4. Review of the Literature Bacterial colonization,
tracheobronchitis and pneumonia following tracheostomy and
long-term intubation in pediatric patients. (Chest
1979;76;420-424). 27 patients with CNS diagnosis and artificial
airways 100% had airway colonization TB defined as purulent
secretions without clinical or radiographic evidence for pneumonia
16.5 trach cultures/patient/year Bacteria profile changed 50% of
the time with pneumonia 24 (89%) had recurrent chronic TB and 68
episodes of pneumonia (2.8 episodes per patient) Antibiotic
treatment changed bacteria profile Pseudomonas, serratia, strep
pneumoniae, alpha-strep, E coli, staph, anaerobes (2 patients had
positive blood cultures) 4 of 37
5. Review of the Literature Suspected Respiratory Tract
Infection in the Tracheostomized Child: The Pediatric
Pulmonologists Approach. (Chest 1998;113;1549-1554). Goal to
determine standard of care for differentiating colonization from
infection in trached children (multiple diagnoses) by survey of
practitioners in academic setting (34/46 responded) Average 48.5
+/- 77 patients (50% vented) 91% get trach culture if change in
trach secretions (regardless clinical status) Most frequent change
(green sputum, then foul smelling, then fever) Most frequent
indication for Abx Tx (WBCs in sputum, then resp illness, then
green or foul smelling secretions) 79% managed over telephone No
formal protocol Most centers will not treat with Abx in presence of
purulence if patient well Most common Abx Bactrim and Augmentin
outweighed nebulized tobi/gent No waiting for culture to prescribe
(base on previous), no f/u cultures 5 of 37
6. Review of the Literature Oropharyngeal carriage and lower
airway colonization/infection in 45 tracheotomized children.
(Thorax 2002;57;1015-1020). 5-year prospective study of 45 children
(neuro and airway obstruction) initially intubated then trached in
a PICU before transfer to chronic ward Infection treated with Abx
for fever>38.5C, leukocytosis, increased CRP, purulent
secretions (>106 CFU/ml) Pneumonia only diagnosed if + CXR
Compared potential pathogens in mouth with lower airway 6/45 had
sterile lower airways (these patients had normal mouth flora) 39/45
(86%) had colonized/infected lower airways post trach Community
flora more common following trach (S pneumoniae, M catarrhalis, H
influenzae, S aureus, E coli) Hospital flora more common intubated
(pseudomonas, acintobacter, klebsiella, S maltophilia) 33% post
trach with pseudomonas (no change) but increased S aureus 6 of
37
7. Review of the Literature Surveillance tracheal aspirate
cultures do not reliably predict bacteria cultured at the time of
an acute respiratory infection in children with tracheostomy tubes.
(Chest 2011;DOI 10.1378/ Chest 10-2539). Study designed to
characterize practice of obtaining and using info from trach
cultures to guide treatment of lower resp tract infections Records
retrospectively reviewed from 170 children over 4 years Survey of
pediatric pulmonologists and otolarygologists (ENT) 54% of
pulmonologists and 15% of ENT obtain routine tracheal aspirates,
among physicians who obtain cultures, 80% of ENT and 97% of
pulmonologists use info to guide therapy In children with
surveillance cultures, common for recovered pathogenic bacteria
(when patient ill) to be different than from previous surveillance
culture Potentially ineffective antibiotic coverage would have been
chosen in 56% of cases if previous trach culture had been used to
guide therapy Limited value using previous trach cultures to guide
therapy Probably little value obtaining routine trach cultures 7 of
37
8. Review of the Literature A pediatric home health infection
control surveillance program: Implementation to outcomes. (Caring
2005, Sept. 26-33). Childrens Homecare of Columbus, Ohio Monitored
respiratory infections in home-bound trach dependent children
Clinical; fever>99 axillary, new or increased secretions,
purulence, cough, SOB, RR, new chest findings Diagnostic criteria;
trach culture and or CXR Needed one clinical and one diagnostic or
3 clinical and Abx prescribed 6 to 12 respiratory infections per
1,000 trach days 8 of 37
10. What We Know! Microbiological colonization well described
May be different from when first hospitalized to steady state
Microbiological colonization is dynamic, often changes over time
and after antibiotic treatment Should not base treatment on cystic
fibrosis model 10 of 37
11. What We Know! Surveillance cultures probably not helpful
Role of anaerobes unclear Different prescribing patterns for
threshold of tracheobronchitis Oral antibiotics most common
treatment in the past Most managed over the phone Little data on
frequency of respiratory infections or tracheobronchitis in trached
patients at home 11 of 37
12. What We Dont Know! Standard of care in the PHS community: -
Telephone or office visit to manage episodes - Prescribing patterns
of antibiotics; neb vs. oral vs. IV vs. combination - Duration of
treatment - Cultures obtained? - Other interventions implemented?
12 of 37
13. What We Dont Know! Episodes of TB per patient per year
Episodes of TB per 1,000 trach days Failed treatment for TB
episodes resulting in hospitalization (still in review) Incidence
of fever with TB episodes Difference in TB episodes related to: -
Suction technique - Vent or no vent - Patient ability to cough or
not cough - Diagnosis - Age 13 of 37
14. PHS Tracheobronchitis Study Objective: - Document standard
of care in community - Frequency of TB episodes - Most common
presenting clinical symptoms - Identify risk factors associated
with development of TB in trached home care patients - Episodes of
home treatment failure resulting in a respiratory hospitalization
14 of 37
15. PHS Tracheobronchitis Study Study Design: - Prospective
surveillance study 12-month duration - Final 225 trached patients
(started 238; 13 patients dropped out, ended up with 140 vent, 85
humidity) - Patient ages (0-40 years) - Surveyed monthly by PHS
respiratory therapists for Abx treated TB episodes -
Tracheobronchitis episode defined as respiratory symptoms and
illness in a tracheostomized patient felt to warrant antibiotic
treatment by a health care provider 15 of 37
16. Pneumonia New crackles CXR findings Health care provider
diagnosed (Still in review of hospital records) 16 of 37
17. Patients Greater/Less Than 18 Years of Age Patients Min Max
Mean Std Median Mode All 225 0 40 10.08 9.1086 7.0 0 < 18 years
175 0 17 6.22 5.5043 4.0 0 >= 18 years 50 18 40 23.60 5.6460
22.0 18 17 of 37
18. Age Subcategories Patients Min Max Mean Std Median ModeAll
225 0 40 10.08 9.1086 7.0 0