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At-Sea Flexible Dining: Take It Away
July 24, 2012 | By Sue Bryant | 45 Comments
45 Responses to "At-Sea Flexible Dining: Take It Away"
Tracy Mitchell
July 24th, 2012 @ 3:44 pm
I have had only positive experiences with my two anytime dining attempts. I agree with the points you made in your article. However, I must divulge that I always develop a rapport with the maitre'd to ensure my requirements are met. I get a table for two and the same waiter every night and everyone gets the extra tips that they would with regular assi
gned dining. Wink wink
Barbara Herron
July 24th, 2012 @ 4:43 pm
We've had great experiences with MyTime Dining. We always get a table for two unless we indicate we'd like to share. The maitre'd is great about placing us with the same wait staff, so we get to know them, they get to know us, and we tip above and beyond the mandatory gratuity (and usually tip the maitre'd, too!). We like being able to pick different times, depending on what's going on, especially on port days when we may not want to hurry back and get ready for dinner at 6, or have to wait until 8:30. On sea days, we usually dine around 7. And we've always been there for the napkin-waving and serenade. The waiters have paraded through the mezzanine on the ships we've been on. All in all, we love it.
July 24th, 2012 @ 4:50 pm
I won a cruise on Norwegian to the Bahamas. It was my first experience with Freestyle Dining. Can't say one bad thing about the service or food on this medium sized ship. I could understand the mega ships having long waits and other issues.
Lisa Bowgren
July 24th, 2012 @ 5:00 pm
I agree with Tracy. We've done the flexible dining twice now and have always been able to secure a table for two and most times can request the same server, etc. I love the flexibility of eating at whatever time we want!
Vicki Yarnell
July 24th, 2012 @ 5:03 pm
I agree! Put me down for second seating….plenty of time to get ready after a day on the beach or by the pool and then I can walk straight to my table where the rest of my bottle of wine from the night before will be waiting and with a nod the bar steward will be off to get my Coke Zero. Nothing beats getting familiar with the wait staff over the length of the cruise.
July 24th, 2012 @ 5:07 pm
I personally haven't had to wait long for flexible dining. And if the wait is say, longer than 15 mins, I always seem to find another place to dine. Fortunately, I've never felt I've received not as good service, even when comparing it to specialty dining venues.
I like the flexibility and I'd have to agree with you that your last point doesn't matter to me.
Gail Heywood
July 24th, 2012 @ 5:31 pm
I have been on both 'anytime' and 'fixed' dining, and frankly I prefer the latter. If we choose to eat on the lido or one of the upper dining rooms, that's our choice. I like having the same waiter every evening–you develop a rapport and they know exactly what you like. On the 'anytime' ship, one night our table was right next to the kitchen–felt like we were in a traffic zone. Another night we were seated next to a table of screaming kids. I have never had a bad table (knock on wood!) on the ships where you a predetermined dinner time. I was never that lucky to have the maitre'd do more than say 'good evening' as you walked into the dining room. On the any time ship, he never came to our table during the entire cruise. To me, it also seems a big chaotic when all the 'anytime' patrons are waiting in line…more leisurely when people are granted to walk in at the pre-determined time. Just my two cents…we're cruising again in November and yes, we chose a dining time.
Charlie Wallace
July 24th, 2012 @ 5:32 pm
We found ourselves in a "dine as you wish" category once because an early fixed seating assignment wasn't available. For us, it was not the experience we have come to love while cruising. The relationship with our wait staff is a significant part of our experience. We can "eat as we wish" or even "dress as we wish" at home. A little structure and and an opportunity to dress for dinner helps make cruising the vacation we love.
Nancy J
July 24th, 2012 @ 5:33 pm
I have done both and am much happier with the assigned dining times and tables. My experience shows that even with any time options the actual dining times seem to parallel the standard dining times. For instance walking in at 7:00 we found that there were no anytime tables available and had to wait for the earliest diners to depart which was about a half hour later. Many evenings we were able to get a preferred server we had used previously, but it wasn't always possible. I suspect that less experience wait staff is used for the anytime option. We have reverted to assigned times and seating which we feel provides better service, a personal relationship with the waitstaff and less stressful.
Tanya Palmer
July 24th, 2012 @ 5:38 pm
My only experience with flexible dining was in the small Blu dining room on the Celebrity Summit. It was FANTASTIC. Never a wait, aside from the one night we came just as the first round of diners were finishing up and waited for a window table, and truly fabulous service. Admittedly we bonded most with the maitre'd and wine steward but the bond WAS there.
Janet Hay
July 24th, 2012 @ 6:10 pm
We always do anytime dining, usually go around 8:15. Last cruise in April with Holland America we got a table for 2 every night and the same waiters most nights. We also like being off to the side as its not so busy and noisy.
Jo Williams
July 24th, 2012 @ 6:22 pm
Totally disagree. I prefer the anytime dining because I don't want to have to rush back from excursion to quickly get ready for dinner. If we are happy with our waiter on first night, we ask for him for rest of the cruise – never been a problem. We've always had excellent service & good location of tables. If you want something special or different table, just ask! Just finished my 13th cruise & doing 14 next April – love it & anytime dining!
July 24th, 2012 @ 6:42 pm
One of the main reasons that we sail NCL is that they know how to do anytime dining. We may not be hungry at the same time every evening, or our plans may change from minute to minute. After all, we are on vacation. Sometimes we have had large groups or just a table for two by the window, it's never a problem. When we had have to wait, we were given a pager and could go anywhere on the ship until our table was ready. Incidentally, we have never had to wait more than 15 or 20 minutes. As for the service, when we encounter exceptional service, we request that server every time and are always accommodated. We have tried anytime dining on Carnival and not only did we have to pay a premium but the service was substandard. Needless to say Freestyle is the way to go and NCL has gotten right.
July 24th, 2012 @ 7:06 pm
One of the best parts of the cruise for me is the dining experience. We always eat at 6pm and have met some lovely people at a mixer table. We have also had a small table just for our party. I love the way the waiters become one of the family.
And thanks to Tracy, I now know that the Maitre d' is good for something! We have never understood why anyone would think they deserve a tip!
Sherri Lorenz
July 24th, 2012 @ 7:23 pm
I have experienced my time dining on my last two cruises, I would say I had a good experience the first time on our trip to Alaska. However, in the Caribbean, if we didn't go early, we waited, sometimes up to an hour. We have a cruise booked in September and went back to assigned dining. If we don't like the timing, we will hit the buffet, we prefer to not have to wait though, and feel you do get more personal service with the same wait staff nightly. p.s. we did tip extra still to our wait staff, we left it with our waiter nightly. I feel strongly about how hard everyone works and won't let my convenience affect their tips from me.
July 24th, 2012 @ 8:10 pm
Having done fixed seating as well as flexible dining, I much preferred the flexible. I didn't have to worry about being there at a specific time, I didn't have to wait around for the show from the waiters, and dinner was more speedy. I was seated with the same waiter every night, even when we were not at the same time each night. We got the table size we wanted with no problem. We never had to wait more than a few minutes. I may try fixed dining again in the future, but maybe not.
Dan Bahr
July 24th, 2012 @ 9:04 pm
We have cruised a dozen times and always had the late seating until our last cruise on the Allure. My Time Dining was so good we will probably never go back to specific time seating. We never waited more than 5-10 minutes to get a table and we never felt like we were in Siberia. The wait staff was efficient and courteous and we had no problem getting a table for two.
July 24th, 2012 @ 9:10 pm
3 ncl cruises and one more booked Freestyle dinning is the only way for me. I'll eat when I want to and only with my family or friends. Who wants to go eat at the same time daily and take 1.5 hours or longer.. Not me NCL is my cruise line
Myriam Burgos
July 24th, 2012 @ 9:33 pm
We have had the same positive experience as Tracy with the anytime dining option. We usually dine between 7:00 – 8:00 p.m. and ask for a table for two. Usually after the first two nights we get to know some of the friendly waiters and then we ask to be seated in the tables they wait. We will keep asking for the anytime dining option whenever it is available.
July 24th, 2012 @ 10:55 pm
I agree with the above comment. We just asked for the same waiter every night and everyone was happy. Also, we didn't have a line, we were given a pager and came back when it went off.
July 24th, 2012 @ 11:28 pm
I agree. I'm split with any time and second sitting. I much prefer the second sitting, where I can simply walk into the dining room and head right for my table without having to wait to find out where I'll be. I like my servers getting to know me- that I like water with a lot of ice, that I like tea after my meal, etc. It's a much classier situation. On my last cruise, I did ask for a waiter we all liked. Sometimes we got him, others we didn't. I like that people can choose, however. There seem to be a lot here who like anytime dining. I don't.
July 24th, 2012 @ 11:33 pm
We had fixed seating on the Mariner and anytime dining on the Oasis. Had the same wait staff every night and never had to wait. I don't understand the problem.
July 24th, 2012 @ 11:34 pm
The young lady writing this article is greatly mistaken…..and very narrow in her thoughts. I have been on 10 different cruises, having both types of seating….I greatly prefer the system used by NCL…. Never had to wait for a table over 5 minutes, had the same waiter each night, (also sometime for breakfast), so, sorry…but I greatly disagree with her…
July 25th, 2012 @ 10:34 am
I have been on ships and I have done both. I prefer the scheduled dining. My reasoning, I can and will build a relationship with my waiter & I will tip. I really hate tipping for poor service; and poor service is what I feel i get when i participate in the "anytime" dining. I have never had to wait in a dining room line over 8 min. The line on the lido deck is ALWAYS longer than the dining room. As a chef, I love to cook, eat and have a great time while I'm out eating. I really HATE tipping for bad service (2nd time for emphasis). Furthermore I do not like the singing and dancing in the dining room, I think it cheapens the experience. I really do get ample entertainment on the ships; I should not be forced into more silly "entertainment" while I am eating (if you can call it entertainment).
