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Study design of ventilator-associated tracheitis (VAT) in the neonatal and pediatric intensive care units between 1 January 2007 and 31 December 2009.
Source publication
The optimal duration of antibiotic therapy for ventilator-associated tracheitis (VAT) has not been defined, which may result in unnecessarily prolonged courses of antibiotics. The primary objective of this study was to determine whether prolonged-course (≥7 days in duration) therapy for VAT was more protective against progression to hospital-acquir...
Context in source publication
Context 1
... medical records of all of these children were reviewed to de- termine whether they met inclusion criteria. Seventy-two chil- dren were excluded because of preexisting tracheostomies (Figure 1). Of the 336 children with endotracheal tubes who had bacteria cultured from their sputum samples, 37 children were excluded because of a new infiltrate on chest imaging. ...
Similar publications
Measuring the attributable mortality of ventilator-associated pneumonia (VAP) is challenging and prone to different forms of bias. Studies addressing this issue have produced variable and controversial results.
We estimate the attributable mortality of VAP in a large multicenter cohort using statistical methods from the field of causal inference.
P...
Citations
... In addition, antibiotics can be toxic and exacerbate end organ damage in critically ill patients [35]. In the pediatric population, studies have focused on shortening antibiotics for specific diseases such as tracheitis, community-acquired pneumonia, and urinary tract infections [39][40][41]. Additionally, multiple studies have been done to reduce the use or misuse of antibiotics in the neonatal population. ...
Purpose of Review
This review explores the current literature on the diagnosis and management of pediatric culture negative sepsis.
Recent Findings
We explored logistical factors associated with culture negative sepsis, potential diagnostic tools such as biomarkers, and the limited evidence for treatment of culture negative sepsis in children. In the setting of a negative blood culture, but high clinical suspicion for bacterial infections, clinicians look to biomarkers to help guide the use of antibiotics. These biomarkers, however, are not consistently helpful. In general, procalcitonin is superior to CRP for its specificity of a bacterial infection. However, evidence shows this biomarker may better serve to rule out bacterial infection. Other studies suggest procalcitonin may be used as a method to determine the length of antibiotic therapy, but these protocols have not been standardized. Few studies look at appropriate antibiotic duration for culture negative sepsis but suggest it may be adequate to treat for 5–7 days.
Summary
Overall, culture negative sepsis remains difficult to diagnose and has limited guidance for treatment. This is an important area for future research to help limit the misuse of antibiotics in the era of growing antimicrobial resistance.
... 12 Children with tracheostomies are frequently treated with broad spectrum antimicrobials for the prevention or treatment of respiratory tract infections. There is however little consensus in practice, with variation in the indication for treatment/ prophylaxis, choice of antimicrobial, route of administration, and duration of treatment, between different centres [15][16][17] . Of course the clinical complexity of children requiring tracheostomies undoubtedly contributes to this heterogeneity in practice; many children with tracheostomies have comorbidities affecting multiple systems. ...
... Six retrospective cohort studies looked at the use of systemic antimicrobials; these are summarised on table 1. Of these studies, one covered initiation of antimicrobials in outpatient clinics 27 , four looked at choice of inpatient antimicrobials [28][29][30][31] , and one assessed impact of duration of antimicrobial therapy for airway infections 16 . ...
