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To the Editor —Cardenas et al. raise several important criticisms of our study [1]. As they note, after initial clarithromycin-based triple therapy, only 34% of children in the intervention group cleared their infection. However, after repeat treatment with metronidazole-based triple therapy of children still infected after 2 months, 75% had no active infection at the 8-month follow-up. As was reported in our companion study [2], this result agrees with previous findings that in vitro metronidazole resistance may not correlate with treatment failure. Also, secondary analyses revealed no significant difference in the prevalence of iron deficiency between groups according to their Helicobacter pylori infection status at the end of the study—results that would not be affected by treatment failure. Thus, we do not believe that our negative results can be attributed to treatment failure

Although the results differ from those of most treatment efficacy trials, our 34% response rate after initial therapy may represent more accurately the true field effectiveness of treatment, rather than the higher responses found during highly structured studies. Treatment trials also have been conducted primarily in populations in developed countries with a relatively low prevalence of H. pylori whereas most of the world’s children live in developing countries, which have a high prevalence of H. pylori. Thus, we continue to support the idea that Alaskan Natives represent an ideal population in which to evaluate our research question for applicability to most of the world

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