Diagnostic yield of bronchoscopy with bronchoalveolar lavage in febrile patients with hematologic malignancies and pulmonary infiltrates

Abstract

Infectious complications are a major cause of morbidity and mortality in immunosuppressed patients. Febrile patients with hematologic malignancies and pulmonary infiltrates have high mortality rates, especially if mechanical ventilation is required. The diagnostic value of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) in these patients is controversial. We retrospectively analyzed the microbiological results of BAL samples obtained during 249 FOB examinations from 199 febrile patients with hematologic malignancies and pulmonary infiltrates (underlying diseases: acute leukemia 103 patients, lymphoma 84 patients, other malignancies 12 patients). Two hundred forty-six examinations could be evaluated. Seventy-three out of 246 BAL samples were sterile; 55 samples showed microbiological findings classified as contamination or colonization. One hundred eighteen samples showed positive microbiological results of bacteria and/or fungi classified as causative pathogens. Thereof, in 70 samples, only bacterial pathogens were detectable (Gram-positive, 35; Gram-negative, 30; mixed Gram-positive and Gram-negative, 5). Thirteen samples showed both fungi and bacterial pathogens. In 33 samples, only fungi were detectable, thereof, in 15 samples Aspergillus species, in 16 samples Candida species, and in 2 both. In two samples, a viral pathogen could be detected. Three nonlethal complications (bleeding, arrhythmia) occurred that required early termination of FOB. In 94 (38.2%) patient episodes, antibiotic treatment was modified as a result of microbiological findings in BAL samples. Our results show that FOB with BAL is a valuable diagnostic tool with low complication rates in high-risk febrile patients with hematologic malignancies and pulmonary infiltrates, contributing crucial results for the individual case, and also improving epidemiologic knowledge.

Therapeutic implication of BAL in patients with neutropenia

“…Azoulay et al [2] even demonstrated that in critically ill hematological and oncological patients with acute respiratory failure, non-invasive strategies had a higher diagnostic yield than bronchoscopy and BAL. On the other hand, the studies of Dunagan et al [8], Hummel et al [14], and Peikert et al [21] were in favor for the application of BAL in immunocompromised patients. They stated good diagnostic yield and frequent therapeutic implications in more than 50% of patients, although an impact on survival could not be demonstrated.…”

“…There exist some data that support a frequent use of BAL in immunocompromised patients with pulmonary infiltrates [8,14,21]. But, especially in severely ill patients with neutropenia, BAL is associated with a high rate of complications [2,11,30].…”

“…It has been shown in patients with different kinds of immunosuppression that BAL may provide a diagnostic yield in 13 to 60% of cases [2,8,14,15,24,25,29]; but there exists only a few data concerning BAL in patients with pneumonia during neutropenia [3,5,9,11,21,27,30]. Maschmeyer et al [19] recommended BAL in febrile neutropenic patients not responding to empirical antimicrobial therapy, in case of positive chest radiography findings.…”

Role of bronchoalveolar lavage in evaluating new pulmonary infiltrates on computed tomography in haematology patients with fever unresponsive to broad-spectrum antibiotics

“…Although a large recent study has supported the role of BAL in the assessment of such patients, it did not assess the clinical benefit following BAL or report on complications other than death (Hummel et al, 2008). It also failed to state the type of antimicrobial agents used in the study, and these may have changed over the 15-year study period.…”

Role of bronchoscopy in diagnosis of pulmonary infections in non-HIV immune compromised host

“…12,[16][17][18] The treatment modification rate was higher in our study compared to other studies. Among patients in whom treatment was modified, those in whom antibiotic were changed as per culture sensitivity pattern showed maximum clinical improvement with 90%, followed by those in whom anti tuberculosis treatment was started showed 70% improvement and those in whom antifungals were started 60% clinical improvement.…”