Tracheostomies are indicated in children to facilitate long-term ventilatory support, aid in the management of secretions, or to manage upper airway obstruction. Children with tracheostomies often experience ongoing airway complications, of which respiratory tract infections are common. They subsequently receive frequent courses of broad spectrum antimicrobials for the prevention or treatment of respiratory tract infections. However, there is little consensus in practice with regard to the indication for treatment/ prophylactic antimicrobial use, choice of antimicrobial, route of administration, or duration of treatment between different centres. Routine antibiotic use is associated with adverse effects and an increased risk of antimicrobial resistance. Tracheal cultures are commonly obtained from paediatric tracheostomy patients, with the aim of helping guide antimicrobial therapy choice. However, a positive culture alone is not diagnostic of infection and the role of routine surveillance cultures remains contentious. Inhaled antimicrobial use is also widespread in the management of tracheostomy associated infections; this is largely based upon theoretical benefits of higher airway antibiotic concentrations. The role of prophylactic inhaled antimicrobial use for tracheostomy associated infections remains largely unproven. This systematic review summarises the current evidence base for antimicrobial selection, duration, and administration route in paediatric tracheostomy associated infections. It also highlights significant variation in practice between centres and the urgent need for further prospective evidence to guide the management of these vulnerable patients.

Background: There is an increasing importance to increasing the day-case rate for children undergoing adenotonsillectomy. The primary aim of this study was to evaluate the immediate post-operative complication (IPOC) rate of children undergoing adenotonsillectomy for the treatment of paediatric obstructive sleep apnoea (OSA), with a view to increasing the day-case rate. IPOC was defined as any adverse clinical events experienced if admitted, or as a re-presentation to the emergency department/ward if done as a day-case, within 24 hours of the surgery. The secondary aim was to evaluate the risk factors predictive of IPOC. Methods: A retrospective analysis of children undergoing adenotonsillectomy for OSA between 01/11/2019–31/03/2022. Results: 464 children were included. Children done as a day-case experienced 0% IPOC (n=260; 220 were planned day-case). Children done as an inpatient experienced 16.7% IPOC (n=34/204). Every child who experienced IPOC had one or more of the following four clinical features: age <3 years, <15 kg, >98th weight centile, significant medical comorbidities. 269 children had none of these four clinical features, and experienced 0.371% IPOC (n=1/269; primary post-tonsillectomy bleed). Children with pre-operative oximetry scores of McGill 3-4 experienced 0% IPOC if they had none of the four clinical features (n=20). The overall readmission rate was 2.80% (n=13/464). Conclusion: Our experience suggests children with none of the four clinical risk factors identified can have adenotonsillectomy performed as a day-case procedure, irrespective of the pre-operative oximetry results. Pre-operative oximetry does not appear to add any additional value in predicting adverse post-operative events.