July 25th, 2012 @ 11:32 am
We have been on more than two dozen cruises so far, and used both fixed and anytime dining. Hands down, we preferr anytime! We have never had a problem waiting more than a few minutes, wine from the last evening is always brought to us, waiters are just as accommodating as in fixed…as a matter of fact.. We were told by the maitre 'd that only the Best waiters are in anytime as they can handle it, and they are happier there as they already got tips in advance and never get stiffed! We have had future menus brought to us to check over, and received special requests not on the menu- causing envy from neighboring tables. BTW…we only ask for tables for two and it is NEVER a problem on any ship or cruise we use.
July 25th, 2012 @ 11:44 am
I always enjopyed getting a table for eight or ten and meeting a bunch of new people every night or staying with the same crowd for the entire cruise. Too often with Freestyle dining we wind up at a side table for two and a new waiter every time. When they're not "required" to be personable, they are often very businesslike and I might as well be at Denny's. I'm all for assigned seating and a late dinner.
July 25th, 2012 @ 12:14 pm
Only drawback I found on Princess was that if you sign up for traditional dining, you can't opt for anytime dining in other restaurants unless you are invited by other passengers who are doing anytime.
July 25th, 2012 @ 1:40 pm
I have had good experiences with set time dining (always with shipmates our age and never at to large of a table) until we cruised on a "mega" ship. We were placed with a family who acted like we weren't even there. Could be because we were used to fill the last two seats at the table. We excused ourselves before dessert on the first night and were switched to my time dining. Since most of the ships seem to be going to the large tables I will not take my chances and choose my time dining. Eat with who ever I feel like that night.
July 25th, 2012 @ 2:50 pm
My BFF/TA(she's a CLIA certified Master Class Cruise Specialist) and I have been cruising for 15 years. We had always done assigned dining and liked it. In December 2010 she got an offer from her NCL district manager to take a cruise on the Jewel. We had been on a variety of ships but not NCL. She had a group sailing on NCL for the first time so she decided we should go so she could give her group advice on what to expect. WE HATED IT.
Our first night in the dining room was so bad we didn't go back there the rest of the cruise. It was so noisy in there that we couldn't hear each other talking and we were sitting by each other. It was like we were in a Cracker Barrel on a busy Sunday. We could barely hear our waiter. Speaking of the waiter he came to our table twice. Nobody came to refill our ice tea glasses. We had to grab someone going by if we needed something. When my husband and I and my BFF cruise we enjoy eating with the same wait staff. We like the fact that you can talk to your tablemates without yelling. I'm disabled and on every cruise, but the NCL one, the wait staff asked what I needed to make my meal enjoyable and I never had to ask for anything after that. They were always there offering their assistance. We appreciated that. After our NCL dining room fiasco we ate at the buffet and their 24 hour cafe. Their food was very good but the atmosphere was crappy. We could have eaten in one of the pay restaraunts but we shouldn't have to do that to get a peaceful meal. We would only do it if it's a special occasion.
We have had great cruises made special by the wait staff in the dining rooms and our tablemates. If we are tired from activities in port or we get back late we go to the buffets. We will never do freestyle dining.
July 25th, 2012 @ 4:02 pm
Have done both. find anytime on NCL is fine but anytime on Princess is utter chaos not in the dining room but at the theater. Mass choas at shows, even arriving 30 minutes prior sometimes diffciclut to get a seat. Either traditional or anytime would be great but both is awful.
July 25th, 2012 @ 4:24 pm
We've done My Time Dining on 4 cruises now, all of them long (10-18 nights), all of Royal Caribbean. We love the flexibility and have not had the problems Sue experienced. As someone mentioned, maybe the trick is to immediately get to know the dining host and/or the head waiter – call them by name, smile, say please and thank you, and make sure they know your name. We've never waited more than 10 minutes for a table, and those waits were only because we requested a specific server's section. We've had the same servers for entire cruises, and they've been very efficient and friendly and quickly learned what we like, just as the servers in fixed dining did. And, yes, they did get extra tips at the end of the cruise. We've had tables for 2 when we wanted them, larger tables when we requested them. Absolutely no down side for us – will never go back to fixed.
July 25th, 2012 @ 4:27 pm
Does any one know of passengers going on the Diamond Princess to China, Japan and Russia in September 2012? If so, have you selected shore excursions on your own or with P/O?
July 25th, 2012 @ 4:50 pm
We thoroughly enjoy flexible dining times so we don't have to be on a schedule. We have no desire for a table for two because we want to meet and mingle with fellow passengers. We've never had a problem getting a sharing table and most of the time can get the same waiter if requested. Service is usually quite good. We hope never to have to return to the structured seating. Late dinner is way too late for us and early seating is a bit early. So flexibility allows us to meet our needs around 7 and the schedule from our trips, naps, and activities without rushing.
July 25th, 2012 @ 4:55 pm
We've had anytime dining on 13 out of 14 cruises. Obviously enjoy the former. We have always found on three different cruise lines that we could get a table for two with no waiting and have usually been able to request the same table and staff for the entire cruise. We tend to prefer to eat early so maybe that helps. Should we have a reservation for a specialty restaurant, we always let the staff know the night before so they don't hold the table, but it is always waiting when we return to the main dining room.
July 25th, 2012 @ 6:11 pm
My experience has been quite different from the author's.
I have been on numerous cruises with anytime dining, including on Carnival, NCL, Princess, and RCCL. I have never had any difficulty whatsoever getting a table for two. I have never had to wait more than 15 minutes for a table, and we have eaten at all times from very early to very late. While it is true that the waiters do not know my personal desires, but service has always been at least acceptable, and generally excellent, on the whole equal to the service we had back with assigned dining. Being courteous to and appreciative of the staff seems to generally work wonders — life is a mirror, although somewhat distorted on occasion :-) .
I would never go back to assigned dining. And no, I have never greased the palm of the Maitre'd in advance (although I always give an envelope to especially helpful staff at the end of the cruise).
July 25th, 2012 @ 9:38 pm
I am for "take it away"…… having done anytime dining only once because it was all that was left since we booked our cruise last minute. While we didn't have to wait long most nights, we were ALWAYS asked if we would sit at a larger table (the wait was much longer for a smaller table). We are of the old school who enjoy getting to know our table mates throughout the week and discussing our day. We found that in anytime dining the tables were not seated in any particular order which resulted in people being seated all during our meal at the adjoining tables. Too much moving around. My waiter did not know what kind of roll I liked, or that I wanted my iced tea and then a glass of wine (only red) and there was no rapport. One night, after our table of 6 was fully seated (they don't start serving until it is) 2 of the people took one look at the menu and left…… leaving our waiter waiting for 2 more people …… finally we demanded to be served. Another night we said we did not mind being seated at a large table and were seated at a 10 top. They then proceeded to seat all the tables around us leaving us alone at a 10 top….. we felt the kids that nobody wanted to sit with in the lunchroom …… that is my experience and I didn't like it !
July 25th, 2012 @ 10:23 pm
We usually do anytime dining because the standard times are too early and too late. So we go at 7 or so and it works perfect for us. We usually agree to hare and it is a good way to meet other passengers. Some nights great, some nights….. Glad it was just for one night. On Princess,usually there are specific anytime dining rooms ( as in more than one) so no feeling of being an outcast.
July 26th, 2012 @ 3:47 am
Not sure what cruise lines the author sailed with to have those negative experiences with flexible dining. I have never had a problem getting a table for two, have always had good service and, often, exemplary service. I love flex dining. If I were forced to take set seating, I would likely go to another cruise line. The need to tailor my entire evening around a set dining time strikes me as stressful in terms of fitting in shows I want to see or whether or not I just feel like lounging around longer before diner or eating earlier because I want to make it a short night. I tend to agree with an earlier blogger who said that NCL knows how to do flexible dining best. Afterall, they invented it. On RCCL, they did relegate the My Time Diners to the top tier of the main dining room which was the least desirable location. This is the key reason I would likely not sail with RCCL again.
July 26th, 2012 @ 11:35 am
We have been on several cruises and have always done assigned dining. The most recent was in February this year on the Grand Princess where we tried Anytime dining. We always had a table for 2, same wai staff and never waited over 15 minutes. We will definately do Anytime again.
cindy Paulos
July 29th, 2012 @ 2:39 pm
The Aqua Class on Celebrity has really addressed this issue.
The Dining provided by Blu is the finest you could find. Anytime dining, personal service, perfect setting to relax and meet new friends.
I'm a Vegetarian, and I was concerned about the choices I might have.
But with the Blu restaurant everything was fresh, and delicious
with a HUGE selection of different delectable meals.
If you are looking for a great choice for intimate dining
Blu on Celebrity is it.
George Cossey
July 31st, 2012 @ 12:41 am
We normally cruise on Princess and go with the Anytime Dining. My wife has allergy issues and we make the wait staff aware of them the first night. Thereafter, we almost always get the same table and wait staff and the menu for the following night so my wife can ensure that the food will not trigger a reaction.
Charisse Scully
July 31st, 2012 @ 4:12 pm
We absolutely love Any-Time Dining offered on Princess. I think the other cruise lines should take lessons from them, they have it down to a science. In all honesty, we love sitting with strangers. I love my hubby but I get to talk to him all the time. It's nice to meet new people. Several times we've had to tell them we do NOT want a table for only two.
