What is the best available evidence for the antibiotic treatment of tracheitis?

Comment by InpharmD Researcher

Limited data is available on the optimal antibiotic choice for tracheitis, and treatment is generally not recommended unless there are specific risk factors, such as bacterial exacerbation of chronic bronchitis. When indicated, options like amoxicillin, doxycycline, or tetracycline may be used. In ventilator-associated tracheobronchitis (VAT), antibiotics can reduce ICU mortality and prevent progression to ventilator-associated pneumonia (VAP), but prolonged courses do not offer extra protection and increase the risk of multidrug-resistant organisms, making short-course therapy the preferred approach. In pediatric patients, airway management is critical, often requiring intubation, with empiric broad-spectrum antibiotics like amoxicillin-clavulanic acid or a third-generation cephalosporin recommended until microbiological results guide therapy.

Background

The term acute bronchitis and tracheitis are often grouped together and referenced within the literature given that acute bronchitis is a clinical diagnosis characterized by cough due to acute inflammation of the trachea and large airways without the evidence of pneumonia. [1], [2]

The guidelines for the use of antibiotics in acute upper respiratory infections published in the American Family Physician (AFP) journal recommends against treating acute bronchitis with antibiotics in otherwise healthy adults. Given that 90% of cases are nonbacterial, antibiotic treatment is reserved for patients with acute bacterial exacerbation of chronic bronchitis and chronic obstructive pulmonary disease (COPD), usually smokers. Amoxicillin, TMP-SMX, or doxycycline is considered when antibiotic treatment is indicated. [3]

Key recommendations for acute bronchitis published in AFP journal include consideration of using dextromethorphan, guaifenesin, or honey to manage acute bronchitis symptoms, avoidance of beta-2 agonists for the routine treatment of acute bronchitis unless wheezing is present, and limiting over-the-counter (OTC) cough medications containing antihistamines and antitussives in children younger than four years old. [4]

According to the 2005 European Respiratory Society (ERS) guidelines for the management of adult lower respiratory infection, no clear distinction is possible between tracheitis and acute bronchitis in a real clinical setting, and acute tracheobronchitis is often referred to as acute bronchitis. The guidelines recommend only considering antibiotic treatment in certain subgroups of the lower respiratory tract infection (LRTI) with suspected or definite pneumonia; selected exacerbations of COPD; aged > 75 years and fever; cardiac failure; insulin-dependent diabetes mellitus; or a serious neurological disorder. Tetracycline and amoxicillin are first-choice antibiotics if indicated. Tetracycline has the advantage that it also covers M. pneumoniae. [5]

Per the 2017 European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline and position paper, the use of nebulized antimicrobials as adjuvants to intravenous antibiotics for the treatment of ventilator-associated tracheobronchitis (VAT) is not recommended given the low quality of evidence. The authors recommend against the use of inhaled antibiotics as the sole therapy for VAT and also as a substitute for intravenous antibiotics due to lack of solid data. [6]

References:

[1] Zoorob O, Sidani MA, Fremont RD, et al. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2012;86(9):817-822.
[2] Wenzel RP. Acute Bronchitis and Tracheitis. Goldman's Cecil Medicine. 2012;586-587. doi:10.1016/B978-1-4377-1604-7.00096-8.
[3] Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician. 2006;74(6):956-966.
[4] Kinkade S, Long NA. Acute bronchitis. Am Fam Physician. 2016;94(7):560-565.
[5] M. Woodhead, F. Blasi, S. Ewig, et al. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2005;26 (6):1138-1180. doi: 10.1183/09031936.05.00055705.
[6] Rello J, Solé-Lleonart C, Rouby JJ, et al. Use of nebulized antimicrobials for the treatment of respiratory infections in invasively mechanically ventilated adults: a position paper from the European Society of Clinical Microbiology and Infectious Diseases. Clin Microbiol Infect. 2017;23(9):629-639. doi: 10.1016/j.cmi.2017.04.011.
Literature Review

A search of the published medical literature revealed 4 studies investigating the researchable question:

What is the best available evidence for the antibiotic treatment of tracheitis?

Level of evidence

B - One high-quality study or multiple studies with limitations  Read more→


Please see Tables 1-4 for your response.

