Bacterial Tracheitis
Sujatha Rajan, MD, Assistant Professor of Pediatrics, Albert Einstein School of Medicine; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Diseases, Schneider Children's Hospital, North Shore-Long Island Jewish Health System
Kathryn Clark Emery, MD, Associate Professor, Department of Pediatrics, University of Colorado Health Sciences Center; Consulting Staff, Department of Emergency Medicine, Children's Hospital of Denver; Sunil K Sood, MBBS, DCh, MD, Professor of Clinical Pediatrics, Department of Pediatrics, Albert Einstein College of Medicine; Chief, Pediatric Infectious Diseases, Firm Director, Pediatric Unit, Schneider Children's Hospital at North Shore, North Shore University Hospital
Updated: Jun 23, 2009
Introduction
Background
Although bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction, it is currently more prevalent than acute epiglottitis. Patients may present with crouplike symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard croup therapy and may experience acute respiratory decompensation.1
Pathophysiology
Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.
Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.
Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury to trachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms.
Frequency
United States
Tan and Manoukian reported that 500 children were hospitalized for croup at one pediatric hospital over a 32-month period.2 Approximately 98% had viral croup, and 2% had bacterial tracheitis. Cases usually occur in the fall or winter months, mimicking the epidemiology of viral croup.
International
According to a recent study, bacterial tracheitis remains a rare condition, with an estimated incidence of approximately 0.1 cases per 100,000 children per year.3
Mortality/Morbidity
The predominant morbidity and mortality is related to the potential for acute upper airway obstruction and induced hypoxic insults. The mortality rate has been estimated at 4-20%. In the acute phase, patients generally do well if the airway is adequately managed and if antibiotic therapy is promptly initiated.
Sex
In most epidemiologic studies, male cases are preponderant. Gallagher et al reported a male-to-female predominance of 2:1.4
Age
Bacterial tracheitis may occur in any pediatric age group. Gallagher et al reported 161 cases of patients younger than 16 years.4 The age range was from 3 weeks to 16 years, with a mean age of 4 years. This is in contrast to viral laryngotracheobronchitis, which occurs in patients aged 6 months to 3 years.
Clinical
History
Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.
In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful.
In a study by Salamone et al, a significant subset of older children (mean age, 8 y) did not have severe clinical symptoms.5
The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.
Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened.
Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea.
A high index of suspicion for bacterial tracheitis is needed in children with viral croup?like symptoms who do not respond to standard croup treatment or clinically worsen.
Physical
Inspiratory stridor (with or without expiratory stridor)
Barklike or brassy cough
Hoarseness
Worsening or abruptly occurring stridor
Varying degrees of respiratory distress
Retractions
Dyspnea
Nasal flaring
Cyanosis
Sore throat, odynophagia
Dysphonia
No drooling
No specific position of comfort (The patient may lie supine.)
Causes
S aureus: Community-associated methicillin-resistant S aureus (CA-MRSA) has recently emerged as an important agent in the United States; this could result in a greater frequency of MRSA strains that cause tracheitis.
S pyogenes, Streptococcus pneumoniae, and other alpha hemolytic streptococcal species
Moraxella catarrhalis: Recent reports suggest it is a leading cause of bacterial tracheitis and associated with increased intubation.
Haemophilus influenzae type B (Hib): This cause is less common since the introduction of the Hib vaccine.
Klebsiella species
Pseudomonas species
Anaerobes
Peptostreptococcus species
Bacteroides species
Prevotella species
Other
Mycoplasma pneumoniae
Mycobacterium tuberculosis (endobronchial disease)
Differential Diagnoses
Angioedema
Epiglottitis
Candidiasis
Peritonsillar Abscess
Croup
Retropharyngeal Abscess
Diphtheria
Tuberculosis
Other Problems to Be Considered
Uvulitis
Workup
Laboratory Studies
Obtain bacterial culture and Gram stain of tracheal secretions and blood cultures in patients with suspected bacterial tracheitis.
Imaging Studies
Radiography of neck
Neither definitive nor essential
Portable, not in the radiology suite, only in the stable patient
May reveal subglottic narrowing on anteroposterior (AP) views - Steeple sign, similar to croup
Steeple sign.
May reveal clouding of tracheal air column or irregular tracheal margin on lateral view
Concretions of epithelium and inflammatory cells possibly mimicking a foreign body
Procedures
Laryngotracheobronchoscopy
Only definitive means of diagnosis
Direct visualization and culture of purulent tracheal secretions
May be therapeutic by performing tracheal toilet and stripping purulent membranes
Pediatric-sized bronchoscopes and experts at pediatric airway management not available at all facilities
Treatment
Medical Care
Treatment of bacterial tracheitis consists of the following:
Airway
Maintenance of an adequate airway is of primary importance.
