Role of bronchoalveolar lavage in immunocompromised patients with pneumonia treated with a broad spectrum antibiotic and antifungal regimen

Abstract

Background-In a retrospective study the value of bronchoalveolar lavage (BAL) in the diagnosis of pneumonia was investigated in 95 immunocompromised patients suVering from haematological disorders and receiving a regimen of broad spectrum antibiotics and antifungal agents (BSAR). Methods-With the exception of four afebrile patients, all had fever, raised C reactive protein (CRP) levels, and new infiltrates visible on chest radiography. All patients underwent BAL to identify the organism causing the pneumonia and surveillance cultures were performed regularly for pathogens at diVerent sites. Following classification of the isolates, patients with positive cultures were subdivided into two groups, pathogenic or contaminated. We investigated whether relevant pathogens were cultured only from the BAL fluid and whether they were susceptible to BSAR. Results-Although 77 of the 95 patients were thrombocytopenic, bleeding during BAL occurred in only 15% of all patients. Ten days after the procedure the fever improved in 88% of patients, radiographic findings improved in 71%, and CRP levels improved in 75% of patients; 22% of patients died within 28 days. Pathologically relevant isolates were found in 65% of all patients. Respiratory pathogens were detected only in the BAL fluid of 29 of the 95 patients (35% Gram positive species, 40% Gram negative species, 11% Mycobacterium, 11% fungi, and 3% cytomegalovirus). In 16 of these 29 patients (55%) the pathogens cultured only from the BAL fluid were resistant to treatment. Pathogens detected only in the BAL fluid were not susceptible to a standard broad spectrum antibiotic and antifungal regimen including teicoplanin, ceftriaxon, tobramycin, and amphotericin B in 12 of the 29 patients (41%). Conclusions-Our data suggest that 12 patients were treated with broad spectrum antimicrobial agents which were not directed at the appropriate organism on in vitro sensitivity tests without BAL. BAL is a relatively safe procedure in the diagnosis of pneumonia, supplying important information in immunocompromised patients as well as in immunocompromised patients receiving BSAR. (Thorax 2001;56:115-120)

Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation

“…When reported, FOB typically occurred 4 or more days following the initiation of empiric antibiotics. 11,12,25,27,28 Thus, our findings corroborate previous observations that link diagnostic delays to poor patient outcome and underscore the futility of late FOBguided antimicrobial adjustments in offsetting mortality among HSCT recipients with suspected pneumonia. A notable difference in our study compared with previousreports, however, is the significantly lower mortality rate associated with antibiotic modifications following early FOB.…”

“…Our overall yield of 55% is notable in light of the near universal administration of antimicrobial therapy following HSCT, which may diminish the sensitivity and specificity of bronchoscopically obtained cultures. 12,17,21 We found that early FOBs were 2.5 times more likely to establish a diagnosis of pneumonia compared to late examinations (Po0.0001). Furthermore, early and late FOBs differed qualitatively in terms of responsible pathogens and resistance characteristics.…”

“…In another study of immunocompromised patients with unexplained pulmonary infiltrates, a 64% diagnostic yield of TBBx was reported. 12 HSCT recipients comprised a minority of the patients in each of these studies, which likely impacts their findings. Nondiagnostic FOBs in our study prompted evaluation for open lung biopsy in a small number (7%) of patients.…”

“…[6][7][8] The diagnostic yield of FOB in the immunocompromised host is variable (31-80%), and consensus regarding its utility in guiding therapeutic decisions and influencing outcomes-even when a likely pathogen is recovered-is lacking. 5,[9][10][11][12][13][14][15][16] Additionally, FOB-related complication rates in the post transplant setting exceeding 20% in some studies have increased skepticism for this procedure. 1,17 We hypothesized that the low diagnostic yields of post transplant FOB correlate with the duration of previous empiric antimicrobial therapy and delays in referrals for the procedure.…”

The clinical importance of bronchoalveolar lavage in allogeneic SCT patients with pneumonia

“…5,8,22,23 Other studies have shown diagnostic yields of 51-80%. 3,19,[24][25][26] In total, 7 BALs were performed in children and contributed to the diagnosis in four of these. There are some difficulties associated with bronchoscopies in children, such as the frequent need for general anesthesia and difficulties in performing the procedure because of their small airways.…”