Widespread “test-and-treat” practices raise concerns over H. pylori management in children

For the screening and diagnosis of paediatric Helicobacter pylori infection at a tertiary centre in Singapore, endoscopies are often skipped in favour of a “test-and-treat” approach based on noninvasive testing, a practice that deviates from recommended protocols.

In a retrospective review, 117 of 1,397 children (8.4 percent) who underwent stool antigen testing tested positive for H. pylori infection. Meanwhile, five of 85 children (5.9 percent) who underwent a urea breath test (UBT) had a positive result. The primary indication for screening was abdominal pain. [Pediatr Gastroenterol Hepatol Nutr 2024;27:336-344]

Confirmatory endoscopic evaluation was performed in 30 children (24.6 percent). And in the subgroup of 12 children who were naïve to treatment, only seven had biopsy-proven disease, with the remainder having false-positive stool antigen test results. Chronic gastritis was the most common histopathological finding, followed by H. pylori inclusion bodies and lymphoid follicles. 

Of the 122 children with positive screening test, 111 (91.0 percent) received triple therapy, seven (5.7 percent) received only proton pump inhibitors (PPIs), and four (3.3 percent) received no treatment. A 14-day course of PPI, amoxicillin, and clarithromycin was the most common treatment regimen.

H. pylori eradication was observed in 62 children (50.8 percent), including in 12 who underwent endoscopy, 28 who underwent stool antigen testing, and 16 who underwent UBT. Symptom resolution occurred in 62 children (50.8 percent). Of the 92 children who received treatment based on positive noninvasive testing alone, 32 (34.8 percent) had documented eradication, and 14 of them had persistent symptoms.

“The audit showed that the ‘test-and-treat’ strategy was more widely used than endoscopy-based invasive diagnostic testing, with only a small subset of patients having had a gastric biopsy culture. This mirrors the physician management patterns reported in the literature, which highlights low compliance with existing guidelines,” the investigators said. [J Pediatr Gastroenterol Nutr 2021;73:178-183]

They pointed out that while the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommend against a test-and-treat approach, the increased use of noninvasive tests may have been due to their ease of administration and short turnaround time. [J Pediatr Gastroenterol Nutr 2017;64:991-1003]

“The advantages of stool antigen testing include easy sample collection, no need for fasting, and no dependence on operator or clinician experience. There are also fewer risks to patients than endoscopy, which is a highly specialized procedure that requires a referral to a paediatric gastroenterologist and the administration of intravenous sedation for paediatric patients. This makes endoscopy less appealing for caregivers and attending physicians,” the investigators said.

However, they highlighted a significant concern regarding the high false-positive rate of noninvasive testing, given that almost half of the treatment-naïve children with a positive screening test who underwent endoscopy did not have biopsy-proven disease.

“The findings of this audit provide a basis for hospital-wide quality improvement initiatives that seek to improve the testing and treatment of H. pylori infections in children,” the investigators said.