 

Antimicrobial Treatment For Ventilator-Associated Tracheobronchitis: A Randomized, Controlled, Multicenter Study

Design

A prospective, randomized, controlled, multicenter study

N=58

Objective

To determine the impact of antimicrobial treatment on outcome in ventilator-associated tracheobronchitis (VAT) patients.

Study Groups

Antibiotic treatment (n=22)

No antibiotic treatment (n=36)

Inclusion Criteria

Patients with 18 years of age or older, with the presence of the first episode of VAT diagnosed more than 48 hours after starting mechanical ventilation.

Exclusion Criteria

Pregnant, history of severe immunosuppression, tracheostomy at ICU admission, ventilator-associated pneumonia (VAP) before VAT, had already participated in this study, or little chance of survival.

Methods

Patients were randomly assigned to receive either intravenous (IV) antimicrobial treatment for 8 days or no antibiotic treatment. The initial empirical antibiotic regimen was based on results of the last endotracheal aspirate culture and was modified if considered inappropriate after receiving definitive microbiologic results. No patient received aerosolized antibiotics, and all were followed until ICU discharge or 28 days after random assignment.

Duration

June 2005 to June 2007.

Outcome Measures

Primary Outcome: Duration of mechanical ventilation

Secondary Outcomes: Mechanical ventilation-free days, length of ICU stay, subsequent VAP, ICU mortality, and infection or colonization related to MDR bacteria

Baseline Characteristics

  

Antibiotic treatment

(n=22)

No antibiotic treatment

(n=36)

 p-Value

Mean age, years

 62 ± 15 67 ± 12 p=0.194

Male

 15 (68%) 24 (66%) p>0.999

Mean Simplified Acute Physiology Score (SAPS) II

 47 ± 14 47 ± 18 p=0.994

Mean Logistic Organ Dysfunction (LOD) score

 6.6 ± 3.5 6.2 ± 3.6 p=0.711

Prior antibiotic treatment

 9 (40%) 12 (33%) p=0.585

Duration of mechanical ventilation before random assignment, days

 17 ± 9 13 ± 6 p=0.232

Results

Primary Endpoint

Antibiotic treatment

(n=22)

No antibiotic treatment

(n=36)

p-Value

Duration of mechanical ventilation, days

 29 ± 17 26 ± 15 p=0.816

Mechanical ventilation-free days, median

 12 (8-24) 2 (0-6) p<0.001

Length of ICU stay, days

 40 ± 23 36 ± 21 p=0.558

Ventilator-associated pneumonia

 3 (13%) 17 (47%) p=0.011

ICU mortality

 4 (18%) 17 (47%) p=0.047

Infection or colonization related to MDR bacteria

 9 (40%) 13 (36%) p=0.784

Adverse Events

Common Adverse Events: N/A

Serious Adverse Events: N/A

Percentage that Discontinued due to Adverse Events: N/A

Study Author Conclusions

In patients with VAT, antimicrobial treatment is associated with a greater number of days free of mechanical ventilation and lower rates of VAP and ICU mortality. However, antibiotic treatment has no significant impact on the total duration of mechanical ventilation or ICU stay.

InpharmD Researcher Critique

The trial was stopped early due to the apparent benefit of treatment on ICU mortality rate in the antibiotic group; however, the primary endpoint was found to be non-significant. The population size was quite small and conducted in France. Furthermore, the study was not blinded and antibiotic treatment was not standardized in all treated patients.

 

References:

Nseir S, Favory R, Jozefowicz E, et al. Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care. 2008;12(3):R62. doi:10.1186/cc6890.

Comparison Of Azithromycin And Amoxicillin/Clavulanic acid In The Treatment Of Acute Tracheobronchitis And Acute Infectious Exacerbations Of Chronic Bronchitis In Adults

Design

A randomized, multicentre, open-label, comparative trial

N=759

Objective

To compare the efficacy and tolerance of a 3-day regimen of azithromycin, 500 mg once daily, with a 5-10-day regimen of amoxicillin/clavulanic acid, 625 mg three times daily, in adult patients with acute tracheobronchitis or acute infectious exacerbations of chronic bronchitis (AIECB).

