The impact on community acquired pneumonia empirical therapy of diagnostic bronchoscopic techniques

Abstract

The aim of the present study was to examine the modification of initial empirical treatment based on the microbiological results of bronchoscopic techniques after comparing the diagnostic yield of protected specimen brush (PSB) and bronchoalveolar lavage (BAL) in the immunocompetent patient with community acquired pneumonia (CAP) with results obtained from conventional sputum cultures. 88 patients with presumptive diagnosis of CAP necessitating hospitalization were prospectively studied. Fibreoptic bronchoscopy with quantitative PSB and BAL cultures for common pathogens, mycobacteria and fungi was performed. Conventional sputum cultures were also obtained. PSB and BAL quantitative cultures added 26.1% and 36.4%, respectively, more microbiological documentation for CAP compared to conventional sputum cultures (p < 0.0001). Gram staining was indicative of the pathogen mostly in cases where Streptococcus pneumoniae was isolated, which was also the most frequently isolated pathogen (19.3%), followed by Haemophilus influenzae (9%). M. tuberculosis was isolated in 6.8% of patients. Modification of treatment ensued in 27.3% of patients because of the application of the cultures of sputum and invasive technique. PSB and BAL added significant information to the aetiological diagnosis of hospitalized immunocompetent patients with CAP.

Early fiberoptic bronchoscopy during non-invasive ventilation in patients with decompensated chronic obstructive pulmonary disease due to community-acquired-pneumonia

“…The spectrum of microorganisms isolated in our study belongs to the typical bacterial pattern of CAP found in patients with COPD at advanced stages [35,36]. Concerning the change of the initial empirical antibiotic therapy on the basis of BAL results, the rate of 26.7% and 33.3% found in the CMV and NPPV groups, respectively, is consistent with a recent finding of 27.3% reported in immunocompetent CAP patients [32]. However, the clinical meaning of this result should be scaled down if we consider that the changes of the initial therapy were not due to the inadequacy of the empiric approach recommended by the guidelines for such COPD patients with severe CAP [19] but to the de-escalation strategy and occurrence of drug resistance.…”

“…The high diagnostic yield of BAL for the identification of the bacterial aetiology of CAP both in NPPV (80%) and in CMV-treated patients (60%) is difficult to compare with previously published data (36 to 78%) [32-34] due to the large heterogeneity existing among the different studies in terms of severity of CAP, underlying diseases, need for MV, previous use of antibiotics, and hospital setting. We decided to perform BAL to have more chances to achieve a microbial diagnosis as an adequate sputum sample was not easily available in such critical patients.…”

British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE

“…Protected catheters have a lower risk of contamination 211. Protected catheter and BAL samples have a reported sensitivity based on quantitative cultures of 64.7–70% and 73.8–77% respectively in patients with community-acquired pneumonia who had a bronchoscopy within 12 h of hospital admission 212 213. The yield is lower when bronchoscopy is performed after treatment failure (lack of response after 72 h) 214…”

Comparación de citocinas plasmáticas en pacientes con neumonía adquirida en la comunidad con y sin diagnóstico previo de EPOC por una técnica multiplex

“…Tampoco se encontraron diferencias significativas en la duración del período de hospitalización (grupo 1: 13,8 [5,6]; grupo 2: 10,7 [2,3]). Por el contrario, los pacientes del grupo 1 mostraron valores saturación de O 2 al ingreso significativamente menores ( fig.…”

“…Se incluyeron en él los primeros 10 pacientes ingresados por NAC con diagnóstico previo de EPOC (grupo 1) y los primeros 10 pacientes ingresados con NAC pero sin diagnóstico de EPOC (grupo 2). El diagnóstico de neumonía adquirida en la comunidad se establecio cuando el paciente cumplía los siguientes criterios: aparición de un nuevo infiltrado en la radiografía de tórax más al menos 1 de los siguientes síntomas de infección del tracto respiratorio inferior: fiebre 4 37,8 1C, tos, esputo, disnea, dolor pleurítico, leucocitosis y confusión mental 5 . Los pacientes con EPOC habían sido previamente diagnosticados de esta enfermedad en el Servicio de Medicina Interna de nuestro hospital de acuerdo a la ''iniciativa global para los criterios diagnósticos de la enfermedad pulmonar obstructiva crónica'' 6 .…”