Tracheostomies are indicated in children to facilitate long-term ventilatory support, aid in the management of secretions, or to manage upper airway obstruction. Children with tracheostomies often experience ongoing airway complications, of which respiratory tract infections are common. They subsequently receive frequent courses of broad spectrum antimicrobials for the prevention or treatment of respiratory tract infections. However, there is little consensus in practice with regard to the indication for treatment/ prophylactic antimicrobial use, choice of antimicrobial, route of administration, or duration of treatment between different centres. Routine antibiotic use is associated with adverse effects and an increased risk of antimicrobial resistance. Tracheal cultures are commonly obtained from paediatric tracheostomy patients, with the aim of helping guide antimicrobial therapy choice. However, a positive culture alone is not diagnostic of infection and the role of routine surveillance cultures remains contentious. Inhaled antimicrobial use is also widespread in the management of tracheostomy associated infections; this is largely based upon theoretical benefits of higher airway antibiotic concentrations. The role of prophylactic inhaled antimicrobial use for tracheostomy associated infections remains largely unproven. This systematic review summarises the current evidence base for antimicrobial selection, duration, and administration route in paediatric tracheostomy associated infections. It also highlights significant variation in practice between centres and the urgent need for further prospective evidence to guide the management of these vulnerable patients.
... In the concordant group, excess DOT was calculated based on each organism's treatment indication. For organisms growing in a culture with an indication of tracheitis, any therapy beyond 5 days was considered excess (13). For organisms growing in a culture with an indication of pneumonia, any therapy beyond 7 days was considered excess (14). ...
Endotracheal aspirate cultures (EACs) help diagnose lower respiratory tract infections in mechanically ventilated patients but are limited by contamination with normal microbiota and variation in laboratory reporting. Increased use of EACs is associated with increased antimicrobial prescribing, but the impact of microbiology reporting on prescribing practices is unclear. This study was a retrospective analysis of EACs from mechanically ventilated patients at Children's Hospital Colorado (CHCO) admitted between 1 January 2019 and 31 December 2019. Chart review was performed to collect all culture and Gram stain components, as well as antibiotic use directed to organisms in culture. Reporting concordance was determined for each organism using American Society for Microbiology guidelines. Days of therapy were calculated for overreported and guideline-concordant organisms. A multivariable model was used to assess the relationship between organism reporting and total days of therapy. Overall, 448 patients with 827 EACs were included in this study. Among patients with tracheostomy, 25 (8%) organisms reported from EACs were overreported and contributed 48 days of excess therapy, while 227 (29%) organisms from the EACs of endotracheally intubated patients were overreported, contributing 472 excess days of therapy. After adjustment, organism overreporting was associated with a >2-fold-higher rate of antimicrobial therapy than guideline-concordant reporting (incident rate ratio [IRR], 2.83; 95% confidence interval [CI], 1.23, 6.53; P < 0.05). Overreported organisms from respiratory cultures contribute to excess antimicrobial therapy exposure in mechanically ventilated patients. Microbiology laboratories have an opportunity to mitigate antimicrobial overuse through standardized reporting practices.
... One retrospective study found that prolonged antibiotics for ventilator-associated tracheitis did not protect against VAP but did increase the prevalence of multidrug-resistant organisms. 272 Whether, when, and how long to treat ventilatorassociated tracheitis to prevent VAP in children remains unresolved. 273 ...
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
... Ventilator-associated respiratory tract infections are the most common hospital-acquired infections in intensive care units [1,2]. Ventilator-associated tracheitis (VAT) lies on the continuum between respiratory tract colonization and ventilator-associated pneumonia (VAP) [3,4]. VAP is well-defined in neonates by the National Healthcare Safety Network (NHSN) as persistent radiographic findings-infiltrate, consolidation, cavitation, or pneumatocele-plus clinical signs and symptoms-worsening gas exchange with three of the following criteria: temperature instability, leukopenia or leukocytosis, purulent or changing sputum or secretions, respiratory distress or apnea, lung field auscultative findings, cough, or bradycardia or tachycardia [5]. ...
... Antibiotic overuse increases the risk for multi-drug resistant organisms and the overall cost of care [13]. Prolonged antibiotic use ≥7 days does not reduce the risk for progression of VAT to VAP and increases risk for multidrug-resistant organism acquisition [3]. ...
