Positive Bronchoalveolar Lavage Cultures Research Articles

The performance of bronchoalveolar lavage Aspergillus PCR testing in solid organ transplant recipients with invasive pulmonary aspergillosis.

Invasive aspergillosis affects solid organ transplant (SOT) recipients, carrying a high risk of mortality and morbidity in this population. Rapid and accurate diagnosis is essential to ensure the initiation of correct antifungal therapy. We aimed to evaluate the performance of the bronchoalveolar lavage (BAL) Eurofins Viracor Aspergillus PCR (AspPCR) in diagnosing invasive pulmonary aspergillosis (IPA) in SOT recipients. We conducted a multicenter retrospective study of SOT recipients in Arizona from February 2019 to December 2022 who had AspPCR done at the time of the clinical encounter. Probable IPA was defined as a positive BAL culture with Aspergillus spp. with clinical and imaging findings of IPA per EORTC/MSGERC criteria. Ninety-nine SOT recipients with 131 encounters with BAL AspPCR testing were included. The median age was 66, the majority were White, non-Hispanics (60%), and males (66%). Among the participants, 93 lung transplant recipients with 87 of the encounters received antifungal prophylaxis active against Aspergillus spp. Sixty-four encounters had BAL galactomannan (GM), all of which had BAL GM <1 OD, and one case had a serum GM of 10 OD. Nine cases met the definition of IPA. The sensitivity of the BAL AspPCR was 67% (95% CI 30%-93%), and the specificity was 98% (95% CI 93%-99%). BAL AspPCR had moderate sensitivity and high specificity in identifying IPA in our cohort of SOT recipients. Further studies in populations with a higher prevalence of IPA are needed to evaluate the performance of this test.

Comparing semi-recumbent lateral position vs semi-recumbent position in preventing VAP and ARDS in traumatic brain injury patients requiring mechanical ventilation

Background and aimsVentilator-associated pneumonia is a common nosocomial infection in the intensive care unit among traumatic brain injury patients, resulting in increased morbidity and mortality. We have assessed the effectiveness of semi-recumbent lateral positioning in comparison with semi‐recumbent positioning to prevent ventilator-associated pneumonia and acute respiratory distress syndrome in traumatic brain injury patients requiring mechanical ventilation. MethodsIn a single-blind prospective randomised clinical trial, 100 patients were recruited in the intensive care unit and randomly assigned to the control group (n = 50) and intervention group (n = 50). Patients in control group maintained semi-recumbent position with 30–45° head of bed elevation and intervention group maintained semi-recumbent lateral position with lateral turning ≥45° and head of bed elevation 30–45° every 4 h. Bronchoalveolar lavage for diagnosis of ventilator-associated pneumonia, Glasgow Coma Score, clinical pulmonary infection score, duration of mechanical ventilation, PaO2/FiO2 ratio and incidence of acute respiratory distress syndrome were investigated for 10 days. ResultsComparing semi-recumbent position with semi-recumbent lateral position, the latter showed significant decrease in ventilator-associated pneumonia with lower clinical pulmonary infection score at day 3 (6.5 ± 2.9; 1.8 ± 2.1; p < 0.001), day 7 (6.6 ± 2.6; 2.6 ± 2.3; p < 0.001) and day 10 (7.7 ± 2.9; 2.3 ± 2.3; p = 0.001) and decreased incidence of positive bronchoalveolar lavage cultures at day 3 (p = 0.02), day 7 (p < 0.001) and day 10 (p = 0.001). Duration of mechanical ventilation was significantly reduced at day 7 (p = 0.04) and day 10 (p < 0.001). The incidence of acute respiratory distress syndrome was not different. ConclusionSemi-recumbent lateral position results in significant less incidence of ventilator-associated pneumonia and reduced duration of mechanical ventilation. Trial registration numberICMR-NIMS CTRI/2019/01/016829.

Healthcare providers consistently overestimate the diagnostic probability of ventilator-associated pneumonia.

