Chest
Volume 85, Issue 1, January 1984, Pages 39-44
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Respiratory Infection Complicating Long-term Tracheostomy: The Implication of Persistent Gram-negative Tracheobronchial Colonization

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Colonization of the lower respiratory tract by enteric Gram-negative bacilli (EGNB) has been a frequent finding in patients with long-term tracheostomies; however, the association of hospitalization and certain features of serious illness with this phenomenon has not been clearly established. Because such factors can render the oropharynx more susceptible to EGNB colonization, we sought to discover whether they can also have this effect on the tracheobronchial tree and its microflora. Thus, we collected serial paired culture samples from these two mucosal sites in 15 subjects with long-term tracheostomies and examined patterns and rates of colonization and related these findings to clinical parameters. In 49 sets of cultures, we found that EGNB (especially Pseudomonas species) were present in significantly fewer upper-airway cultures (36.7 percent) than lower-airway cultures (75.5 percent) (p = 0.009). At the tracheobronchial site, seven subjects had persistent EGNB colonization, all with Pseudomonas species, while only one subject had this finding at the oropharyngeal site (p = 0.015). Patients with persistent tracheobronchial colonization were more ill than those without this finding. They were treated with higher doses of prednisone (p=0.06), received antibiotics more offen, and developed purulent tracheobronchitis more often (100 percent vs 25 percent) than patients without persistent colonization. In addition, in the month following the culture survey, four subjects developed pneumonia, and three of these had previous persistent tracheobronchial colonization. The findings suggest that in this population of patients, there was an enhanced susceptibility for more frequent and more persistent EGNB colonization of the lower respiratory tract than the upper respiratory tract and that these two mucosal sites became colonized independently of one another. Furthermore, persistent colonization was associated with greater clinical illness and may have predisposed patients to symptomatic infection.

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MATERIALS AND METHODS

All individuals with long-term tracheostomies hospitalized at a local rehabilitative facility were potentially eligible for this study; however, we eliminated anyone with acute pneumonia, as defined by a thorough history, physical examination, and chest roentgenogram. Subjects meeting these criteria were selected for study if they were to remain in the hospital for at least four weeks and were free of pneumonia during this time. For one month after completion of the study, patients remaining in

Frequency of EGNB

The frequency of EGNB isolation was determined in multiple cultures from two respiratory mucosal sites (Table 1). During the study, 49 paired sets of serial buccal and tracheal mucosa cultures were collected from 15 subjects. The EGNB were isolated in 37 (76 percent) of 49 tracheal cultures, 28 of which contained Pseudomonas species. These included P aeruginosa, P maltophila, and other Pseudomonas species isolates. At the buccal site, 18 (37 percent) of 49 cultures contained EGNB, of which nine

DISCUSSION

Classic studies of hospitalized individuals have established that EGNB are present in the respiratory tract with a frequency that parallels certain aspects of serious illness. Thus, Johanson et al,6 using a multiple-culture survey technique, observed that these organisms were present in the oropharynx of only 6 percent of normal subjects, while they could be found in as many as 35 percent of moderately ill and 73 percent of moribund patients. More recently, Irwin et al13 confirmed the high rate

ACKNOWLEDGMENT

We thank Mrs. Mae Day and Ms. Joan Paquette for providing secretarial assistance and Dr. Curtland C. Brown and the medical administration of Gaylord Hospital for providing support for this study.

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Manuscript received May 9; revision accepted June 6.

Recipient of an American Lung Association Fellowship and National Research Service Award training grant HL-07410-03.

Supported by National Institutes of Health grant HL-22302.

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