Study Groups

Azithromycin (n=501)

Amoxicillin/clavulanic acid (n=258)

Inclusion Criteria

Between 18 and 75 years of age, and provide written consent with acute tracheobronchitis or AIECB.

Exclusion Criteria

Pregnant or nursing women, women of childbearing age who were not using a reliable method of contraception, known allergy to Beta-lactam antibiotics or macrolides, use of antibiotic a week prior, use of any investigational drug in a preceding month, taking ergot or digitalis derivative cyclosporin or phenytoin.

Methods

Patients were randomized (2:1) to receive either azithromycin (two 250 mg capsules taken once daily at least 1 hour before or 2 hours after a meal for 3 days), or amoxicillin/clavulanic acid (one 625 mg tablet taken three times daily, during or shortly after meals for 5-10 days). 

Duration

Not specified.

Outcome Measures

Primary Outcome: Clinical status at visit 2 as either cure, improvement, or failure.

Baseline Characteristics

  

Azithromycin

(n=501)

Amoxicillin/clavulanic acid

(n=258)

 p-Value

Mean age, years

 45 ± 13.3 44 ±13.9 p=0.279

Female

230 (46%) 106 (41%) p=0.181

Acute bronchitis

 407 (81%) 213 (83%) p=0.656

Mean duration infection present, days

 5.1 ± 5.7 4.5 ± 4.2 p=0.151

Results

Primary Endpoint (Number of patients with acute trancheobronchitis)

Azithromycin

(n=404)

Amoxicillin/clavulanic acid

(n=213)

p-Value

Number of patients cured with acute bronchitis

 293 (72.5%) 138 (64.8%) p=0.124

Number of patients with improvement in acute bronchitis

 76 (18.8%) 49 (23.0%) -

Number of patients failed with acute bronchitis

 35 (8.7%) 26 (12.2%) -

Adverse Events

Common Adverse Events: Gastrointestinal system (71.4% Azithromycin vs 80.6% amoxicillin/clavulanic acid).

Serious Adverse Events: N/A

Percentage that Discontinued due to Adverse Events: More patients in the amoxicillin/clavulanic acid group discontinued treatment due to adverse events (7%), compared to the azithromycin group (1.2%).

Study Author Conclusions

In the present study included 620 adult patients with acute tracheobronchitis and 139 with AIECB, a 3-day course of azithromycin, given once daily, gave a better overall response than a 5-10-day course of amoxicillin/clavulanic acid, given three times daily.

Azithromycin showed clear advantages in patient compliance, produced a more rapid cure, and was better tolerated with fewer gastrointestinal side-effects and more patients completing the course of treatment. These results confirm the value of short-term treatment with azithromycin for community-acquired lower respiratory tract infections.

InpharmD Researcher Critique

The study did not find a significant difference between groups in the numbers cured and improved for patients with acute tracheobronchitis, but those receiving azithromycin had fewer relapses. The study was conducted in Belgium back in the 1990s; thus, the study findings need to be interpreted with caution.

 

References:

Biebuyck XA. Comparison of azithromycin and amoxicillin/clavulanic acid in the treatment of acute tracheobronchitis and acute infectious exacerbations of chronic bronchitis in adults. J Int Med Res. 1996;24(5):407-418. doi: 10.1177/030006059602400502.

 

Ventilator-Associated Tracheitis in Children: Does Antibiotic Duration Matter?
Design

Retrospective cohort study

N= 1616 participants
Objective To determine whether prolonged-course (≥7 days) antibiotic therapy for ventilator-associated tracheitis (VAT) is more protective against progression to hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP) compared to short-course therapy (<7 days), and to assess the likelihood of multidrug-resistant organisms (MDRO) acquisition with prolonged-course therapy
Study Groups

118 patients meeting VAT criteria

<7 days of antibiotics (n = 36)

≥7 days of antibiotics (n = 82)

150 patients with clinician-suspected VAT

<7 days of antibiotics (n = 50) 

≥7 days of antibiotics (n = 100)
Inclusion Criteria Children ≤18 years of age, admitted to neonatal ICU (NICU) or pediatric ICU (PICU), intubated for ≥48 hours, received antibiotic therapy for VAT
Exclusion Criteria Preexisting tracheostomy, new infiltrate visible on chest imaging compared to radiographic findings from the time of intubation
Methods

Medical records were reviewed for all children treated with antibiotics for suspected VAT. Data on demographics, microbiology, radiography, and clinical information were collected. Children were categorized based on whether they met the criteria for VAT. Those who did not meet the criteria were classified as treated for suspected VAT. 