To assess the accuracy of provider estimates of ventilator-associated pneumonia (VAP) diagnostic probability in various clinical scenarios. We conducted a clinical vignette-based survey of intensive care unit (ICU) physicians to evaluate provider estimates of VAP diagnostic probability before and after isolated cardinal VAP clinical changes and VAP diagnostic test results. Responses were used to calculate imputed diagnostic likelihood ratios (LRs), which were compared to evidence-based LRs. Michigan Medicine University Hospital, a tertiary-care center. This study included 133 ICU clinical faculty and house staff. Provider estimates of VAP diagnostic probability were consistently higher than evidence-based diagnostic probabilities. Similarly, imputed LRs from provider-estimated diagnostic probabilities were consistently higher than evidence-based LRs. These differences were most notable for positive bronchoalveolar lavage culture (provider-estimated LR 5.7 vs evidence-based LR 1.4; P < .01), chest radiograph with air bronchogram (provider-estimated LR 6.0 vs evidence-based LR 3.6; P < .01), and isolated purulent endotracheal secretions (provider-estimated LR 1.6 vs evidence-based LR 0.8; P < .01). Attending physicians and infectious disease physicians were more accurate in their LR estimates than trainees (P = .04) and non-ID physicians (P = .03). Physicians routinely overestimated the diagnostic probability of VAP as well as the positive LRs of isolated cardinal VAP clinical changes and VAP diagnostic test results. Diagnostic stewardship initiatives, including educational outreach and clinical decision support systems, may be useful adjuncts in minimizing VAP overdiagnosis and ICU antibiotic overuse.

A retrospective study on parapneumonic effusion in 130 dogs with a clinical diagnosis of pneumonia.

To screen the occurrence of parapneumonic effusion in dogs. Medical records were searched for dogs with a presumptive diagnosis of bacterial pneumonia from 2017 to 2021 at the Liege university teaching hospital. Bacterial pneumonia was presumptively diagnosed based on compatible clinical signs and findings; thoracic radiographs compatible with bacterial bronchopneumonia; and either increased serum C-reactive protein (CRP) levels, a positive bronchoalveolar lavage culture or a positive clinical evolution in response to antibiotic therapy. Patients diagnosed with parasitic or other non-bacterial inflammatory pneumonia or with pulmonary neoplasia were excluded. Signalment, clinical findings, and outcome were recorded. One hundred and thirty dogs were included in the study, of which 44 dogs (33.8%) developed a parapneumonic effusion. Four of these dogs (4/44; 9%) had thoracocentesis performed, displaying a modified transudate (2) or septic exudate (2). Although parapneumonic effusion in dogs with a presumptive diagnosis of bacterial pneumonia appears to be rather common (33.8%), thoracocentesis or chest tube placement was rarely performed. Furthermore, the outcome of dogs with and without parapneumonic effusion appears to be similar.

Pathogenic bacteria in bronchoalveolar lavage cultures and pediatric laryngotracheal reconstruction outcomes.

The primary objective was to determine if treating pathogenic bacteria in bronchoalveolar lavage (BAL) cultures improves outcomes after pediatric double stage laryngotracheal reconstruction (dsLTR). Case series with chart review. Tertiary children's hospital. All children (<18 years) obtaining flexible bronchoscopy with BAL cultures before dsLTR between 2016 and 2022 were included. Cultures identified abnormal bacterial growth or normal respiratory flora. Thirty-day postoperative surgical site or lung infections were captured and tracheostomy decannulation rates were obtained for children with at least 12 months of follow-up. Twenty-seven children obtained presurgical BAL cultures before dsLTR. Median age at reconstruction was 2.9 years (interquartile range: 2.3-3.5) and 89% (24/27) had high grade subglottic stenosis. Positive cultures were obtained in 56% of children (N = 15) with Pseudomonas aeruginosa (40%, 6/15) and methicillin-resistant Staphylococcus aureus (33%, 5/15) the most frequent organisms. All children with positive cultures were treated based on culture and sensitivity data. Postoperative infections developed in 22% (6/27) of children with equal distribution of surgical site and respiratory infections among children with pathogenic bacteria and normal respiratory flora. At 12 months after surgery, the decannulation rate was no different between those treated and not treated for a presurgical positive BAL culture (47% vs. 58%, p = 0.70). Pathogenic bacteria are common in BAL cultures from tracheostomy-dependent children before dsLTR. Treatment keeps respiratory infections and decannulation rates similar to children with negative cultures, suggesting continued benefit of flexible bronchoscopy and BAL in preparation for these surgeries.

