Care Trajectory, Microbiological Ecology, and System-Level Determinants of Tracheitis in Tracheostomized Children

Purpose To evaluate the determinants of tracheitis in tracheostomized pediatric patients by integrating microbiological, clinical, and system-level factors, with particular emphasis on the role of care environment. Methods This retrospective observational study included pediatric patients with tracheostomy followed at a tertiary care center from 2020 to 2024. Data on demographics, comorbidities, functional status, and tracheal aspirate microbiology were extracted from medical records. Tracheitis was analyzed as global, PICU-specific, and post-PICU outcomes. Multivariable logistic regression and generalized estimating equations were used to assess patient-level and environment-level effects. Results Ninety-six patients were included. Tracheitis occurrence was strongly influenced by care environment, with lower odds in post-PICU settings than in the PICU (OR 0.40, 95% CI 0.24 to 0.68; p < 0.001). Gram-negative microorganisms were independently associated with tracheitis (OR 2.25, 95% CI 1.35 to 3.75; p = 0.002), and prematurity also emerged as a significant predictor (OR 2.49, 95% CI 1.40 to 4.42; p = 0.002). Neurological comorbidity showed a borderline association (OR 1.69; p = 0.096). Model discrimination was moderate (AUC 0.725 to 0.749). Conclusion Tracheitis in tracheostomized children reflects a dynamic interaction between care environment, microbial ecology, and host vulnerability. Gram-negative profiles and prematurity are key determinants, while the PICU setting represents a high-risk ecological context.