July 31st, 2012 @ 5:35 pm
I like assigned seating. I enjoy getting to know my tablemates and hearing the day's adventures at dinner. I also like having the same waiters every night. I would NEVER do "anytime dinner."
P&O Cruises Australia
August 1st, 2012 @ 1:09 am
We operate an hybrid of the anytime time/fixed time dining. We have a reservation style in place where passengers are able to reserve a time that suits them for dining. If so inclined, they are also able to reserve the same table (and wait staff that comes with that table). We find this is the best way to ensure our passengers have the flexibility to make their cruise holiday their own!
August 15th, 2012 @ 5:46 pm
Having experienced booked sittings and anytime dining we have to say from personal experience that it is anytime dining for us.
Early sitting is too early, it means rushing back from excursions and racing to get ready for dinner.
We have had to put up with overbearing bores and know it alls, people who continually turn up late making everyone wait. Even a couple who spent the whole cruise refusing to speak to fellow diners, not even saying hello.
The late sittings are way too late for us.
7pm is an ideal time for us to eat, anytime dining gives us that flexibility. I have already made my 7pm reservations for my next two cruises.
We like to think that we are friendly we enjoy meeting different people every night and rarely request a table for two. As for waiters we find that there is a pool of waiters who serve anytime only and got to know several of them.
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Koletzko, Sibylle*; Jones, Nicola L.†; Goodman, Karen J.‡; Gold, Benjamin§; Rowland, Marion||; Cadranel, Samy¶; Chong, Sonny#; Colletti, Richard B.**; Casswall, Thomas††; Elitsur, Yoram‡‡; Guarner, Jeannette§§; Kalach, Nicolas||||; Madrazo, Armando¶¶; Megraud, Francis##; Oderda, Giuseppina***; on Behalf of the H pylori Working Groups of ESPGHAN and NASPGHAN
*Dr von Haunersches Kinderspital, Ludwig-Maximilians-University of Munich, Munich, Germany
†Division of Gastroenterology, Hepatology, and Nutrition, SickKids Hospital, University of Toronto, Toronto
‡Department of Medicine, University of Alberta, Edmonton, Canada
§Children's Center for Digestive Healthcare, Atlanta, GA
||Children's Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Ireland
¶Queen Fabiola Children's Hospital, Brussels, Belgium
#Queen Mary's Hospital for Children, Carshalton, Surrey, UK
**Department of Pediatrics, University of Vermont, Burlington, VT
††Division of Paediatrics, Karolinska University Hospital, Stockholm, Sweden
‡‡Department of Pediatrics, Marshall University, Huntington, WV
§§Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
||||St Antoine Pediatric Clinic, Faculté Libre de Médecine, Lille, France
¶¶Hospital de Pediatria, Centro Medico Nacional Siglo XXI, Mexico City, Mexico
##Laboratoire de Bactériologie, Hôpital Pellegrin, Bordeaux, France
***Scienze Mediche, Clinica Pediatrica, Universita degli Studi di Novara, Novarra, Italy.
Address correspondence and reprint requests to Prof Dr Sibylle Koletzko, MD, Dr von Haunersches Kinderspital, Ludwig-Maximilians-University of Munich, Lindwurmstraße 4, D-80337 Munich, Germany (e-mail: email@example.com).
Received 28 March, 2011
Accepted 29 March, 2011
The authors report no conflicts of interest other than those reported on the ESPGHAN and NASPGHAN Web sites.
Sibylle Koletzko and Nicola Jones contributed equally to this article.
Objective: As the clinical implications of Helicobacter pylori infection in children and adolescents continue to evolve, ESPGHAN and NASPGHAN jointly renewed clinical guidelines using a standardized evidence-based approach to develop updated recommendations for children and adolescents in North America and Europe.
Methods: An international panel of 11 pediatric gastroenterologists, 2 epidemiologists, 1 microbiologist, and 1 pathologist was selected by societies that developed evidence-based guidelines based on the Delphi process with anonymous voting in a final face-to-face meeting. A systematic literature search was performed on 8 databases of relevance including publications from January 2000 to December 2009. After excluding nonrelevant publications, tables of evidence were constructed for different focus areas according to the Oxford classification. Statements and recommendations were formulated in the following areas: whom to test, how to test, whom to treat, and how to treat. Grades of evidence were assigned to each recommendation based on the GRADE system.
Results: A total of 2290 publications were identified, from which 738 were finally reviewed. A total of 21 recommendations were generated, and an algorithm was proposed by the joint committee providing evidence-based guidelines on the diagnostic workup and treatment of children with H pylori infection.
Conclusions: These clinical practice guidelines represent updated, best-available evidence and are meant for children and adolescents living in Europe and North America, but they may not apply to those living on other continents, particularly in developing countries with a high H pylori infection rate and limited health care resources.
The current recommendations for managing Helicobacter pylori infection in children are as follows:
1. The primary goal of clinical investigation of gastrointestinal symptoms is to determine the underlying cause of the symptoms and not solely the presence of H pylori infection.
2. Diagnostic testing for H pylori infection is not recommended in children with functional abdominal pain.
3. In children with first-degree relatives with gastric cancer, testing for H pylori may be considered.
4. In children with refractory iron-deficiency anemia, in which other causes have been ruled out, testing for H pylori infection may be considered.
5. There is insufficient evidence that H pylori infection is causally related to otitis media, upper respiratory tract infections, periodontal disease, food allergy, sudden infant death syndrome (SIDS), idiopathic thrombocytopenic purpura, and short stature.
6. For the diagnosis of H pylori infection during esophagogastroduodenoscopy (EGD), it is recommended that gastric biopsies (antrum and corpus) for histopathology be obtained.
7. It is recommended that the initial diagnosis of H pylori infection be based on either a positive histopathology plus a positive rapid urease test or a positive culture.
8. The 13C-urea breath test (UBT) is a reliable noninvasive test to determine whether H pylori has been eradicated.
9. A validated enzyme-linked immunosorbent assay (ELISA) test for detection of H pylori antigen in stool is a reliable noninvasive test to determine whether H pylori has been eradicated.
10. Tests based on the detection of antibodies (IgG, IgA) against H pylori in serum, whole blood, urine, and saliva are not reliable for use in the clinical setting.
11. It is recommended that clinicians wait at least 2 weeks after stopping proton pump inhibitor (PPI) therapy and 4 weeks after stopping antibiotics to perform biopsy-based and noninvasive tests (UBT, stool test) for H pylori.
12. In the presence of H pylori–positive peptic ulcer disease (PUD), eradication of the organism is recommended.
13. When H pylori infection is detected by biopsy-based methods in the absence of PUD, H pylori treatment may be considered.
14. A "test and treat" strategy is not recommended in children.
15. In children who are infected with H pylori and whose first-degree relative has gastric cancer, treatment may be offered.
16. Surveillance of antibiotic resistance rates of H pylori strains in children and adolescents is recommended in the different countries and geographic areas.
17. First-line eradication regimens are the following: triple therapy with a PPI + amoxicillin + clarithromyin or an imidazole or bismuth salts + amoxicillin + an imidazole or sequential therapy.
18. Antibiotic susceptibility testing for clarithromycin is recommended before initial clarithromycin-based triple therapy in areas/populations with a known high resistance rate (>20%) of H pylori to clarithromycin (Fig. 1).
19. It is recommended that the duration of triple therapy be 7 to 14 days. Costs, compliance, and adverse effects should be taken into account.
20. A reliable noninvasive test for eradication is recommended at least 4 to 8 weeks following completion of therapy.
21. If treatment has failed, 3 options are recommended: EGD, with culture and susceptibility testing including alternative antibiotics, if not performed before guide therapy; fluorescence in situ hybridization (FISH) on previous paraffin-embedded biopsies if clarithromycin susceptibility testing has not been performed before guide therapy; modification of therapy by adding an antibiotic, using different antibiotics, adding bismuth, and/or increasing the dose and/or duration of therapy.
Children differ from adults with respect to H pylori infection in terms of the prevalence of the infection, the complication rate, the near-absence of gastric malignancies, age-specific problems with diagnostic tests and drugs, and a higher rate of antibiotic resistance. Compared with adults, PUD is found less often in infected children undergoing upper endoscopy. In a large European multicenter study including 1233 symptomatic children with H pylori infection, PUD was diagnosed in <5% of children younger than 12 years of age and ∼10% of teenagers (1). Gastric malignancies associated with H pylori infection typically occur in adulthood, with only a few case reports of lymphomas in the pediatric age group (2,3). The differential diagnosis for abdominal pain and dyspeptic symptoms is different. Children are often unable to provide precise descriptions of the location and the character of the pain (4,5). Some disorders such as idiopathic thrombocytopenic purpura, which have been associated with H pylori infection in adults, do not show a relation in children, probably because of a different pathogenesis in the pediatric population. The level of evidence for most disease outcomes is lower. Few randomized placebo-controlled treatment trials are available for the different outcomes, often with only small numbers of cases included (6,7). These and other differences explain why some of the recommendations for adults (8) may not apply in children.
H pylori infection is usually acquired during the first years of life in both developing and industrialized countries (9,10). In Europe and North America, the epidemiology of H pylori infection in children has changed in recent decades. Low incidence rates are found in the northern and western European countries, resulting in prevalence far below 10% in children and adolescents. In contrast, the infection is still common in certain geographic areas such as southern or eastern Europe, Mexico, and certain immigrant populations from South America, Africa, and most Asian countries, and aboriginal people in North America (11–13). The different prevalence of infection and the corresponding effect on health care resources in industrialized compared with developing countries require different recommendations with respect to testing and treating children. These guidelines apply only to children living in Europe and North America, but not to those living in other continents, particularly in developing countries with a high H pylori infection rate in children and adolescents and with limited resources for health care. The guidelines may need to be adapted to national health care systems because certain tests or treatment regimens may not be available and/or reimbursed by health insurance programs.
