Prevalence of respiratory colonisations and related antibiotic resistances among paediatric tracheostomised patients of a long-term rehabilitation centre in Italy

Abstract

Patients with brain injury are prone to bacterial colonisations because of mechanical ventilation during intensive care and the long-term retention of tracheostomical tubes during rehabilitation. Reduced levels of isolation, typical of rehabilitation, could also contribute to propagate colonisations. We evaluated the presence of bacteria through different stages of healthcare, their antibiotic resistances and their clinical impact in a rehabilitation setting. This retrospective study included all tracheostomised patients referred to the paediatric brain injury unit of the Scientific Institute IRCCS E. Medea (Italy) over a six-year period. Data were collected from antibiograms regarding the presence of bacterial species and antibiotic resistances; clinical data were collected from medical records. Antibiograms revealed bacteria and antibiotic resistances typical of intensive care, while prevalence patterns were characteristic for each species (P. aeruginosa and S. aureus prevailing in the acute setting, K. pneumoniae, A. baumannii and others in rehabilitation). Despite very frequent antibiotic resistances, consistent with Italian averages, we observed a limited clinical impact for these colonisations. We analysed risk factors correlating to the development of respiratory symptoms and found a role for the acute clinical course after brain injury (having undergone neurosurgery; duration of intensive care stay) as well as for rehabilitation (duration of coma). Our data suggest that, in a long-term perspective, an appropriate balance is yet to be found between patient isolation and social interactions, to control respiratory colonisations and antibiotic resistances without compromising rehabilitation. They also suggest that regular containment measures should be complemented by thorough training to non-medic personnel and parents alike.

Performance of a tracheostomy removal protocol for pediatric patients in rehabilitation after acquired brain injury: Factors associated with timing and possibility of decannulation

“…Rehabilitation began 61.5 (38-90.5) days after injury, patients remained in the rehabilitation unit for their first stay 160.5 (126-216) days until discharge, evolving from an admittance DRS of 23.5 (22)(23)(24) to 20 (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Dysphagic patients were 116 (93.5%) at admittance, reduced to 77 (62.1%) at discharge; respiratory complications regarded 47 (37.9%) patients at admittance and 51 (41.1%) at discharge, (Table 1).…”

“…Pediatric patients with sABI may often benefit from tracheostomy, especially after very severe injuries, or when not conscious, disyphagic, or unable to manage respiratory secretions. [1][2][3] As respiratory care and infection management is crucial in this setting, 15 we devised a protocol for infection prevention and decannulation. 8 At variance with what is reported for adult or non-ABI patients, 25 we consider tracheostomy removal optional if any risk connected with the decannulation procedure exists.…”

“…Regarding the detailed protocol for decannulation, we previously described it together with its connections to infection management. 8,15 Figure 1 reports the full details of prerequisites for decannulation, the decision steps and all required exams. Briefly, the prerequisites that determine the eligibility of patients for tracheostomy removal, are: the independency of oxygen supplement or assisted ventilation, the absence of respiratory insufficiency or central apnea, assessed by performing an oxymetric monitoring with saturimetry and a monitoring of the respiratory rate and heart rate.…”

“…13,14 Decannulation failure, defined as the need to place back the tracheostomy tube after decannulation, should be avoided to minimize the need of additional interventions and recannulation procedures, which may increase the risk of respiratory infection for the patient and the risk of ambient contamination. 8,15 The incidence of decannulation failure varies depending on the length of time considered for failure determination (2-3 days, 1-2 weeks, several months), and it ranges from 9% up to 45%. [16][17][18][19] Studies have investigated the risk factors leading to failure, identifying among them physical complications, including granulomas, tissue overgrowth, sub/supra-glottic stenosis, and tracheomalacia 20 ; functional complications may also contribute, for instance insufficient deglutition reflexes, suboptimal secretion management, and intermittent apnea.…”

Resistance Profile From Staphylococcus Aureus And Pseudomonas Aeruginosa Obtained From Tracheostomized Children

“…The contamination and the consequent lower respiratory tract colonization are facilitated, and the main bacteria found were Pseudomonas aeruginosa and Staphylococcus aureus 5,6 . Both microorganisms exhibit high resistance rates to β-lactams, the most commonly group used in medical routine 7 .…”