Diagnostic Yield of Bronchoalveolar Lavage in Nepalese Patients Presenting with Chronic Cough with Normal Radiological Imaging in Tertiary Care Hospital

Background: Cough is one of the most common symptoms that lead patients to seek medical attention. The diagnosis of chronic cough is complex and challenging. In our setting, a large proportion of patients with cough are treated empirically without a definite diagnosis. Despite investigation and treatment, fiberoptic bronchoscope with bronchoalveolar lavage (BAL) has been shown to be a useful technique in a selected group of patients with unexplained chronic persistent cough. The aim of the study was to determine the diagnostic yield of bronchoalveolar lavage in Nepalese patients presenting with chronic cough with normal radiological imaging. Methods: This was a hospital based cross sectional study. The patients presenting with chronic cough (&gt;8 weeks) with normal radiological imaging were enrolled in the study. Results: 1 patient (2.6%) sputum sample for AFB was negative however BAL sample of the same patient sent for Gene xpert came positive for Mycobacterium Tuberculosis, 5 patients (12.8%) had positive BAL culture, 29 patients (74.4%) had normal cellular pattern in BAL Cytology. Conclusion: Diagnostic yield of BAL was very low for chronic cough in our study. Patient presenting with eosinophilic pattern in BAL had cough variant asthma suffer from non-productive cough in the absence of other asthma symptoms such as dyspnea and wheezing. Thus, though fiberoptic bronchoscope with BAL is indicated in chronic cough of unknown etiology, its diagnostic yield is low

791. ICU Provider Overestimation of Ventilator-Associated Pneumonia Diagnostic Probability: An Opportunity for Diagnostic Stewardship

Abstract Background Overdiagnosis of ventilator-associated pneumonia (VAP) is common in intensive care units (ICUs). Because VAP is a clinical diagnosis without an easily accessible confirmatory diagnostic test, understanding how ICU physicians practice diagnostic reasoning in suspected VAP is vital to informing diagnostic stewardship efforts. We aimed to assess the accuracy of ICU practitioner estimates of VAP diagnostic probability. Methods We conducted a survey of physicians at Michigan Medicine ICUs. Providers were presented with clinical vignettes (Figure 1) in which mechanically ventilated patients developed clinical signs suggestive of VAP and then had radiographic/microbiologic tests performed. Providers were asked to estimate the probability of VAP before and after each presented clinical sign or test result, which were then used to impute provider-estimated likelihood ratios (pLRs) for each clinical sign and diagnostic test. Provider-estimated probabilities and LRs were compared to evidence-based VAP probabilities and LRs (eLRs) derived from systematic reviews and meta-analyses. Survey Case Example. Results Of 102 survey respondents, 54% felt moderately to extremely confident in their ability to accurately diagnose VAP. Providers significantly overestimated the pre and post-test probability of VAP in all clinical scenarios (provider-estimated VAP diagnostic probabilities are visualized using density plots relative to evidence-based diagnostic probability in Figure 2). Median pLRs for nearly all VAP clinical signs and diagnostic tests were also significantly higher than eLRs (Figure 3), most notably for isolated purulent endotracheal secretions (pLR 1.54 vs eLR 0.76, p&amp;lt; 0.01), positive chest radiograph (pLR 6.0 vs eLR 3.55, p&amp;lt; 0.01), and positive bronchoalveolar lavage culture (pLR 5.7 vs eLR 1.37, p&amp;lt; 0.01). Density Plots of Provider-Estimated vs Evidence-Based Diagnostic Probability of Ventilator-Associated Pneumonia. Provider-Estimated vs Evidence-Based Diagnostic Likelihood Ratios for Clinical Signs and Test Results Related to Ventilator-Associated Pneumonia. Conclusion Physicians routinely overestimated the diagnostic probability of VAP and the positive LRs of possible VAP clinical signs, as well as VAP diagnostic radiographic and microbiologic tests. Educational initiatives addressing and calibrating ICU providers’ perceptions of VAP diagnostic probability warrant investigation as an antimicrobial stewardship tool. Disclosures Owen Albin, MD, Charles River Laboratory: Advisor/Consultant|Cipla Pharmaceuticals: Advisor/Consultant|Shionogi Inc: Advisor/Consultant.

