Assessment of Community Pediatric Providers’ Approach to Children With Helicobacter pylori

**Background** Helicobacter pylori is a gram-negative bacterium that typically infects children aged 5–10 years, with global prevalence ranging from 2.5% to 34.6%. Unlike in adults, pediatric infection often presents without gastroduodenal ulcer or gastric cancer, and testing is not recommended for functional abdominal pain. In 2016, ESPGHAN/NASPGHAN updated guidelines emphasizing endoscopy with culture to guide therapy, discouraging the former “test and treat” strategy. When culture is unavailable, empiric therapy with high-dose amoxicillin, metronidazole, and a proton pump inhibitor (PPI) is recommended. Noninvasive test of cure (stool antigen or urea breath test) should be performed at least 4 weeks after treatment. This study assessed knowledge and practice habits of community pediatric providers in Connecticut regarding these guidelines.

**Methods** A one-time cross-sectional observational study was conducted. Subjects included Connecticut primary care pediatric practitioners affiliated with one tertiary care center and/or the Connecticut American Academy of Pediatrics chapter. An electronic survey was developed using Qualtrics and distributed via email list-serve from July 2019 to September 2019, with two reminder emails in October 2019. The survey addressed diagnostic testing, first-line treatment choice, antibiotic dosing, and preferred test of cure, based on recent guideline changes. Iterative feedback was obtained from general pediatricians and pediatric gastroenterologists. Providers voluntarily completed the anonymous online form. Institutional review board exemption was obtained (Human Investigation Committee 200022326). Results were analyzed with descriptive statistics in Excel.

**Key Results** A total of 101 providers completed the questionnaire. Demographics: 70.3% female, 91% physicians, 83.2% had >10 years of experience, and 51% reported diagnosing H. pylori in practice. For diagnostic testing (multiple choices allowed), 56.4% used stool antigen testing, 43.6% used urea breath testing, and 17% used blood serology. Among those performing stool antigen testing, 34% reported patients were on PPIs during testing (with 5.7% reporting >95% of patients on PPIs). Regarding referral patterns, 25.8% referred >95% of patients to pediatric gastroenterology, while 24.7% referred <5%. For first-line treatment, only 28% correctly selected amoxicillin and metronidazole. Of those, 20% selected the correct amoxicillin dose. Overall, 46% chose amoxicillin and clarithromycin, and 14% chose clarithromycin and metronidazole. For test of cure, 63.4% assessed cure by resolution of symptoms, 24.8% used repeated stool antigen testing, and 22.8% used repeated urease breath testing. Only 42% selected either urease breath test or stool antigen testing. The most commonly used resources were UpToDate (45%) and Redbook (31%).

**Clinical Implications** The study reveals a significant evidence-practice gap among community pediatric providers in managing H. pylori. Most providers continue to use noninvasive testing and the “test and treat” strategy, contrary to guidelines. A third performed stool antigen testing while patients were on PPIs, risking false negatives. Only 28% correctly identified first-line antibiotics, and many used clarithromycin despite rising resistance (estimated 23%–46% in the US). Dosing errors were common. The majority assessed cure by symptom resolution rather than recommended noninvasive testing. These practices can lead to poor resource utilization, inadequate antibiotic prescriptions, worsening antibiotic resistance, and prolonged symptoms. The study is limited by its single-state, observational design and reliance on self-reported data. Future interventions should include educational outreach, integration of practice protocols, and improved resources such as pediatric-focused UpToDate content.