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.