Bacterial tracheitis (also called bacterial croup, membranous tracheitis, or pseudomembranous croup) is an acute, potentially life-threatening bacterial infection of the trachea that typically occurs as a secondary infection following a viral upper respiratory illness. It is most common in children but can occur at any age. The hallmark is a croup-like illness that fails to respond to standard croup therapy (nebulized epinephrine and corticosteroids), with high fever, toxic appearance, and copious purulent tracheal secretions. [1-3]
1. History
- Prodromal viral URI lasting 2–7 days (present in ~55% of cases), followed by acute deterioration [1-2]
- Barking/brassy cough (85%), stridor (77%), voice changes/hoarseness (67%) [2]
- High fever with rapid progression of respiratory distress
- Failure to improve with nebulized racemic epinephrine — a key distinguishing feature [3]
- Ask about: duration of illness, preceding viral symptoms (rhinorrhea, low-grade fever), timeline of worsening, ability to handle secretions, drooling, positional preferences, immunization status
- Important negatives: absence of drooling and dysphagia (more suggestive of epiglottitis), no sudden onset without prodrome (foreign body), no history of choking event
2. Alarm Features
- Toxic appearance with high fever unresponsive to standard croup treatment [1][3]
- Rapidly progressive stridor and respiratory distress
- Inability to handle secretions / thick mucopurulent sputum
- Hypoxia, cyanosis, altered mental status
- Respiratory arrest — reported in 2.7% of cases in one series [2]
- Biphasic stridor suggesting critical airway narrowing
- Failure to respond to nebulized epinephrine is a cardinal red flag [3-4]
3. Medications
Empiric IV antibiotics should cover the most common pathogens — Staphylococcus aureus (most frequent, including MSSA and potentially MRSA), Group A Streptococcus, Moraxella catarrhalis, Streptococcus pneumoniae, and Haemophilus influenzae: [1-2][5-6]
- First-line empiric regimen: Broad-spectrum IV antibiotics such as a third-generation cephalosporin (e.g., ceftriaxone) plus an anti-staphylococcal agent (e.g., nafcillin/oxacillin for MSSA; vancomycin or clindamycin if MRSA is suspected based on local prevalence) [6-7]
- Narrow antibiotics based on culture and sensitivity results
- Transition to oral antibiotics for 10–14 days total course after clinical improvement [8]
- Antiviral therapy (oseltamivir) if concurrent influenza is identified [9]
- Nebulized epinephrine and corticosteroids are not effective as definitive treatment (unlike croup) but may provide temporary symptomatic relief [3]
- Avoid sedatives or anxiolytics that may compromise airway protective reflexes
4. Diet
- NPO initially if airway intervention is anticipated
- Advance to clear liquids and regular diet as airway stabilizes
- Maintain adequate hydration with IV fluids during acute illness
- No specific dietary triggers or long-term dietary management
5. Review of Systems
- Respiratory: cough quality (barking vs. productive), stridor (inspiratory vs. biphasic), dyspnea, positional breathing preferences
- ENT: voice changes, hoarseness, drooling, dysphagia, sore throat
- Constitutional: fever, malaise, toxic appearance, decreased oral intake
- Infectious: recent sick contacts, viral prodrome, immunization status (Hib, influenza)
- Neurologic: level of alertness, agitation (may indicate hypoxia)
6. Collateral History and Family History
- Daycare/school exposure and sick contacts
- Recent viral illness in household members
- Immunization history — particularly Hib vaccine (to assess epiglottitis risk) and influenza vaccine [10]
- Prior episodes of croup or recurrent upper airway obstruction (4 patients in one series had recurrence at 4–12 months) [2]
- History of Down syndrome or immunodeficiency — associated with increased susceptibility [4]
- Intubation history or known subglottic stenosis
7. Risk Factors
- Age: historically younger children (mean ~5–6 years), though younger children (<4 years) more likely to require intubation [5]
- Preceding viral respiratory infection (influenza A identified in 72% of viral cultures in one large series) [5]
- Seasonal: predominantly cold months (October–March) [11]