In 2000, the Pediatric Task Force of the H pylori Study Group of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) published consensus statements on H pylori infection in children (14). Shortly thereafter, a working group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published a Medical Position Paper on the same topic, including recommendations for treatment (15). In 2004, the Canadian Helicobacter Study Group initiated a consensus conference including patients from Canada, the United States, and Europe. Recommendations covered how to approach H pylori infection in children (6). In 2005, ESPGHAN and NASPGHAN decided independently to renew their guidelines, this time with a joint evidence-based methodology. The councils of both societies decided in 2006 that the process should be combined to have the same recommendations for North America and Europe.
The following 4 areas were identified and covered by 4 subgroups, which formulated the critical questions for each area:
1. Who should be tested? (differentiating among screening, surveillance, and clinically based testing)
2. What tests should be used?
3. Who should be treated?
4. What treatment regimens are most appropriate?
Each society assigned 1 chair (Benjamin Gold for NASPGHAN and Sibylle Koletzko for ESPGHAN). At least 2 members from each society were assigned to the subgroups for the 4 areas of interest. Members were mostly pediatric gastroenterologists, but experts in epidemiology, microbiology, and pathology were also selected based on their peer-reviewed publications, research activities in the field, and participation in national or international activities. The European patients were recruited from the Pediatric Task Force on H pylori Infection (ESPGHAN Working Group on H pylori) and also included a representative from the European Helicobacter Study Group (Francis Mégraud).
A systematic literature search was designed by Karen Goodman, an epidemiologist, using accessible databases of relevance: PubMed, MEDLINE, EMBASE, Cochrane Library, Biosis Previews, EBM Reviews, ISI Web of Science, and Scopus. The search included publications from 2000 to August 2007. The search included publications of all types presenting or reviewing data on H pylori in patients younger than 20 years old, selecting on Medical Subjects Headings (MeSH) terms as listed below, with no language restrictions:
Search Strategy
The search identified 1979 unique publications and an additional 63 publications were generated from the citations of relevant reviews. Of these 2042 papers, the following were excluded: 800 that did not present evidence on relevant topics; 635 that did not present evidence for pediatric groups; 40 letters, commentaries, or case reports; 33 abstracts; 25 non–English-language publications that did not present relevant data in an English-language abstract; and 19 nonsystematic reviews. The total number of selected papers was 490, including 80 reviews. The papers were grouped according to the review focus areas. Summaries of review papers were prepared and tables were constructed to organize key data regarding study, quality, and findings from the original research reports.
In addition, within each subgroup, the members were asked to search the literature with respect to their topics to add evidence that may have been missed by the search criteria. In particular, this increased inclusion of publications from less widely circulated journals and from non–English-language sources. Grading of the quality of evidence was performed by epidemiologists and individual group members, according to the classification system of the Oxford Centre for Evidence-Based Medicine (http://www.cebm.net/index.asp), because this is the only grading system in which studies of diagnostic tests can be scored accordingly. The lists of rated articles and synthesis tables were circulated to the subgroups, and the information was expanded or revised upon closer inspection as appropriate.
In preparation for a meeting in December 2007 in Munich, Germany, each subgroup had formulated the statements circulated to each member of the subgroups. In addition, the European members of the 4 subgroups presented the statements during the annual meeting of the ESPGHAN Pediatric Task Force in October 2007 in Istanbul, Turkey, where they were extensively discussed and adapted according to the comments of the attendees.
At the meeting in Munich, the group voted on 2 iterations of each of the consensus statements. Statements were revised based on feedback provided from the patients and further critical review of the available literature. Some of the statements were deleted by voting and the content of these was condensed into comments pertaining to relevant statements that remained. Additional statements were added on matters that had not been addressed previously.
All of the votes were anonymous. A 6-point scale was used: 1, agree strongly (A+); 2, agree moderately (A); 3, just agree (A–); 4, just disagree (D–); 5, disagree moderately (D); and 6, disagree strongly (D+). Agreement with the statement (the sum of voting for A+, A, or A–) by three-quarters (ie, ≥75%) of the voting members was defined a priori as consensus. The level of agreement in the final vote is provided for each statement, expressed as a percentage.
Grades of evidence for each statement were based on the grading of the literature and were finally assigned using the GRADE system of 2004 (16) as follows:
1. High: further research is unlikely to change our confidence in the estimate of effect.
2. Moderate: further research is likely to have an important influence on our confidence in the estimate of effect and may change the estimate.
3. Low: further research is very likely to have an important influence on our confidence in the estimate of effect and may change the estimate.
4. Very low: any estimate of effect is uncertain.
The designation "not applicable" was used for situations in which these grades of evidence were not relevant for a particular statement.
The Munich meeting was organized by Sibylle Koletzko and supported financially by NASPGHAN and ESPGHAN. There was no financial support from industry. Seven North American members (4 from the United States, 2 from Canada, 1 from Mexico) and 8 European members attended the final meeting. One attendee, who was not eligible to vote, observed and documented the voting process, which was later compared with the recorded electronic voting slides. The statements were presented at the World Congress of Pediatric Gastroenterology in Iguassu Falls, Brazil, on August 19, 2008 to the scientific community and feedback was requested. The first-draft manuscript was prepared by the chair of the European group, Sibylle Koletzko, in collaboration with Nicola Jones of the North American group, and the 2 epidemiologists Karen Goodman and Marion Rowland. Because of a change in the NASPGHAN chair, the manuscript was on hold for 18 months. In December 2009, an updated systematic literature search was performed including articles published from September 2007 to 2009. A total of 248 new publications were retrieved and reviewed for new evidence, which may have influence on the recommendations, the evidence, or the strength of recommendations compared with the version presented in August 2008 at the World Congress. The new literature was implemented in the final draft, which then was circulated to all members of the consensus group and their input was worked into the manuscript.
For the first round of voting, 43 statements were presented and agreement was reached for 22 of them. Several statements were omitted, some combined into 1, and others reworded after discussion. There were 21 statements in the final round of voting, and consensus was reached for all of them. The result of the final voting is provided for every statement.
Recommendation 1 The primary goal of clinical investigation of gastrointestinal symptoms is to determine the underlying cause of the symptoms and not solely the presence of H pylori infection.
Agree: 100% (A+ 92%, A 8%). Grade of evidence: not applicable.
Recommendation 2 Diagnostic testing for H pylori infection is not recommended in children with functional abdominal pain.
Agree: 92% (A+ 54%, A 23%, A− 15%, D− 8%). Grade of evidence: high.
Comment on Recommendations 1 and 2:
Abdominal complaints such as pain, nausea, or other dyspeptic symptoms are nonspecific and can be caused by different organic diseases within and outside the digestive tract. These diseases may be missed or their diagnosis and treatment delayed, if a noninvasive test for H pylori infection is positive and treatment initiated. For example, Levine et al (17) performed endoscopy in children with epigastric pain and symptoms suggestive of gastroesophageal reflux disease. After treatment, improvement of epigastric pain correlated with improvement of reflux disease, but was not related to H pylori eradication. Abdominal complaints may also be part of a functional gastrointestinal disorder (18). Children younger than 8 years old, or even as old as 12 years, may not be able to provide accurate descriptions of the degree, character, and location of pain (4). Whether H pylori gastritis causes abdominal pain in the absence of PUD is still debatable. Several studies from the 1990s applied different noninvasive tests for H pylori infection and compared the prevalence of positive results in children with recurrent abdominal pain and controls and found no significant difference in infection rates between cases and controls (19,20). A meta-analysis of 45 studies concluded that H pylori infection is not associated with abdominal pain (21). Epidemiological studies on the prevalence of chronic or recurrent abdominal pain in pediatric age groups in different European countries yielded estimated frequencies ranging from 0.3% to 19%; however, the frequencies in different countries were not related to the background of H pylori prevalence in the respective countries (4). More recent case-control studies confirmed the lack of evidence for a causal relation between H pylori infection and abdominal pain. In a study of 1221 children from Germany, Bode et al (22) identified in a multivariable logistic regression analysis that social and familial factors (single-parent household, family history of PUD, or functional pain) were significantly associated with abdominal pain, but not with the H pylori status of the child, as assessed by the 13C-UBT. Tindberg et al (23) reported no significant association of recurrent abdominal pain with H pylori infection in 695 schoolchildren between 10 and 12 years old. In fact, an inverse relation was noted for H pylori positivity and the occurrence of any abdominal pain after adjustment for selected possible confounders (odds ratio [OR] 0.5; 95% confidence interval [CI] 0.3–0.8).
Several uncontrolled intervention studies showed improvement of symptoms after treatment; however, in some of the studies, treatment success was not monitored and eradication of the bacteria was assumed in cases with symptomatic improvement (12,24–26). Other studies had a short follow-up period of a few weeks only (27). These uncontrolled intervention studies provide weak evidence of a causal relation between H pylori infection and abdominal pain, particularly because functional abdominal pain resolves in 30% to 70% of patients by 2 to 8 weeks after diagnosis accompanied by reassurance of the child and the parents (28,29).
Only 1 double-blind randomized placebo-controlled trial was performed in a population of symptomatic children with H pylori infection, excluding cases of PUD (30). In this small trial with 20 children studied for 12 months, a relation between symptom relief and H pylori eradication or histological healing was not observed.
In summary, at present, there is inadequate evidence supporting a causal relation between H pylori gastritis and abdominal symptoms in the absence of ulcer disease. Therefore, cases of abdominal pain consistent with the diagnostic criteria of functional pain (18) should not be investigated for H pylori, unless upper endoscopy is performed during the diagnostic workup in search for organic disease.
