Short vs. (vs) Prolonged Course of Therapy for Ventilator-associated Tracheitis (VAT) Caused by Non-lactose-fermenting Gram-negative Rods (NLFGNR) in the Pediatric Intensive Care Unit (PICU)

Abstract

BackgroundIt is still unclear whether prolonged duration of therapy (DOT) for VAT might be protective against progression to pneumonia. From a stewardship view, shortening DOT may help to contain emergence of multidrug-resistant organisms (MDRO) in PICU. To this effect, we sought to compare clinical characteristics and outcomes in PICU patients with NLFGNR VAT treated with >7 days (prolonged course group, PCG) vs. ≤7 days (short course group, SCG).MethodsThis retrospective stewardship evaluation between January 2009 and July 2016 was conducted in a 12-bed PICU. Antibiotic choice and DOT were at the physicians’ discretion. VAT was defined by signs and symptoms and positive sputum (≥moderate polymorphonuclear cells and ≥moderate NLFGNR growth) without radiographic findings. Primary outcomes were rate of microbiologically documented or clinically suspected (CS) pulmonary infection recurrence and emergence of resistance (≥4 increase in minimal inhibitory concentration) or MDRO within 30 days of VAT treatment. Thirty-day readmission and in-hospital mortality were also assessed.ResultsFifty patients were included (PCG n = 27, SCG n = 23). Median age was 1.6 years (0–18.8), PIM2 score was 1 (0.1–82.8), 62% of patients had a tracheostomy at baseline, 70% had P. aeruginosa, and these were comparable between groups. More patients in PCG vs. SCG (44% vs. 13%, P = 0.03) had an admission diagnosis of respiratory failure. Mechanical ventilation (12.5 vs. 5 days, P < 0.01) and PICU stay (16 vs. 6 days, P < 0.01) were longer in PCG vs. SCG. Median DOT was 10 (8–30) in PCG vs. 6 days (3–7) in SCG, with β-lactams as the common agents and no difference in combination therapy (33% vs. 13%, P = 0.1). Clinical response at the end of treatment was 89% in PCG and 100% in SCG, P = 0.2. Recurrence was 26% in PCG and 9% (all CS) in SCG, P = 0.2 at 17 days (1–29) and 9.5 days (4–15) P = 0.5, respectively. Emergence of resistance or MDRO occurred in 15% in PCG vs. 0% in SCG, P = 0.1. Readmission and in-hospital mortality were 7% vs. 9%, P = 0.9 and 7% vs. 0%, P = 0.5 in PCG and SCG, respectively.ConclusionIn this small cohort of PICU patients with NLFGNR VAT, there was no microbiologically documented recurrence and emergence of resistance or MDRO in SCG compared with PCG. Our findings suggest that short DOT may be considered for children who are less sick including those with a tracheostomy at baseline.Disclosures All authors: No reported disclosures.