Enhancing respiratory disease diagnosis by bronchoalveolar lavage in Kashmir: an audit of findings

ObjectiveTo study bronchoalveolar lavage (BAL) findings in various respiratory diseases in children in Kashmir India.DesignProspective observational study.SettingPaediatric department of the tertiary care hospital.PatientsChildren of both genders from 1 month to...

Retrospective Review of Flexible Bronchoscopy in Pediatric Cancer Patients.

The use of flexible bronchoscopy (FB) with bronchoalveolar lavage (BAL) to diagnose and manage pulmonary complications has been shown to be safe in adult cancer patients, but whether its use is safe in pediatric cancer patients remains unclear. Thus, to describe the landscape of FB outcomes in pediatric cancer patients and to help define the populations most likely to benefit from the procedure, we undertook a retrospective review of FBs performed in patients younger than 21 years treated at our institution from 2002 to 2017. We found that a greater volume of total fluid instilled during BAL was significantly associated with increased probabilities of positive BAL culture (p=0.042), positive bacterial BAL culture (p=0.037), and positive viral BAL culture (p=0.0496). In more than half of the FB cases, findings resulted in alterations in antimicrobial treatment. Our study suggests that for pediatric cancer patients, FB is safe, likely provides diagnostic and/or therapeutic benefits, and has implications for treatment decisions.

1312. Evaluation of a Multiplexed PCR Pneumonia Panel in a Tertiary Care Medical Center

Abstract Background Syndromic PCR testing for lower respiratory pathogens may give rapid, actionable results to aid in management decisions for suspected pneumonia cases. We sought to evaluate the performance of a multiplexed PCR pneumonia panel compared to routine microbiologic work-up in a tertiary care patient population. Methods Sputum and bronchoalveolar lavage (BAL) samples from Keck Medical Center (Los Angeles, CA) inpatients submitted for clinical microbiology work-up Dec 2019-Jun 2020 were tested by a multiplexed PCR panel (FilmArray Pneumonia Panel, BioFire Diagnostics). We compared panel results for typical bacterial pathogens to those of quantitative culture and susceptibility testing. We retrospectively determined the incidence of non-panel respiratory pathogens as detected by standard of care tests in this patient cohort. Results 68 of 180 samples yielded 80 positive bacterial PCR results: 34 were detected by both PCR panel and culture and 46 by PCR panel only, yielding a sensitivity of 100% (34/34) for pathogens detected and specificity of 73.1% (114/156) among negative cultures (normal flora or no growth). Concordant results had PCR Bin values ≥10^5 copies/mL whereas all 18 targets detected at 10^4 copies/mL were culture-negative. Among resistance gene targets, the panel detected 12 MRSA specimens, of which MRSA grew in only 4 cultures; E. coli and CTX-M in 1 specimen from which grew normal flora; and multiple gram-negative organisms and KPC in 1 specimen from which culture isolated carbapenem-resistant P. aeruginosa. Quantitation from positive BAL cultures (n=25) correlated weakly with PCR Bin values (R-squared=0.17). Non-PCR panel pathogens were detected in 22 of 180 (12.2%) specimens through routine methods (16 molds, 3 AFB, and 3 non-fermenter gram-negative bacteria). Conclusion The pneumonia panel had excellent sensitivity for its target bacterial pathogens, but results were often positive in negative cultures. This could be due to antecedent antibiotic therapy, differences in reporting threshold versus culture, or inability of PCR to discern results from normal flora. Non-panel pathogens were detected in a significant proportion in our population. The pneumonia panel should be implemented and interpreted carefully with consideration of antimicrobial stewardship. Disclosures All Authors: No reported disclosures

Long-term outcomes of metallic endobronchial stents in lung transplant recipients are not affected by bacterial colonization.

