Chest
Volume 141, Issue 3, March 2012, Pages 625-631
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Original Research
Critical Care
Surveillance Tracheal Aspirate Cultures Do Not Reliably Predict Bacteria Cultured at the Time of an Acute Respiratory Infection in Children With Tracheostomy Tubes

https://doi.org/10.1378/chest.10-2539Get rights and content

Background

The aim of this study was to characterize the practice of routinely obtaining tracheal aspirate cultures in children with tracheostomy tubes and to analyze the appropriateness of using this information to guide antibiotic selection for treatment of subsequent lower respiratory infections.

Methods

Pediatric otolaryngologists and pulmonologists were surveyed regarding surveillance culture practices. Records of children with tracheostomy tubes from January 1, 2003, through December 31, 2007, were reviewed. Consecutive cultures were compared for similarity of bacteria and antibiotic sensitivity when a clinic culture preceded a culture from when the child was ill and received antibiotics and when a hospital culture preceded a hospital culture from a separate hospitalization.

Results

Seventy-nine of 146 pulmonologists and five of 33 otolaryngologists obtained routine surveillance tracheal aspirate cultures (P < .001); 97% of pulmonologists used these cultures to guide subsequent empiric therapy. There were 36 of 170 children with one or more eligible pairs of cultures. Nearly all children had a change in flora in their tracheal cultures. Limiting empiric antibiotic choices to those that would cover microbes isolated in the previous culture likely would not have been effective in covering one or more microbes isolated in the second culture in 56% of pairs with the first culture from hospitalization vs 30% with the first culture from an outpatient setting (P = .15).

Conclusions

This study demonstrated that there are significant changes in bacteria or antibiotic sensitivity between consecutive tracheal cultures in children with tracheostomy tubes. Use of prior tracheal cultures from these children was of limited value for choosing empiric antibiotic therapy in treating acute lower respiratory exacerbations. Surveillance cultures, thus, are an unnecessary burden and expense of care.

Section snippets

Survey

In order to assess clinical practice patterns regarding the use of surveillance tracheal cultures, we conducted an Internet-based survey that was distributed via e-mail to pediatric pulmonologists on the ped-lung LISTSERV ([email protected]) and also to members of the American Society of Pediatric Otolaryngology. The survey asked the participants two questions: Do you obtain routine surveillance tracheal aspirate cultures from children with tracheostomies? If yes, do you use the routine

Survey

The survey yielded responses from 39 pediatric otolaryngologists and 150 pediatric pulmonologists. The results showed that 54% of pulmonologists and 15% of otolaryngologists obtained routine surveillance tracheal aspirate cultures in children with tracheostomy tubes (P < .001). Among those who obtained surveillance cultures, 80% of otolaryngologists and 97% of pulmonologists used these cultures to guide treatment of acute chest infections when they occurred.

Chart Analysis

A total of 170 children with

Discussion

This study provides further confirmation of airway colonization with potentially pathogenic bacteria in children who have long-standing tracheostomy tubes.7 Similar airway colonization occurs in respiratory diseases such as COPD and CF. The role of colonizing bacteria in the development of respiratory infections differs between these two diseases, resulting in different management strategies for individuals with CF or COPD. There has been no consensus on which strategy is most appropriate for

Conclusions

This study demonstrates large drift over time in bacterial flora of the tracheobronchial tree in children with tracheostomy tubes. The variability is evident when comparing outpatient tracheal aspirate cultures with inpatient cultures, as well as when comparing cultures from two separate hospital admissions. Additionally, change was noted in antibiotic sensitivity to persistent organisms among all comparisons. These findings suggest that there is limited value in using previous tracheal

Acknowledgments

Author contributions: Dr Kirse had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Cline: contributed to review and extraction of data from all patient charts, development of the data table, data analysis, and writing of the initial and final drafts of the manuscript.

Dr Woods: contributed to review of all data, statistical analysis, interpretation of the results and the meaning of the bacterial cultures,

References (12)

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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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