Nieman: Sometimes, best course of action for common infection is not to treat with drugs

A very worried mom sees a pediatrician because her nine-year-old son has suffered from abdominal pains over the past two years. Her primary care clinician ran some tests and one particular test came back positive for an organism named Helicobacter pylori (H pylori).

Before seeing the pediatrician, she did what many parents do – embarked on her own research. As a result, she is very concerned that unless this organism gets treated by what is called triple therapy (an antibiotic combined with a so-called proton pump inhibitor and metronidazole) the child will never get better.

The inexperienced pediatrician, intimidated by an assertive parent, calls the infectious disease clinic at the university-affiliated hospital and is told that even if it is an infection, they do not see children with this infection. Instead, a gastroenterologist should be called. To see the latter expert will take months.

The story goes from bad to worse with the mom storming out of the clinic, angry and frustrated by the suggestion that no treatment is needed. The whole fiasco — costing lots of dollars and plenty of time to sort through – could have been avoided if the test was never ordered in the first place?

Later, the pediatrician does her own research on the most popular go-to-when-uncertain resource, called Up To Date. There she sees that something uncommon happened when it comes to H. pylori: The European Society for Gastroenterology and the North American Society for Gastroenterology joined forces and studied the best way to manage this infection.?

Their bottom line is simple: “We recommend against the test and treat strategy.”

H. pylori remains one of the most common human infections worldwide. The prevalence varies widely according to different geographic areas. It is founded in less than five per cent of children in Scandinavia; in 30 to 40 per cent of children in North America and in more than 70 per cent of children in children from Africa and Latin America.?

H. pylori is acquired predominantly during early childhood and most infections occur before the age of 10. The majority of children are asymptomatic and the vast majority of infections do not present with abdominal pain.?

For parents who worry about a child with abdominal pains, I usually tell them to look out for four red flags: pain associated with weight loss, vomiting, blood in the feces and pain which wakes the child up at night or makes him or her get out of bed at 3 a.m. to rush to the toilet to pass unusual-looking feces (an urgency to defecate at an odd time of the day).

In the absence of these red flags, there is no need to test for H. pylori by running a stool test or sending the child for a urea breath test.?

As is the case so often in medicine, there are exceptions. I call it the “I-before-E-except-after-C moments – before spellcheck, this was a rule to help us all spell properly.?

Testing for H. pylori is indicated when there is a strong family history of gastric or duodenal ulcers, a family history of gastric cancer or mucosal lymphoma and in cases where treating iron deficiency anemia is refractory.?

Invasive testing, only done by a properly trained gastroenterologist, involves endoscopy, and while down there, biopsies of suspicious gastric areas in at least six different spots are done. This allows for proper histological testing and also for determining which antibiotic is the best if treatment will be commenced.

The other kink in the story of asymptomatic H. pylori is that, the vast majority of patients who received the triple therapy properly and consistently for at least two weeks, get re-infected and that the treatment also does not get rid of abdominal pains.

In the old days, antibiotics were often overused. We have come a long way toward being more mindful and cautious before reaching out for an Rx pad, or to be more current … using a computer rather than pen to print off or fax in an antibiotic prescription.

What bedevils the story of H. pylori even further is that the approach to managing it in children and adults is quite different. Thus, when laypeople do their research and fail to appreciate that, they may fall into a common trap: projection. Often we rely on anecdotal stories and we project based on what happened to Uncle So-and-so who was seen in another country where they practice medicine differently from North America.

I am reminded of two sayings when it comes to educating skeptical and worried families: “Facts tell but stories sell” and “A man convinced against his will is of the same opinion still.” (The latter is a quote from Dale Carnegie’s book?How to Win?Friends and Influence People)

Over 90 per cent of Canadians are not ingesting enough fibre. So when I tell my patients to eat more fibre, the pesky abdominal pains often become significantly less. Sticking to fundamentals matters a great deal.

Dr. Nieman is the founder of Centre 70 Pediatrics and has written monthly columns for the Herald since 1999. He has run every day for the past 15 years and completed 125 marathons.