Airway Microbiology in Tracheostomized Children

Factors associated with tracheostomy-associated infection treatment: A multicenter observational study

OBJECTIVE

To characterize factors that influence the decision to treat suspected pediatric bacterial tracheostomy-associated respiratory infections (bTRAINs; e.g., pneumonia, tracheitis).

METHODS

We conducted a multicenter, prospective cohort study of children with pre-existing tracheostomy hospitalized at six children's hospitals for a suspected bTRAIN (receipt of respiratory culture plus ≥1 doses of an antibiotic within 48 h). The primary predictor was respiratory culture growth categorized as Pseudomonas aeruginosa, P. aeruginosa + ≥1 other bacterium, other bacteria alone, or normal flora/no growth. Our primary outcome was bTRAIN treatment with a complete course of antibiotics as documented by the discharge team. We used logistic regression with generalized estimating equations to identify the association between our primary predictor and outcome and to identify demographic, clinical, and diagnostic testing factors associated with treatment.

RESULTS

Of the 440 admissions among 289 patients meeting inclusion criteria, 307 (69.8%) had positive respiratory culture growth. Overall, 237 (53.9%) of admissions resulted in bTRAIN treatment. Relative to a negative culture, a culture positive for P. aeruginosa plus ≥1 other organism (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.02-5.0)] or ≥1 other organism alone (aOR: 2.8; 95% CI: 1.4-5.6)] was associated with treatment. Several clinical and diagnostic testing (respiratory Gram-stain and chest radiograph) findings were also associated with treatment. Positive respiratory viral testing was associated with reduced odds of treatment (aOR: 0.5; 95% CI: 0.2-0.9).

CONCLUSIONS

Positive respiratory cultures as well as clinical indicators of acute illness and nonculture test results were associated with bTRAIN treatment. Clinicians may be more comfortable withholding antibiotics when a virus is identified during testing.

Repeat tracheal aspirate cultures in pediatric intensive care patients: Frequency, resistance, and antimicrobial use

OBJECTIVE

To evaluate the clinical impact and features associated with repeat tracheal aspirate (TA) cultures in children admitted to the intensive care unit.

DESIGN

Retrospective cohort study.

SETTING

A 338-bed freestanding, tertiary pediatric academic medical center with pediatric medical intensive care unit (PICU) and cardiac intensive care units (CICU).

PATIENTS

Children ≤18 years of age who were admitted to either the PICU or CICU who had ≥2 TA cultures in a single intensive care admission.

METHODS

Patients with ≥2 TA cultures between 2018 and 2019 were included in this study. The following information was collected: patient demographics, clinical data summarizing patient condition at the time of culture collection, number of TA cultures per patient, antibiotic usage, and microbiologic data. Descriptive statistics established the frequency of TA collection, time between culturing, clinical reasoning for collection, antibiotic exposure, and development of multidrug-resistant organisms (MDRO).

RESULTS

Sixty-three patients had repeat TA cultures and accounted for 252 TA cultures during the study period. Most patients with repeat TA cultures were admitted to the PICU (71%) and were male (65%). A median of 3 TA cultures per patient were obtained with 50% of repeat cultures occurring within 7 days from the previous culture. Sixty-six percent of patients had the same organism cultured on ≥2 TA cultures. Most antibiotics were not modified or continued to treat the results of the TA culture.

CONCLUSIONS

Repeat TA cultures frequently show the same pathogens, and results do not often influence antibiotic selection or usage. Repeat TA cultures did demonstrate the development of MDROs.

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.

Microbiology and management of respiratory infections in children with tracheostomy

Tracheostomy-related respiratory infections are common, though the diagnosis and management can be challenging in children. The goal of this review article was to provide an overview of the current knowledge known about recognizing and treating respiratory infections in this population and to emphasize future areas for further research. While several small and retrospective papers attempt to provide information, there remain more questions than answers. We have reviewed ten published articles to understand this topic, bringing to light significant variation in clinical practices across institutions. While identifying the microbiology is important, it is also crucial to recognize when to treat. Differentiating acute infection, chronic infection, and colonization are important features that influence the treatment of lower respiratory tract infection in children with a tracheostomy.

