricht V/Florence Consensus report) have been published regarding the management.
Abstract: Background Since the 'Fourth Chinese National Consensus Report on the management of H. pylori infection' was published in 2012, three important consensuses (Kyoto global consensus report on H. pylori gastritis, The Toronto Consensus for the Treatment of H. pylori Infection in Adults and Management of H. pylori infection-the Maastricht V/Florence Consensus Report) have been published regarding the management of H. pylori infection. Materials and methods A Delphi method was adopted to develop the consensus of relevant 'statements'. First, the established 'statements' were sent to experts via email. Second, after undergoing two rounds of consultation, the initial statements were discussed face to face and revised in the conference item by item on 16 December 2016. Finally, 21 core members of conferees participated in the final vote of statements. Voting for each statement was performed using an electronic system with levels of agreements shown on the screen in real time. Results Consensus contents contained a total of 48 "statements" and related 6 parts, including indications for H. pylori eradication, diagnosis, treatment, H. pylori and gastric cancer, H. pylori infection in special populations, H. pylori and gastrointestinal microbiota. Conclusions Recommendations are provided on the basis of the best available evidence.
249 citations
Catholic University of the Sacred Heart1, University of Basel2, Erasmus University Rotterdam3, University of Ljubljana4, Charles University in Prague5, University of Messina6, University of Freiburg7, Medical University of Vienna8, Leeds Teaching Hospitals NHS Trust9, Rikshospitalet–Radiumhospitalet10
TL;DR: This guideline refers to infants, children, and adolescents ages 0 to 18 years, and indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography.
Abstract: This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.
175 citations
TL;DR: The areas covered include: indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; endoscope management of corrosive ingestion and stricture/stenosis; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography.
Abstract: This Executive summary of the Guideline on pediatric gastrointestinal endoscopy from the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) refers to infants, children, and adolescents aged 0 – 18 years. The areas covered include: indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; endoscopic management of corrosive ingestion and stricture/stenosis; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease (IBD) have been dealt with in other Guidelines and are therefore not mentioned in this Guideline. Training and ongoing skill maintenance will be addressed in an imminent sister publication.
143 citations
TL;DR: Probiotics are recommended to supplement triple therapy in pediatrics, and the effectiveness of triple therapy is associated with specific probiotic supplementation.
Abstract: The aim of this study was to identify the best probiotic supplementation in triple therapy for pediatric population with Helicobacter pylori infection. Eligible trials were identified by comprehensive searches. Relative risks with 95% confidence intervals and relative ranks with P scores were assessed. Twenty-nine trials (3122 participants) involving 17 probiotic regimens were identified. Compared with placebo, probiotic-supplemented triple therapy significantly increased H. pylori eradication rates (relative ratio (RR) 1.19, 95% CI 1.13–1.25) and reduced the incidence of total side effects (RR 0.49, 95% CI 0.38–0.65). Furthermore, to supplemented triple therapy, Lactobacillus casei was identified the best for H. pylori eradication rates (P score = 0.84), and multi-strain of Lactobacillus acidophilus and Lactobacillus rhamnosus for total side effects (P score = 0.93). As for the subtypes of side effects, multi-strain of Bifidobacterium infantis, Bifidobacterium longum, L. acidophilus, L. casei, Lactobacillus plantarum, Lactobacillus reuteri, L. rhamnosus, Lactobacillus salivarius, Lactobacillus sporogenes, and Streptococcus thermophilus was the best to reduce the incidence of diarrhea; multi-strain of Bacillus mesentericus, Clostridium butyricum, and Streptococcus faecalis for loss of appetite; multi-strain of B. longum, Lactobacillus bulgaricus, and S. thermophilus for constipation; multi-strain of Bifidobacterium bifidum, B. infantis, L. acidophilus, L. bulgaricus, L. casei, L. reuteri, and Streptococcus for taste disturbance; Saccharomyces boulardii for bloating; and multi-strain of Bifidobacterium breve, B. infantis, L. acidophilus, L. bulgaricus, L. casei, L. rhamnosus, and S. thermophilus for nausea/vomiting. Probiotics are recommended to supplement triple therapy in pediatrics, and the effectiveness of triple therapy is associated with specific probiotic supplementation.