We evaluated associations of endobronchial stenting with airway bacterial colonization, the antimicrobial resistance profile, hospitalizations for pneumonia and survival in lung transplant recipients. This is a retrospective single-centre study of 582 recipients of lung transplant during 2002-2018. We compared outcomes of 57 patients (9.7%) who received endobronchial stents (intervention group) to a control group of 57 patients without stents who were matched one to one for age, sex, year of transplantation, unilateral/bilateral transplantation and underlying disease. For the intervention compared to the control group, airway colonization was more common for Pseudomonas (86% vs 35%, P < 0.001), Acinetobacter (21% vs 7%, P = 0.05), Klebsiella (21% vs 5%, P = 0.02) and Staphylococcus species (11% vs 0%, P = 0.02). The respective proportions of patients with positive bronchoalveolar lavage cultures on the third post-transplantation day, the day of stent insertion and 6-month post-stent insertion were 47.4%, 50.9% and 65.4% for Pseudomonas sp.; 15.8%, 12.3% and 3.8% for Klebsiella sp.; and 8.8%, 5.3% and 5.8% for Acinetobacter sp. The mean number of hospitalizations for pneumonia per patient was higher, without statistical significance, in the intervention than the control group (1.5 ± 1.7 vs 0.9 ± 1.5, P = 0.1). Kaplan-Meier survival curves did not show a statistically significant difference between the intervention group and the entire group without endobronchial stents (n = 525) (P = 0.4). Lung transplant recipients with endobronchial stents were more likely to be colonized with pathologic bacteria and having pneumonia; however, stent placement was not associated with increased long-term mortality with appropriate stent maintenance.

Ibuprofen does not prevent postbronchoscopy fever in children undergoing broncho-alveolar lavage.

Fiber-optic bronchoscopy (FOB) of the lower airways is a routine examination performed for investigating varying respiratory complaints in children. A common side effect is a transient high fever on the day of the FOB. Such episodes are usually unrelated to an infectious process but may cause clinical uncertainty and parental anxiety. We have previously shown that a single dose of systemic dexamethasone significantly reduces the rate of fever postbronchoscopy (FPB). To prospectively analyze the effect of a prophylactic dose of ibuprofen upon the FPB. Children presenting for elective FOB and broncho-alveolar lavage (BAL) were randomized, in a double-blind fashion, to receive a single dose of ibuprofen syrup 10 mg/kg or placebo prior to the procedure. Parents were contacted the next day to record the presence or absence of fever. Sixty-one children were included in the final analysis. Thirty-one children were in the treatment group and 30 in the placebo group. FPB occurred in 40 children (65%). There was no difference in the rate of FPB between placebo (63%) and treatment (67%) groups (P = .717). Fifty (82%) children had a positive BAL culture. Among them, 38 had FPB (76%) compared with only 2 of 11 (18%) of those with negative culture (P = .00026, relative risk 4.18). About 80% of positive cultures grew Haemophilus influenza. There was no significant difference between the number of BALs with a positive culture between the treatment and placebo groups (87% vs 77%, P = .35). FPB occurs in around twothirds of children when BAL is performed. Fever occurred significantly more frequently when BAL culture is positive. A single standard dose of the nonsteroidal anti-inflammatory drug ibuprofen administered before a FOB does not prevent FPB.

CORRELATION OF ENVIRONMENTAL MICROBIAL DIVERSITY WITH AIRWAY DISEASE IN REFRACTORY ASTHMA

TYPE: Abstract Publication TOPIC: Allergy and Airway PURPOSE: The influence of subacute bacterial infection in refractory asthma remains elusive. Bacterial dysbiosis and potentially environmental microbe exposures contribute to disease in asthma. We hypothesize that biodiversity within home environments influences airway microbiome and control of disease in refractory asthma. METHODS: We examined the microbiome of bronchoalveolar lavage (BAL) samples and home dust specimens of 5 refractory asthmatics, at time points 12 months apart. A custom, aggressive genomic DNA extraction was used to obtain a more diverse composition of microbial DNA. Bacterial 16S rDNA (V4-V5) was amplified, packaged into libraries, and sequenced in a multiplex manner using 2X300bp Illumina chemistry. Sequences were processed and profiled using QIIME2. Clinical parameters collected include BAL cell count differential, cultures, Asthma Control Test (ACT) and FEV1. RESULTS: Two subjects had positive BAL cultures, one with rare Pseudomonas and another with Mycobacterium. Follow-up bronchoscopy showed culture resolution and reduced airway neutrophilia after directed treatment. Subjects with clinical improvement (3 of 5) trended toward a significant increase in BAL biodiversity by genus (p=0.065, two-tailed T-test), and reduced environmental microbial DNA at month 12. Subjects without clinical improvement of asthma (2 of 5) demonstrated predominant pathogenic bacterial DNA and negative BAL cultures, therefore untreated clinically. CONCLUSIONS: Preliminary analysis of environmental and airway microbiome suggests asthma control is dependent on treatment of clinical and sub-clinical microbes. Higher airway and lower environmental biodiversity may correlate with improved asthma control. CLINICAL IMPLICATIONS: Our research shows clinical cultures are sub-optimal in identifying bacterial species in the lower airways. DISCLOSURE: No significant relationships. KEYWORDS: airway microbiome, refractory asthma