Airway multidrug-resistant organisms in a population of tracheostomy and chronic ventilator-dependent children at a tertiary care pediatric hospital

OBJECTIVE/BACKGROUND

Children with tracheostomies are at an increased risk of bacterial respiratory tract infections. Infections caused by multidrug-resistant organisms (MDROs) are more difficult to treat and can result in severe complications. This study aimed to investigate the risk factors and sequelae of MDRO positivity in tracheostomy and chronic ventilator-dependent children.

METHODS

We performed a retrospective chart review of 75 tracheostomy and chronic ventilator-dependent children at St. Louis Children's Hospital. Data on demographics, respiratory cultures, hospitalizations, emergency department (ED) visits, and antibiotic usage were collected. We determined the frequency of MDRO positivity and compared the number of hospitalizations, number of ED visits, and antibiotic usage in patients with and without MDRO-positive cultures. Patient clinical variables were analyzed before and after MDRO acquisition.

RESULTS

We found 75.7% (56/74) of our participants had an MDRO-positive culture, with methicillin-resistant Staphylococcus aureus (MRSA, n = 36, 64%) and Pseudomonas aeruginosa (n = 8, 14%) being the most commonly detected organisms. Participants with a greater number of annual nonpulmonary admissions (odds ratio [OR] = 1.99, 95% confidence interval [CI] (1.21-3.29), p = 0.008], inpatient antibiotic courses [OR = 1.27, 95% CI (1.07-1.50), p = 0.006], total antibiotic courses [OR = 1.26, 95% CI (1.08-1.48), p = 0.004], and chronic antibiotic use [OR = 2.31, 95% CI (1.12-4.74), p = 0.03] were at an increased risk for MDRO positivity. Those who were MDRO-positive had more pulmonary admissions following MDRO acquisition compared those who were MDRO-negative [p = 0.005] but not more antibiotic usage or ED visits.

CONCLUSION

Frequent antibiotic usage and hospitalizations increase the risk of MDRO acquisition in children with tracheostomies and ventilator-dependence. Further antibiotic stewardship may help prevent resistant infections in technology-dependent children.

Diagnosis, management, and outcomes of pediatric tracheostomy-associated infections: A scoping review

BACKGROUND

Children with tracheostomy are frequently admitted to the hospital for tracheostomy-associated respiratory infections (TRAINs). However, there remains a paucity of evidence to direct the diagnosis, treatment, and prevention of TRAINs. An important first step to addressing this knowledge gap is to synthesize existing data regarding TRAINs to inform current practice and facilitate innovation.

DATA SOURCES

We searched PubMed, Embase, Cochrane Library, CINAHL, and Web of Science from inception to October 2020. Original research articles and published abstracts including children and young adults 0-21 years of age with tracheostomy were included. Included studies assessed the clinical definitions of and risk factors for TRAINs, microbiologic epidemiology and colonization of tracheostomies, and treatment and outcomes of TRAINs.

DATA SYNTHESIS

Out of 5755 studies identified in the search, 78 full-text studies were included in the final review. A substantial number of studies focused on the detection of specific pathogens in respiratory cultures including Pseudomonas aeruginosa. Several different definitions of TRAIN including clinical, microbiologic, and laboratory testing results were utilized; however, no uniform set of criteria were identified. The few studies focused on treatment and prevention of TRAIN emphasized the role of empiric antimicrobial therapy and the use of inhaled antibiotics.

CONCLUSIONS

Despite a growing number of research articles studying TRAINs, there is a paucity of prospective interventional trials to guide the diagnosis, treatment, and prevention of respiratory disease in this vulnerable population. Future research should include studies of interventions designed to improve short- and long-term respiratory-related outcomes of children with tracheostomy.