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Bacterial and fungal colonization of endotracheal tubes in children: a prospective study
J S Rubenstein1, K Kabat, S T Shulman
1Division of Pediatric Critical Care, Northwestern University Medical School, Chicago, IL.
Insights
Buccal mucosa colonization precedes endotracheal pathogen acquisition in intubated children. Gastric pH and Pediatric Risk of Mortality scores can predict this colonization, guiding selective decontamination strategies.
Area of Science:
- Pediatric critical care medicine
- Infectious disease epidemiology
- Microbiology
Background:
- Endotracheal colonization by pathogens poses a significant risk to intubated children.
- Identifying predictors of colonization is crucial for timely intervention.
Purpose of the Study:
- To determine the frequency and origin of endotracheal colonization in intubated children.
- To assess the predictive value of Pediatric Risk of Mortality (PRM) scores and gastric pH for endotracheal colonization.
Main Methods:
- Prospective study in a multidisciplinary pediatric ICU.
- Collected cultures from buccal mucosa, endotracheal aspirates, and gastric aspirates.
- Calculated PRM scores and measured gastric pH at intubation.
Main Results:
- Buccal mucosa colonization with Candida species occurred in 53% of children at intubation, correlating with PRM scores.
- 58% of children acquired endotracheal pathogens post-intubation, with the buccal mucosa as the initial site in 70%.
- Gastric pH > 3.0 and PRM score > 8 predicted colonization with significant accuracy.
Conclusions:
- Buccal mucosa colonization is a key precursor to endotracheal colonization in pediatric patients.
- Gastric pH and PRM scores are valuable predictors of pathogenic endotracheal colonization within 4 days of intubation.
- Selective decontamination targeting the buccal mucosa may be beneficial for high-risk children.
Objectives:
To evaluate both the frequency and route of endotracheal colonization of intubated children by pathogens and to assess the usefulness of Pediatric Risk of Mortality scoring and measurement of gastric pH in predicting this colonization.
Design:
Prospective data collection.
Setting:
A multidisciplinary pediatric ICU.
Patients:
Nineteen children with medical/surgical problems who were intubated for at least 4 days.
Interventions:
Buccal mucosa, and endotracheal and gastric aspirates were cultured for pathogens immediately after endotracheal intubation and daily for 4 to 5 days. Pediatric Risk of Mortality scores were calculated at the time of endotracheal intubation; gastric pH was measured each time that the cultures were obtained.
Measurements And Main Results:
The buccal mucosae of ten (53%) of 19 children were colonized with Candida species at the time of endotracheal intubation. This colonization correlated with the degree of physiologic instability as measured by Pediatric Risk of Mortality scores (12.9 +/- 2.8 SEM for those patients colonized vs. 4.9 +/- 1.0 for those patients not colonized; p = .01), but not with preintubation antibiotic therapy. Eleven (58%) children acquired 27 endotracheal pathogens after the day of intubation. The buccal mucosa was the initial site of colonization of 19 (70%) of 27 of the acquired pathogens. A gastric pH of > 3.0 at the time of intubation correctly predicted colonization in nine of 11 children (p < .025, Fisher's exact test); a Pediatric Risk of Mortality score of > 8 at the time of endotracheal intubation correctly predicted colonization in eight of 11 patients (p < .05, Fisher's exact test).
Conclusions:
Colonization of the buccal mucosa appears to be the crucial antecedent to endotracheal colonization in children. In children, gastric pH and Pediatric Risk of Mortality scores at the time of endotracheal intubation can predict pathogenic endotracheal colonization within 4 days of intubation. Selective decontamination regimes may be appropriate for these patients, especially those regimes that are directed to the buccal mucosa.