The Diagnostic Utility and Clinical Implications of Bronchoalveolar Lavage in Cancer Patients With Febrile Neutropenia and Lung Infiltrates

Abstract

Introduction Febrile neutropenia (FN) is a dreaded complication of cancer chemotherapy and frequently associated with respiratory infections. Flexible bronchoscopy (FB) serves as a useful diagnostic tool in this regard. Objective To determine the diagnostic yield, safety and clinical implications of bronchoalveolar lavage (BAL) in cancer patients with FN, having lung infiltrates on radiographic chest imaging. Methods We reviewed medical records of FN patients who underwent FB at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from July 2015 till July 2018. The culture yield of BAL, resultant change of management and outcome over the subsequent 30 days were retrospectively analysed. Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY) was used for data analysis. Results Ninety FN patients, with mean age 26 ± 18 years and predominantly males (65.6%, n = 59) were included in the study. Seventy-seven (85.6%) had hematological and 13 (14.4%) solid organ malignancy. The mean absolute neutrophil count was 0.20 +/-0.36/ µL. BAL cultures were diagnostic in 40 (44%) patients; the etiology was bacterial, fungal and mixed in 25 (62.5%), 14 (35%) and one (2.5%) patient, respectively. All patients were on empirical antibiotics prior to bronchoscopy: 32 (35.6%) on antibacterial alone and 58 (64.4%) on antibacterial plus antifungal therapy. Change of management occurred in 51 (56.7%) patients after BAL results, including de-escalation from dual antibiotics in 28 (55%) and initiation of new culture sensitive antibiotic in 23 (45%). FB-associated complications developed in three (5.6%) non-intensive care patients (ICU), including transient hypoxia in two and minor hemoptysis in one patient, while five (14.8%) mechanically ventilated patients in ICU experienced worsening of oxygenation parameters within 48 hours. Overall, 24 (26.7%) patients died. Mortality was 3.7% in non-ICU and 69% in ICU setting and significantly higher in patients with fungal pneumonias (p-value 0.01) and with prolonged neutropenia (p-value 0.001).

Diagnostic Utility of Bronchoalveolar Lavage in Patients with Acute Leukemia under Broad-Spectrum Anti-Infective Treatment

“…By investigating 88 BAL fluids of AL patients with clinically suspected infection and radiological infiltrates under broad-spectrum antibiotic and antifungal treatment, positive microbiological BAL fluids with clinically relevant pathogens were obtained in 47% of our cases. These results are consistent with previously reported studies describing 39–54% of positive BAL fluids [ 13 , 20 , 21 , 22 , 23 ]. However, in some studies, lower rates, with a range of approximately 23–32% of positive BAL fluids, were reported [ 12 , 14 , 24 , 25 ].…”

“…Of note, despite the extensive empiric anti-infective treatment in our study population, in nearly every second BAL fluid (47%), relevant pathogens could be isolated. Aspergillus fumigatus was the most detected pathogen albeit the empiric anti-fungal treatment in every patient, indicating the high risk of invasive aspergillosis in patients with AL underlying previous reported data [ 20 , 22 , 25 ]. Remarkably, no multi-resistant pathogens were isolated despite the administration of broad-spectrum antibiotics and anti-fungal agents.…”

“…BAL findings resulted in subsequent anti-infective treatment changes in 15% of patients, which is in line with one of the very few studies investigating the impact of BAL in patients with AL under extensive anti-infective therapies, showing a low rate of 9.3% of BAL-guided treatment changes [ 12 ]. In all other reported patient cohorts, the rate of treatment changes was higher with a range of 24–57% [ 13 , 14 , 20 , 21 , 22 , 23 , 24 , 25 ]. This could be mainly explained by the more frequent use of pre-emptive treatment approaches in the other reported studies, whereas here we report on patients who were exclusively treated empirically with broad-spectrum antibiotic and combined antifungal therapies.…”

Clinical Utility of Stepwise Bronchoalveolar Lavage Fluid Analysis in Diagnosing and Managing Lung Infiltrates in Leukemia/Lymphoma Patients With Febrile Neutropenia

“…Several other studies have reported similar modification rates, ranging from 38.2% to 63.3%, with effective outcomes in a majority of patients. 20,22,28 The impact of BAL on reducing unnecessary antimicrobial use, especially in regions with high drug resistance and limited resources, is important without affecting response rates. We observed that change in antimicrobial therapy resulted in a 17.3% ( P = .063) increase in clinical response compared with no change in therapy, demonstrating the high clinical relevance of BAL findings.…”

How I approach: the transplant recipient with fever and pulmonary infiltrates

“…BAL may lead to changes in clinical management in the range of 50% of cases and in general were very well tolerated (26)(27)(28). One study comparing BAL to lung biopsy in pediatric HSCT patients at a single institution found that 40% of the 101 BALs revealed a pathogen, while 94% of the 19 lung biopsies identified an etiology (29).…”