Pediatric ventilator-associated tracheobronchitis and pneumonia: time to regroup?

Antibiotic Choice and Outcomes for Respiratory Infections in Children With Tracheostomies

OBJECTIVE

Respiratory infections are a major cause of hospitalization in children with tracheostomies, contributing significantly to hospital expenses. Limited data exist to describe optimal diagnostic strategies or management recommendations for these infections. This study aimed to explore factors associated with antibiotic therapy, including usage, administration route, duration, variables influencing the decision to prescribe antibiotics, and outcomes in children with tracheostomies experiencing episodes of respiratory infection other than pneumonia (tracheobronchitis and nonspecific respiratory episodes [NSRE]).

METHODS

We conducted a retrospective cohort study using the medical records of 83 children who underwent tracheostomy and received treatment at a tertiary hospital from 2010 to 2021.

RESULTS

A total of 164 episodes of tracheobronchitis and 98 episodes of NSRE were analyzed. Children with tracheobronchitis were more frequently treated with antibiotics: 75% in nonhospitalized cases and 76% in hospitalized cases. In NSRE, antibiotic prescription dropped to 40% and 29%, respectively. Out of 51 tracheobronchitis and 15 NSRE initially treated with oral antibiotics, a switch to intravenous administration was deemed necessary in only 7 tracheobronchitis cases (14%). Fever was significantly associated with antibiotic prescription in tracheobronchitis and NSRE, regardless of hospitalization status. Two children died within the 28-day period following the onset of tracheobronchitis symptoms.

CONCLUSIONS

Many cases identified as tracheobronchitis, along with a greater number of NSRE cases, resolved without requiring antibiotics. Although fever was associated with increased antibiotic prescription, it does not necessarily indicate severity. Therefore, careful consideration should be given before prescribing antibiotics, especially in febrile cases, to avoid unnecessary treatments.

Tracheobronchitis in Noncritically Ill Children With Tracheostomy: Can Quantitative Tracheal Cultures Assist in the Management?

BACKGROUND AND OBJECTIVES

Bacteria in tracheal aspirate samples from children with tracheostomy can indicate infection or colonization. Our study aimed to determine whether bacterial counts > 104 or > 105 CFU (colony forming units)/mL are more frequently associated with tracheobronchitis. Additionally, we aimed to examine the association between bacterial count and variables distinguishing colonization from infection in tracheobronchitis, along with clinical severity indicators.

METHODS

Retrospective cohort study of children with tracheostomy at La Paz University Hospital, Madrid (June 2018-April 2023). Inclusion criteria were tracheal aspirate cultures with bacterial growth in noncritical patients under 18. For multiple cultures within the same episode, the first showing bacterial growth was considered; when multiple isolates were present, the highest bacterial count was used.

RESULTS

We analyzed 552 tracheal aspirate cultures from 62 children. Among the 447 cultures with bacterial growth (81%), 113 (25.3%) were related to episodes of tracheobronchitis. No significant differences were found in bacterial counts > 104 or > 105 CFU/mL between tracheobronchitis episodes and those not meeting criteria for tracheobronchitis or pneumonia (p = 0.405, p = 0.485) or when compared to pneumonia (p = 0.553, p = 0.552). Similarly, in tracheobronchitis episodes, no differences were observed in the bacterial count for variables distinguishing colonization from infection or in clinical severity indicators, except for antibiotic prescriptions, which were significantly higher with bacterial counts > 105 CFU/mL (p = 0.037).

CONCLUSIONS

We were unable to demonstrate an association between higher bacterial counts in tracheal aspirate and tracheobronchitis in children with tracheostomy. This raises doubts about the reliability of bacterial count as a diagnostic tool for tracheobronchitis.

Microbiological patterns of bacterial infections in tracheostomized children: Reducing uncertainty in continuous care

BACKGROUND AND OBJECTIVES

Respiratory infections are the most frequent cause of hospitalization in tracheostomized children. However, there is a lack of publications to guide their management. The primary objective was to describe the microbiological isolates and their antibiotic susceptibilities of bacterial respiratory infections in a population of tracheostomized children.

METHODS

Retrospective follow-up study of children with tracheostomy seen at a tertiary hospital. Respiratory infection episodes in patients under 18 years of age who had a tracheostomy and bacterial isolation with a count ≥104 Colony Forming Units/mL in tracheal aspirate were included.

RESULTS

The study analyzed 328 respiratory infection episodes: 164 tracheobronchitis (50%), 112 nonspecific respiratory episodes (34.1%), and 52 pneumonias (15.9%). The most commonly isolated microorganisms were Pseudomonas aeruginosa, Serratia marcescens, and Staphylococcus aureus. The antibiotics that exhibited the highest effectiveness were meropenem (92%), imipenem (87%), and levofloxacin (86%). When hospitalization exceeded 7 days, there was a higher chance of isolating Escherichia coli and Klebsiella pneumoniae (p < 0.001 and p = 0.001, respectively), as well as an increased rate of multidrug resistance (27% vs. 7%, p = 0.035). In 75.3% of cases, the microorganism had been previously isolated in a sample taken 7-30 days before the current one, with a higher frequency observed in the case of P. aeruginosa (95.2%) compared to other microorganisms (65.3%, p < 0.001).

CONCLUSIONS

Meropenem, imipenem, and levofloxacin provided the most effective coverage for these infections. The risk of multidrug resistance increased with longer hospital stays, especially for E. coli and K. pneumoniae. Recent isolation of P. aeruginosa may justify empirical coverage.

Tracheobronchitis in children with tracheostomy tubes: Overview of a challenging problem

Tracheobronchitis is common in children with tracheostomy tubes. These children are predisposed to respiratory infections due to the bypassing of normal upper airway defense mechanisms by the tracheostomy, bacterial colonization of the tracheostomy tube itself, and underlying medical conditions. Diagnosis of bacterial tracheobronchitis is challenging due to the difficulty in differentiating between bacterial colonization and infection, as well as between viral and bacterial etiologies. Difficulty in diagnosis complicates management decisions, and there are currently no consensus guidelines to assist clinicians in the treatment of these patients. Frequent administration of systemic antibiotics causes adverse effects and leads to the emergence of resistant organisms. Topical administration of antibiotics via nebulization or direct instillation may lead to a significantly higher concentration of drug in the upper and lower airways without causing systemic side effects, although therapeutic trials in children with tracheostomy tubes are lacking. Several preventative measures such as regular airway clearance and the use of a speaking valve may mitigate the risk of developing respiratory infections.