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Suspected respiratory tract infection in the tracheostomized child: the pediatric pulmonologist's approach
L S Rusakow1, M Guarín, C B Wegner
1Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, USA.
Insights
Pediatric pulmonologists lack consensus on distinguishing bacterial airway colonization from infection in children with long-term tracheostomies, leading to empirical antibiotic use. Further research is needed to develop objective criteria for optimal patient care.
Area of Science:
- Pediatric Pulmonology
- Infectious Diseases
- Respiratory Medicine
Background:
- Children with long-term tracheostomies often have bacterial airway colonization.
- Differentiating colonization from active infection is challenging for guiding antibiotic therapy.
Purpose of the Study:
- To assess consensus among pediatric clinicians on managing respiratory infections in tracheostomized children.
- To investigate current practices regarding tracheal aspirate cultures and antibiotic use.
Main Methods:
- A questionnaire survey was distributed to 47 pediatric pulmonary centers.
- Responses were received from 34 centers (72%) representing diverse patient loads.
Main Results:
- Management practices varied significantly across centers (65%), often influenced by the child's specific condition.
- Common triggers for cultures included changes in secretions (91%) or unexplained fever (21 centers).
- Antibiotic treatment decisions were based on factors like leukocytes in secretions (21 centers) or respiratory illness symptoms (18 centers), with 97% using empirical, often enteral, antibiotics.
Conclusions:
- While pediatric pulmonologists share some common approaches, a definitive consensus on managing suspected respiratory infections in tracheostomized children is lacking.
- Current clinical practice relies heavily on empirical antibiotic administration.
- Developing objective criteria to distinguish bacterial colonization from infection is crucial for optimizing care in this vulnerable population.
Study Objectives:
It is difficult to determine, in the child with a long-term tracheostomy, when bacterial airway colonization has progressed to a respiratory infection requiring antibiotic treatment. Our aim was to investigate whether there is a consensus regarding this and related chronic care issues among clinicians treating these patients.
Design And Setting:
A questionnaire asking about practices regarding use of tracheal aspirate cultures and antibiotics was distributed to 47 pediatric pulmonary centers.
Participants:
Individuals representing 34 centers (72%), caring for 10 to 400 patients, responded.
Interventions:
None.
Results:
At 65% of centers, management is variable, dependent on the patient's underlying condition. The most common indications to obtain a culture were change in secretions (91%) or fever without an obvious source (21 centers). Indications to treat with antibiotics included many leukocytes in secretions (21 centers) or a respiratory illness (18 centers). When treating, 97% prescribe antibiotics empirically, most often enterally; nine centers use inhaled antibiotics. In most centers (79%), management is often done by telephone.
Conclusions:
Although pediatric pulmonologists tend to have similar approaches to assessment and management of suspected respiratory tract infections in tracheostomized children, no clear consensus exists, and much of current practice is empirical. To optimize care of these patients, studies should be conducted to develop criteria to objectively differentiate bacterial airway "colonization" from "infection."