Avoid agitating the child. If the patient's respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.
If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotracheal tube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation.
Intravenous access and medication
Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.
Antibiotic regimens have traditionally included a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and a penicillinase-resistant penicillin (eg, oxacillin, nafcillin). Recently, clindamycin (40 mg/kg/d intravenously [IV], divided every 8 h) is used instead of penicillinase-resistant penicillin against community acquired?methicillin-resistant S aureus (CA-MRSA) in places where resistance rates of CA-MRSA to clindamycin is low.6
Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community.
Surgical Care
Tracheostomy
Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged.
Pulmonary toilet is potentially better with tracheostomy.
Consultations
Otorhinolaryngology - For endoscopic procedures and acute airway management
Pediatric intensivist - Necessary because of potential for acute decompensation
Medication
Antibiotic agents
Empiric antimicrobial therapy in bacterial tracheitis must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Oxacillin (Bactocill, Prostaphlin)
Provides empiric therapy against etiologic agents, specifically penicillinase-producing strains of Staphylococcus.
Dosing
Adult
1-2 g IV q6h
Pediatric
150 mg/kg/d IV divided q6h
Interactions
Oxacillin decreases effects of contraceptives and tetracycline; administered concomitantly with disulfiram and probenecid, may increase oxacillin levels; effect of anticoagulants increase when large IV doses of oxacillin given
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution in patients with severe renal impairment; use with caution in patients with a documented hypersensitivity to cephalosporins
Cefotaxime (Claforan)
Provides empiric therapy, especially against H influenzae, and modest activity against anaerobes.
Dosing
Adult
1-2 g IV q8h
Pediatric
150 mg/kg/d IV divided q6h
Interactions
Probenecid may increase cefotaxime levels; coadministration with furosemide or aminoglycosides may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dosage modification in patients with CrCl is <20 mL/min
Vancomycin (Vancocin)
May be used in severe cases or in cases with a history of allergies instead of oxacillin for coverage of gram-positive organisms (eg, S aureus, S pyogenes).
Dosing
Adult
15 mg/kg/dose IV q8h; not to exceed 2 g/d
Pediatric
Administer as in adults
Interactions
The neuromuscular blockade may be enhanced when used concurrently with nondepolarizing muscle relaxants
Contraindications
Documented hypersensitivity; avoid in patients with previous hearing loss
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Dosage modification required for patients with impaired renal function; red man syndrome is considered a function of the infusion rate
Clindamycin (Cleocin)
Use in combination with chloramphenicol in patients who are allergic to penicillin. Clindamycin in combination with cefuroxime is an acceptable regimen for patients who are not allergic.
Dosing
Adult
600-1200 mg/d IV divided bid-qid
Pediatric
40 mg/kg/d IV divided q8h
Interactions
Increases duration of neuromuscular blockade induced by tubocurarine or pancuronium; CYP450 3A4 inhibitors (eg, saquinavir, ketoconazole) may decrease clearance
Contraindications
Documented hypersensitivity to clindamycin or any component; previous pseudomembranous colitis; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dosage adjustment may be necessary in patients with severe hepatic dysfunction; no change is necessary with renal insufficiency
Follow-up
Further Inpatient Care
Consider extubation when bacterial tracheitis appears to be resolving, especially with decreased secretions suctioned from the endotracheal tube.
Further Outpatient Care
Patient should complete an appropriate course (usually 10 d) of oral antibiotics.
Transfer
Transfer is required for patients in respiratory distress, patients in need of a pediatric intensive care unit, and patients who need a pediatric-sized bronchoscope.
Complications
Pneumonia - Reported in 19-60% of cases (Guidelines for avoiding health care?associated pneumonia have been established.7 )
Septicemia
Toxic shock
Adult respiratory distress syndrome (ARDS)
Endotracheal tube complications
Plugging, accidental extubation
Postextubation stridor, subglottic stenosis
Anoxic encephalopathy
Cardiorespiratory arrest
Prognosis
Once the patient is past the acute phase, complete recovery is expected.
Patient Education
Keep immunizations up-to-date.
Miscellaneous
Medicolegal Pitfalls
Always consider epiglottitis, foreign body, and bacterial tracheitis before settling for a diagnosis of croup.
