Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patients
1Paediatric intensive care unit, Department of Paediatrics, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009 Kaunas, Lithuania, www.kaunoklinikos.lt
2 Department of Laboratory Medicine, Hospital of Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009 Kaunas, Lithuania, www.kaunoklinikos.lt
3 Paediatric pulmonology sector, Department of Paediatrics, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009 Kaunas, Lithuania, www.kaunoklinikos.lt Abbreviated Title: Colonization of lower airways in intubated paediatric patients
DOI: 10.22514/SV141.052018.5 Vol.14,Issue 1,March 2018 pp.30-37
Published: 27 March 2018
Background. Ventilator-associated pneu-monia (VAP) still remains a common de-vice-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the low-er airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit.
Methods. This was a prospective obser-vational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lu-men of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pedi-atric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was per-formed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry).
Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colo-nized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group,
Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower air-way group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter / Pseudomonas / Steno-trophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005).
Conclusions. Oropharyngeal contamina-tion of the lower airways is the most im-portant route of colonization. Different pathogens enter the lower airways at dif-ferent time intervals from the insertion of an endotracheal tube.
colonization, airway, intubation, mechanical ventilation, bronchoalveolar lavage, ventilator-associated pneumonia
TOMAS KONDRATAS,VAIDOTAS GURSKIS,RIMANTAS KEVALAS,STRA VITKAUSKIENE,'DOVILE EVALDA GRINKEVICIUTE,LAIMUTE VAIDELIENE. Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patients. Signa Vitae. 2018. 14(1);30-37.
1. Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SA, Leblebicioglu H, Mehta Y, et al. International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control 2016 Oct 11.
2. Craven DE, Lei Y, Ruthazer R, Sarwar A, Hudcova J. Incidence and outcomes of ventilator-associated tracheobronchitis and pneu-monia. Am J Med 2013 Jun;126(6):542-9.
3. Fernandez JF, Levine SM, Restrepo MI. Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumo-nia. Chest 2012 Jul;142(1):231-8.
4. Palmer LB. Ventilator-associated infection. Curr Opin Pulm Med 2009 May;15(3):230-5.
5. Blot SI, Poelaert J, Kollef M. How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients. BMC Infect Dis 2014 Nov 28;14:119.
6. Burmester M, Mok Q. How safe is non-bronchoscopic bronchoalveolar lavage in critically ill mechanically ventilated children? In-tensive Care Med 2001 Apr;27(4):716-21.
7. de BJ, Midulla F, Barbato A, Clement A, Dab I, Eber E, et al. Bronchoalveolar lavage in children. ERS Task Force on bronchoalveolar lavage in children. European Respiratory Society. Eur Respir J 2000 Jan;15(1):217-31.
8. Foglia E, Meier MD, Elward A. Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clin Micro-biol Rev 2007;20(3):409-25.
9. Craven DE, Hjalmarson KI. Ventilator-associated tracheobronchitis and pneumonia: thinking outside the box. Clin Infect Dis 2010 Aug 1;51 Suppl 1:S59-S66.
10. Barth AL, Pitt TL. Auxotrophy of Burkholderia (Pseudomonas) cepacia from cystic fibrosis patients. J Clin Microbiol 1995 Aug;33(8):2192-4.
11. Grothues D, Tummler B. New approaches in genome analysis by pulsed-field gel electrophoresis: application to the analysis of Pseu-domonas species. Mol Microbiol 1991 Nov;5(11):2763-76.
12. Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia 2008. 2016. http://www.
13. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016 Sep 1;63(5):e61-e111.
14. Gurskis V, Asembergiene J, Kevalas R, Miciuleviciene J, Pavilonis A, Valinteliene R, et al. Reduction of nosocomial infections and mortality attributable to nosocomial infections in pediatric intensive care units in Lithuania. Medicina (Kaunas) 2009;45(3):203-13.
15. Slater A, Shann F, Pearson G, PIM Study Group. PIM2: a revised version of the Paediatric Index of Mortality. Intensive Care Med 2003;29(2):278-85.
16. Agvald-Öman C. Colonization, infection and dissemination in intensive care patients [dissertation]. Stockholm: Karolinska Insti-tutet; 2007.
17. Berdal JE, Bjornholt J, Blomfeldt A, Smith-Erichsen N, Bukholm G. Patterns and dynamics of airway colonisation in mechanically-ventilated patients. Clin Microbiol Infect 2007 May;13(5):476-80.
18. Craven DE, Hudcova J, Lei Y. Diagnosis of ventilator-associated respiratory infections (VARI): microbiologic clues for tracheobron-chitis (VAT) and pneumonia (VAP). Clin Chest Med 2011 Sep;32(3):547-57.
19. Craven DE, Chroneou A, Zias N, Hjalmarson KI. Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes. Chest 2009 Feb;135(2):521-8.
20. Liu B, Li SQ, Zhang SM, Xu P, Zhang X, Zhang YH, et al. Risk factors of ventilator-associated pneumonia in pediatric intensive care unit: a systematic review and meta-analysis J Thorac Dis 2013 Aug;5(4):525-31.
21. Roeleveld PP, Guijt D, Kuijper EJ, Hazekamp MG, de Wilde RB, de JE. Ventilator-associated pneumonia in children after cardiac surgery in The Netherlands. Intensive Care Med 2011 Oct;37(10):1656-63.
22. Siempos II, Athanassa Z, Falagas ME. Frequency and predictors of ventilator-associated pneumonia recurrence: a meta-analysis. Shock 2008 Nov;30(5):487-95.
23. Nseir S, Zerimech F, Fournier C, Lubret R, Ramon P, Durocher A, et al. Continuous control of tracheal cuff pressure and microaspira-tion of gastric contents in critically ill patients. Am J Respir Crit Care Med 2011 Nov 1;184(9):1041-7.
24. Vottier G, Matrot B, Jones P, Dauger S. A cross-over study of continuous tracheal cuff pressure monitoring in critically-ill children. Intensive Care Med 2016 Jan;42(1):132-3.
25. Tokmaji G, Vermeulen H, Muller MC, Kwakman PH, Schultz MJ, Zaat SA. Silver-coated endotracheal tubes for prevention of venti-lator-associated pneumonia in critically ill patients. Cochrane Database Syst Rev 2015 Aug 12;(8):CD009201
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