Skip to main content
NCBI home page
Thorax logoLink to Thorax
. 2002 Dec;57(12):1015–1020. doi: 10.1136/thorax.57.12.1015

Oropharyngeal carriage and lower airway colonisation/infection in 45 tracheotomised children

P Morar 1, V Singh 1, Z Makura 1, A Jones 1, P Baines 1, A Selby 1, R Sarginson 1, J Hughes 1, R van Saene 1
PMCID: PMC1758797  PMID: 12454294

Abstract

Background: A study was undertaken to determine the oropharyngeal carrier state of potentially pathogenic microorganisms (PPM) and the magnitude of colonisation and infection rates of the lower airways with these PPM in children requiring long term ventilation first transtracheally and afterwards via a tracheotomy.

Methods: A 5 year, prospective, observational cohort study was undertaken in 45 children (33 boys) of median age 6.4 months (range 0–180) over a 5 year period at the Royal Liverpool Children's NHS Trust of Alder Hey, a university affiliated tertiary referral centre. The children were first admitted to the 20-bed paediatric intensive care unit (PICU) and, following placement of a tracheotomy, they were transferred to a four bedded respiratory ward. The two main indications were neurological disorders and airway obstruction. All children were ventilated transtracheally for a median period of 12 days (range 0–103) and, after placement of the tracheotomy, for a similar period of 12 days (range 1–281). Surveillance cultures of the oropharynx were taken on admission to the PICU and on the day of placement of the tracheotomy. Throat swabs were taken twice weekly during ventilation, both transtracheal and via the tracheotomy. Tracheal aspirates were taken once weekly and when clinically indicated (in cases where the lower airway secretions were turbid).

Results: Twenty five patients (55%) had abnormal flora, mainly aerobic Gram negative bacilli (AGNB), particularly Pseudomonas aeruginosa, while the community PPM Staphylococcus aureus was present in the oropharynx of 37% (17/45) of the study population. The lower airways were sterile in six children; the other 39 patients (87%) had a total of 82 episodes of colonisation. "Community" PPM significantly increased once the patients received a tracheotomy, independent of the number of patients enrolled, episodes of colonisation/infection, and the number of colonised/infected patients. "Hospital" PPM significantly decreased after tracheotomy only when episodes were compared.

Conclusions: While P aeruginosa present in the admission flora caused primary endogenous colonisation/infection during mechanical ventilation on the PICU, S aureus not carried in the throat was responsible for the exogenous colonisation/infection once the patients had a tracheotomy. This is in sharp contrast to adult studies where exogenous infections are invariably caused by AGNB. This discrepancy may be explained by chronic underlying conditions such as diabetes, alcoholism, and chronic obstructive pulmonary disease which promote AGNB, whereas the children were recovering following tracheotomy.

