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Pearce H, Talks BJ, Powell S, Brodlie M, Powell J. A systematic review of antimicrobial therapy in children with tracheostomies. Pediatr Pulmonol 2024; 59:251-259. [PMID: 38010838 DOI: 10.1002/ppul.26766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/05/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
Tracheostomies are indicated in children to facilitate long-term ventilatory support, aid in the management of secretions, or manage upper airway obstruction. Children with tracheostomies often experience ongoing airway complications, of which respiratory tract infections are common. They subsequently receive frequent courses of broad-spectrum antimicrobials for the prevention or treatment of respiratory tract infections. However, there is little consensus in practice with regard to the indication for treatment/prophylactic antimicrobial use, choice of antimicrobial, route of administration, or duration of treatment between different centers. Routine antibiotic use is associated with adverse effects and an increased risk of antimicrobial resistance. Tracheal cultures are commonly obtained from pediatric tracheostomy patients, with the aim of helping guide antimicrobial therapy choice. However, a positive culture alone is not diagnostic of infection and the role of routine surveillance cultures remains contentious. Inhaled antimicrobial use is also widespread in the management of tracheostomy-associated infections; this is largely based on the theoretical benefits of higher airway antibiotic concentrations. The role of prophylactic inhaled antimicrobial use for tracheostomy-associated infections remains largely unproven. This systematic review summarizes the current evidence base for antimicrobial selection, duration, and administration route in pediatric tracheostomy-associated infections. It also highlights significant variation in practice between centers and the urgent need for further prospective evidence to guide the management of these vulnerable patients.
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Affiliation(s)
- Helen Pearce
- Biosciences Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Benjamin James Talks
- Biosciences Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Malcolm Brodlie
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE1 4LP
- Translational and Clinical Research Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
| | - Jason Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
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Zhang J, Liu P, Narayanan AM, Chorney SR, Kou Y, Johnson RF. Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis. OTO Open 2024; 8:e108. [PMID: 38235054 PMCID: PMC10792475 DOI: 10.1002/oto2.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/19/2024] Open
Abstract
Objective This study aimed to determine the direct costs of pediatric tracheostomy care within a health care system. Study Design Prospective analysis. Setting Academic children's hospital. Methods Costs associated with caring for pediatric tracheostomy patients under 18 years were analyzed between 2015 and 2021. Direct costs were calculated using the Medicare/Medicaid charges-to-costs ratio for various visit types. Costs were estimated using generalized linear equations, accounting for confounders. Results A total of 297 children underwent tracheostomy at a median age of 0.94 years. The median follow-up was 2.5 years, resulting in 13,966 visits (mean = 41). The total cost was $321 million. The initial admission accounted for 72% ($231 million) of costs while other inpatient admissions added 24% ($78 million). Emergency department, observation, and outpatient visits comprised 4% of costs. The length of stay (LOS) was the primary cost driver for inpatient visits. Each additional hospital day increased costs by roughly $1195, and each extra admission added about $130,223 after adjusting for confounders. Respiratory failure and infections were the primary reasons for 67% of subsequent admissions. Conclusion Pediatric tracheostomy care generated over $300 million in direct costs over 5 years. Inpatient stays constituted 96% of these costs, with the LOS being a major factor. To reduce direct health expenditures for these patients, the focus should be on minimizing admissions.