... We incorporated expert opinion from pediatric infectious diseases and neonatology experts at our institution. We defined the following recommended criteria for sending a tracheal aspirate culture to evaluate for VAT: 1) The subjective increase in quantity or change in the quality of endotracheal secretions AND one of the following: 2) increased oxygen requirements or ventilator settings, 3) temperature instability with no other cause, 4) increase in apnea or bradycardia, or 5) abnormal white blood cell count (high or low) [3,5,10]. We defined VAT as ≥ 25 PMNs on tracheal aspirate Gram stain and the presence of a pathogenic organism [10,19]. ...
Background
There are no published guidelines regarding the diagnosis and treatment of ventilator-associated tracheitis (VAT) in the neonatal intensive care unit (NICU). VAT is likely over-diagnosed and over-treated, increasing antibiotic burden and cost.
Local problem
Diagnosis and treatment of VAT were entirely NICU provider dependent.
Methods
Retrospective pre- and post-intervention chart reviews were performed.
Interventions
A VAT diagnosis and treatment algorithm was created for use in the care of intubated patients without tracheostomies. 3 plan-do-study-act (PDSA) cycles were used to implement change.
Results
Intubated patients treated for VAT with <25 PMNs on Gram stain decreased from 79% to 35% following the quality improvement (QI) initiative. Treatment of VAT with >7 days of antibiotic therapy decreased from 42% to 10%.
Conclusion
Implementing a QI initiative to improve the diagnosis and treatment of VAT in the NICU decreased the percent of patients treated inappropriately for VAT.
... Similarly, 60% of tracheal aspirates in a Canadian PICU grew Haemophilus influenzae and Pseudomonas aeruginosa [15]. Antibiotic need and duration for ventilatorassociated tracheitis in the pediatric population are not well defined [16,17]. ...
Background
There is limited data on pediatric ventilator-associated events (PedVAE) in the neonatal intensive care unit (NICU) setting, since the CDC mandated state reporting of these events in January 2019. This study sought to describe PedVAE rates and characteristics in the NICU population.
Methods
Single-center case-control study of infants requiring mechanical ventilation in a 39-bed level IV NICU between January 1, 2018 and December 31, 2020. Baseline infant demographic, respiratory support and antibiotic use data was obtained and comparisons were performed between patients with potential PedVAEs and those without events.
Result
Two hundred and nine infants were mechanically ventilated. Two of the 126 patients ventilated for ≥4 days met CDC criteria for PedVAEs with a total of 3 events, and 32 (25%) received antibiotics with escalation of respiratory support, primarily for tracheitis.
Conclusion
NICU-specific data on PedVAE is limited. Only 2 infants in the study period met the current CDC criteria for PedVAE with a rate of 0.9 events per 1000 ventilator days. The current CDC PedVAE definition might be inadequate to identify actionable VAEs to inform prevention efforts in the NICU population, and alternate indices could better characterize these events.
... A retrospective cohort study showed that patients treated for VAT greater than 7 days did not have a lower incidence of VAP compared to those treated for 7 days or less. 7 The study assessed several factors to determine what risk factors were associated with an increase in VAP which included endotracheal tube (ETT) remaining throughout duration of treatment, PRISM score, gram-negative organism present in aspirate, combination antibiotics, additional antibiotic therapy for more than 48 hours within 10 days of VAT diagnosis, and admission to the neonatal intensive care unit. 7 The only statistically significant prognostic indicator for developing VAP was ETT remaining throughout duration of treatment (adjusted HR 4.16 (1.39-12.45), ...
... 7 The study assessed several factors to determine what risk factors were associated with an increase in VAP which included endotracheal tube (ETT) remaining throughout duration of treatment, PRISM score, gram-negative organism present in aspirate, combination antibiotics, additional antibiotic therapy for more than 48 hours within 10 days of VAT diagnosis, and admission to the neonatal intensive care unit. 7 The only statistically significant prognostic indicator for developing VAP was ETT remaining throughout duration of treatment (adjusted HR 4.16 (1.39-12.45), p < 0.01). ...
... p < 0.01). 7 This study, similarly, excluded patients with pre-existing tracheostomies. ...
