What antibiotics are recommended for an infected tracheostomy?

Antibiotic Treatment for Infected Tracheostomies

For infected tracheostomies, piperacillin-tazobactam is the recommended first-line empiric antibiotic therapy due to its broad-spectrum coverage of common pathogens including Pseudomonas and other gram-negative bacteria commonly found in tracheostomy infections.

Microbiology of Tracheostomy Infections

Tracheostomy infections typically involve:

• Gram-negative enteric organisms (most common)
• Pseudomonas aeruginosa (present in up to 86% of pediatric cases) 1
• Other common pathogens: Enterobacter, Klebsiella species 2
• Polymicrobial infections are frequent

Empiric Antibiotic Selection Algorithm

First-line therapy:

• Piperacillin-tazobactam 4.5g IV every 6 hours (for adults) 3, 4
  • Provides excellent coverage against Pseudomonas and other gram-negative bacteria
  • Dosing: 240 mg/kg/day divided every 8 hours (up to 18g daily) for pediatric patients 3

Alternative options (based on patient factors):

1. If MRSA is suspected:

   • Add vancomycin 15 mg/kg IV every 8-12 hours (target trough 15-20 mg/mL) 3
   • OR linezolid 600 mg IV every 12 hours

2. For penicillin allergy:

   • Cefepime 2g IV every 8 hours 3
   • OR (if severe beta-lactam allergy) aztreonam 2g IV every 8 hours plus vancomycin 3

3. For severe infections or septic shock:

   • Consider combination therapy with an aminoglycoside (amikacin, gentamicin, or tobramycin) 3

Risk Factors for More Resistant Organisms

Adjust antibiotic coverage if patient has:

• Prior antibiotic use within 90 days 3
• Hospitalization in a unit with high MRSA prevalence (>20%) 3
• Immunocompromised status
• Previous neck irradiation 5
• Smoking history 5

Duration of Therapy

• 7-14 days depending on clinical response and severity
• Consider longer duration for necrotizing infections

Adjunctive Measures

• Ensure proper tracheostomy care:

  • Use aseptic technique when changing tracheostomy tubes 6
  • Use sterile suction catheters and fluid for suctioning 6
  • Consider closed-circuit suction system with viral filter 6
  • Proper hand hygiene before and after patient contact 6

• For severe necrotizing infections:

  • Consider hourly application of antimicrobial dressings 2
  • May require removal of tracheostomy tube and oral intubation temporarily 2

Special Considerations

Pediatric Patients

• Higher risk of tracheostomy infections compared to adults 1
• Consider prophylactic inhaled antibiotics in recurrent infections:
  • Tobramycin or colistin may reduce systemic antibiotic exposure 7, 1
  • Shown to reduce hospitalizations and ER visits by approximately 40% 1

Monitoring and Follow-up

• Monitor for clinical improvement within 48-72 hours
• Adjust antibiotics based on culture and sensitivity results
• Watch for complications:
  • Tracheal dissolution/necrosis
  • Carotid artery exposure
  • Prolonged ventilator dependency

Pitfalls to Avoid

1. Failure to obtain appropriate cultures before starting antibiotics

   • Always collect samples for culture before initiating antibiotics

2. Underestimating the severity of infection

   • Tracheostomy infections can rapidly progress to necrotizing infections with tracheal dissolution 2

3. Overlooking polymicrobial nature

   • Most tracheostomy infections involve multiple organisms

4. Inadequate local wound care

   • Proper stomal care is essential alongside antibiotic therapy

5. Excessive antibiotic duration

   • Prolonged courses increase risk of resistance and C. difficile infection

By following this approach, you can effectively manage infected tracheostomies while minimizing complications and optimizing outcomes.