781 Incidence and Management of Ventilator-Associated Tracheitis in the Neonatal and Pediatric Intensive Care Units

Sunday, March 21, 2010
Grand Hall (Hyatt Regency Atlanta)
Pranita D. Tamma, MD , Johns Hopkins Hospital, Baltimore, MD
Aaron M. Milstone, MD, MHS , Johns Hopkins University, Baltimore, MD
Emily RM Sydnor, MD , Johns Hopkins Hospital, Baltimore, MD
Christoph U. Lehmann, MD , Johns Hopkns Hospital, Baltimore, MD
Sara Cosgrove, MD, MS , Johns Hopkins School of Medicine, Baltimore, MD
Background: The presence of an endotracheal tube offers a convenient mechanism for bacteria in the nasopharynx to enter the lower respiratory tract, occasionally resulting in ventilator-associated tracheitis (VAT).  The incidence of VAT in the pediatric population is unknown and optimal antimicrobial therapy has not been evaluated. Commonly, children with VAT receive lengthy courses of multiple antibiotics, which may lead to unnecessary costs, toxicities, and multi-drug resistant organisms (MDRO).

Objective: The objective of this study was to evaluate the epidemiology, management, and outcomes of infants and children with VAT admitted to the NICU and PICU at The Johns Hopkins Hospital.

Methods: A retrospective cohort study was conducted evaluating children admitted to The Johns Hopkins Hospital NICU and PICU from January-December 2007.  Children who received mechanical ventilation for at least 72 hours were evaluated to determine if they developed VAT.  We defined VAT as an increase in tracheal secretions and accompanying fever or change in respiratory status with significant quantification of organisms and polymorphonuclear leukocytes on tracheal Gram stain and culture.  Outcome measures included progression to ventilator-associated pneumonia (VAP) within 10 days of discontinuing therapy and emergence of MDRO within 30 days. 
Results: Of children intubated for ≥72 hours, 68/505 (13.5%) were treated for suspected VAT; with a median of 6.5 ventilator days prior to development of VAT.  Of these 15/68 (22%) did not meet our clinical definition.  Prolonged antibiotic courses of at least 7 days (median 10 days) were administered to 41/68 (60%) children.  Including only those children treated for suspected VAT due to Gram-negative organisms, 25/49 (51%) received combination antibiotics.  Of those children treated for suspected VAT with follow up data available for ≥30 days, 12/41 (29%) developed a MDRO within this time period.  Of these, 9/12 (75%) received combination therapy and developed a MDRO (p = 0.27) and 10/12 (83%) received a prolonged course and developed MDRO (p=0.05).  Including only those children who met our clinical definition of VAT, 11/53 (21%) progressed to VAP. There was no difference in progression to VAP between those children treated with prolonged vs. shortened courses (7 vs. 4, p = 0.50); nor monotherapy vs. combination therapy (7 vs. 4, p = 0.50). 

Conclusions: In our cohort, antibiotics were often initiated for VAT without adherence to a strict definition.  Although the number of cases are small, our data suggests that prolonged antibiotic courses may contribute to the development of MDRO, with no significant decrease in likelihood of progression to VAP.  This study identifies the need for prospective studies to further evaluate the management of VAT in the pediatric population.