Evaluation of Ventilator-Associated Tracheitis in Children with Pre-Existing Tracheostomies: Organisms and Empiric Coverage Objectives: This study aims to describe the outcomes, microbiome, and empiric antimicrobial coverage of ventilator associated tracheitis (VAT) in pediatric patients with pre-existing tracheostomies. Patients and Methods: This is a retrospective chart review of pediatric patients with pre-existing tracheostomies admitted to the Children’s Hospital of Georgia for initial inpatient treatment for VAT between January 1, 2007 and February 21, 2021. Patients were evaluated for incidence of ventilator associated pneumonia (VAP), tracheostomy culture results, and antibiotic choice. Results: Thirty-nine patients were included. Across all patients evaluated with pre-existing tracheostomies, 60% developed VAT. There was no difference in the development in VAP between shorter and longer treatment durations (0 vs 1, p = 1). Patients who developed Pseudomonas aeruginosa VAT were likely to have a previous culture of P. aeruginosa (p = 0.003), have a tracheostomy for longer (p = 0.011), and be older than 1 year of age (p = 0.0002). MRSA VAT was associated with a previous culture growing MRSA (p= 0.0042). Conclusions: VAT incidence was higher than what was shown in pediatric patients without pre-existing tracheostomies but VAP incidence was lower and there was no difference between treatment groups. VAT should be treated based on previous cultures and Pseudomonas aeruginosa should be considered as a causative organism.
... Seventy-six children (median age 9.5, IQR 3.6-13.1 years), received ciprofloxacin or levofloxacin for VAT treatment during the study period. Median treatment duration was 8 (range [7][8][9][10] days. Most tracheostomy cultures (n=70/82, 85%) were polymicrobial, with P. aeruginosamost commonly isolated (n=67/224 organisms, 30%). ...
... The most commonly isolated organism in this study was P. aeruginosa , which is similar to the results of other studies in both pediatric 8 and adult critically ill patients 7,19,20 . S. aureus was also commonly isolated, again corroborated by pediatric and adult evidence 7,8,19 . ...
Introduction Pseudomonas aeruginosa is the most commonly isolated organism in children with ventilator-associated tracheobronchitis (VAT). Enteral treatment with ciprofloxacin or levofloxacin is sometimes employed, but supportive data are limited. The purpose of this study was to evaluate the effectiveness and safety of enteral ciprofloxacin and levofloxacin administration for VAT in children. Methods This was a retrospective review of electronic medical records for children less than 18 years of age who received enteral ciprofloxacin or levofloxacin for the treatment of VAT from January 2013 through January 2020 at an academic children’s hospital. Results Seventy-six children (median age 9.5, IQR 3.6-13.1 years), received ciprofloxacin or levofloxacin for VAT treatment during the study period. Median treatment duration was 8 (range 7-10) days. Most tracheostomy cultures (n=70/82, 85%) were polymicrobial, with P. aeruginosa most commonly isolated (n=67/224 organisms, 30%). Sixty-five children (86%) were successfully treated with an enteral fluoroquinolone. Antibiotics were changed or extended for two (3%) children. Ten (13%) children were prescribed antibiotics and eight (11%) required hospitalization for a lower respiratory tract infection within 30 days of completion of their fluoroquinolone course. Six (8%) patients received a seizure rescue medication, seven (9%) experienced emesis, and one (1%) had elevated transaminases. Tendonitis, tendon rupture and QTc prolongation were not observed. Conclusions The results of this study suggest enteral fluoroquinolones may be effective for the treatment of VAT in children. Further study is warranted to clarify the role of these agents in pediatric VAT.