Aspergillus and progression of lung disease in children with cystic fibrosis

BackgroundThe impact of Aspergillus on lung disease in young children with cystic fibrosis is uncertain.AimsTo determine if positive respiratory cultures of Aspergillus species are associated with: (1) increased structural lung...

Change in Clinical Management Associated with Flexible Bronchoscopy and Bronchoalveolar Lavage in Hematopoietic Stem Cell Transplant Recipients with New Pulmonary Infiltrates

BackgroundPulmonary complications occur in 60% of hematopoietic stem cell transplant (HSCT) recipients with significant morbidity and mortality. Bronchoscopy with bronchoalveolar lavage (BAL) is an important diagnostic tool, but yield can be variable. The aim of this study was to investigate the utility of BAL in HSCT patients with new pulmonary infiltrates and determine factors associated with higher BAL yield.MethodsRetrospective review of BAL results from January 2014 to July 2016. Included first bronchoscopy for HSCT patients over 18 years of age. Positive BAL determined by positive culture (bacterial, fungal, mycobacteria), viral PCR, elevated aspergillus galactomannan antigen (AGA), and cytology. Logistic regression analysis was performed.Results54 HSCT recipients were included: 93% allogeneic, 34% neutropenic, 39% on prednisone, 59% on supplemental oxygen, 8% receiving mechanical ventilation (MV), 85% with multilobar infiltrates, 92% on antimicrobials (antibacterial 83%, antifungal 92%, antiviral 13%). 65% had positive BAL (23/54 bacterial, 16/54 elevated AGA, 6/54 fungal, 14/54 viral PCR, 1/54 mycobacteria). Median time to BAL from HSCT was 7.5 months. Not on levofloxacin prophylaxis (P = 0.004), not on MV (P = 0.037), or unrelated donor were associated with positive BAL results. Positive bacterial BAL culture was predictive of antibacterial escalation (P < 0.001). Elevated BAL AGA was associated with antifungal escalation and antibacterial de-escalation (P = 0.012). Antiviral initiation was more likely with positive BAL PCR (P = 0.002). Antifungal de-escalation (P = 0.047) and steroid initiation (P = 0.010) were more likely with negative BAL. 6 month mortality was 41%, and more likely with positive bacterial BAL culture (P = 0.046). Overall positive BAL was not predictive of mortality.ConclusionBronchoscopy with BAL assisted in making critical management changes: elevated AGA with antifungal escalation and antibacterial de-escalation; and negative BAL with prednisone initiation and antifungal de-escalation. Unrelated donors, patients not on levofloxacin, or not on MV were more likely to have a positive BAL. Antimicrobial use likely reduced diagnostic yield for bacterial pathogens. Overall 6 month mortality was high, especially among those with bacterial infections.Disclosures All authors: No reported disclosures.

Shifted focus of bronchoalveolar lavage in patients with suspected thoracic malignancy: an analysis of 224 patients.