- Down syndrome [4]
- Immunodeficiency [4]
- Recent intubation or tracheostomy (though these are typically classified separately)
8. Differential Diagnosis
9. Past Medical History
- Prior episodes of croup or bacterial tracheitis (recurrence documented) [2]
- History of subglottic stenosis or airway anomalies
- Immunodeficiency syndromes
- Down syndrome [4]
- Prior intubation or airway surgery
- Chronic respiratory conditions (asthma, tracheomalacia)
10. Physical Exam
- Vital signs: High fever (often >39°C), tachycardia, tachypnea; monitor for hypoxia
- General: Toxic-appearing child (though some present non-toxic) [12]
- Airway: Inspiratory stridor (may be biphasic if severe), barking cough, hoarseness
- Respiratory: Suprasternal/subcostal/intercostal retractions, nasal flaring, accessory muscle use
- Oropharynx: Normal epiglottis and aryepiglottic folds on direct visualization (distinguishes from epiglottitis) [3]
- Trachea: Copious mucopurulent secretions visible below the subglottis on laryngoscopy [3]
- Neck: Assess for cervical lymphadenopathy, neck swelling
- Auscultation: May have transmitted upper airway sounds; assess for lower airway involvement (crackles, wheezing suggesting extension to bronchi)
11. Lab Studies
- CBC with differential: Leukocytosis with left shift is common but not universal (some patients have normal WBC) [12]
- CRP and procalcitonin: Typically elevated; may help distinguish bacterial from viral process [9]
- Blood cultures: Should be obtained before antibiotics
- Tracheal aspirate/culture: Gold standard for identifying the causative organism — most commonly MSSA, also GAS, Moraxella catarrhalis, S. pneumoniae, H. influenzae [1-2][5]
- Viral respiratory panel: To identify concurrent viral infection (influenza A most common) [5]
- Gram stain of tracheal secretions: Abundant PMNs with organisms [3][7]
12. Imaging
- AP and lateral soft-tissue neck radiographs (if diagnosis uncertain):
- May show subglottic narrowing (steeple sign, similar to croup)
- Ragged or irregular tracheal contour — suggestive of pseudomembranes [1]
- Intraluminal soft tissue densities within the trachea representing purulent exudate [6]
- Normal epiglottis (unlike epiglottitis)
- Radiographs can be completely normal — a normal film does not exclude the diagnosis [1]
- Chest X-ray: Evaluate for concurrent pneumonia or air leak complications
- CT neck/chest: Rarely needed; may be useful if abscess or other complication suspected
- Imaging should not delay airway management in a critically ill child [1]
13. Special Tests
- Direct laryngoscopy and rigid tracheobronchoscopy (under general anesthesia): The definitive diagnostic and therapeutic procedure [4][8]
- Reveals normal epiglottis with subglottic edema and thick mucopurulent membranes/secretions adherent to the tracheal wall [3-4]
- Allows debridement of pseudomembranes and collection of cultures
- Endoscopy is both diagnostic and therapeutic simultaneously [4]
- Fiberoptic nasolaryngoscopy: Can be used for airway reassessment after initial treatment [8]
- Westley Croup Score: May be used initially if croup is suspected, but does not differentiate bacterial tracheitis from viral croup
14. ECG
- Not routinely indicated unless hemodynamic instability or concern for myocarditis
- Monitor for arrhythmias in the setting of severe hypoxia or sepsis
- Continuous cardiopulmonary monitoring is standard during PICU admission [8]
15. Assessment
Bacterial tracheitis is an uncommon but dangerous cause of upper airway obstruction, classically presenting as a croup-like illness that worsens despite standard therapy. Key clinical pearls:
- The classic presentation is a child with a 2–7 day viral prodrome who acutely deteriorates with high fever, toxic appearance, and worsening stridor unresponsive to epinephrine [1][3]
- Presentation is variable — some patients are afebrile and non-toxic, requiring a high index of suspicion [12]
- PICU admission is required in ~69% of cases; intubation in ~43% [2]
- Younger children are more likely to require intubation [5]
- Mortality is low with prompt treatment but death from airway obstruction has been reported (2.7% in one series) [2]
