The effects of nebulized antibiotics in children with tracheostomy
Emine Atag, MD, Medipol University Faculty of Medicine, Division of Pediatric Pulmonology Istanbul, Turkey
Fusun Unal, MD, Medipol University Faculty of Medicine, Department of Pediatrics Istanbul, Turkey
Huseyin Arslan, MD, Medipol University Faculty of Medicine, Division of Pediatric Pulmonology Istanbul, Turkey
Burcu Gizem Teber, MD, Medipol University Faculty of Medicine, Department of Pediatrics Istanbul, Turkey
Leyla Telhan, MD, Medipol University Faculty of Medicine, Department of Pediatrics Istanbul, Turkey
Refika Ersu, Professor, Marmara University Faculty of Medicine, Division of Pediatric Pulmonology Istanbul, Turkey
Fazilet Karakoc, Professor, Marmara University Faculty of Medicine, Division of Pediatric Pulmonology Istanbul, Turkey
Sedat Oktem, Professor, Medipol University Faculty of Medicine, Division of Pediatric Pulmonology Istanbul, Turkey
Address correspondence to: Emine Atag, Division of Pediatric Pulmonology, Medipol University Hospital Göztepe mah., Metin Sk. No:4, 34214 Bağcılar/İstanbul, Turkey, (emineatag@gmail.com)
Tel: +90 533 6850087
Fax:+90212 4607070
Key words: Children, nebulized antibiotics, tracheostomy
Running title: Nebulized antibiotics in children with tracheostomy
Funding Source: No external funding for this manuscript.
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
Conflict of Interest: The authors have indicated they have no potential conflicts of interest to disclose.
Abstract
Introduction
Children with tracheostomy have an increased risk of bacterial colonization and infections of the lower respiratory tracts. This study aimed to investigate the effects of nebulized antibiotics on the bacterial load, the need for oral antibiotic courses, the number of hospitalizations, and the length of stay in the intensive care unit in children with tracheostomy.
Methods
Children with tracheostomy and persistent bacterial colonization who were started on nebulized antibiotic therapy after a lower respiratory tract infection were included to the study. Nebulized gentamicin or colistin were used according to the results of tracheal aspirate cultures. Demographic and clinic characteristics were recorded from one year before until 12 months after initiating nebulized antibiotic treatment.
Results
Nebulized antibiotic treatment was initiated in 22 patients. Inhaled gentamicin was administered to 14 patients (63.6%) and colistin to 8 patients (36.4%). The median duration of treatment was 3 months (2-5 months). Following nebulized antibiotic treatment, median number of hospitalizations decreased from 2 (1-3.5) to 1 (0-1.5) (p=0.04). The median length of stay in the intensive care unit reduced significantly from 89.5 days (43-82.5) to 25 days (7.75-62.75) after starting nebulized antibiotics (p = 0.028). Following nebulized antibiotic treatment colony count also decreased (105 CFU/ml (105-106) vs.6x104 CFU/ml (104-105); p=0.003).
Conclusions
Nebulize antibiotics are a reasonable treatment option for lower respiratory tract infections for tracheotomized children with persistent colonization. Further studies are needed to determine the main indications and the optimal duration and doses of the long-term nebulized antibiotic treatment in these patients.
Abbrevevations
CF: Cystic Fibrosis
P.Aeruginosa: Pseudomonas aeruginosa
Introduction
Children with tracheostomy have an increased risk of bacterial colonization and persistent infection of the lower respiratory tract. Tracheostomy causes failure of the defensive mechanisms of the upper respiratory system, including filtering and removing the microorganisms via mucociliary transport and cough reflex1. In patients with tracheostomy, altered anatomy and recurrent suctioning lead to chronic colonization and subsequent infections2.
Bacterial colonization has been reported in up to 95% of children with a tracheostomy, while the most common agent is Pseudomonas aeruginosa (P. Aeruginosa) , with a rate of 50-90%2,3. P. aeruginosa and other gram negative enteric pathogens are associated with worse clinical outcomes and frequent hospitalizations4,5. Treatment of persistent respiratory infections requires long courses and high doses of systemic antibiotics. Delivering antibiotics directly to the airways via inhalation provides adequate deposition of the drugs in the airways and reduces the rates of systemic side effects and antimicrobial resistance6,7. Studies in children with cystic fibrosis (CF) and non-cystic fibrosis bronchiectasis investigating the use of nebulized antibiotics for chronic respiratory infections caused by gram-negative bacteria demonstrated that nebulized antibiotics are beneficial in reducing bacterial load and improving lung function, as well as reducing morbidity and mortality6-8.
There are limited number of studies evaluating the use of nebulized antibiotics in children with tracheostomy9. Eckerland et al reported the effect of nebulized antibiotic therapy in a small number (n=9) of tracheotomised patients with neurological impairment10. During the first 12 months of therapy, the frequency of respiratory tract infections, the need for systemic antibiotic therapies and hospitalization decreased. However, authors did not describe the indications for the initiation of nebulized antibiotics and the duration of treatment was not reported. In another study, Chen et al. compared the efficacy and safety of nebulized gentamicin and tobramycin in tracheotomised children with tracheitis11. This study showed that both agents were effective and safe and there was no difference between these antibiotics in terms of side effects with a short-term use.
In this study, we aimed to evaluate the effect of nebulized antibiotics on the need for oral antibiotic course, the number of hospitalizations, and the length of stay in the intensive care unit in children with tracheostomy. We also aimed to assess the bacterial load by colony counting in tracheal aspirate cultures of these children We hypothesized that the use of nebulized antibiotics in children with tracheostomy will reduce the number of hospitalizations and the length of stay in the intensive care unit, and the need for oral antibiotics, as well as the bacterial load.