Special Concerns
Predisposing conditions may include the following:
Down syndrome
Anatomic abnormalities such as subglottic hemangioma, tracheobronchomalacia, tracheoesophageal fistula repair
Immunodeficiency
Preceding viral infection, especially parainfluenza
http://emedicine.medscape.com/article/961647-print
Sujatha Rajan, MD, Assistant Professor of Pediatrics, Albert Einstein School of Medicine; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Diseases, Schneider Children's Hospital, North Shore-Long Island Jewish Health System
Kathryn Clark Emery, MD, Associate Professor, Department of Pediatrics, University of Colorado Health Sciences Center; Consulting Staff, Department of Emergency Medicine, Children's Hospital of Denver; Sunil K Sood, MBBS, DCh, MD, Professor of Clinical Pediatrics, Department of Pediatrics, Albert Einstein College of Medicine; Chief, Pediatric Infectious Diseases, Firm Director, Pediatric Unit, Schneider Children's Hospital at North Shore, North Shore University Hospital
Updated: Jun 23, 2009
Introduction
Background
Although bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction, it is currently more prevalent than acute epiglottitis. Patients may present with crouplike symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard croup therapy and may experience acute respiratory decompensation.1
Pathophysiology
Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.
Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.
Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury to trachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms.
Frequency
United States
Tan and Manoukian reported that 500 children were hospitalized for croup at one pediatric hospital over a 32-month period.2 Approximately 98% had viral croup, and 2% had bacterial tracheitis. Cases usually occur in the fall or winter months, mimicking the epidemiology of viral croup.
International
According to a recent study, bacterial tracheitis remains a rare condition, with an estimated incidence of approximately 0.1 cases per 100,000 children per year.3
Mortality/Morbidity
The predominant morbidity and mortality is related to the potential for acute upper airway obstruction and induced hypoxic insults. The mortality rate has been estimated at 4-20%. In the acute phase, patients generally do well if the airway is adequately managed and if antibiotic therapy is promptly initiated.
Sex
In most epidemiologic studies, male cases are preponderant. Gallagher et al reported a male-to-female predominance of 2:1.4
Age
Bacterial tracheitis may occur in any pediatric age group. Gallagher et al reported 161 cases of patients younger than 16 years.4 The age range was from 3 weeks to 16 years, with a mean age of 4 years. This is in contrast to viral laryngotracheobronchitis, which occurs in patients aged 6 months to 3 years.
Clinical
History
Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.
In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful.
In a study by Salamone et al, a significant subset of older children (mean age, 8 y) did not have severe clinical symptoms.5
The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.
Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened.
Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea.
A high index of suspicion for bacterial tracheitis is needed in children with viral croup?like symptoms who do not respond to standard croup treatment or clinically worsen.
Physical
Inspiratory stridor (with or without expiratory stridor)
Barklike or brassy cough
Hoarseness
Worsening or abruptly occurring stridor
Varying degrees of respiratory distress
Retractions
Dyspnea
Nasal flaring
Cyanosis
Sore throat, odynophagia
Dysphonia
No drooling
No specific position of comfort (The patient may lie supine.)
Causes
S aureus: Community-associated methicillin-resistant S aureus (CA-MRSA) has recently emerged as an important agent in the United States; this could result in a greater frequency of MRSA strains that cause tracheitis.
S pyogenes, Streptococcus pneumoniae, and other alpha hemolytic streptococcal species
Moraxella catarrhalis: Recent reports suggest it is a leading cause of bacterial tracheitis and associated with increased intubation.
Haemophilus influenzae type B (Hib): This cause is less common since the introduction of the Hib vaccine.
Klebsiella species
Pseudomonas species
Anaerobes
Peptostreptococcus species
Bacteroides species
Prevotella species
Other
Mycoplasma pneumoniae
Mycobacterium tuberculosis (endobronchial disease)
Differential Diagnoses
Angioedema
Epiglottitis
Candidiasis
Peritonsillar Abscess
Croup
Retropharyngeal Abscess
Diphtheria
Tuberculosis
Other Problems to Be Considered
Uvulitis
Workup
Laboratory Studies
Obtain bacterial culture and Gram stain of tracheal secretions and blood cultures in patients with suspected bacterial tracheitis.
Imaging Studies
Radiography of neck
Neither definitive nor essential
Portable, not in the radiology suite, only in the stable patient
May reveal subglottic narrowing on anteroposterior (AP) views - Steeple sign, similar to croup
Steeple sign.
May reveal clouding of tracheal air column or irregular tracheal margin on lateral view
Concretions of epithelium and inflammatory cells possibly mimicking a foreign body
Procedures
Laryngotracheobronchoscopy
Only definitive means of diagnosis
Direct visualization and culture of purulent tracheal secretions
May be therapeutic by performing tracheal toilet and stripping purulent membranes
Pediatric-sized bronchoscopes and experts at pediatric airway management not available at all facilities
Treatment
Medical Care
Treatment of bacterial tracheitis consists of the following:
Airway
Maintenance of an adequate airway is of primary importance.
