Skip to content

Bacterial Tracheitis

BASICS

  • Definition: Acute, potentially life-threatening bacterial infection of the infraglottic airway, often following a viral prodrome.
  • Key Feature: Airway obstruction from pseudomembranes, thick mucopurulent secretions, and mucosal sloughing.
  • Synonyms: Bacterial croup, laryngotracheobronchitis, pseudomembranous croup

EPIDEMIOLOGY

Feature Detail
Incidence 4–8 per million children/year
Peak age ~5 years
Seasonality Fall and winter
Gender/Genetics No known genetic predisposition
Changing trends ↑ MRSA, ↑ incidence in tech-dependent patients

ETIOLOGY & PATHOPHYSIOLOGY

  • Primary pathogens:
  • Staphylococcus aureus (MSSA most common; MRSA increasing)
  • Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
  • Pseudomonas aeruginosa (especially in tracheostomy)
  • Mechanism:
  • Viral URI → epithelial injury + local immune dysfunction → bacterial superinfection → pseudomembrane formation + sloughing

RISK FACTORS

  • Recent viral URI
  • Tracheostomy, chronic aspiration
  • Recent ENT surgery (tonsillectomy, adenoidectomy)
  • Anatomic abnormalities: Down syndrome, tracheomalacia
  • Coexisting infections: sinusitis, otitis media, pneumonia
  • Poor vaccination status

CLINICAL PRESENTATION

Classic Features

Feature Presentation
Prodrome URI symptoms, mild croup-like symptoms
Progression Rapid deterioration within 1–6 days
Fever High-grade
Stridor Inspiratory, often severe
Toxicity Systemically ill-appearing child
Drooling Usually absent
Voice Normal, unlike epiglottitis
Steroid/epi response No improvement

Suspect bacterial tracheitis in any child with croup unresponsive to steroids or racemic epinephrine.

DIFFERENTIAL DIAGNOSIS

  • Viral croup
  • Epiglottitis
  • Retropharyngeal abscess
  • Diphtheria (esp. if unimmunized)
  • Foreign body aspiration
  • Bacterial pneumonia
  • Bronchiolitis
  • Angioneurotic edema

DIAGNOSIS

Clinical Suspicion

  • Acute febrile illness with stridor + poor response to standard croup treatment

Diagnostic Confirmation

Investigation Findings
Bronchoscopy/Endoscopy Ulcerations, pseudomembranes, mucopurulent secretions, mucosal sloughing
Tracheal secretions Gram stain, aerobic/anaerobic culture, PCR for viral co-infections
Neck X-ray (AP/lateral) Subglottic/tracheal narrowing, may show "steeple sign"
CBC Variable WBC, often leukocytosis with left shift

TREATMENT

Emergency Airway Management

  • ICU admission (94% in studies)
  • Intubation required in ~80% cases (up to 100% in some series)
  • Therapeutic bronchoscopy may be necessary for secretion clearance
  • Mechanical ventilation as needed

Antibiotic Therapy

Empiric Regimen Notes
Vancomycin or clindamycin + ceftriaxone Covers S. aureus (incl. MRSA), S. pneumo
Modify per cultures Especially in children with tracheostomy
  • Corticosteroids and racemic epinephrine are ineffective for bacterial tracheitis.

SURGICAL/OTHER PROCEDURES

  • Bronchoscopy: Diagnostic and therapeutic (secretion clearance)
  • Tracheostomy: Rarely required unless prolonged intubation or chronic airway compromise

COMPLICATIONS

Early Late
Acute respiratory failure Tracheal stenosis (esp. prolonged intubation)
ARDS Recurrent infection in tech-dependent child
Pneumonia, Pneumothorax Chronic lung disease
Toxic shock syndrome, Septic shock Cardiopulmonary arrest, death
DIC —

ONGOING CARE & MONITORING

In-Hospital

  • ICU-level respiratory monitoring
  • Airway suctioning, pulmonary toilet
  • Supportive care: hydration, fever management
  • Open communication with caregivers
  • Length of intubation: 3–11 days
  • Hospital stay: ~3–7 days

Follow-Up

  • Pulmonary or ENT follow-up (esp. if complications occurred)
  • Evaluate for signs of tracheal stenosis
  • Update vaccinations (esp. influenza, Hib, diphtheria)

PROGNOSIS

  • Generally excellent with timely airway support and antibiotic therapy
  • Mortality: Historically up to 20%, now <5% with ICU care
  • Recurrence: Higher in children with artificial airways

PREVENTION

  • Vaccination: Influenza, DTaP, Hib, pneumococcal
  • Infection control: Hand hygiene, avoid exposure to URIs
  • Early treatment of viral URIs in at-risk children

ICD-10 CODES

Code Description
J04.10 Acute tracheitis without obstruction
J04.11 Acute tracheitis with obstruction
J05.0 Acute obstructive laryngitis (croup)

CLINICAL PEARLS

  • Suspect bacterial tracheitis in croup-like symptoms that fail to improve with steroids and racemic epinephrine.
  • Consider in toxic-appearing children with high fever + stridor + normal voice.
  • Bronchoscopy is both diagnostic and therapeutic.
  • Prompt airway protection and broad-spectrum IV antibiotics are critical.