<div>The effects of nebulized antibiotics in children with tracheostomy</div><div>Emine Atag, MD, Medipol University Faculty of Medicine, Division of
Pediatric Pulmonology Istanbul, Turkey</div><div>Fusun Unal, MD, Medipol University Faculty of Medicine, Department of
Pediatrics Istanbul, Turkey</div><div>Huseyin Arslan, MD, Medipol University Faculty of Medicine, Division of
Pediatric Pulmonology Istanbul, Turkey</div><div>Burcu Gizem Teber, MD, Medipol University Faculty of Medicine,
Department of Pediatrics Istanbul, Turkey</div><div>Leyla Telhan, MD, Medipol University Faculty of Medicine, Department of
Pediatrics Istanbul, Turkey</div><div>Refika Ersu, Professor, Marmara University Faculty of Medicine, Division
of Pediatric Pulmonology Istanbul, Turkey</div><div>Fazilet Karakoc, Professor, Marmara University Faculty of Medicine,
Division of Pediatric Pulmonology Istanbul, Turkey</div><div>Sedat Oktem, Professor, Medipol University Faculty of Medicine, Division
of Pediatric Pulmonology Istanbul, Turkey</div><div>Address correspondence to: Emine Atag, Division of Pediatric
Pulmonology, Medipol University Hospital Göztepe mah., Metin Sk. No:4,
34214 Bağcılar/İstanbul, Turkey,
(<i>emineatag@gmail.com</i>)</div><div>Tel: +90 533 6850087</div><div>Fax:+90212 4607070</div><div>Key words: Children, nebulized antibiotics, tracheostomy</div><div>Running title: Nebulized antibiotics in children with tracheostomy</div><div>Funding Source: No external funding for this manuscript.</div><div>Financial Disclosure: The authors have indicated they have no financial
relationships relevant to this article to disclose.</div><div>Conflict of Interest: The authors have indicated they have no potential
conflicts of interest to disclose.</div><div>Abstract</div><div>Introduction</div><div>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.</div><div>Methods</div><div>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.</div><div>Results</div><div>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 (10<sup>5</sup> CFU/ml
(10<sup>5</sup>-10<sup>6</sup>) <i>vs.</i>6x10<sup>4</sup> CFU/ml
(10<sup>4</sup>-10<sup>5</sup>); p=0.003).</div><div>Conclusions</div><div>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.</div><div>Abbrevevations</div><div>CF: Cystic Fibrosis</div><div>P.Aeruginosa: Pseudomonas aeruginosa</div><div>Introduction</div><div>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 reflex<sup>1</sup>. In
patients with tracheostomy, altered anatomy and recurrent suctioning
lead to chronic colonization and subsequent
infections<sup>2</sup>.</div><div>Bacterial colonization has been reported in up to 95% of children with
a tracheostomy, while the most common agent is <i>Pseudomonas
aeruginosa (P. Aeruginosa)</i> , with a rate of
50-90%<sup>2,3</sup>. <i>P. aeruginosa</i> and other gram
negative enteric pathogens are associated with worse clinical outcomes
and frequent hospitalizations<sup>4,5</sup>. 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
resistance<sup>6,7</sup>. 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 mortality<sup>6-8</sup>.</div><div>There are limited number of studies evaluating the use of nebulized
antibiotics in children with tracheostomy<sup>9</sup>. Eckerland
et al reported the effect of nebulized antibiotic therapy in a small
number (n=9) of tracheotomised patients with neurological
impairment<sup>10</sup>. 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
tracheitis<sup>11</sup>. 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.</div><div>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.</div>