Full Text

The Full Text of this article is available as a PDF (129.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aly R., Levit S. Adherence of Staphylococcus aureus to squamous epithelium: role of fibronectin and teichoic acid. Rev Infect Dis. 1987 Jul-Aug;9 (Suppl 4):S341–S350. doi: 10.1093/clinids/9.supplement_4.s341. [DOI] [PubMed] [Google Scholar]
  2. Andrews J. M., Bradley J. E., Wise R. Comparison of 'E' test with conventional agar MIC. J Antimicrob Chemother. 1993 May;31(5):802–803. doi: 10.1093/jac/31.5.802. [DOI] [PubMed] [Google Scholar]
  3. Brook I. Bacterial colonization, tracheobronchitis, and pneumonia following tracheostomy and long-term intubation in pediatric patients. Chest. 1979 Oct;76(4):420–424. doi: 10.1378/chest.76.4.420. [DOI] [PubMed] [Google Scholar]
  4. Dal Nogare A. R., Toews G. B., Pierce A. K. Increased salivary elastase precedes gram-negative bacillary colonization in postoperative patients. Am Rev Respir Dis. 1987 Mar;135(3):671–675. doi: 10.1164/arrd.1987.135.3.671. [DOI] [PubMed] [Google Scholar]
  5. Doern G. V., Vautour R., Gaudet M., Levy B. Clinical impact of rapid in vitro susceptibility testing and bacterial identification. J Clin Microbiol. 1994 Jul;32(7):1757–1762. doi: 10.1128/jcm.32.7.1757-1762.1994. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Feeley T. W., Du Moulin G. C., Hedley-Whyte J., Bushnell L. S., Gilbert J. P., Feingold D. S. Aerosol polymyxin and pneumonia in seriously ill patients. N Engl J Med. 1975 Sep 4;293(10):471–475. doi: 10.1056/NEJM197509042931003. [DOI] [PubMed] [Google Scholar]
  7. Fischler L., Erhart S., Kleger G. R., Frutiger A. Prevalence of tracheostomy in ICU patients. A nation-wide survey in Switzerland. Intensive Care Med. 2000 Oct;26(10):1428–1433. doi: 10.1007/s001340000634. [DOI] [PubMed] [Google Scholar]
  8. Fuxench-López Z., Ramírez-Ronda C. H. Pharyngeal flora in ambulatory alcoholic patients: prevalence of gram-negative bacilli. Arch Intern Med. 1978 Dec;138(12):1815–1816. doi: 10.1001/archinte.1978.03630370033017. [DOI] [PubMed] [Google Scholar]
  9. Hable K. A., Washington J. A., 2nd, Herrmann E. C., Jr Bacterial and viral throat flora. Comparison of findings in children with acute upper respiratory tract disease and in healthy controls during winter. Clin Pediatr (Phila) 1971 Apr;10(4):199–203. doi: 10.1177/000992287101000405. [DOI] [PubMed] [Google Scholar]
  10. Hammond J. M., Potgieter P. D. Is there a role for selective decontamination of the digestive tract in primarily infected patients in the ICU? Anaesth Intensive Care. 1995 Apr;23(2):168–174. doi: 10.1177/0310057X9502300240. [DOI] [PubMed] [Google Scholar]
  11. Heffner J. E. Timing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis. 1993 Mar;147(3):768–771. doi: 10.1164/ajrccm/147.3.768. [DOI] [PubMed] [Google Scholar]
  12. Ketai L. H., Rypka G. The course of nosocomial oropharyngeal colonization in patients recovering from acute respiratory failure. Chest. 1993 Jun;103(6):1837–1841. doi: 10.1378/chest.103.6.1837. [DOI] [PubMed] [Google Scholar]
  13. Mackowiak P. A., Martin R. M., Jones S. R., Smith J. W. Pharyngeal colonization by gram-negative bacilli in aspiration-prone persons. Arch Intern Med. 1978 Aug;138(8):1224–1227. [PubMed] [Google Scholar]
  14. Makkonen T. A., Borthen L., Heimdahl A., Joensuu H., Lehtonen O. P., Nord C. E. Oropharyngeal colonisation with fungi and gram-negative rods in patients treated with radiotherapy of the head and neck. Br J Oral Maxillofac Surg. 1989 Aug;27(4):334–340. doi: 10.1016/0266-4356(89)90048-x. [DOI] [PubMed] [Google Scholar]
  15. Marquette C. H., Georges H., Wallet F., Ramon P., Saulnier F., Neviere R., Mathieu D., Rime A., Tonnel A. B. Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush. Am Rev Respir Dis. 1993 Jul;148(1):138–144. doi: 10.1164/ajrccm/148.1.138. [DOI] [PubMed] [Google Scholar]
  16. Mobbs K. J., van Saene H. K., Sunderland D., Davies P. D. Oropharyngeal Gram-negative bacillary carriage: a survey of 120 healthy individuals. Chest. 1999 Jun;115(6):1570–1575. doi: 10.1378/chest.115.6.1570. [DOI] [PubMed] [Google Scholar]
  17. Mobbs K. J., van Saene H. K., Sunderland D., Davies P. D. Oropharyngeal gram-negative bacillary carriage in chronic obstructive pulmonary disease: relation to severity of disease. Respir Med. 1999 Aug;93(8):540–545. doi: 10.1016/s0954-6111(99)90152-x. [DOI] [PubMed] [Google Scholar]
  18. Noble W. C., Valkenburg H. A., Wolters C. H. Carriage of Staphylococcus aureus in random samples of a normal population. J Hyg (Lond) 1967 Dec;65(4):567–573. doi: 10.1017/s002217240004609x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Palmer L. B., Donelan S. V., Fox G., Bellemore E., Greene W. H. Gastric flora in chronically mechanically ventilated patients. Relationship to upper and lower airway colonization. Am J Respir Crit Care Med. 1995 Apr;151(4):1063–1067. doi: 10.1164/ajrccm.151.4.7697232. [DOI] [PubMed] [Google Scholar]
  20. Petros A. J., O'Connell M., Roberts C., Wade P., van Saene H. K. Systemic antibiotics fail to clear multidrug-resistant Klebsiella from a pediatric ICU. Chest. 2001 Mar;119(3):862–866. doi: 10.1378/chest.119.3.862. [DOI] [PubMed] [Google Scholar]
  21. Rapola S., Salo E., Kiiski P., Leinonen M., Takala A. K. Comparison of four different sampling methods for detecting pharyngeal carriage of Streptococcus pneumoniae and Haemophilus influenzae in children. J Clin Microbiol. 1997 May;35(5):1077–1079. doi: 10.1128/jcm.35.5.1077-1079.1997. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Vaneechoutte M., Verschraegen G., Claeys G., Weise B., Van den Abeele A. M. Respiratory tract carrier rates of Moraxella (Branhamella) catarrhalis in adults and children and interpretation of the isolation of M. catarrhalis from sputum. J Clin Microbiol. 1990 Dec;28(12):2674–2680. doi: 10.1128/jcm.28.12.2674-2680.1990. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Weiss K. S., Wolff A. Serratia marcescens in tracheotomy cultures. Laryngoscope. 1979 Nov;89(11):1831–1838. doi: 10.1288/00005537-197911000-00017. [DOI] [PubMed] [Google Scholar]
  24. van Uffelen R., van Saene H. K., Fidler V., Löwenberg A. Oropharyngeal flora as a source of bacteria colonizing the lower airways in patients on artificial ventilation. Intensive Care Med. 1984;10(5):233–237. doi: 10.1007/BF00256259. [DOI] [PubMed] [Google Scholar]

Articles from Thorax are provided here courtesy of BMJ Publishing Group

RESOURCES