Recommendation 3 In children with first-degree relatives with gastric cancer, testing for H pylori may be considered.
Agree: 93% (A+ 29%, A 50%, A− 14%, D 7%). Grade of evidence: low.
Comment on Recommendation 3:
A causal relation between H pylori infection and the risk of gastric malignancies, including cancer and gastric marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type, has been shown in animal models and is supported by several epidemiological and intervention studies (31–34). Both of these cancer types are extremely rare during the first 2 decades of life. Although H pylori–associated gastric cancer has not been reported in children, MALT lymphomas have been described in a few H pylori–infected pediatric patients (2,3).
In 1994, the World Health Organization declared H pylori a class I carcinogen. A meta-analysis estimated that the risk for gastric cancer is increased by a factor of 2 to 3 in H pylori–infected individuals. The risk is further increased if only noncardia carcinomas are considered; however, the risk of gastric cancer not only depends on the infection itself but also is strongly modified by the presence of bacterial virulence factors (35) and other factors such as the genetic makeup of the host and environmental influences, including diet (36). The eradication of H pylori may have the potential to decrease the risk of gastric cancer (37–39). In a large interventional trial in adults, subgroup analysis suggested that eradication may be beneficial in people without precancerous lesions (39). The time point for an effective intervention, and therefore screening strategy, however, is not yet clear (40). In previous studies of patients younger than 45 years old with gastric cancer, H pylori had been identified as a risk factor (41).
Individuals with a positive family history for gastric cancer are considered a high-risk group. The risk may be particularly high in H pylori–infected children in whom the father or the mother is affected by gastric cancer. This child not only shares genetic and environmental factors with the affected parent but may also have the same bacterial strain with pathogenic properties (42,43). Therefore, the risk of gastric cancer may be much higher for individual children with such histories than what has been estimated from epidemiological studies that lack information on relevant factors.
Although there is little evidence that addresses whether this approach is beneficial, there was strong agreement within the panel that testing for H pylori infection be considered in children with a first-degree relative with gastric cancer. There was also agreement that if H pylori infection is confirmed in these children either with a reliable noninvasive test or with biopsy-based methods, treatment should be offered and the success of therapy evaluated to ensure successful eradication.
Approximately 70% of gastric MALT lymphomas can be successfully treated with H pylori eradication. In the rare cases of H pylori–infected children with established MALT lymphoma, eradication therapy needs to be performed regardless of the staging of the lymphoma. The translocation t(11;18)(q21;q21) characteristic of MALT lymphoma is recognized to be a marker of H pylori independence, but this marker is found in only half of the MALT lymphomas that are resistant to H pylori eradication (44). In patients with the translocation t(11;18)(q21;q21), conventional chemotherapy can be considered in addition to eradication of H pylori.
Screening for H pylori infection in the general population is not recommended. In populations with a high prevalence of H pylori infection, the benefit of screening can be assessed by considering the risk of H pylori–associated gastric cancer in particular populations, along with the health care priorities of those populations. In populations with a high incidence of gastric cancer and in which gastric cancer–screening programs are in place, children can be included in screening programs for H pylori infection, and close surveillance in those who develop atrophy or intestinal metaplasia is indicated.
Recommendation 4 In children with refractory iron-deficiency anemia in which other causes have been ruled out, testing for H pylori infection may be considered.
Agree: 100% (A+ 36%, A 36%, A− 28%). Grade of evidence: low.
Comment on Recommendation 4:
Iron-deficiency anemia in children and adolescents may have different causes. If noninvasive diagnostic tests are not able to find the cause and/or if the iron deficiency is refractory to oral iron therapy, then diagnostic upper endoscopy is indicated. In these situations, mucosal biopsies are taken to rule out pathologic conditions such as celiac disease. In addition, gastric biopsies are taken for evaluation of H pylori by histology and culture because H pylori infection may be the cause of iron-deficiency anemia, even in the absence of erosions or ulceration (45,46) or gastrointestinal symptoms (47).
Several studies have shown an association between low iron status and H pylori infection (48–50). Because both H pylori infection and iron deficiency are associated with poor socioeconomic and hygienic conditions, and cross-sectional studies cannot determine whether the purported cause preceded the effect, only randomized intervention studies can provide strong evidence of a causal relation. The first randomized placebo-controlled study included only 22 H pylori–infected pediatric patients randomized into 3 treatment arms: iron only, eradication therapy only, or both (48). Eradication therapy increased hemoglobin levels even without iron substitution, whereas iron therapy alone did not. In a study of 140 children between 6 and 16 years old from Turkey, it was reported that eradication therapy in the absence of iron supplementation was sufficient to improve iron deficiency and anemia (49); however, this beneficial effect of H pylori therapy on iron status could not be confirmed in recent intervention trials in children living in Alaska and Bangladesh (50,50a). Further placebo-controlled studies are needed to show whether H pylori infection can cause iron deficiency even in the absence of mucosal breaks because low iron status can have harmful effects on both mental and physical development.
Recommendation 5 There is insufficient evidence that H pylori infection is causally related to otitis media, upper respiratory tract infections, periodontal disease, food allergy, SIDS, idiopathic thrombocytopenic purpura, and short stature.
Agree: 100% (A+ 36%, A 28%, A−, 36%). Grade of evidence: low.
Comment on Recommendation 5:
A wide variety of extraintestinal manifestations are suggested to be associated with H pylori infection; however, current evidence for a causal relation for these associations in children is not compelling (51–62).
Numerous tests that detect H pylori are available. They are divided into noninvasive and invasive tests. Invasive tests require gastric tissue for detecting the organism and include culture, rapid urease test, histopathology, polymerase chain reaction, and FISH. (63). Noninvasive tests include different methods for the detection of H pylori antigens in stool, detection of antibodies against H pylori in serum, urine, and oral samples, and the 13C-UBT. The sensitivities and specificities obtained in different pediatric studies have been reviewed by the 4 members of the guideline subgroup and recently published (63).
All diagnostic tests are generally feasible in children; however, tests requiring patient cooperation, such as the UBT, are more difficult to perform in infants, toddlers, or physically challenged children. A crucial question for all tests performed in a pediatric population is whether the accuracy of the applied method is influenced by the age of the tested child. It is necessary to consider different age groups: infants, toddlers, preschool-age and school-age children, and adolescents (64). Most of the validation studies in children included only a few H pylori–infected infants and toddlers. Therefore, the information with respect to sensitivity is limited in these age groups.
It is necessary to compare a test to a reference standard; however, no single test for detection of H pylori infection can be used as a fully reliable reference method. Culture is the only method that is considered to be 100% specific, a positive culture being sufficient to prove H pylori infection, but its sensitivity is lower (65,66). For that reason, concordant results of at least 2 tests are needed to define the H pylori infection status. For noninvasive tests, biopsy-based tests should be the reference. If culture was not successful or not performed, concordant positive results for histology and rapid urease test indicate a positive H pylori status. The definition of a negative H pylori status is that all of 2 or 3 invasive tests performed are negative. For the validation of an invasive test, such as histopathology, other biopsy-based tests, with or without the combination of reliable noninvasive tests, should be the reference. All of the tests are suitable for the detection of infection before and after treatment, with the exception of serology, which may remain positive for some time after successful eradication.
For the interpretation of test results, factors that can lead to false-positive or false-negative results must be known and considered. Antibiotics, including penicillin and cephalosporines, and acid-suppressive drugs, particularly PPIs, should be discontinued before testing for at least 4 and 2 weeks, respectively. This recommendation is extrapolated from adult studies (67–69).
Recommendation 6 For the diagnosis of H pylori infection during EGD, it is recommended that gastric biopsies (antrum and corpus) for histopathology are obtained.
Agree: 93% (A+ 33%, A 40%, A− 20%, D− 7%). Grade of evidence: moderate.
Recommendation 7 It is recommended that the initial diagnosis of H pylori infection be based on either positive histopathology + positive rapid urease test or a positive culture.
Agree: 100% (A+ 36%, A 50%, A− 14%). Grade of evidence: moderate.
Comment on Recommendations 6 and 7:
For histology, 2 biopsies should be obtained from both the antrum and the corpus, and the findings should be reported according to the updated Sydney classification (70). Because the density of H pylori may be patchy, the sensitivity increases with the number of biopsies taken. Normally, the highest bacterial count is found in the antrum; however, in cases of low gastric acidity, the bacteria may be present only in the corpus. In a small single-center study of children undergoing endoscopy for symptoms of acid peptic disease in Italy, in 22 children in whom H pylori infection was identified, biopsies of the cardia were more sensitive for the detection of H pylori than biopsies of the antrum or corpus (71); however, these findings need to be confirmed in additional centers. Special staining (Giemsa or silver stain) and immunohistochemistry may improve the detection of H pylori. Biopsies should be stained with hematoxylin and eosin for histopathology because this is the best method to detect atrophy and intestinal metaplasia. Atrophy can be assessed only in biopsy material that is oriented correctly, and diagnostic concordance between pathologists can be difficult to achieve. Histopathology also allows the recognition of the rare Helicobacter heilmannii infection (72).
