Results
One hundred and sixty children with tracheostomy were followed at Medipol University between 2012 and 2019. Persistent bacterial colonization was present in 57 (36%) of the tracheotomised patients. Nebulized antibiotic treatment was initiated in 22 patients with persistent colonization after a lower respiratory tract infection. There were 15 boys (68%) and 7 girls (32%). The current median age was 75 months (40-115 months). The median age at the time of tracheostomy was 6 months (3-34 months). The median duration of tracheostomy was 32.5 months (19.5-68 months). Fourteen (64%) patients had neuromusculer disease, four patients (18%) had chronic lung disease as underlying primary condition. Neurological impairment such as hypotonia was present in 18 patients (82%). Twenty patients (91%) suffered from concomitant gastrointestinal problems including swallowing dysfunction, gastroesophageal reflux and the need for enteral feeding. Patient characteristics are shown in Table-1. Seventy one percent (n = 15) of the patients were on home mechanical ventilation. Except for one patient with cerebral palsy, all patients with neuromusculer disease or metabolic /syndromic disease were ventilator dependent.
Seventeen (77.3%) patients had P. aeruginosa growth in the tracheal aspirate cultures, Klebsiella pneumonia grew in three (13.6%) and Acinetobacter baumanni in two patiens. (9.1%). Five patients (22.7%) were colonized with more than one bacteria.
Nebulized gentamycin was administered to 14 patients (63.6%) and colimycin to 8 patients (36.4%). In six patients, gentamycin was changed to colimycin based on the antimicrobial resistance results. The median duration of treatment was 3.5 months (3-7.5 months). The median number of the oral antibiotic courses before and after 12 months of nebulized antibiotics were 1 (1-3) and 2 (1-3) respectively (p= 0.474). Following nebulized antibiotic treatment, median number of hospitalizations decreased from 2 (1-3.5) to 1 (0-1.5) (p=0.04).
Additionally, 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 (105CFU/ml (105-106) vs.6x104 CFU/ml (104-105); p=0.003). The median time to first bacterial growth was 3.7 month (1.17-6.62 months) after the discontuniation of the nebulized antibiotics.
The median colony count at the 12th month after the start of the nebulized antibiotics reduced significantly compared to prior to intervention (105 CFU/ml vs 104CFU/ml; p=0.02). Additionally, the number of patients with a colony count of >105 CFU/ml decreased from eighteen to six at the end of the study period (p=0.07) (Table-2). There were no significant correlations between current age, age at the time of tracheostomy, duration of tracheostomy and study outcomes (p>0.05).
Gentamycin resistance was observed in six patients (28.5%) during treatment. No resistance was observed with nebulized colimycin treatment. None of the patients reported respiratory adverse events including chest pain, dyspnea, bronchospasm during nebulized antibiotic treatment. Renal function tests were within normal limits during the nebulized antibitic treatment in all patients.
During follow-up, 3 patients were decannulated (14%). Two patients had congenital heart disease and one patient had chronic lung disease. During follow-up, 4 patients died due to their underlying diseases (18%).