Clinical utility of bronchoalveolar lavage and respiratory tract biopsies in diagnosis and management of suspected invasive respiratory fungal infections in children

Abstract

BAL and biopsy in children with an oncological diagnosis or those undergoing HSCT only infrequently lead to changes in management in the era of empiric therapy with broad-spectrum anti-fungal agents.

Diagnostic yield of bronchoalveolar lavage in immunocompromised children with malignant and non‐malignant disorders

“…Our study supports the observations made in prior series that a positive result from BAL impacts treatment decisions . We found that most negative BALs were associated with discontinuing at least one non‐targeted antimicrobial, although often another non‐targeted agent was continued.…”

“…Furthermore, negative BALs may have reflected non‐infectious causes of lower tract disease such as graft‐versus‐host disease or pulmonary fibrosis, as has been previously described . Recent comparison studies have suggested that lung biopsy may elucidate noninfectious diagnoses in a manner superior to that of BAL, though this procedure is associated with higher morbidity and mortality than BAL.…”

Cost analysis of bronchoalveolar lavage and respiratory tract biopsies in the diagnosis and management of suspected invasive fungal infection in children with cancer or who have undergone stem cell transplant

“…Nevertheless, our study demonstrates that the costs related to diagnosis and initial management of RT‐IFI in pediatric oncology and HSCT patients are significantly higher when patients undergo an invasive diagnostic procedure. Combined with our previous data that BAL and RTB only infrequently (8%–13% of the time) lead to a change in management in this population in the era of empiric broad‐spectrum antifungal therapy and advanced imaging techniques, the significantly higher morbidity and costs make these invasive diagnostic techniques less attractive. Currently utilized noninvasive diagnostic methods include testing for galactomannan, a cell wall component of aspergillus species, and 1,3‐β‐ d ‐glucan, a major cell wall component of most fungal species except zygomycetes and cryptococcus species, which can both provide supportive evidence of RT‐IFI, but have inadequate sensitivity/specificity and are lacking in information on speciation and antifungal susceptibilities .…”

“…A review of the electronic medical record revealed 119 oncology or post‐HSCT patients at our institution who were suspected of have RT‐IFI between 2007 and 2012. Eighteen of these patients were excluded from this study and our previous study because their fungal infection did not involve the respiratory tract. Twenty‐five patients were excluded from the current study due to insufficient cost data available in our database.…”

“…These charges, however, were not exclusively related to the IFI, and there was no evaluation related to different diagnostic techniques. Data previously published by our institution showed that not only are BAL/RTB associated with higher morbidity, but their results lead to a change in management in children with an oncological diagnosis or undergoing HSCT in only 8% to 13% of cases . Therefore, we sought to analyze the costs related to IFI in patients diagnosed using suggestive CT scan findings alone versus those who underwent a BAL or RTB.…”