Bronchoscopies are extensively adopted for diagnosing and staging thoracic malignancies, but studies are missing as how to keep the process streamlined and more efficient. To evaluate current role of bronchoalveolar lavage (BAL) for cancer and possible infection diagnosis when practicing comprehensive bronchoscopy for patients suspected with thoracic malignancy, and provide foundation for possible practice modification. We retrospectively analyzed a prospectively kept database of immunocompetent patients undergoing bronchoscopy for suspected non-hematologic malignancies. Clinical, radiographic data, bronchoscopic sampling techniques and diagnostic results were recorded. Initially undiagnostic patients were followed up for 2 years for a definitive diagnosis. Of 224 patients included, 179 (79.9%) were confirmed with active thoracic malignancies. BAL diagnostic yield of cancer based on different radiographic characters of target lesion are as follow: isolated lymphadenopathies 0%, central lesions 45.5%, peripheral masses (diameter ≥3 cm) 21.4%, peripheral large nodules (2≤ diameter <3 cm) 15.8%, and peripheral small nodules (diameter <2 cm) 7.1%, while composite bronchoscopy achieved diagnostic yield of 93.3%, 95.5%, 91.7%, 76.9%, and 66.7% in corresponding lesion types. No cancer was diagnosed solely by BAL-cytology. Proportions of patients with positive BAL culture did not differ significantly between patients with and without pre-test suspicion for infections (P=0.199). In multivariable analysis, infections were associated with age ≥75 (OR 3.0; 95% CI: 1.29-7.06), chronic obstructive pulmonary disease (COPD) (OR 2.7; 95% CI: 1.14-6.26) and diabetes mellitus (DM) (OR 4.5; 95% CI: 1.90-10.44). Omitting BAL cytology in settings of comprehensive bronchoscopy may not compromise cancer diagnosis. For patients primarily suspected with thoracic malignancy, performing BAL culture only based on clinical suspicion could miss important infectious etiology.

Pseudooutbreak of rapidly growing mycobacteria due to Mycobacterium abscessus subsp bolletii in a digestive and respiratory endoscopy unit caused by the same clone as that of a countrywide outbreak.

The nontuberculous mycobacteria (NTM) are widely spread. In Brazil, 2,520 cases of rapidly growing mycobacteria (RGM) infections after medical procedures were reported, with 5.4% of cases related to nonsurgical invasive procedures and with an occurrence of 1 clone (BRA100) of Mycobacterium abscessus subsp bolletii. To describe a pseudooutbreak of M abscessus subsp bolletii in an endoscopy and bronchoscopy unit. The alert for a pseudooutbreak was given when 3 patients, in the same week, had a positive bronchoalveolar lavage culture for M abscessus subsp bolletii. The patients had no symptoms/signs of mycobacterial infection; thus, contamination of bronchoscopes was suspected. Samples for culturing were collected from bronchoscopes, digestive endoscopes, automated disinfection machines, and the water supply. Clinical samples were identified by polymerase chain reaction restriction-enzyme analysis (PRA) of the hsp65 gene and their pulsed-field gel electrophoresis pattern was compared with environmental samples. The investigation demonstrated a contamination of bronchoscopes, digestive endoscopes, and disinfection machines. Molecular typing demonstrated that all strains belonged to the same clone (MAB01), identical to clone BRA100. Cross-transmission due to poor disinfection as well as resistance to glutaraldehyde may play roles in the spread of MAB01 M abscessus subsp bolletii, which may have a unique resistance to the environment and adaption to human hosts. However the water supply may have played a role. Attention is needed to ensure the quality of water used to rinse disinfected equipment.

The efficiency of routine endotracheal aspirate cultures compared to bronchoalveolar lavage cultures in ventilator-associated pneumonia diagnosis.

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in İntensive Care Units (ICUs) and its mortality rate varies from 24% to 50%. The most important factor in decreasing the mortality is administering adequate antibiotics as early as possible. In this study, we investigate the efficiency of routine endotracheal aspirate (EA) cultures to identify the etiology of VAP earlier. Fifty-nine patients who were accepted to our ICU with acute cerebrovascular disease with mechanical ventilation (MV) requirement were chosen for this study over a 12-month period. The patients intubated in our ICU were included in the study to exclude prior colonization. Upon ICU admission, the patient's; age, sex, comorbidities, diagnosis, acute physiology and chronic health evaluation II score, and sequential organ failure assessment (SOFA) score were recorded. When bronchoalveolar lavage (BAL) was performed, the SOFA score, temperature, leukocyte count, C-reactive protein levels, PaO2/FiO2ratio, PCO2, clinical pulmonary infection score value, length of MV, and presence of antimicrobiological treatments were recorded. Routine microbiological analysis was performed by EA (pre-VAP EA) twice weekly in all patients until the endotracheal tube was removed. When VAP was suspected, fiberoptic bronchoscopy examination with BAL was performed. A diagnosis of VAP was established when the BAL quantitative culture grew at least one microorganism at a concentration ≥104 cfu/mL. VAP was diagnosed in 41 (69%) of the 59 patients based on BAL culture results. Among 41 positive BAL cultures, pre-VAP EA identified the same microorganism with the same antibiotics resistance pattern in 23 (56%) patients. Regarding only late-onset VAP, pre-VAP EA identified the same microorganisms found by BAL culture in 17 (63%) of the 27 cases. Among 18 BAL culture negative patients, 7 (39%) patients had negative prior pre-VAP EA culture results. Acinetobacter baumannii was the most frequently isolated microorganism from BAL cultures (n = 21, 51%). The diagnostic value of pre-VAP EA results in predicting A. baumannii VAP documented with the following values (sensitivity: 62%; specificity: 95%, positive predictive value: 87%, negative predictive value: 82%). VAP patients should be treated with international guidelines, but if pre-VAP EA cultures identify multidrug resistant pathogens, the initial antibiotic therapy should cover these microorganisms. Thus, quantitative EA cultures are a useful noninvasive diagnostic tool in critically ill patients suspected of having pneumonia especially in the case of VAP.