In children with suspected H pylori infection, it is highly recommended to take not only biopsies for histopathology but also 1 biopsy each for a rapid urease test and, if available, culture. The suspicion of an infection is often based on the macroscopic findings of a nodular mucosa in the antrum or bulbus and/or gastric or duodenal erosions or ulcerations. The rationale for the recommendation to perform more than 1 diagnostic test is based on the sensitivity results of invasive tests, which range from 66% to 100% for histology and from 75% to 100% for rapid urease tests in published series from children (63). With decreasing prevalence of the infection in pediatric populations in many areas of Europe and North America, the predictive values of the diagnostic test results fall. For example, a test with a sensitivity of 90% has a positive predictive value of only 50%, if the prevalence of the infection in the population is 10%. Therefore, concordant positive results on 2 different tests are recommended to confirm the diagnosis and justify the costs and adverse effects of treatment. If the results of histology and rapid urease test are discordant, then a noninvasive test (UBT or stool test) should be applied. One exception from the rule of 2 concordant test results is a positive culture, which is 100% specific and therefore in itself sufficient to diagnose H pylori infection. Another exception is the presence of a bleeding peptic ulcer, in which case 1 positive biopsy-based test is considered to be sufficient to initiate anti-H pylori therapy. A recent meta-analysis on the accuracy of diagnostic tests in adults with PUD clearly indicated that active bleeding decreases the sensitivity of invasive diagnostic tests, but the specificity is high (73).
Recommendation 8 The13C-UBT is a reliable noninvasive test to determine whether H pylori has been eradicated.
Agree: 94% (A+ 67%, A 20%, A− 7%, D− 6%). Grade of evidence: high.
Comment on Recommendation 8:
The UBT has been evaluated in a large number of pediatric studies of high quality against a reference standard, both before and after therapy (74–78). In spite of a high variability of tracer dose and tracer application, the type of test meal, the duration of the fasting period before the meal, the time point of breath sampling, the type of analysis, and the cutoff levels, this test has a high accuracy, sensitivity, and specificity (63,64). When the UBT is performed, the patient should have an empty stomach before receiving an acid drink (apple or orange juice, citric acid solution) because the urease activity of the bacteria decreases rapidly with increasing pH (79). After ingestion of the tracer, the drink without tracer should be provided to the child to avoid degradation of the tracer by oral flora. This is a particular problem in infants and toddlers and may at least in part explain the lower specificity reported in children younger than 6 years old compared with older children (74,76,80–84). False-positive results can also occur in young children because of the lower distribution volume and a different CO2 production rate, which can be adjusted for (85).
Recommendation 9 A validated ELISA for detection of H pylori antigen in stool is a reliable noninvasive test to determine whether H pylori has been eradicated.
Agree: 86% (A+ 21%, A 29%, A− 36%, D 7%, D+ 7%). Grade of evidence: moderate.
Comment on Recommendation 9:
Detection of H pylori antigen in stool is an attractive noninvasive method that seems suitable for both clinical use and epidemiological studies. Several methods are available for the detection of H pylori antigen in stool, such as enzyme immunoassay (EIA) based on polyclonal or monoclonal antibodies, and immunochromatographic tests (so-called rapid or quick tests). Stool tests are generally more convenient in pediatric patients than the UBT. Stool samples can be obtained from children without their active collaboration and are transportable by mail for analysis. Neither keeping the samples at room temperature for up to 5 days nor freezing for months or even years seems to influence the accuracy of the stool tests (86–89). In most countries, an EIA would be less costly than the UBT. In addition, the EIA stool test is the only diagnostic noninvasive test that has not shown an age dependence on the accuracy of the test results (64,87). Therefore, validation studies in adults may be extrapolated to children.
The first commercial EIA test to detect H pylori antigen in stool was the Premier Platinum HpSA (Meridian Diagnostics, Cincinatti, OH). This test is based on polyclonal antibodies. There is a wide range for sensitivity and specificity of the test in children, both pretreatment (86,90–98) and posttreatment (89,91,92,95). Testing the same stool samples with different production lots of the polyclonal test indicated interassay variation (99). This may explain the wider range reported for the sensitivity and specificity of the polyclonal stool tests. A different polyclonal EIA (Equipar Diagnostici, Saronno, Italy) was recently evaluated against invasive methods, but the present study included only 33 children with a biopsy-proven H pylori status (100).
So far, only the EIA based on monoclonal antibodies has achieved the accuracy of the UBT, which is considered the reference standard of the noninvasive tests (87,99,101–103). A systematic review and meta-analysis of the 8 studies directly comparing the polyclonal with the monoclonal EIA, including pediatric and adult patients, confirmed the significantly better performance with respect to sensitivity of the monoclonal test, both before and after therapy (104). No difference in accuracy has been observed between studies in adults and children, and within the pediatric studies, young age did not influence the performance of the tests (87,99,101–103).
So-called rapid or office-based fecal tests based on an immunochromography using monoclonal antibodies have been evaluated in children (102,105). The accuracy was lower compared with EIA, even though the tests were based on the same antigens. Although these tests have improved over time, the problem of interobserver variability in weakly positive tests remains unresolved (102,106).
Additional ELISA tests for the detection of H pylori antigen in stool will be developed and evaluated in the near future. Therefore, this statement applies only to the tests that have been evaluated in pediatric populations and have shown an equal or better performance as the UBT or validated stool tests (87,104).
Recommendation 10 Tests based on the detection of antibodies (IgG, IgA) against H pylori in serum, whole blood, urine, and saliva are not reliable for use in the clinical setting.
Agree: 87% (A+53%, A 20%, A− 13%, D− 7%, D 7%). Grade of evidence: high.
Comment on Recommendation 10:
H pylori infection induces an early increase of specific IgM and a later and persistent increase of specific IgA and IgG antibodies. These antibodies can be detected in whole blood, serum, urine, and saliva (63). In general, serologic assays cannot be used on their own to perform the diagnosis of H pylori infection or to monitor the success of therapy because the sensitivity and specificity for detection of antibodies (IgG or IgA) against H pylori in children vary widely. Specific IgG may remain positive for several months or even years after the infection resolves. Thus, the tests cannot be used reliably for treatment outcomes.
Many tests based on the detection of antibodies are commercially available, easy to perform, and inexpensive. In spite of these advantages, they have not been recommended for clinical practice in pediatric patients by previous American, Canadian, or European consensus statements (6,14,15).
The main problems are age dependence, particularly with respect to sensitivity in younger children, and test-to-test variability. IgA-based tests detect only 20% to 50% of H pylori–infected children, and are not suitable for diagnosis. IgG-based tests offer a better sensitivity than IgA-based tests, but the sensitivity of most tests is much lower when used in children compared with adults from the same geographic region. The use of cutoff values obtained in validation studies in adults results in a failure to detect a large proportion of infected children, especially in children younger than 6 to 8 years. Oliveira et al (107) used a second-generation EIA in comparison with biopsy-based methods and found a low sensitivity of 44% in children ages 2 to 6 years. Sensitivity increased to 77% in children ages 7 to 11 years and to 93% in adolescents, which is comparable with results in adults. When 2 IgG-based EIAs were applied to sera of 175 children with biopsy-proven H pylori status, a remarkable difference of sensitivity was observed, mainly in the younger age groups (108). Immunoblotting was found to be superior to serology for diagnosis of H pylori infection in children (109). In a European multicenter study, however, a more recent third-generation EIA seems to perform better, with sensitivity just less than the UBT (76). Tests based on the detection of H pylori antibodies in saliva or office-based tests on whole blood or serum display even worse performance characteristics than laboratory-based serologic EIAs. Therefore, these tests cannot be recommended in children of any age group (63).
Recommendation 11 It is recommended that clinicians wait at least 2 weeks after stopping PPI therapy and 4 weeks after stopping antibiotics to perform biopsy-based and noninvasive tests (UBT, stool test) for H pylori.
Agree: 100% (A+ 47%, A 40%, A− 13%). Grade of evidence: high.
Comment on Recommendation 11:
Studies in adults suggest that antibiotic or PPI therapy can cause false-negative test results because of a reduction in bacterial load without eradication of the bacterium (69,110,111). Therefore, it is recommended that testing be performed at least 4 weeks after completion of antibiotic treatment and 2 weeks following cessation of PPI therapy.
Recommendation 12 In the presence of H pylori–positive PUD, eradication of the organism is recommended.
Agree: 100% (A+ 79%, A, 13%, A− 7%). Grade of evidence: high.
Comment on Recommendation 12:
Several meta-analyses in adults consistently demonstrate that eradication of H pylori in patients with PUD significantly reduces the relapse rate for ulcer disease and for recurrent bleeding ulcers (112,113). Previous pediatric studies in children with PUD indicated that the relapse rate is high without treatment of H pylori infection (114). Only 1 randomized controlled pediatric trial in H pylori–infected children with PUD (n = 106) has been published. This trial compared the eradication rate of H pylori and the cure rate of PUD with 3 different treatment regimens, but did not report the recurrence of ulcer or bleeding ulcer in those who failed bacterial eradication (115). Although there are differences in the etiologies and clinical presentation and frequency of PUD in children compared with adults (1,116), it can be assumed that recurrence of H pylori–related PUD can be prevented in children by eradication of the infection. Therefore, eradication of the infection is recommended in a child with H pylori infection and PUD. The indication applies also for healed ulcers or a history of PUD.
Recommendation 13 When H pylori infection is detected by biopsy-based methods in the absence of PUD, H pylori treatment may be considered.
Agree: 79% (A+ 29%, A 50%, D− 21%). Grade of evidence: low.
