Helicobacter Test INFAI for children of the age 3-11 may be used for in vivo diagnosis of gastroduodenal Helicobacter pylori infection: - for the evalutation of the success of eradication treatment, or, - when invasive tests cannot be performed, or - when there are discordant results arising from invasive tests. This medicinal product is for diagnostic use only.

This medicinal product should be administered by a healthcare professional and under appropriate medical supervision. Posology Helicobacter Test INFAI for children of the age 3-11 is a breath test for single administration. Children from the age of 3 to 11 must take the contents of 1 jar with 45 mg. Method of administration For performance of the test, 100 ml 100 % orange juice for patients from the age of 3 to 11 (as a pre-administered test meal), as well as tap water (for dissolving the 13C-urea powder) are necessary. The patient must have fasted for over 6 hours, preferably overnight. The test procedure takes approximately 40 minutes. In case it is necessary to repeat the test procedure, this should not be done until the following day. The suppression of Helicobacter pylori might give false negative results. Therefore the test shall be used after at least four weeks without systemic antibacterial therapy and two weeks after last dose of acid antisecretory agents. Both might interfere with the Helicobacter pylori status. This is especially important after Helicobacter eradication therapy. It is important to follow the instructions for use adequately (see section 6.6), otherwise the reliability of the outcome will become questionable.

The test must not be used in patients with documented or suspected gastric infection or atrophic gastritis, which might interfere with the urea breath test (see section 4.2).

A positive test alone does not constitute indication for eradication therapy. Differential diagnosis with invasive endoscopic methods might be indicated in order to examine the presence of any other complicating conditions, e.g. ulcer, autoimmune gastritis and malignancies. There is insufficient data on the diagnostic liability of the Helicobacter Test INFAI for children of the age 3-11 to recommend its use in patients with gastrectomy and in patients younger than 3 years of age. In individual cases of A-gastritis (atrophic gastritis) the breath test may have false positive results; other tests may be required to confirm the Helicobacter pylori status. If the patient vomits during the test procedure, necessitating the repetition of the test, this should be done in fasted condition and not before the following day (see section 4.2).

Helicobacter Test INFAI for children of the age 3-11 will be affected by all treatments interfering with Helicobacter pylori status or urease activity.

Not applicable.

None.

None known. Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.

Due to the fact that only 45 mg of 13C-urea is delivered, an is not expected.

Pharmacotherapeutic group: Other diagnostic agents, ATC code: VO4CX For the amount of 45 mg 13C-urea, which is administered per unit in the course of the breath test, no pharmacodynamic activity is described. After oral ingestion the labelled urea reaches the gastric mucosa. In the presence of Helicobacter pylori the 13C-urea is metabolised by the enzyme urease of Helicobacter pylori. 2H2N(13CO)NH2 + 2H2O Enzyme urease 4NH3 + 213CO2 The carbon dioxide diffuses into the blood vessels. From there it is transported as bicarbonate into the lung and liberated as 13CO2 with the exhaled air. In the presence of bacterial urease the ratio of the 13C/12C-carbon isotopes is significantly changed. The portion of 13CO2 in the breath samples is determined by isotope-ratio-mass-spectrometry (IRMS) and stated as an absolute difference (?d-value) between the 00-minute- and the 30-minute-values. Urease is produced in the stomach only by Helicobacter pylori. Other urease producing bacteria were seldom found in the gastric flora. The cut off point for discriminating Helicobacter pylori-negative and positive patients is determined to be ?d-value of 4 ‰, which means that an increase of the ?d-value by more than 4 ‰ indicates an infection. In comparison to bioptic diagnostics of an infection with Helicobacter pylori, the breath test achieved in a clinical trial on 168 patients from the age of 3 to 11, a sensitivity of 98.4 % [90 %-CI: = 93.9 %], and a specificity of 98.1 % [90 %-CI: = 95.1 %]. In the absence of bacterial urease, the whole amount of the administered urea after absorption from the gastrointestinal tract will be metabolised like the endogenous urea. Ammonia which is produced as described above by the bacterial hydrolysis is included into the metabolism as NH4 +.

The orally applied 13C-urea is metabolised to carbon dioxide and ammonia or is integrated into the body’s own urea cycle. Any increase in 13CO2 will be measured by isotopic analysis. Absorption and distribution of 13CO2 is faster than the urease reaction. Therefore, the rate-limiting step in the whole process is the cleavage of 13C-urea by Helicobacter's urease. Only in Helicobacter pylori- positive patients does the administration of 45 mg labelled urea lead to a significant increase of 13CO2 in the breath sample within the first 30 minutes.

No concerns in relation to the clinical use of the product.

None.

Not applicable.

3 years

Do not store above 25 °C.

