Prophylactic antibiotics should be used in children with repaired oesophageal atresia and tracheo-oesophageal fistula: The case against

Abstract

To address the question if children with repaired esophageal atresia (rEA)/trachea-esophageal fistula (TEF) will benefit from preventive antibiotics with the ultimate goal of preserving lung function, we need to have a clear understanding of the factors determining early and late complications influencing lung function. One of those factors may be the occurrence of (recurrent) pulmonary infections and/or an increased susceptibility to airway infections. If recurrent pulmonary infections do indeed play an important role in the pulmonary complications observed in this patient group, prophylactic antibiotics may be considered. The occurrence of bronchiectasis is a well-known late complication of recurrent lower airway infections. The presence of bronchiectasis can be used as a sign of asymptomatic or non-recognized or insufficient treatment of pulmonary infections, often associated with an underlying immune deficiency or lung disorder (e.g. cystic fibrosis). To decide which antibiotic to use, information regarding the bacterial colonisation of the airways and the causative pathogens of the pulmonary infections are obviously needed. Reviewing the published data and guidelines regarding the care of patients with EA, a number of publications need to be discussed in more detail to assist us in answering the questions raised. In 2008, Gupta and Sharma published a clinical management strategy in which the total care for children born with EA is described [1]. The authors’ state in this management strategy that antibiotics should be prescribed immediately after a child with EA is born, without mentioning a specific indication. Although, the authors are warning us that long-term complications localised in the lungs (e.g. bronchitis, frequent pneumonia) are to be expected, which may indirectly indicate the justification for the antibiotics up front. A restricted number of papers can be found in which an attempt has been made to analyse the respiratory morbidity observed in patients with EA TEF and to determine the occurrence and influence of lower airway infections on the pulmonary function [2–6]. Robertson and colleagues analysed 25 patients with rEA + TEF and used questionnaires and pulmonary function tests to assess the respiratory morbidity [5]. Half of the patients had an abnormal pulmonary function test but no association could be shown with the occurrence of recurrent pneumonias as reported in the questionnaires. In the publication from a Scandinavian group, describing 27 adolescents aged 10 – 20 years with rEA + TEF, the results of a longitudinal follow-up study are described including spirometry and lung biopsies [2]. A validated questionnaire for asthma and allergy symptoms was used in which the authors included an additional question about pneumonia. Fourteen (52%) of the patients reported a pneumonia ever but there was no association with the overall respiratory morbidity and/or the pulmonary function test. In addition, the bronchial biopsies taken did not show any signs of bronchial remodelling or marked continuous inflammation. Sistonen and colleagues identified 262 adult patients who underwent surgery