Comment on Recommendation 13:
The finding of H pylori–associated gastritis in the absence of PUD during diagnostic endoscopy poses a dilemma for the endoscopist (see comment for recommendations 1, 2, and 3). As outlined in the comments for recommendations 1 and 2, there is inadequate evidence supporting a causal relation between H pylori gastritis and abdominal symptoms in the absence of ulcer disease. Therefore, eradication of the organism in the absence of ulcers may not result in improvement of symptoms. As reviewed in the comment for recommendation 3, H pylori is a risk factor for the development of gastric malignancies; however, only a fraction of infected individuals develop cancer. The carcinogenic risk is modified by strain-specific bacterial factors, host responses, and/or specific host–microbe interactions. (117). Current evidence suggests that in high-risk populations such as in China, the eradication of H pylori may have the potential to decrease the risk of gastric cancer in a subset of individuals without precancerous lesions (39). Prospective intervention trials are of variable quality and results may not be generalizable from 1 population to another. As noted in the comment to recommendation 12, eradication of H pylori can prevent recurrence of PUD. In adults with nonulcer dyspepsia, eradication of H pylori may reduce the development of peptic ulcers (118). A potential benefit of chronic infection with certain H pylori strains cannot be excluded (119). Therefore, the decision to treat H pylori-associated gastritis without duodenal or gastric ulcer is subject to the judgment of the clinician and deliberations with the patient and family, taking into consideration the potential risks and benefits of the treatment in the individual patient.
Recommendation 14 A "test and treat" strategy is not recommended in children.
Agree: 80% (A+ 47%, A 20%, A− 13%, D− 13%, D 7%). Grade of evidence: moderate.
Comment on Recommendation 14:
The primary goal of testing is to diagnose the cause of clinical symptoms. By definition, a "test and treat" strategy (the detection of the presence of H pylori infection by a noninvasive test followed by treatment in the case of a positive test) will not provide this information in children (see comments on recommendations 1 and 2). Therefore, in contrast to current guidelines for adults (8,120), current evidence does not support this practice in children.
Recommendation 15 In children who are infected with H pylori and whose first-degree relative has gastric cancer, treatment can be offered.
Agree: 93% (A+ 20%, A 47%, A− 27%, D+ 6%). Grade of evidence: low.
Comment on Recommendation 15:
Please refer to the comment on recommendation 3.
Recommendation 16 Surveillance of antibiotic resistance rates of H pylori strains in children and adolescents is recommended in different countries and geographic areas.
Agree: 100% (A+ 60%, A 20%, A− 20%). Grade of evidence: not applicable.
Comment on Recommendation 16:
Several European studies have documented high resistance rates to clarithromycin and metronidazole in pediatric and adult populations (1,121–123). Increasing rates of primary clarithromycin resistance have been reported from several countries (124–126). A prospective US multicenter study in adults and children also documented similar high resistance rates (127). In 2 small studies from the United States (Michigan and West Virginia), a high proportion of isolates were resistant to clarithromycin (128,129). Antibiotic resistance is an important factor in treatment success (130). Indeed, eradication rates in children treated with standard therapy are also decreasing over time, in part related to increased antibiotic resistance. H pylori antibiotic susceptibility data are not available for most geographic regions. Therefore, it is recommended that continuous surveillance of resistance rates be undertaken to effectively guide initial empiric therapy with the aim of improving treatment outcomes.
Recommendation 17 First-line eradication regimens are the following: triple therapy with a PPI + amoxicillin + imidazole; or PPI + amoxicillin + clarithromycin; or bismuth salts + amoxicillin + imidazole; or sequential therapy.
Agree: 100% (A+ 36%, A 40%, A− 14%). Grade of evidence: moderate.
Recommendation 18 Antibiotic susceptibility testing for clarithromycin is recommended before initial clarithromycin-based triple therapy in areas/populations with a known high resistance rate (>20%) of H pylori to clarithromycin.
Recommendation 19 It is recommended that the duration of triple therapy be 7 to 14 days. Costs, compliance, and adverse effects should be taken into account.
Agree: 93% (A+ 27%, A 40%, A− 27%, D− 6%). Grade of evidence: moderate.
Comment on Recommendations 17–19:
The goal of treatment is at least a 90% eradication rate on a per-protocol basis at the first attempt. A high initial eradication rate will prevent the development of antibiotic resistance and spread of resistant H pylori strains in the population. For individual patients, a high initial success rate will reduce the need for further treatments and procedures, including endoscopies.
The combination of 2 antibiotics and a PPI has been the recommended first-line therapy since the first published pediatric guidelines (6,14,15). Studies comparing the various treatment options in the pediatric population remain limited. In 2000, Oderda et al (131) performed a systematic review of the published eradication treatment studies in children. Because of the marked heterogeneity and the limited number of well-designed studies, it was difficult to make definitive recommendations. In 2001, the first randomized double-blind trial comparing dual therapy of amoxicillin and clarithromycin with triple therapy including omeprazole in children confirmed that in intention-to-treat analysis, triple therapy was far superior to dual therapy with eradication rates of 74.2% versus 9.4% (132).
A recent meta-analysis of eradication treatment efficacy in children concluded that, in general, the methodological quality of the studies was poor and that additional well-designed randomized trials are needed (7). Thus, current recommendations remain mainly extrapolated from adult studies.
Recent data indicate a falling rate of H pylori eradication in response to treatment. For example, the European pediatric treatment registry reported results from the use of 27 different regimens in 518 children with H pylori(133). The overall eradication rate was 65.6%, lower than previously reported, but was higher in children with peptic ulcers (79.7%). One potential reason for this decline is antibiotic resistance (134). Based on the negative effect of antibiotic resistance on treatment outcomes, the rates of resistance in the area where the child lives or comes from should be taken into account when deciding on the initial therapeutic regimen for eradication (1).
Clarithromycin resistance adversely affects eradication rates in children (135,136). Studies in children addressing the role of susceptibility testing to target initial therapy are limited; however, 3 studies in children suggest that tailoring therapy based on antibiotic susceptibility testing can enhance eradication rates (137–139). In a study of 58 German children, clarithromycin and metronidazole susceptibility testing was used to guide standard triple therapy and resulted in a high eradication rate of 93% (137). An earlier study of 2 consecutive groups of 75 H pylori–infected children treated with either triple therapy, including amoxicillin and clarithromycin (group 1), or antibiotic therapy, guided by susceptibility testing (group 2), demonstrated enhanced eradication in the group with susceptibility-guided therapy (93% vs 81%) (138). Therefore, clarithromycin-based triple therapy can only be recommended as first-line therapy if susceptibility testing in the individual patient revealed a clarithromycin-susceptible strain or if the clarithromycin resistance rate in this area is known to be low. In the absence of these conditions, clarithromycin-based triple therapy cannot be recommended as first-line therapy.
Declining eradication rates with these standard triple regimens have led to the development of alternate treatment options (134). Sequential therapy involves dual therapy with a PPI and amoxicillin for 5 days followed sequentially by 5 days of triple therapy (a PPI with clarithromycin and metronidazol/tinidazol). In fact, this regimen can be considered as quadruple therapy provided in a sequential manner. It is speculated that the initial use of amoxicillin reduces the bacterial load and provides protection against clarithromycin resistance. In 2005, 74 children were randomized to receive either sequential treatment (omeprazole + amoxicillin for 5 days, followed by omeprazole + clarithromycin + tinidazole for another 5 days) or triple therapy for 1 week (140). Successful eradication was achieved in 97.3% of children receiving sequential therapy compared with 75.7% on standard triple therapy. In a subsequent study evaluating adjunctive probiotic supplementation, eradication of 82.5% was obtained from a group of 40 children receiving sequential therapy (141). Based on these studies suggesting that sequential therapy is at least as effective as standard therapy, sequential therapy was recommended as a first-line treatment option. It is important to note that the data in children are mostly limited to Italian studies, and therefore additional studies in North America and different European countries are needed to confirm that the findings apply to other locations. Furthermore, clarithromycin resistance has a negative effect on eradication success even with this regimen, although less so compared with standard triple therapy (136,142,143).
Bismuth-based triple therapy is also recommended as an alternate first-line therapy. Although there are no well-designed randomized studies directly comparing this regimen with the alternate recommended first-line therapies, in a study reported by the European pediatric treatment registry, bismuth-containing triple therapies were more efficacious than PPI-containing ones (77% versus 64%) when used as first-line treatment (133). In addition, bismuth-based triple therapy may be less costly than the other options; however, concerns regarding the palatability of bismuth potentially affecting adherence should also be considered.
Conflicting data exist regarding the benefit of longer duration of therapy for first-line regimens in adults (142,144). A systematic review of therapy in children found no benefit from longer duration of therapy (131). In contrast, a recent meta-analysis of studies in children suggested that longer duration of therapy was associated with improved eradication rates (7). Similarly, a meta-analysis comparing sequential therapy with standard triple therapy showed higher eradication rates with longer duration of triple therapy up to 14 days (142). Therefore, based on these data, recommended duration of therapy is 7 to 14 days, taking into consideration cost, compliance, and side effects. Suggested doses are given in Table 1.
Recommendation 20 A reliable noninvasive test for eradication is recommended at least 4 to 8 weeks following completion of therapy.
Agree: 93% (A+ 53%, A 27%, A− 13%, D− 7%). Grade of evidence: low.
Comment on Recommendation 20:
Even when children become asymptomatic after treatment, it is recommended that the success of treatment regardless of the initial endoscopic findings be evaluated. The absence of symptoms does not necessarily mean the infection has been eradicated (30). Particularly in children who had PUD, persistence of infection would warrant additional treatment. Reliable tests to monitor successful eradication include the 13C-UBT and a monoclonal ELISA for detection of H pylori antigen in stool. A follow-up endoscopy is not routinely indicated unless other causes of ulceration (eg, eosinophilic gastroenteropathy, Crohn disease) are suspected or if biopsies are needed for culture and antibiotic susceptibility testing.
Recommendation 21 If treatment has failed, there are 3 options recommended:
1. EGD, with culture and susceptibility testing, including alternate antibiotics if not performed before guide therapy.
2. FISH on previous paraffin-embedded biopsies if clarithromycin susceptibility testing has not been performed before guide therapy.
