Bismuth salts in the treatment of Helicobacter pylori infection in children.

Delghani et al. [1] evaluated the efficacy of three different regimens for eradication of Helicobacter pylori (H. pylori) infection in children. The authors concluded that quadruple therapy containing bismuth yields better results and can be used as first-line of therapy. The study is both well designed and well managed, and highlights the need for novel therapies in children with H. pylori infection. Here are some important points of the study that should be discussed. The study group was composed of 120 children with a mean age of 12 ± 4 years (range 2–18 years). H. pylori eradication was assessed with urea breath test (UBT). The utility of UBT in children over 6 years of age was confirmed by numerous studies. The sensitivity and specificity for children in this group were found to be 100 and 98% respectively, with positive predictive value (PPV) and negative predictive values (NPV) of 98 and 100% respectively. In young children, however, false-positive results compromise the accuracy of the test. For children under the age of 6 years, specificity was determined to be 88% and PPV 69% [2]. The accuracy of UBT can be improved by increasing delta over baseline (DOB) cut-off values; however, the false-positive rate remains high [2, 3]. It would be better to provide brief methodologic data regarding UBT including information at least about cut-off values and whether values are adjusted for age. The authors reported the eradication rate with quadruple therapy with bismuth 91.8% compared to 82.1 and 80.5% with current triple therapies containing clarithromycin in the second group and metronidazole in third group, respectively. The authors suggested quadruple therapy as the first-line of therapy for the eradication of H. pylori infection in children in their geographic area. Treatment of H. pylori infection in children with protocols containing bismuth compounds have been reported with variable success [4–7]. In a recent report of pooled data [8], bismuth triple therapies were found to be more efficacious than proton pump inhibitor triple therapies (77 vs. 64%) as a first-line treatment. Indeed, the eradication rate is better with quadruple therapy in the present study, but not sufficiently high to suggest it as a first-line therapy (p = 0.33). Secondly, bismuth compounds are major drugs of rescue regimens after H. pylori treatment failure. The most important cause of treatment failure is drug resistance. In this case, it is fairly logical to reserve bismuth compounds as a second-line option to decrease the risk of drug resistance. Although the use of bismuth compounds has been reported in children [8], they still require approval to use. Therefore, the use of bismuth compounds in children may be of ethical concern. In adults, it has recently been suggested that fluoroquinolone-based rescue therapies constitute an encouraging second-line strategy, representing an alternative to quadruple therapy with efficacy, simplicity, and safety [9–11]. Although pediatric data is limited, fluoroquinolone-based therapies can be tried as rescue therapy in children over the age of 8 [12]. Lastly, compliance is an important determinant of treatment success. Multiple drug use is an important risk factor and therefore compliance is expected to be low with quadruple therapy. In conclusion, it is still too early to suggest quadruple therapy containing bismuth compounds as a first-line option in children with H. pylori infection. Moreover, we need further comparable studies in order to determine the case for quadruple therapies containing bismuth compounds as a second-line option. S. Gokce (&) Pediatric Gastroenterology, Hepatology and Nutrition, Dr. Sami Ulus Children’s Hospital, Ankara, Turkey e-mail: drgokce0007@yahoo.com