Avoid agitating the child. If the patient's respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.
If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotracheal tube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation.
Intravenous access and medication
Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.
Antibiotic regimens have traditionally included a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and a penicillinase-resistant penicillin (eg, oxacillin, nafcillin). Recently, clindamycin (40 mg/kg/d intravenously [IV], divided every 8 h) is used instead of penicillinase-resistant penicillin against community acquired?methicillin-resistant S aureus (CA-MRSA) in places where resistance rates of CA-MRSA to clindamycin is low.6
Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community.
Surgical Care
Tracheostomy
Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged.
Pulmonary toilet is potentially better with tracheostomy.
Consultations
Otorhinolaryngology - For endoscopic procedures and acute airway management
Pediatric intensivist - Necessary because of potential for acute decompensation
Medication
Antibiotic agents
Empiric antimicrobial therapy in bacterial tracheitis must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Oxacillin (Bactocill, Prostaphlin)
Provides empiric therapy against etiologic agents, specifically penicillinase-producing strains of Staphylococcus.
Dosing
Adult
1-2 g IV q6h
Pediatric
150 mg/kg/d IV divided q6h
Interactions
Oxacillin decreases effects of contraceptives and tetracycline; administered concomitantly with disulfiram and probenecid, may increase oxacillin levels; effect of anticoagulants increase when large IV doses of oxacillin given
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution in patients with severe renal impairment; use with caution in patients with a documented hypersensitivity to cephalosporins
Cefotaxime (Claforan)
Provides empiric therapy, especially against H influenzae, and modest activity against anaerobes.
Dosing
Adult
1-2 g IV q8h
Pediatric
150 mg/kg/d IV divided q6h
Interactions
Probenecid may increase cefotaxime levels; coadministration with furosemide or aminoglycosides may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dosage modification in patients with CrCl is <20 mL/min
Vancomycin (Vancocin)
May be used in severe cases or in cases with a history of allergies instead of oxacillin for coverage of gram-positive organisms (eg, S aureus, S pyogenes).
Dosing
Adult
15 mg/kg/dose IV q8h; not to exceed 2 g/d
Pediatric
Administer as in adults
Interactions
The neuromuscular blockade may be enhanced when used concurrently with nondepolarizing muscle relaxants
Contraindications
Documented hypersensitivity; avoid in patients with previous hearing loss
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Dosage modification required for patients with impaired renal function; red man syndrome is considered a function of the infusion rate
Clindamycin (Cleocin)
Use in combination with chloramphenicol in patients who are allergic to penicillin. Clindamycin in combination with cefuroxime is an acceptable regimen for patients who are not allergic.
Dosing
Adult
600-1200 mg/d IV divided bid-qid
Pediatric
40 mg/kg/d IV divided q8h
Interactions
Increases duration of neuromuscular blockade induced by tubocurarine or pancuronium; CYP450 3A4 inhibitors (eg, saquinavir, ketoconazole) may decrease clearance
Contraindications
Documented hypersensitivity to clindamycin or any component; previous pseudomembranous colitis; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dosage adjustment may be necessary in patients with severe hepatic dysfunction; no change is necessary with renal insufficiency
Follow-up
Further Inpatient Care
Consider extubation when bacterial tracheitis appears to be resolving, especially with decreased secretions suctioned from the endotracheal tube.
Further Outpatient Care
Patient should complete an appropriate course (usually 10 d) of oral antibiotics.
Transfer
Transfer is required for patients in respiratory distress, patients in need of a pediatric intensive care unit, and patients who need a pediatric-sized bronchoscope.
Complications
Pneumonia - Reported in 19-60% of cases (Guidelines for avoiding health care?associated pneumonia have been established.7 )
Septicemia
Toxic shock
Adult respiratory distress syndrome (ARDS)
Endotracheal tube complications
Plugging, accidental extubation
Postextubation stridor, subglottic stenosis
Anoxic encephalopathy
Cardiorespiratory arrest
Prognosis
Once the patient is past the acute phase, complete recovery is expected.
Patient Education
Keep immunizations up-to-date.
Miscellaneous
Medicolegal Pitfalls
Always consider epiglottitis, foreign body, and bacterial tracheitis before settling for a diagnosis of croup.
Special Concerns
Predisposing conditions may include the following:
Down syndrome
Anatomic abnormalities such as subglottic hemangioma, tracheobronchomalacia, tracheoesophageal fistula repair
Immunodeficiency
Preceding viral infection, especially parainfluenza
http://emedicine.medscape.com/article/961647-print
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