Treatment of Bacterial Tracheitis in Children
Immediate Airway Management is the Priority
Bacterial tracheitis is a life-threatening emergency requiring immediate airway stabilization, aggressive antibiotic therapy, and intensive monitoring—the decision to intubate should be made early based on clinical severity rather than waiting for deterioration. 1
Indications for Intubation
- Intubate immediately if the child presents with any of the following: imminent respiratory failure, severe suprasternal or intercostal retractions, poor air entry despite oxygen supplementation, altered mental status from hypoxia, or inability to clear copious mucopurulent secretions. 1, 2, 3
- The threshold for intubation should be lower in younger children (especially those <2 years), as they have smaller airways that obstruct more rapidly with mucopurulent exudate accumulation. 1, 2
- Do not delay intubation waiting for bronchoscopy or culture results—clinical presentation of stridor with fever unresponsive to croup therapy warrants empiric intubation and antibiotic initiation. 1, 4
- Duration of intubation typically ranges from 2 to 72 hours (median 48 hours), depending on clearance of secretions and clinical improvement. 2
Empiric Antibiotic Therapy: Start Immediately
Initiate broad-spectrum intravenous antibiotics immediately upon suspicion of bacterial tracheitis, targeting Staphylococcus aureus (the most common pathogen) and Haemophilus influenzae. 2, 3
First-Line Antibiotic Regimen
- Cefuroxime or ceftriaxone (second- or third-generation cephalosporin) is the preferred empiric agent, providing coverage against both S. aureus and H. influenzae. 2
- Add vancomycin or teicoplanin if methicillin-resistant S. aureus (MRSA) is suspected based on local epidemiology or if the child is critically ill. 2
- In the reported case series, 91% of children received cephalosporins as empiric therapy, with vancomycin or teicoplanin added in 33% of cases for enhanced S. aureus coverage. 2
Alternative Regimen
- Cefamandole has been used successfully when H. influenzae is isolated from tracheal cultures. 3
- Erythromycin was used in one case (9%), but cephalosporins remain the standard due to superior coverage. 2
Duration of Antibiotic Therapy
- Continue IV antibiotics until the child is clinically improved (typically 7–10 days total), then consider switching to oral therapy if cultures guide narrower coverage. 1, 2
Aggressive Airway Clearance Techniques
Vigorous suctioning of mucopurulent secretions via the endotracheal tube is essential to prevent reobstruction and should be performed frequently (every 1–2 hours initially). 1, 3
- Flexible bronchoscopy is the gold standard for diagnosis and therapeutic clearance of thick secretions obstructing the trachea. 1, 3
- Bronchoscopy allows direct visualization of mucopurulent exudate coating the tracheal mucosa and confirms the diagnosis when imaging or clinical features are equivocal. 1, 3
- Bronchoscopy is not required in all cases—if the clinical presentation is classic (stridor, fever, failed croup therapy) and the child responds rapidly to intubation and antibiotics, bronchoscopy may be deferred. 1
Role of Corticosteroids
- Corticosteroids were administered in 75% of cases in one case series, though their benefit in bacterial tracheitis (as opposed to viral croup) is not well established. 2
- Consider corticosteroids if there is significant airway edema or if the child initially presented with viral croup that progressed to bacterial superinfection. 1, 2
Monitoring and Complications
Intensive Care Unit Admission
- All children with bacterial tracheitis require PICU admission for close cardiorespiratory monitoring, frequent suctioning, and readiness for reintubation if needed. 1, 2
Potential Complications
- Lobar pneumonia developed in 25% of cases in one series, requiring extended antibiotic therapy. 2
- Congestive heart failure occurred in one case (8%), likely secondary to severe hypoxia or sepsis. 2
- Toxic shock syndrome has been reported in association with S. aureus bacterial tracheitis. 5
Diagnostic Approach
Clinical Presentation
- Suspect bacterial tracheitis in any child with stridor and high fever (≥39°C) who fails to respond to standard croup therapy (nebulized epinephrine, corticosteroids). 1, 2, 4
- The child may initially present with viral croup symptoms that suddenly worsen, with increased work of breathing, toxic appearance, and copious purulent secretions. 1, 4
Definitive Diagnosis
- Direct visualization of the trachea via bronchoscopy showing mucopurulent exudate adherent to the tracheal wall is the only definitive diagnostic method. 1, 3
- Tracheal aspirate culture should be obtained during bronchoscopy or via endotracheal tube suctioning to guide antibiotic therapy. 2, 3
- S. aureus was isolated in 42% of cases, making it the most common pathogen. 2
- H. influenzae was isolated in other cases, particularly in younger children. 3
Key Pitfalls to Avoid
- Do not mistake bacterial tracheitis for viral croup or epiglottitis—bacterial tracheitis presents with high fever, toxic appearance, and copious purulent secretions, whereas viral croup typically responds to nebulized epinephrine and corticosteroids. 1, 4
- Do not delay intubation in a child with severe respiratory distress—waiting for bronchoscopy or culture results can lead to complete airway obstruction and cardiopulmonary arrest. 1, 3
- Do not rely on imaging alone—while lateral neck X-rays may show subglottic narrowing, bronchoscopy is required for definitive diagnosis and therapeutic clearance. 1, 3
- Maintain a high index of suspicion in any child with upper airway obstruction and fever who does not fit the typical clinical picture of croup or epiglottitis. 4
Prognosis
- With early diagnosis and aggressive treatment (intubation, antibiotics, airway clearance), complete recovery is expected in all cases. 1, 2
- The prognosis is generally excellent if the correct treatment is provided promptly, though delayed recognition can result in significant morbidity or mortality. 2, 5