Legionellosis in Patients With Cancer

Background Legionella species cause severe pneumonia in the immunocompromised population, especially those with cell-mediated immunodeficiency. However, the varied clinical and radiographic presentation of Legionnaires disease can make diagnosis very difficult, which can result in a delay of appropriate therapy. For that reason, we performed this study to review the characteristics of Legionella pneumonia in immunocompromised patients with underlying cancer. Methods The study was a retrospective chart review of 11 patients with Legionella pneumonia at the Moffitt Cancer Center diagnosed between March 2005 and February 2014. The patients were identified on the basis of a positive bronchoalveolar lavage culture for Legionella and/or a positive Legionella urine antigen. Summarized host characteristics included underlying malignancy, absolute neutrophil count, and absolute lymphocyte count at the time of diagnosis as well as the computed tomographic chest imaging findings. Results Of the 11 patients included, 10 had Legionella pneumophila and 1 had L. feeleii. Nine (81.8%) of the 11 patients had a hematologic malignancy and 2 (18.2%) of the 11 patients had a solid organ tumor. One (9.0%) of the 11 patients had an underlying lung disease. At the time of the diagnosis, 3 (27.2%) of the 11 patients were neutropenic (absolute neutrophil count, <500 cells/mm3) and 8 (72.7%) of the 11 patients were lymphopenic (absolute lymphocyte count, <1500 cells/mm3). Four (36.3%) of the 11 patients had bilateral pneumonia. Three (27.2%) of the 11 patients had nodular consolidation. However, only 2 (18%) of the 11 patients were found to have consolidation along with ground-glass opacity. All patients were treated with levofloxacin. Seven (63.6%) of the 11 patients adequately responded to the therapy, 1 (9.0%) patient died because of pneumonia, and 3 (27.3%) patients died because of the underlying cancer. Conclusions Legionnaire disease remains a life-threatening illness in patients with cancer. Our study found that most patients are lymphopenic, with multifocal consolidation in 2 of 3 patients. In addition, nodular opacities on computed tomographic imaging were described in more than one third of our patients, which resembles a mold pneumonia. All the cases that were thought to be a mold pneumonia were diagnosed as Legionella by bronchoalveolar lavage culture or the Legionella urine antigen, emphasizing the need for heightened awareness and testing for this pathogen.

Diagnostic value of bronchoalveolar lavage in leukemic and bone marrow transplant patients: the impact of antimicrobial therapy.

There is significant morbidity and mortality from pneumonia in leukemic and bone marrow transplant patients. We sought to explore the diagnostic yield of bronchoalveolar lavage (BAL) in these patients with new pulmonary infiltrates. A retrospective chart review of approximately 200 Non- human immunodeficiency virus (HIV) leukemic and Hematopoietic stem cell transplantation (HSCT) patients who underwent bronchoscopy at a single academic cancer center was performed. Antimicrobial use for less than 24 hours at the time of BAL was associated with a higher yield in this population (56.8% versus 32.8%, p<0.001). This supports performing bronchoscopy with BAL within 24 hours of antimicrobial therapy in leukemic and HSCT patients.