KEYWORDS
Antimicrobial therapy, respiratory tract infections, paediatric tracheostomy
INTRODUCTION
Paediatric tracheostomy is mainly performed in infancy, to facilitate long-term ventilation or manage upper airway obstruction1–4. Over half of these children remain cannulated for life5,6. Paediatric tracheostomy has been identified as an area requiring care quality improvements1,7–9. Most children with tracheostomies will experience ongoing airway complications, of which respiratory tract infections are the most common, accounting for over a fifth of hospital readmissions in this group2,7,10–12. Complications increase the frequency of patients’ hospital visits and healthcare costs; they can also impair the quality of life of children and their carers4,6,10,13,14. A retrospective cohort study reporting healthcare costs for 1122 children, who underwent tracheostomy insertion in England over a 5 year period, reported 1213 hospital admissions for lower respiratory tract infections (LRTI) in the first year after tracheostomy alone costing £8,446,138 ($11,554,072).12Children 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 centres15–17. 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. Indeed, one study of 21,541 hospital admissions of children with tracheostomies in the United States found children to have a mean of five chronic health conditions.11Further, 81% had a complex chronic condition lasting at least 1 year, as defined by Feudtner et al.18; most commonly children had underlying neuromuscular (46%), congenital/ genetic (27%), or respiratory (20%) conditions.
The long-term effect of antimicrobial exposure on microbial communities and the presence of antimicrobial resistance genes within them (their “resistome”) is not fully understood and remains an active area of research19,20. Nevertheless, repeated cycles of broad spectrum antimicrobials increases the risk of drug-resistant organisms.21The increasing prevalence of antimicrobial resistance is a growing concern for the management of vulnerable patient groups, and healthcare in general; the World Health Organisation even lists antimicrobial resistance as one of their top 10 threats to humanity22. Studies of children with tracheostomies frequently demonstrate airway bacterial colonisation, often with drug resistant Pseudomonas aeruginosa and Methicillin-resistant Staphylococcus aureus.23The microbiology and antimicrobial resistance patterns of tracheostomy associated infections has been summarised in recent reviews15,24,25. This review aims to summarise the current evidence for the use of antimicrobial therapies in the management of tracheostomy dependent children and identify core areas of need for further research.
METHODS
The aim of this systematic review was to summarise and characterise existing literature addressing the use of antimicrobials in paediatric patients with a tracheostomy. A comprehensive search of PubMed (National Library of Medicine) and Embase (Elsevier) online databases was undertaken on 4th April 2023 using the search terms (‘children’ OR ‘paediatric’ OR ‘infant’ OR ‘adolescent’) AND ‘tracheostomy’ AND (‘respiratory tract infection’ OR ‘tracheitis’ OR ‘anti-infective agents’). Search results were limited to English Language articles published in the last 20-years. Further articles were obtained through their bibliographies. Inclusion criteria were full-text articles of any study design reporting the use of antimicrobial agents in tracheostomy dependent children. Exclusion criteria were conference abstracts without a full-text available and literature reviews without a meta-analysis. The titles and abstracts were assessed for eligibility by one independent reviewer, and full-text copies of all of the articles deemed potentially relevant were retrieved. Two review authors then independently reviewed full text articles. PRISMA guidelines were adhered to26.