Antimicrobial susceptibility‐guided treatment is superior to empiric therapy for Helicobacter pylori infection in children

OBJECTIVES: Helicobacter pylori (HP) clinical guidelines encourage obtaining gastric biopsy culture and antimicrobial susceptibilities to guide therapy. Susceptibility-guided treatment (SGT) reduces unnecessary exposure to ineffective antibiotics, minimizes adverse events, and promotes antimicrobial stewardship. However, real-world data on its effectiveness remains limited. We aim to compare the efficacy of SGT to empirical therapy (ET). METHODS: Retrospective cohort study, single pediatric tertiary care center, Boston Children's Hospital, January/2019 to June/2024. First-time H. pylori-histological diagnosis and subsequent treatment. Data extracted: demographic variables, endoscopy indications, endoscopic and histological findings, prior antimicrobial use, treatment regimen, eradication, and antimicrobial susceptibility. We compared eradication rates on patients who received ET versus those who received SGT and among SGT recipients. RESULTS: Two hundred and eighteen study subjects (95 ET, 123 SGT) were included. Mean age:13.6 ± 4.8 years, 50.9% male, 59.6% White, 38.1% Hispanic. Endoscopic findings: gastritis (92.7%), duodenitis (11.5%), gastric ulcer/erosion (5.0%), duodenal ulcer/erosion (13.3%). Eradication success was significantly higher in the SGT group (89.4%,110/121) compared to the ET group (70.2%, 66/94) (p < 0.001). Resistance rates: clarithromycin (26.8%), metronidazole (18.7%), fluoroquinolones (9.8%), amoxicillin (3.3%), rifampin (8.9%), no tetracycline resistance. Amoxicillin resistance was strongly associated with failure (27.3% vs. 0.9%, p = 0.002), as was dual clarithromycin-metronidazole resistance (36.4% vs. 8.2%, p = 0.018). In univariate analysis, amoxicillin resistance had the strongest association with failure (odds ratio [OR] 40.9, p < 0.001), followed by dual clarithromycin-metronidazole resistance (OR 6.41, p = 0.016), and metronidazole resistance (OR 4.26, p = 0.034). CONCLUSION: SGT resulted in higher eradication rates than ET. Clarithromycin and metronidazole resistance rates were >15%. Antibiotic resistance, especially to amoxicillin, is a major driver of eradication failure.