81 citations
Cites background from "Evidence-based Guidelines From ESPG..."
...pylori in children has been recommended in Europe and North American [6], but...
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...Triple therapy with a proton pump inhibitor (PPI) + two antibiotics as a firstline therapy for the eradication of H. pylori in children has been recommended in Europe and North American [6], but eradication failure resulting from bacterial resistance and side effects associated with antibiotics has restricted triple therapy in children [7, 8]....
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References
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TL;DR: A system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts is developed, and a summary of the approach from the perspective of a guideline user is presented.
Abstract: Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations Systematic and explicit methods of making judgments can reduce errors and improve communication We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts In this article we present a summary of our approach from the perspective of a guideline user Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk It is also important to consider costs (resource utilisation) before making a recommendation Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues
7,608 citations
"Evidence-based Guidelines From ESPG..." refers methods in this paper
...ww ing of the literature and were finally assigned using the GRADE m of 2004 (16) as follows:...
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TL;DR: The Sydney System for the classification of gastritis emphasized the importance of combining topographical, morphological, and etiological information into a schema that would help to generate reproducible and clinically useful diagnoses as discussed by the authors.
Abstract: The Sydney System for the classification of gastritis emphasized the importance of combining topographical, morphological, and etiological information into a schema that would help to generate reproducible and clinically useful diagnoses. To reappraise the Sydney System 4 years after its introduction, a group of gastrointestinal pathologists from various parts of the world met in Houston, Texas, in September 1994. The aims of the workshop were (a) to establish an agreed terminology of gastritis; (b) to identify, define, and attempt to resolve some of the problems associated with the Sydney System. This article introduces the Sydney System as it was revised at the Houston Gastritis Workshop and represents the consensus of the participants. Overall, the principles and grading of the Sydney System were only slightly modified, the grading being aided by the provision of a visual analogue scale. The terminology of the final classification has been improved to emphasize the distinction between the atrophic and nonatrophic stomach; the names used for each entity were selected because they are generally acceptable to both pathologists and gastroenterologists. In addition to the main categories and atrophic and nonatrophic gastritis, the special or distinctive forms are described and their respective diagnostic criteria are provided. The article includes practical guidelines for optimal biopsy sampling of the stomach, for the use of the visual analogue scales for grading the histopathologic features, and for the formulation of a comprehensive standardized diagnosis. A glossary of gastritis-related terms as used in this article is provided.
4,511 citations
TL;DR: H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users and a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45.
Abstract: Background: Guidelines on the management of Helicobacter pylori , which cover indications for management and treatment strategies, were produced in 2000. Aims: To update the guidelines at the European Helicobacter Study Group (EHSG) Third Maastricht Consensus Conference, with emphasis on the potential of H pylori eradication for the prevention of gastric cancer. Results: Eradication of H pylori infection is recommended in ( a ) patients with gastroduodenal diseases such as peptic ulcer disease and low grade gastric, mucosa associated lymphoid tissue (MALT) lymphoma; ( b ) patients with atrophic gastritis; ( c ) first degree relatives of patients with gastric cancer; ( d ) patients with unexplained iron deficiency anaemia; and ( e ) patients with chronic idiopathic thrombocytopenic purpura. Recurrent abdominal pain in children is not an indication for a “test and treat” strategy if other causes are excluded. Eradication of H pylori infection ( a ) does not cause gastro-oesophageal reflux disease (GORD) or exacerbate GORD, and ( b ) may prevent peptic ulcer in patients who are naive users of non-steroidal anti-inflammatory drugs (NSAIDs). H pylori eradication is less effective than proton pump inhibitor (PPI) treatment in preventing ulcer recurrence in long term NSAID users. In primary care a test and treat strategy using a non-invasive test is recommended in adult patients with persistent dyspepsia under the age of 45. The urea breath test, stool antigen tests, and serological kits with a high accuracy are non-invasive tests which should be used for the diagnosis of H pylori infection. Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended first choice treatment. Bismuth-containing quadruple therapy, if available, is also a first choice treatment option. Rescue treatment should be based on antimicrobial susceptibility. Conclusion: The global burden of gastric cancer is considerable but varies geographically. Eradication of H pylori infection has the potential to reduce the risk of gastric cancer development.