Combination antibiotic therapy was defined as using a β-lactam (penicillin, cephalosporin, or carbapenem) plus an aminoglycoside for at least 24 hours after bacterial susceptibility data were available. Therapy lasting 7 days or more was classified as prolonged-course, while therapy shorter than 7 days was classified as short-course. The 7-day cutoff was based on the median therapy duration for all children.
Duration

January 1 2007 through December 31, 2009

Antibiotic therapy duration: median 9.8 days for prolonged-course, 5.9 days for short-course

Follow-up: 10 days for HAP/VAP, 30 days for MDRO acquisition
Outcome Measures

Primary: Diagnosis of HAP or VAP within 10 days of discontinuing antibiotic therapy for VAT

Secondary: Acquired colonization or infection with an MDRO within 30 days of initiating antibiotics for VAT
Baseline Characteristics Variable ≤6 days of antibiotics (n=36) ≥7 days of antibiotics (n=82) p-value ≤6 days of antibiotics (n=50) ≥7 days of antibiotics (n=100) p-value
Age, median years (IQR) 1.0 (0.9–12) 0.9 (0.6–14) -- 0.8 (0.5–12) 0.8 (0.5–14) --
PRISM score, median value (IQR) 12 (8–20) 12 (8–21) 0.60 12 (9–20) 12 (10–26) --
Unit     0.24     0.56
NICU 28 (78%) 55 (67%) -- 18 (36%) 41 (41%) --
PICU 8 (22%) 27 (33%) -- 32 (64%) 59 (59%) --
Male 24 (67%) 54 (66%) 0.93 35 (70%) 63 (63%) 0.40
Gram-negative organisms from sputum 26 (72%) 68 (83%) 0.18 30 (60%) 78 (78%) .02
Preexisting conditions     0.22     .047
Prematurity 6 (17%) 22 (27%) -- 15 (30%) 33 (33%) --
Neuromuscular 9 (25%) 10 (12%) -- 9 (18%) 10 (10%) --
Cardiovascular 3 (8%) 13 (16%) -- 5 (10%) 16 (16%) --
Genetic/metabolic 2 (6%) 4 (5%) -- 2 (4%) 6 (6%) --
Respiratory 3 (8%) 12 (15%) -- 3 (6%) 13 (13%) --
Trauma 7 (20%) 10 (12%) -- 8 (16%) 10 (10%) --
Gastrointestinal 4 (11%) 2 (2%) -- 4 (8%) 2 (2%) --
Immunocompromised 0 (0) 1 (1%) -- 0 (0) 2 (2%) --

Abbreviations: IQR, interquartile range; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit; PRISM, patient’s pediatric risk of mortality

In the NICU, VAT was commonly linked with Enterobacteriaceae and Pseudomonas aeruginosa. While S. aureus VAT was seen in the NICU, it was more prevalent in the PICU. In older patients, Streptococcus pneumoniae and Haemophilus influenzae were frequently identified as causes of VAT.

  
Results Variable Unadjusted HR (95% CI) p-value Adjusted HRa (95% CI) p-value
≥7 days of antibiotics for VAT 1.41 (0.56–3.52) 0.47 1.08 (0.40–2.91) 0.88
ETT remains b 4.85 (1.67–14.16) <0.01 4.16 (1.39–12.45) <0.01
PRISM score c 1.04 (0.95–1.15) 0.37 1.03 (0.94–1.13) 0.50
Gram-negative organism from sputum 3.24 (0.76–13.73) 0.11 2.18 (0.50–9.61) 0.30
Combination antibiotics d 1.81 (0.83–3.97) 0.14 1.31 (0.49–3.47) 0.59
Additional antibiotic therapy for >48 h within 10 days of VAT diagnosis 1.20 (0.40–2.11) 0.43 1.43 (0.59–3.58) 0.36
NICU e 0.49 (0.22–1.08) 0.08 0.93 (0.36–2.39) 0.88