... 22 One pediatric study concluded that prolonged antibiotics (older than 7 days) for VAT did not protect against hospital-acquired pneumonia or VAP. 23 Martin-Loeches et al and Moncayo-Nieto et al found that adult patients with VAT had a resolution of symptoms at 72 hours, supporting a 3-day course of antibiotics. 19,20 Preliminary evaluation of our Medical Intensive Care Unit (MICU) practice revealed variation in criteria to obtain a tracheal aspirate culture, with the most common indications being fever (55% of samples), increased ventilator settings (40%), and increased supplemental oxygen requirement (35%). ...
There is no consensus definition for ventilator-associated tracheitis and limited evidence to guide diagnosis and treatment. To improve acute tracheitis evaluation and management, this quality improvement project aimed to (1) improve the appropriateness of tracheal aspirate cultures while decreasing the number of unnecessary cultures by 20% and (2) decrease antibiotic use for acute tracheitis not consistent with local guidelines by 20% over 12 months among pediatric patients requiring mechanical ventilation.
Methods:
All patients admitted to the Medical Intensive Care Unit requiring mechanical ventilation via an artificial airway were included. Tracheal aspirate sampling criteria, technique, and minimum intervals were standardized. Primary outcome measures were the number of tracheal aspirate cultures obtained per 100 ETT/tracheostomy days and ventilator-associated antibiotic days per 100 ETT/tracheostomy days. Improvement cycles included: Implementation of tracheal aspirate sampling criteria, sampling technique standardization, limiting repeat cultures to >72-hour intervals, and standardizing empiric antibiotic therapy.
Results:
Tracheal aspirate culture rate decreased from 10.70 to 7.10 cultures per 100 ETT/tracheostomy days (P < 0.001). Cultures meeting sampling criteria increased from 28% to 80%. Ventilator-associated antibiotic use decreased from 24.88 to 7.30 ventilator-associated antibiotic days per 100 ETT/tracheostomy days. There were no associated increases in ventilator-associated events or days of mechanical ventilation.
Conclusions:
Implementation of standardized criteria for tracheal aspirate sampling, improved tracheal aspirate sampling technique, limiting repeat tracheal aspirate cultures, and utilizing standardized antibiotic treatment guidelines safely decreased resource utilization and antibiotic use among critically ill children requiring mechanical ventilation.
... Previous studies [24,25] have concluded that the hospitalization time of patient needs to be strictly controlled, which is one of the effective measures to prevent MDRI. Mechanical ventilation can significantly increase the chance of respiratory infection [26,27]. The establishment of an artificial airway in an ICU patient results in the disappearance of the natural barrier of the upper respiratory tract and direct communication of the lower respiratory tract with the outside air. ...
Background:
The risk factors for multi-drug resistant infection (MDRI) in the pediatric intensive care unit (PICU) remain unclear. It's necessary to evaluate the epidemiological characteristics and risk factors for MDRI in PICU, to provide insights into the prophylaxis of MDRI clinically.
Methods:
Clinical data of 79 PICU children with MDRI were identified, and 80 children in PICU without MDRI in the same period were selected as control group. The related children's characteristics, clinical care, microbiologic data, treatments provided, and outcomes of the patients with were reviewed and collected. Univariate and multivariate logistic regression analyses were performed to identify the potential risks of MDRI in PICU.
Results:
Of the diagnosed 79 cases of MDRI, there were28 cases of CR-AB, 24 cases of MRSA, 22 cases of PDR-PA,3 cases of VRE and 2 cases of CRE respectively. Univariate analyses indicated that the length of PICU stay, the duration of mechanical ventilation > 5 days, parenteral nutrition, coma, urinary catheter indwelling, invasive operation, 2 or more antibiotics use were associated with MDRIs (all p < 0.05); The logistic multiple regression analyses indicated that coma, parenteral nutrition, 2 or more antibiotics use and the duration of mechanical ventilation > 5 days were independent risk factors associated with MDRI (all p < 0.05).
Conclusions:
This present study has identified several potentially modifiable risk factors for MDRI in PICU, it's conducive to take appropriate measures targeting risk factors of MDRI for health care providers to reduce MDRI.
