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Pseudomonas Positive Urine Culture Rates In Medically Complex Children With Tracheostomies
Kara McAbee, MD, Jonathan Ellison, MD, John Kryger, MD, Katherine Sheridan, BS, Martin Bantchev, MS, Travis Groth, MD, Samantha Siodlarz, BS, Elizabeth Roth, MD.
Children's Wisconsin, Milwaukee, WI, USA.
Background: Pseudomonas aeruginosa is an uncommon yet difficult to treat pathologic microbe. It forms biofilms on medical devices, and after tracheostomy placement up to 90% of children will become colonized with Pseudomonas. It is unknown whether this tracheostomy colonization puts these patients at risk for Pseudomonas colonization elsewhere or increases the risk of Pseudomonas positive urine cultures (UCx) and urinary tract infections (UTI). General recommended empiric antibiotic therapy for UTI does not include anti-pseudomonal coverage. The primary objective of this study is to determine if children with a tracheostomy are more likely to have Pseudomonas positive UCx than similarly medically complex children without a tracheostomy. Methods: Institutional Review Board approval was obtained. Records were reviewed from patients seen at a free-standing children’s hospital from 1/1/2013-12/31/2023. We utilized an institutional database to identify cases, which were defined as patients with a tracheostomy who had a UCx on file. Control patients were identified through the Complex Care Registry (CCR), and also had a UCx on file. Qualifications to be included on the CCR includes 1. Patients with medical conditions affecting ≥3 organ systems requiring on-going follow up with ≥3 subspecialists and 2. ≥10 subspecialty clinic visits or ≥5 inpatient days in the year prior to enrollment. As such, these patients are similar in medical complexity to tracheostomy patients. Data collected on each group included demographics, medical history, and UCx results. Abnormal UCx results were defined as growth of any organism. Results: We identified 794 patients with a tracheostomy who had a UCx collected (cases) and 801 medically complex patients without a tracheostomy (controls). Demographic information is in Table 1. UCx data is in Table 2. Tracheostomy patients had 1,789 abnormal UCx, 16% of which were positive for Pseudomonas. Control patients had 2,467 abnormal UCx, 13% of which were positive for Pseudomonas. Tracheostomy patients with an abnormal UCx were significantly more likely to have a Pseudomonas positive UCx than similarly medically complex patients who had an abnormal UCx (X2 = 7.94, p=0.005). Conclusions: Both medically complex children and children with a tracheostomy have higher rates of Pseudomonas positive UCx (13 and 16%, respectively) than reported in the general population (3-9%). In addition, children with a tracheostomy are significantly more likely to have Pseudomonas positive UCx than similarly medically complex children, putting them at even greater risk. Therefore, when these children are suspected of having a UTI or require antibiotic prophylaxis prior to urologic surgery, empiric antibiotic therapy to cover Pseudomonas should be strongly considered. This is a novel concept that has not been reported in the literature. Further research into the clinical impacts of incorrect empiric antibiotic coverage in tracheostomy patients is warranted.
| | |
| Cases (Tracheostomy patients) | Controls (Medically complex patients) |
| Total patients | 794 | 801 |
| Sex | | |
| Female | 353 (44%) | 399 (50%) |
| Male | 441 (56%) | 402 (50%) |
| Race | | |
| White | 498 (63%) | 538 (67%) |
| Black | 223 (28%) | 193 (24%) |
| Asian | 23 (3%) | 35 (5%) |
| American Indian | 8 (1%) | 10 (1%) |
| Other/Unknown | 42 (5%) | 25 (3%) |
| Ethnicity | | |
| Hispanic | 94 (12%) | 140 (17%) |
| Non-Hispanic | 700 (88%) | 661 (83%) |
| Age (birth year) | | |
| Before 1999 | 57 (7%) | 11 (1%) |
| 2000-2004 | 84 (11%) | 50 (6%) |
| 2005-2009 | 93 (12%) | 103 (13%) |
| 2010-2014 | 146 (18%) | 158 (20%) |
| 2015-2019 | 224 (28%) | 314 (39%) |
| 2020-2023 | 190 (24%) | 167 (21%) |
Table 1: Demographic data
| | | |
| Cases (Tracheostomy patients) | Controls (Medically complex patients) | |
| Urine Cultures Collected | 2828 | 2467 | |
| Abnormal Urine Cultures | 1789 (63%) | 1446 (59%) | |
| Pseudomonas Positive Urine Cultures | 288 (16% of abnormal cultures) | 182 (13% of abnormal cultures) | p=0.005 |
Table 2: Urine culture data
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