Abbreviations: CI, confidence interval; ETT, endotracheal tube; HR, hazard ratio; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit; PRISM, pediatric risk of mortality score.

a HR adjusted for variables in table from diagnosis of VAT until development of HAP or VAP or 10 days after antibiotic completion.

b ETT remained in place for duration of antibiotic course for VAT.

c Per 1 unit increase.

d Combination therapy defined as the use of a b-lactam plus aminoglycoside as definitive antibiotic therapy for >24h after bacterial susceptibility data known.

e Infant admitted to NICU compared with admission to PICU.
Adverse Events Three children developed Clostridium difficile infection within 5 days of antibiotic therapy completion.
Study Author Conclusions Prolonged-course antibiotic therapy for VAT does not protect against progression to HAP or VAP compared to short-course therapy and is associated with a significantly increased risk of subsequent MDRO acquisition. Judicious use of antibiotics in children with VAT may decrease the emergence of MDROs without compromising clinical outcomes.
Critique Surveillance for MDRO colonization was only performed for ICU patients, potentially affecting detection rates post-transfer, though no significant surveillance bias was observed. The findings may not apply to children with tracheostomies, who were excluded due to different risk factors. Combining NICU and PICU data might limit generalizability to other institutions, as patient populations can vary. Additionally, observational data can be influenced by confounding by indication, where more ill children might receive longer antibiotic courses, though exploratory analysis and propensity score techniques suggest physician preference rather than illness severity likely drove treatment duration.
References:

Tamma PD, Turnbull AE, Milstone AM, Lehmann CU, Sydnor ER, Cosgrove SE. Ventilator-associated tracheitis in children: does antibiotic duration matter?. Clin Infect Dis. 2011;52(11):1324-1331. doi:10.1093/cid/cir203

Tracheitis Diagnosis and Treatment Recommendations from Reviews

Review 1

Casazza G, Graham ME, Nelson D, et al. Pediatric bacterial tracheitis-a variable entity: Case series with literature review. Otolaryngol Head Neck Surg. 2019;160(3):546-549. doi: 10.1177/0194599818808774.

Pediatrics

Diagnosis:

  • Common presenting symptoms: cough, stridor (inspiratory or biphasic), voice changes or hoarseness, fever, and dysphagia or odynophagia.
  • Many patients present with a viral prodrome prior to presenting to the institution.

Treatment:

  • Management of the airway is critical.
  • Rigid bronchoscopy is considered the gold standard for determining the presence or absence of tracheal membranes.
  • Once the airway is stabilized, treatment of all patients, regardless of severity, includes systemic antibiotics and supportive care.
 
 

Review 2

Blot M, Bonniaud-Blot P, Favrolt N, et al. Update on childhood and adult infectious tracheitis. Med Mal Infect. 2017;47(7):443-452. doi: 10.1016/j.medmal.2017.06.006.

Adults/Pediatrics

Diagnosis:

  • Viral tracheitis is considered as laryngotracheobronchitis (LTB).
  • Sudden onset of presentation with upper airway non-specific prodromes 12 to 48 hours before viral LTB onset.
  • Fever is not always observed, and symptom duration is short (resolves within less than 48 hours).
  • A bacterial origin is suspected when stridor, respiratory distress, toxic appearance, high fever, orthopnea, and or dysphagia is present.
  • Biological samples help confirm the bacterial origin. X-rays help in confirming the bacterial tracheitis diagnosis by visualizing intratracheal opacities.
  • CT scans are much more efficient than x-rays, but its main limitation is the resulting radiation.

 Treatment:

  • Tracheal intubation is usually required in 75% of pediatric patients.
  • The combination of amoxicillin-clavulanic acid or 3rd generation cephalosporin is the best choice for bacterial tracheitis, and should then be tailored to the microbiological results.
  • Duration of treatment has not been clearly defined.

Review 3

Kuo CY, Parikh SR. Bacterial tracheitis. Pediatr Rev. 2014;35:497. doi: 10.1542/pir.35-11-497.