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Affiliation(s)
- Jinghan Zhang
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Palmila Liu
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Ajay M. Narayanan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Stephen R. Chorney
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Children's Health Airway Management ProgramChildren's Medical Center DallasDallasTexasUSA
| | - Yann‐Fuu Kou
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Children's Health Airway Management ProgramChildren's Medical Center DallasDallasTexasUSA
| | - Romaine F. Johnson
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Children's Health Airway Management ProgramChildren's Medical Center DallasDallasTexasUSA
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Powell J, Powell S, Mather MW, Beck L, Nelson A, Palmowski P, Porter A, Coxhead J, Hedley A, Scott J, Rostron AJ, Hellyer TP, Zaidi F, Davey T, Garnett JP, Agbeko R, Ward C, Stewart CJ, Taggart CC, Brodlie M, Simpson AJ. Tracheostomy in children is associated with neutrophilic airway inflammation. Thorax 2023; 78:1019-1027. [PMID: 36808087 PMCID: PMC10511973 DOI: 10.1136/thorax-2022-219557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/29/2022] [Indexed: 02/22/2023]
Abstract
BACKGROUND Tracheostomies in children are associated with significant morbidity, poor quality of life, excess healthcare costs and excess mortality. The underlying mechanisms facilitating adverse respiratory outcomes in tracheostomised children are poorly understood. We aimed to characterise airway host defence in tracheostomised children using serial molecular analyses. METHODS Tracheal aspirates, tracheal cytology brushings and nasal swabs were prospectively collected from children with a tracheostomy and controls. Transcriptomic, proteomic and metabolomic methods were applied to characterise the impact of tracheostomy on host immune response and the airway microbiome. RESULTS Children followed up serially from the time of tracheostomy up to 3 months postprocedure (n=9) were studied. A further cohort of children with a long-term tracheostomy were also enrolled (n=24). Controls (n=13) comprised children without a tracheostomy undergoing bronchoscopy. Long-term tracheostomy was associated with airway neutrophilic inflammation, superoxide production and evidence of proteolysis when compared with controls. Reduced airway microbial diversity was established pre-tracheostomy and sustained thereafter. CONCLUSIONS Long-term childhood tracheostomy is associated with a inflammatory tracheal phenotype characterised by neutrophilic inflammation and the ongoing presence of potential respiratory pathogens. These findings suggest neutrophil recruitment and activation as potential exploratory targets in seeking to prevent recurrent airway complications in this vulnerable group of patients.
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Affiliation(s)
- Jason Powell
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Michael W Mather
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lauren Beck
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Nelson
- Department of Applied Science, Northumbria University, Newcastle upon Tyne, UK
| | - Pawel Palmowski
- Protein and Proteome Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Porter
- Protein and Proteome Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Coxhead
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Hedley
- Bioinformatics Support Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fatima Zaidi
- Discovery and Translational Science, Metabolon, Morrisville, North Carolina, USA
| | - Tracey Davey
- Electron Microscopy Research Services, Newcastle University, Newcastle upon Tyne, UK
| | - James P Garnett
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Agbeko
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Intensive Care, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Chris Ward
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J Stewart
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Coggins SA, Edwards EM, Flannery DD, Gerber JS, Horbar JD, Puopolo KM. Serratia Infection Epidemiology Among Very Preterm Infants in the Neonatal Intensive Care Unit. Pediatr Infect Dis J 2023; 42:152-158. [PMID: 36638403 PMCID: PMC9846441 DOI: 10.1097/inf.0000000000003736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Serratia spp. are opportunistic, multidrug resistant, Gram-negative pathogens, previously described among preterm infants in case reports or outbreaks of infection. We describe Serratia late-onset infection (LOI) in very preterm infants in a large, contemporary, nationally representative cohort. METHODS In this secondary analysis of prospectively collected data of preterm infants born 401-1500 grams and/or 22-29 weeks gestational age from 2018 to 2020 at 774 Vermont Oxford Network members, LOI was defined as culture-confirmed blood and/or cerebrospinal fluid infection > 3 days after birth. The primary outcome was incidence of Serratia LOI. Secondary outcomes compared rates of survival and discharge morbidities between infants with Serratia and non-Serratia LOI. RESULTS Among 119,565 infants, LOI occurred in 10,687 (8.9%). Serratia was isolated in 279 cases (2.6% of all LOI; 2.3 Serratia infections per 1000 infants). Of 774 hospitals, 161 (21%) reported at least one Serratia LOI; 170 of 271 (63%) cases occurred at hospitals reporting 1 or 2 Serratia infections, and 53 of 271 (20%) occurred at hospitals reporting ≥5 Serratia infections. Serratia LOI was associated with a lower rate of survival to discharge compared with those with non-Serratia LOI (adjusted relative risk 0.88, 95% CI: 0.82-0.95). Among survivors, infants with Serratia LOI had higher rates of tracheostomy, gastrostomy and home oxygen use compared with those with non-Serratia LOI. CONCLUSIONS The incidence of Serratia LOI was 2.3 infections per 1000 very preterm infants in this cohort. Lower survival and significant morbidity among Serratia LOI survivors highlight the need for recognition and targeted prevention strategies for this opportunistic nosocomial infection.