2,266 citations
"Evidence-based Guidelines From ESPG..." refers background or result in this paper
...Quadruple therapy is the recommended secondline therapy in most guidelines (8,15); however, this regimen i s complicated to administer....
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...These and other differences explain why some of the recommendations for adults (8) may not apply in children....
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...Therefore, in contrast to current guidelines for adults (8,120), current evidence does not support this practice in children....
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TL;DR: The Rome III child and adolescent criteria represent an evolution from Rome II and should prove useful for both clinicians and researchers dealing with childhood FGIDs.
1,676 citations
"Evidence-based Guidelines From ESPG..." refers background in this paper
...Abdominal complaints may also be part of a functional gastrointestinal disorder (18)....
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...Therefore, cases of abdominal pain consistent with the diagnostic criteria of functional pain (18) should not be investigated for H pylori, unless upper endoscopy is performed during the diagnostic workup in search for organic disease....
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...In patients with the translocation t(11;18)(q21;q21), conventional chemotherapy can be considered in addition to eradication of H pylori....
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...The translocation t(11;18)(q21;q21) characteristic of MALT lymphoma is recognized to be a marker of H pylori independence, but this marker is found in only half of the MALT lymphomas that are resistant to H pylori eradication (44)....
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TL;DR: It was found that the incidence of gastric cancer development at the population level was similar between participants receiving H pylori eradication treatment and those receiving placebo during a period of 7.5 years in a high-risk region of China.
Abstract: ContextAlthough chronic Helicobacter pylori infection
is associated with gastric cancer, the effect of H pylori treatment on prevention of gastric cancer development in chronic carriers
is unknown.ObjectiveTo determine whether treatment of H pylori infection
reduces the incidence of gastric cancer.Design, Setting, and ParticipantsProspective, randomized, placebo-controlled, population-based primary
prevention study of 1630 healthy carriers of H pylori infection
from Fujian Province, China, recruited in July 1994 and followed up until
January 2002. A total of 988 participants did not have precancerous lesions
(gastric atrophy, intestinal metaplasia, or gastric dysplasia) on study entry.InterventionPatients were randomly assigned to receive H pylori eradication treatment: a 2-week course of omeprazole, 20 mg, a combination
product of amoxicillin and clavulanate potassium, 750 mg, and metronidazole,
400 mg, all twice daily (n = 817); or placebo (n = 813).Main Outcome MeasuresThe primary outcome measure was incidence of gastric cancer during follow-up,
compared between H pylori eradication and placebo
groups. The secondary outcome measure was incidence of gastric cancer in patients
with or without precancerous lesions, compared between the 2 groups.ResultsAmong the 18 new cases of gastric cancers that developed, no overall
reduction was observed in participants who received H pylori eradication treatment (n = 7) compared with those who did not (n =
11) (P = .33). In a subgroup of patients with no
precancerous lesions on presentation, no patient developed gastric cancer
during a follow-up of 7.5 years after H pylori eradication
treatment compared with those who received placebo (0 vs 6; P = .02). Smoking (hazard ratio [HR], 6.2; 95% confidence interval
[CI], 2.3-16.5; P<.001) and older age (HR, 1.10;
95% CI, 1.05-1.15; P<.001) were independent risk
factors for the development of gastric cancer in this cohort.ConclusionsWe found that the incidence of gastric cancer development at the population
level was similar between participants receiving H pylori eradication treatment and those receiving placebo during a period
of 7.5 years in a high-risk region of China. In the subgroup of H pylori carriers without precancerous lesions, eradication of H pylori significantly decreased the development of gastric
cancer. Further studies to investigate the role of H pylori eradication in participants with precancerous lesions are warranted.
1,357 citations
"Evidence-based Guidelines From ESPG..." refers background in this paper
...Current evidence suggests that in high-risk populations such as in China, the eradication of H pylori may have the potential to decrease the risk of gastric cancer in a subset of individuals without precancerous lesions (39)....
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...In a large interventional trial in adults, subgroup analysis suggested that eradication may be beneficial in people without precancerous lesions (39)....
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