Pediatrics

Diagnosis:

  • Presentation of a several-day prodrome of an upper respiratory tract viral infection (cough, coryza, and sore throat) then develops into the rapid onset of high temperatures (>101.3 degrees Fahrenheit), stridor, hoarseness, and a toxic appearance.
  • Odynophagia, dysphagia, drooling, and “sniffing” are usually absent, with leukocytosis or leukopenia often being present.
  • In patients with a stable airway, anteroposterior and lateral neck radiography followed by examination with flexible laryngoscopy should be performed.

Treatment:

  • Endotracheal intubation in severe respiratory distress.
  • Empiric broad-spectrum intravenous antibiotic: vancomycin or clindamycin plus ampicillin-sulbactam, a third-generation cephalosporin, or a fluoroquinolone.
  • Steroids and epinephrine have no proven efficacy.

Bacterial tracheitis occurrence peaks in the fall and winter months.  

Review 4

Tebruegge M, Pantazidou A, Yau C, et al. Bacterial tracheitis – tremendously rare, but truly important: A systematic review. Pediatr Infect Dis J. 2009;4:199-209. doi: 10.3233/JPI-2009-0179.

 

Adults/Pediatrics

Diagnosis:

Bacterial tracheitis vs viral croup

Children with viral croup generally do not appear ‘toxic’ and almost invariably show some response to inhaled adrenaline or corticosteroids.

Bacterial tracheitis vs epiglottis

Epiglottis in bacterial tracheitis generally appears normal or only mildly inflamed.

Drooling is an uncommon finding, distinguishing bacterial tracheitis from epiglottitis.
  • Prodromal symptoms suggestive of a minor URTI, including coryza, cough, and a low-grade fever that typically present for 2-5 days.
  • A clinical hallmark: stridor, which can have a biphasic character, and dyspnea. Most patients have a severe increase of dyspnea that develops rapidly, resulting in the need for intubation within the first 24 hours following the onset of stridor.
  • Narrowing of the tracheal air-shadow on a radiographic examination.

Treatment:

  • Airway management is the most urgent aspect of care for patients with bacterial tracheitis.
  • Despite the absence of solid evidence, glucocorticoids are used in the first few days to reduce airway inflammation and edema.
  • Antimicrobial therapy (empiric): a 3rd generation cephalosporin (ex: ceftriaxone or cefotaxime), and a penicillinase-resistant penicillin (ex: flucloxacillin or cloxacillin).

The most common reported causative organisms were Staphylococcus aureus (41%), Haemophilus influenzae (18%), Streptococcus pneumoniae (15%), Moraxella catarrhalis (13%) and Streptococcus pyogenes (9%).

There is a high degree of overlap in clinical presentation between epiglottitis, bacterial tracheitis and upper airway abscess.

Review 5

Graf J, Stein F. Tracheitis in pediatric patients. Semin Pediatr Infect Dis. 2006;17(1):11-13. doi: 10.1053/j.spid.2005.11.004.

Pediatrics

Diagnosis:

  • Acute onset of symptoms including airway obstruction or impending respiratory failure, tachypnea, stridor, a hoarse voice, fever, cough, or increased secretions from the nose and mouth.
  • The patient may be somnolent or combative.
  • A chest radiograph can differentiate tracheitis from pneumonia.
  • A definitive diagnosis can be made with direct laryngoscopy and tracheoscopy, with a gram stain of tracheal secretions to evaluate for the presence of leukocytes and bacteria.

Treatment:

  • Adequate airway protection.
  • Often orotracheal or nasotracheal intubation is required to ensure a patent airway.
  • Once a secure airway is established, broad-spectrum parenteral antibiotics can be administered empirically.
  • Coverage for an antibiotic regimen should include Staphylococcus, Streptococcus, and Hemophilus.
  • Steroids and vasoconstrictors have been used, but none have been reported as effective specifically in tracheitis.

InpharmD Researcher Critique: No clear distinction exists in diagnosing and/or treating bacterial tracheitis between the adult and pediatric population. Tracheal intubation is often required in severe respiratory distress secondary to bacterial tracheitis. Once adequate airway protection is secured, broad-spectrum IV antibiotics (e.g., vancomycin or clindamycin plus ampicillin-sulbactam, a third-generation cephalosporin, or a fluoroquinolone) are given empirically. The duration of treatment for both VAT and bacterial tracheitis has not been clearly defined.