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Affiliation(s)
- Sarah A. Coggins
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Erika M. Edwards
- University of Vermont, Burlington, VT, USA
- Vermont-Oxford Network, Burlington, VT, USA
| | - Dustin D. Flannery
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey S. Gerber
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey D. Horbar
- University of Vermont, Burlington, VT, USA
- Vermont-Oxford Network, Burlington, VT, USA
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Hall N, Rousseau N, Hamilton DW, Simpson AJ, Powell S, Brodlie M, Powell J. Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals. BMJ Open 2023; 13:e065698. [PMID: 36720577 PMCID: PMC9890767 DOI: 10.1136/bmjopen-2022-065698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers. DESIGN Qualitative semistructured interview study. SETTING One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation. PARTICIPANTS A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre. INTERVENTION Interviews undertaken by telephone or video link. PRIMARY AND SECONDARY OUTCOME MEASURES Qualitative reflexive thematic analysis with QSR Nvivo 12. RESULTS This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies. CONCLUSIONS Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.
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Affiliation(s)
- Nicola Hall
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Surgical, Diagnostic and Devices Division, University of Leeds, Leeds, UK
| | - David W Hamilton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Jason Powell
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
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Flannery DD, Edwards EM, Coggins SA, Horbar JD, Puopolo KM. Late-Onset Sepsis Among Very Preterm Infants. Pediatrics 2022; 150:189935. [PMID: 36366916 DOI: 10.1542/peds.2022-058813] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the epidemiology, microbiology, and associated outcomes of late-onset sepsis among very preterm infants using a large and nationally representative cohort of NICUs across the United States. METHODS Prospective observational study of very preterm infants born 401 to 1500 g and/or 22 to 29 weeks' gestational age (GA) from January 1, 2018, to December 31, 2020, who survived >3 days in 774 participating Vermont Oxford Network centers. Late-onset sepsis was defined as isolation of a pathogenic bacteria from blood and/or cerebrospinal fluid, or fungi from blood, obtained >3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without late-onset sepsis. RESULTS Of 118 650 infants, 10 501 (8.9%) had late-onset sepsis for an incidence rate of 88.5 per 1000 (99% confidence interval [CI] [86.4-90.7]). Incidence was highest for infants born ≤23 weeks GA (322.0 per 1000, 99% CI [306.3-338.1]). The most common pathogens were coagulase negative staphylococci (29.3%) and Staphylococcus aureus (23.0%), but 34 different pathogens were identified. Infected infants had lower survival (adjusted risk ratio [aRR] 0.89, 95% CI [0.87-0.90]) and increased risks of home oxygen (aRR 1.32, 95% CI [1.26-1.38]), tracheostomy (aRR 2.88, 95% CI [2.47-3.37]), and gastrostomy (aRR 2.09, 95% CI [1.93-2.57]) among survivors. CONCLUSIONS A substantial proportion of very preterm infants continue to suffer late-onset sepsis, particularly those born at the lowest GAs. Infected infants had higher mortality, and survivors had increased risks of technology-dependent chronic morbidities. The persistent burden and diverse microbiology of late-onset sepsis among very preterm infants underscore the need for innovative and potentially organism-specific prevention strategies.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology.,Clinical Futures, Children's Hospital of Philadelphia; Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Erika M Edwards
- Larner College of Medicine.,College of Engineering and Mathematical Sciences at the University of Vermont, Burlington, Vermont.,Vermont Oxford Network, Burlington, Vermont
| | - Sarah A Coggins
- Division of Neonatology.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey D Horbar
- Larner College of Medicine.,Vermont Oxford Network, Burlington, Vermont
| | - Karen M Puopolo
- Division of Neonatology.,Clinical Futures, Children's Hospital of Philadelphia; Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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