3. Modify therapy by adding an antibiotic, using different antibiotics, adding bismuth, and/or increasing dose and/or duration of therapy.
Agree: 100% (A+ 29%, A 43%, A− 28%) Grade of evidence: not applicable.
Comment on Recommendation 21:
Primary antibiotic resistance adversely affects treatment outcomes (see comment for recommendation 20). In addition, a 12-year observational study from Belgium demonstrated secondary resistance following treatment in 39 of 87 strains obtained from children who had failed initial therapy (122). The present study suggests that development of secondary antibiotic resistance may be common in children. Thus, if possible, primary culture with antibiotic sensitivity testing should be performed to guide second-line therapy in an H pylori–infected child who has failed initial therapy.
If primary culture and sensitivity testing is not available, then the choice of second-line therapy must take into account the initial therapy administered and avoid readministering an antibiotic that was previously provided (145). Another option available at some centers is FISH to detect primary clarithromycin resistance on previously obtained biopsies (65,129,146). Clarithromycin should only be used as part of second-line therapy if the strain is found to be sensitive.
If it is not possible to perform a primary culture, then the following therapeutic regimens are suggested as second-line or salvage therapy.
* Quadruple therapy: PPI + metronidazole + amoxicillin + bismuth. Quadruple therapy is the recommended second-line therapy in most guidelines (8,15); however, this regimen is complicated to administer. Furthermore, bismuth salts are not universally available.
* Triple therapy: PPI + levofloxacin (moxifloxacin) + amoxicillin. Evaluation of regimens using fluoroquinolones, including levofloxacin, as second-line therapy in children is limited. In adult studies, this regimen appears to be effective. In a recent meta-analysis of studies in adults (147), triple therapy with levofloxacin appeared to be as efficacious as quadruple therapy for second-line treatment; however, there are concerns regarding increasing rates of quinolone resistance (145). Therefore, this regimen should not be used if the child has received fluoroquinolones previously. Although the studies on the ideal duration of therapy for second-line treatment are not conclusive, a longer duration of therapy of up to 14 days is recommended.
These clinical guidelines represent updated, best-available evidence, and expert opinion regarding the management of H pylori infection in children in Europe and North America developed through a rigorous standardized process. The goal of these recommendations is to improve the care of children and adolescents with H pylori infection. As the clinical implications of H pylori infection in the pediatric setting continue to evolve, these guidelines will need to be updated.
We thank Kathleen Ismond, library scientist, who conducted searches and helped prepare tables; Stephanie Joyce and Monica Sierra, student research assistants, who helped prepare tables; and Andrea Schwarzer, MD, who assisted during the consensus meeting and helped with the voting system. We also thank Stephen Czinn, Mark Gilger, Richard Peek, Frédérick Gottrand, and the members of the ESPGHAN Working Group on H pylori Infection for their fruitful input and the members of the GI Committee of ESPGHAN for the critical review of the manuscript.
This article has been cited 7 time(s).
antibiotic resistance; children and adolescents; diagnostic tests; Helicobacter pylori; treatment
Copyright 2011 by ESPGHAN and NASPGHAN
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I'm a Sacramento native and UCLA alum (go Bruins!) I live with my dear husband in Santa Monica and work in Malibu. If you have an idea for a Blurb album, but don't trust yourself to put it together, I'll help! I've been making books for friends and family as long as I can remember. And now I'm a professional magazine editor and travel writer. This is my thing. I'd love to take on your project. Email me at theashtoneditorial{@}gmail.com.
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Cora Louise 2015 Published November 30, 2015
Parent Ed 2014-15 Published June 15, 2015
Cora Louise Published November 30, 2013
Julia & Rico Published November 19, 2011
Liz & David May 22nd, 2011 Published May 08, 2011
Julia & Rico Published August 16, 2010
Jenny& Dan July 18, 2009 Published July 08, 2009


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MIDLAND - Run production?
Maybe nerves. Possibly the lengthy road trip. Even graduation on the minds of seven seniors.
But of all the items the Randall Raiders had no reason to fret over entering their Class 4A regional semifinal best-of-three series against Fort Worth Western Hills was the ability to score runs.
No. 4-ranked Randall had outscored its previous three playoff opponents 24-3 entering Thursday's series against No. 3-ranked Western Hills. The Raiders own a gaudy .328 team batting average and crashed down fences this season for 33 home runs.
However, Hills pitcher Jason Hopson changed that tune Thursday night, checking the Raiders on one hit during the Cougars Game 1 2-1 victory at McMurry College in Abilene.
Hopson, not overpowering but able to throw off-speed stuff, allowed just two Randall runners in scoring position. Randall catcher Josh Payne collected the lone hit when he ripped a high fastball to the wall in left field for a run-scoring double in the sixth inning.
What also frustrated the Raiders was the fact their pitcher - junior Chance Douglass - was more dominating than Hopson. Douglass struck out 12 batters and his fastball was clocked above 90 miles per hour by major league scouts in attendance.
Randall coach Steve Ribera said his team lacked discipline at the plate and then "when we did hit the ball it was right at them like (Branden) Knapp's two ropes. But I still feel good about this team and their focus."
Payne said when the Raiders take the field for Game 2 of this series at 2 p.m. on Christensen Field in Midland, look for a different Randall team at the plate.
"We were real impatient (against Hopson)," said Payne, who has nine hits in the Raiders four playoff games. "It wasn't even that good of curveball. We were out in front of everything. Whenever we hit the ball we seemed to hit it right at them.
"That's not going to happen again."
This afternoon the 26-5 Raiders must pull off a sweep of Western Hills (28-3) to keep their dream alive of capturing the first UIL state baseball title in the Amarillo-area since Dumas in 1971.
Ribera said he will go with lefty senior Knapp (7-1) to start game two. Western Hills coach Steve Jimenez declined to name a starter following Thursday's game mentioning a trio of pitchers. However, common sense makes the likely choice unbeaten junior Ryne Tacker (8-0). Tacker played a strong shortstop for the Cougars in game one.
Randall takes a valuable lesson into its hopeful marathon day of baseball today.
Last year, in this same round, the Raiders opened with a 4-3 win over Weatherford in game one of a best-of-three series. But Weatherford stunned Randall by winning a pair of classic games - the final 6-5 - on a Saturday to pull out the series.
"We know it can it be done," Payne said. "We are kind of ticked that first game didn't go to us. If (Hopson's) their number one, then I'm feeling pretty good about (today)."
Seven of the Raiders players graduated Friday night at the Amarillo Civic Center. The team was scheduled to board a bus and then spend the night in Lubbock. ... Douglass' stock in the professional baseball world skyrocketed Thursday night. The Major League Scouting Bureau and a Pittsburgh Pirates scout were in attendance and their actions spoke volumes. The Pirates scout made a phone call to his boss in the fifth inning calling Douglass "the real deal."
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This document is intended for the use of operations managers, project directors, and Research Foundation personnel. The Research Foundation must ensure that all expenditures comply with sponsor, Research Foundation and University guidelines. The Research Foundation at Fredonia relies upon the campus' state purchasing department located on the 4th floor of Maytum Hall for taxpayer identification numbers, to ensure that minority business requirements are satisfied, for state contract satisfaction, and for bids over $25,000.
Purchase Orders
Research Foundation purchase orders are system-generated documents that, when accepted by the supplier, serve as a contractual relationship between the Research Foundation and the supplier. The purchase order obligates the supplier to supply the goods and/or services ordered in accordance with the terms specified by the purchase order. It obligates the Research Foundation to pay for the goods and/or services, as long as the goods are received in acceptable condition and the services are rendered in an acceptable manner in accordance with the agreement of the parties.
Out-of-Pocket Expense Reimbursement Policy
Project directors and Research Foundation personnel can be reimbursed for project-related purchases made with personal funds (including credit cards) if purchases comply with the requirements of the campus, the sponsors, and The Research Foundation. Requests for reimbursement should be placed on a state requisition form with the original receipts or documentation attached, description and purpose of the purchase, amount requested, appropriate authorization, the name and address of the person to be reimbursed, expenditure category, and the project, task, and award number to which the expenditure should be charged. Please be advised:
The reimbursement may be disallowed if the Research Foundation determines that the purchase violated any federal, sponsor, or Research Foundation regulations.
Vendor Payments
When payment needs to be made to a vendor (supplier), a state purchase requisition must be prepared. It must contain the original invoice from the vendor, any receipts, description of the expense, amount due, appropriate authorization, the TIN or FIND number, the name and address of the organization to be paid, the expenditure category, and the project, task, and award to which the expenditure should be charged. If any of the preceding information is missing from the requisition, it will be returned so that the appropriate information can be collected, therefore, resulting in a delay of payment.


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As part of National Nursing Home Week, nursing homes throughout the area have special activities planned.
The American Health Care Association designated May 13, 2007, through May 19, as a week to "Treasure Our Elders."
For the past four years, WBKO's Gene Birk and Amy Bingham have been invited to call BINGO numbers and this year the special activity took place on May 14, at Hopkins Nursing Home in Woodburn, Ky.
Gene and Amy are just two of many in the community who came out to help. Myla Thomas and Scooter Davis from WBVR were on hand, as well as Warren County Sheriff Jerry "Peanuts" Gaines, Woodburn Police officer Audrey Spies and many more.
For more information on National Nursing Home Week and to access a planning guide, as well as supporting resources for your local nursing home, go to www.nnhw.org.
And to view photos from Monday's BINGO at Hopkins Nursing Home, view our image gallery below.