- Complications include respiratory arrest, pneumonia, subglottic stenosis, pneumothorax/pneumomediastinum, and sepsis [2][11]
16. Treatment Plan
Initial stabilization
- Airway is the priority — have equipment for intubation and surgical airway immediately available
- Minimize agitation; allow child to remain in position of comfort
- Supplemental oxygen; continuous pulse oximetry and cardiopulmonary monitoring
Definitive management
- Direct laryngoscopy and bronchoscopy for diagnosis, debridement of pseudomembranes, tracheal suctioning, and culture collection [4][8]
- Broad-spectrum IV antibiotics initiated empirically after cultures obtained:
- Cover S. aureus (including MRSA if local prevalence warrants), GAS, H. influenzae, Moraxella [6]
- Typical regimen: IV vancomycin (or clindamycin) + third-generation cephalosporin (e.g., ceftriaxone)
- Narrow based on culture results
- Intubation if needed — use an endotracheal tube 0.5–1.0 size smaller than expected due to subglottic edema; frequent suctioning of thick secretions is critical [3][11]
- Repeat bronchoscopy at 48–72 hours to reassess airway and confirm resolution [8]
- Transition to oral antibiotics for a total course of 10–14 days after clinical improvement [8]
- Antiviral therapy (oseltamivir) if influenza co-infection is identified [9]
17. Disposition
- All patients with suspected bacterial tracheitis require hospital admission — this is not an outpatient disease
- PICU admission for most patients given risk of acute airway decompensation (~69% require PICU) [2]
- Intubated patients: extubation criteria include defervescence, air leak around the tube, decreased secretion volume/viscosity, and healing confirmed on bronchoscopy [11]
- Mean hospital length of stay: ~5–9 days (range 3–21 days) [8][11]
- Consult: Otolaryngology (ENT) for airway endoscopy; Pediatric ICU; Infectious Disease if atypical organisms or immunocompromised host
18. Follow Up / Return Precautions
- Follow-up with ENT and primary care within 1–2 weeks of discharge
- Complete the full antibiotic course (10–14 days total) [8]
- Return immediately for: recurrence of stridor, worsening cough, fever, respiratory distress, difficulty breathing, poor oral intake, or change in voice
- Recurrence has been documented at 4–12 months after initial episode in a small percentage of patients [2]
- Counsel families that full recovery is expected in most cases, but to maintain a low threshold for re-evaluation
- Consider evaluation for underlying immunodeficiency or airway anomaly if recurrent episodes occur [4]
References
1. Croup. — Bjornson CL, Johnson DW. Lancet. 2008.
2. Pediatric Bacterial Tracheitis-a Variable Entity: Case Series With Literature Review. — Casazza G, Graham ME, Nelson D, et al. Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2019.
3. Bacterial Tracheitis. — Jones R, Santos JI, Overall JC. The Journal of the American Medical Association. 1979.
4. Airway Endoscopy in the Diagnosis and Treatment of Bacterial Tracheitis in Children. — Eckel HE, Widemann B, Damm M, Roth B. International Journal of Pediatric Otorhinolaryngology. 1993.
5. Is Bacterial Tracheitis Changing? A 14-Month Experience in a Pediatric Intensive Care Unit. — Bernstein T, Brilli R, Jacobs B. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America. 1998.
6. Croup. — Cherry JD. The New England Journal of Medicine. 2008.
7. Bacterial Tracheitis, Diagnosis and Treatment. — Mahajan A, Alvear D, Chang C, Warren WS, Varma BK. International Journal of Pediatric Otorhinolaryngology. 1985.
8. Bacterial Tracheitis: A Therapeutic Approach. — Shargorodsky J, Whittemore KR, Lee GS. The Laryngoscope. 2010.
9. Clinical Presentations and Diagnostic Approaches of Pediatric Necrotizing Tracheobronchitis With Influenza a Virus and Staphylococcus Aureus Co-Infections. — Hu C, Zhang N, Xu D, et al. Scientific Reports. 2024.
10. Croup: Rapid Evidence Review. — Cooke A, Conway S, Griffin L. American Family Physician. 2026.
11. Bacterial Tracheitis in Children. — Kasian GF, Bingham WT, Steinberg J, et al. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne. 1989.
12. Bacterial Tracheitis: A Varied Entity. — Miranda AD, Valdez TA, Pereira KD. Pediatric Emergency Care. 2011.