Most children have symptoms of viral respiratory infection for 1 to 3 days before the onset of severe symptoms of stridor and dyspnea. In a few children, onset is acute and is characterized by respiratory stridor, high fever, and often copious purulent secretions. Rarely, bacterial tracheitis develops as a complication of viral croup or endotracheal intubation. As in patients with epiglottitis, the child may have marked toxicity and respiratory distress that may progress rapidly and may require intubation.
Complications of bacterial tracheitis include hypotension, cardiorespiratory arrest, bronchopneumonia, and sepsis. Subglottic stenosis secondary to prolonged intubation is uncommon. Most children treated appropriately recover without sequelae.
Diagnosis of bacterial tracheitis is suspected clinically and can be confirmed by direct laryngoscopy, which reveals purulent secretions and inflammation in the subglottic area with a shaggy, purulent membrane, or by lateral neck x-ray, which reveals subglottic narrowing that may be irregular as opposed to the symmetric tapering typical of croup. Direct laryngoscopy should be done in controlled circumstances where an artificial airway can be rapidly established if necessary.
Treatment of bacterial tracheitis in severe cases is the same as that for epiglottitis; whenever possible, endotracheal intubation should be done in controlled circumstances by a clinician skilled in managing a pediatric airway.
Initial antibiotics should cover S. aureus, including methicillin-resistant S. aureus (MRSA), and streptococcal species; IV vancomycin and ceftriaxone may be appropriate empirically. Ceftaroline, as monotherapy, is a reasonable alternative to this combination regimen. Therapy for critically ill children should be guided by a consultant knowledgeable in local susceptibility patterns. Once definitive microbial diagnosis is made, coverage is narrowed and continued for ≥ 10 days.
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