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.