Factors associated with tracheostomy-associated infection treatment: A multicenter observational study
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Published on: May 18, 2019
John M Morrison1,2, Naoko Kono3, Margaret Rush4,5
1Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
Insights
Bacterial tracheostomy-associated respiratory infections (bTRAINs) in children are treated more often when respiratory cultures are positive for bacteria, especially Pseudomonas aeruginosa. Viral detection may lead clinicians to withhold antibiotics.
Area of Science:
- Pediatric Infectious Diseases
- Critical Care Medicine
- Respiratory Medicine
Background:
- Pediatric bacterial tracheostomy-associated respiratory infections (bTRAINs) pose a significant clinical challenge.
- Understanding factors influencing treatment decisions for bTRAINs is crucial for optimizing patient care.
- Previous research has not fully elucidated the specific drivers of antibiotic prescribing for these infections.
Purpose of the Study:
- To identify factors influencing the decision to administer antibiotic treatment for suspected pediatric bacterial tracheostomy-associated respiratory infections (bTRAINs).
- To analyze the association between respiratory culture results and bTRAIN treatment.
- To explore the impact of clinical and diagnostic findings on treatment decisions.
Main Methods:
- A multicenter, prospective cohort study involving children with pre-existing tracheostomies hospitalized with suspected bTRAINs.
- Respiratory cultures were analyzed, categorizing growth as Pseudomonas aeruginosa, mixed bacteria, other bacteria alone, or normal flora.
- Logistic regression with generalized estimating equations was used to determine associations between predictors and bTRAIN treatment.
Main Results:
- Of 440 admissions, 53.9% received bTRAIN treatment; 69.8% had positive respiratory cultures.
- Positive cultures for Pseudomonas aeruginosa with other organisms (aOR 2.3) or other bacteria alone (aOR 2.8) were associated with increased treatment.
- Positive viral testing was associated with reduced odds of antibiotic treatment (aOR 0.5).
Conclusions:
- Positive respiratory bacterial cultures and clinical indicators of acute illness significantly influence bTRAIN treatment decisions.
- Diagnostic test results, including Gram-stain and chest radiography, are associated with treatment.
- Identification of a virus may lead clinicians to withhold antibiotics, suggesting a role for diagnostic testing in guiding therapy.
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.
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