Introduction
Ventilator-associated tracheobronchitis (VAT) is an infection in tracheostomy-dependent patients and those who are temporarily intubated secondary to acute illness. Although no formal definition exists, VAT is generally considered to lie on the continuum between bacterial colonization of the trachea and ventilator-associated pneumonia (VAP)1. Ventilator-associated tracheobronchitis is typically signified by the presence of an artificial airway for at least 48 hours along with new or increased sputum production, elevated or depressed temperature or white blood cell count, and a tracheal gram stain with the presence of moderate to heavy white blood cells and bacterial growth. Additionally, a lack of chest radiograph findings indicating pneumonia is usually required for diagnosis of VAT1-3. Development of VAT in children increases days of mechanical ventilation and pediatric intensive care unit (ICU) length of stay4,5, while treatment of VAT with appropriate antibiotics is associated with a decrease in mechanical ventilation days and incidence of VAP6,7.
The most common causative organisms isolated in infants and children with VAT are Pseudomonas aeruginosa , Haemophilus influenzae , Klebsiella species, Staphylococcus aureus , and Enterobacteriaceae species. Initial treatment typically includes obtaining a tracheal culture and initiating either broad-spectrum antibiotics or antibiotics based on previous culture results8, with the majority of hospitalized patients initiated on intravenous antibiotics at diagnosis. Targeted therapy is based on susceptibilities of organisms isolated from the tracheal culture. Optimal treatment duration has not been determined; however, data favors shorter (≤7 days) versus longer courses8. Once symptomatic improvement occurs and justification no longer exists for hospitalization, patients are often transitioned to enteral antibiotics to complete the treatment course at home.
Enteral treatment options for P. aeruginosa , the most commonly isolated organism, are limited to the fluoroquinolones ciprofloxacin and levofloxacin. Both treat the most commonly isolated pathogens in VAT, with the exception of S. aureus for ciprofloxacin and methicillin-resistant S. aureus for levofloxacin. The absolute oral bioavailability of ciprofloxacin and levofloxacin is excellent (70% and 99%, respectively) and the area under the curve of the oral and intravenous formulations are equivalent for both medications9,10, resulting in comparable tissue exposure between formulations. Because of these factors, either ciprofloxacin or levofloxacin is often used for treating VAT when an enteral medication is desired. Enteral fluoroquinolones have favorable efficacy and safety in treatment of pulmonary exacerbations in the pediatric cystic fibrosis population11,12 (11, 12). Enteral treatment with ciprofloxacin or levofloxacin is sometimes employed in VAT, despite not being labeled for this indication and limited supportive data. The purpose of this study was to evaluate the effectiveness and safety of the use of enteral ciprofloxacin or levofloxacin for VAT in children.