A test set contains the following parts: No. Component Quantity 1 Jar (10 ml volume, polystyrene with polyethylene snap cap) containing 45 mg 13C-urea powder for oral solution 1 2 Labelled sample glass- or plastic- containers for sampling, storing and transporting the breath samples for analysis: Sampling time: 00-minute-value Sampling time: 30-minute-value 2 2 3 Bendable straw for collection of the breath samples into the corresponding sample containers 1 4 Data sheet for patient documentation 1 5 Package leaflet 1 6 Page of barcode labels and sticker 1

1. The test is to be performed in the presence of a qualified person. 2. Each patient should be documented according to the provided data sheet. It is recommended to perform the test with the patient being in a resting position. 3. The test starts with the collection of samples for the determination of baseline- value (00-minute-value): • Take the straw and the two sample tubes with the label “Sampling time: 00-minute-value” out of the test set. • Remove the stopper from one of the sample tubes, unwrap the straw and place the straw into the container. • Now the patient breathes gently through the straw until the inner surface of the sample tube steams up. • By continuously breathing the patient must pull out the straw and immediately close the sample tube with its stopper. (If the sample tube remains open for more than 30 seconds, the test result might be falsified.) • Hold the sample tube upright and stick the bar-code label marked “00-minute-value” round the sample tube, so that the lines of the bar- code are horizontal. 4. Fill up the second sample tube (Label “Sampling time: 00-minute-value”) with breath by following the same procedure. 5. Now 100 ml of 100 % orange juice must be drunk by the patient without delay. 6. Now the preparation of the test solution follows: • The jar labelled “13C-urea powder” is taken from the test set, opened, and filled up to three quarters of its volume with tap water. • Close the jar and shake it carefully until all the powder is dissolved. Pour the contents into a drinking glass. • Fill the 13C-urea jar to the brim with water for a second and third time and add these contents to the drinking glass (total volume of tap water should be approximately 30 ml). 7. This test solution must now be drunk immediately by the patient, and the time of application must be noted. 8. Thirty minutes after administration of the test solution (point 7), collect the 30-minute-value samples in the two containers which are left in the test package (Label “Sampling time: 30-minute-value”), as described under steps 3 to 4. Use the bar-code labels marked “30-minute-value” for these samples. 9. Put the relevant bar-code label on the data sheet for patient documentation. Finally seal the package with the sticker. 10. The sample tubes have to be sent in the original packaging, for analysis, to a qualified laboratory. Analysis of breath samples and testing specification for laboratories The breath samples, collected in 10 ml glass- or plastic sample tubes, are analysed by isotope ratio mass spectrometry (IRMS). The analysis of the 13C/12C-ratio in carbon dioxide of breath is an integrated part of the diagnostic test Helicobacter Test INFAI. The accuracy of the test strongly depends on the quality of the breath analysis. The specification of breath analysis parameters like linearity, stability (reference gas precision), and precision of measurement are fundamental for the accuracy of the system. It has to be ensured that the analysis is carried out by a qualified laboratory. The method validated in the application is as follows: • Sample preparation for (IRMS) To determine the 13C/12C-ratio of carbon dioxide in breath by mass spectrometric analysis the carbon dioxide must be separated from the breath and introduced into the mass spectrometer. The automatic preparation system for isotope mass spectrometers which is dedicated for breath test analysis is based on a gas-chromatographic continuous flow separation technique. Water is removed from the sample by means of a Nafion water trap or the gas- chromatographic preparation system that separates the individual gases in a gas chromatographic column with Helium as eluent. Passing the column the separated gas species of breath are detected by an ionisation detector. The fraction of carbon dioxide gas, identified by its characteristic retention time, is introduced into mass spectrometer. • Mass spectrometric analysis To analyse the separated carbon dioxide sample gas its molecules must be ionised, formed into a beam, accelerated by an electric field, deflected in a magnetic field, and finally detected. These five processes take place in the analyser of a mass spectrometer, which consists of three separate sections: the source, flight tube, and collector. Ionisation, beam formation and acceleration all occur in the source, magnetic deflection takes place in the flight tube and detection takes place in the collector. • Sample inlet For introduction of the carbon dioxide into the analyser many sample inlet systems are available. For breath test analysis the individual balancing of the carbon dioxide of the sample to a reference standard gas is essential. This ensures the high accuracy of this system, as calculation of the isotopic content in carbon dioxide is done with respect to an independent standard. • Specifications for determining 13C/12C-ratios The breath test concept relies on the administration of a specifically 13C-labelled urea whose metabolite utilisation is monitored by measuring 13CO2 in the expired breath gas. • The mass spectrometer must be capable of: Multiple replicate analyses: Minimum of 3 replicate analyses of the same sample during operation Security access: Storing of operating parameters and of results under security access to avoid later manipulation Adjustment: 13C/12C-ratio with respect to Pee Dee Beliminate (PDB) Sample loop: < 200 µl The principal tests to verify the specifications are linearity, stability (reference gas precision), and precision of measurement. • All mass spectrometers for breath analysis must comply with the following specifications: Linearity: = 0.5 ‰ for breath samples varying between 1 % and 7 % CO2-concentration Stability: = 0.2 ‰ on 10 consecutive pulses Precision of measurement: = 0.3 ‰ for 13C at natural abundance using a 10 ml breath sample tube with 3 % CO2 breath concentration Helicobacter pylori infection is present if the difference in 13C/12C of baseline-value and 30-minute-value exceeds 4.0 ‰. Alternatively, any other suitable-validated method may be used, carried out by any objectively qualified laboratory.

Feb. 16, 2026

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