Antibiotic Use and Infection Patterns in Pediatric Tracheostomy Patients During Index Hospitalization.

Objective: To evaluate antibiotic utilization as a process measure in pediatric tracheostomy patients, establishing baseline variation across diagnostic categories to inform quality improvement and stewardship initiatives. Methods: We retrospectively studied pediatric tracheostomy patients at a tertiary children's hospital (2015-2024). Antibiotic use was quantified across diagnostic categories, with prophylactic courses defined as 2 days or less. Cultures were reviewed to distinguish true bacterial infections from viral detections and colonization. Mixed-effects logistic regression modeled infection risk, accounting for patient clustering. Sensitivity analyses excluded patients hospitalized over 365 days. Results: Of 429 patients (6.8 months [IQR 4.3-55.9]), respiratory conditions were most common (43.8%), followed by cardiac (19.3%). Cardiac patients had the highest antibiotic exposure (mean 52.1 days) despite low infection rates (17.8%), while trauma patients had the highest infection rates (31.5%). Diagnostic category did not significantly affect infection risk after accounting for clustering. Only 19.6% of 38,030 cultures showed true bacterial infection (median time 14.1 days posttracheostomy). Viral detection cascades triggered 11.4% of bacterial cultures within 48 hours. Discussion: Antibiotic prescribing patterns often reflect institutional preferences rather than true infection risk. Individual patient factors more strongly predict infection than diagnostic category. This highlights the need for personalized stewardship and standardized viral detection protocols. Implications for Practice: High variability in antibiotic utilization across diagnostic categories represents a measurable stewardship target. Reducing unnecessary exposure may decrease length of stay, healthcare costs, and antibiotic-associated complications.