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

Abstract

Pulmonary infiltrates frequently complicate hematopoietic SCT (HSCT). The utility of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) in the evaluation of new pulmonary infiltrates, particularly as it relates to optimal timing of the procedure, is unclear. Based on this, we retrospectively reviewed 501 consecutive, adult, nonintubated patients who underwent 598 BALs for evaluation of new pulmonary infiltrates during the first 100 days following HSCT to determine whether diagnostic yields for infection, subsequent antimicrobial treatment modifications and patient outcomes differed following early vs late referrals for the procedure. The overall yield of BAL for clinically significant pathogens was 55%. Notably, the yield was 2.5-fold higher among FOBs performed within the first 4 days of presentation (early FOB) compared to those performed late, and highest (75%) when performed within 24 h of clinical presentation. Rates of FOB-guided adjustments in antimicrobial therapy (51%) did not differ significantly between early and late examinations. However, late FOB-related antibiotic adjustments were associated with 30-day pulmonary-associated deaths that were threefold higher (6 vs 18%, P ¼ 0.0351). Major FOB-related complications occurred in only three (0.6%) patients. We conclude that early referral for FOB in this patient setting is associated with higher diagnostic yields and may favorably impact survival.

Performance of Galactomannan, Beta- d -Glucan, Aspergillus Lateral-Flow Device, Conventional Culture, and PCR Tests with Bronchoalveolar Lavage Fluid for Diagnosis of Invasive Pulmonary Aspergillosis

“…Being an abundant component of inhaled air, these organisms represent one of the leading causes of IFI-related morbidity and mortality (1)(2)(3)(4)(5). Due to the crude mortality of 80 to 90% in the absence of adequate treatment, timely diagnosis and early start of antifungal therapy are key factors in the successful treatment of IPA, as delayed antifungal therapy has a negative impact on the survival of these patients (6). Various studies have shown that early diagnosis and initiation of antifungal therapy may improve IFI survival to Ͼ80% (7)(8)(9).…”

Diagnostic Value of Bronchoalveolar Lavage in Leukemic and Bone Marrow Transplant Patients: The Impact of Antimicrobial Therapy

“…This was similar to the finding reported by Shannon who had a 32% yield in patients with an ANC <100 and a 50% yield in patients with an ANC <500. 10 Mechanically ventilated patients had a higher BAL yield. This may be a reflection of the small sample size or severity of illness.…”

“…This correlates with Shannon's findings of an improved BAL sensitivity in early versus late BAL in a similar population. 10 Interestingly, among patients already on antimicrobial therapy for >48h at the time of BAL, a change in the regimen during the 48h preceding BAL was associated with a better yield. This may be a reflection of sample size, a new infection, inappropriate antimicrobial change, severity of illness, or less likely colonization.…”

“…[5][6][7][8][9] Studies of BAL sensitivity in hematopoietic stem cell transplant (HSCT) patients report yields of 22-65%. 6,7,[9][10][11][12] With respect to the yield of BAL in non-resolving pneumonia one study in the general intensive care unit (ICU) setting, Pereira Gomes reported a 72% yield in 53 patients. 13 We sought to examine the effect of antimicrobial treatment on BAL results in a large study population of leukemic and bone marrow transplant patients.…”

Survey of antifungal prophylaxis and fungal diagnostic tests employed in malignant haematology and haemopoietic stem cell transplantation (HSCT) inAustralia andNewZealand

“…However, the >48 h delay reported between time of referral time of procedure in 40% of hospitals is considered suboptimal; yield from BAL is highest when performed within 24 h of new infiltrates and declines significantly by 5 days. 19 Inclusion of respiratory physicians within the multidisciplinary team providing care for these patients should be encouraged. In contrast, non-culture-based tests and TDM were generally available off-site.…”