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Clinical Investigations in Critical Care |

Impact of BAL in the Management of Pneumonia With Treatment Failure*: Positivity of BAL Culture Under Antibiotic Therapy

João Carlos Pereira Gomes, MD; Wilson L. Pedreira Jr., MD; Evangelina M. P. A. Araújo, MD; Francisco G. Soriano, MD; Elnara M. Negri, MD; Leila Antonângelo, MD; Irineu Tadeu Velasco, MD
Author and Funding Information

*From the Emergency (Drs. Pereira Gomes, Soriano, and Velasco), Bronchoscopy (Drs. Pedreira and Negri), and Pathology (Drs. Araújo and Antonângelo) Departments, Hospital das Clínicas da Faculdade de Medicina, University of São Paulo Medical School, São Paulo, Brazil.

Correspondence to: João Carlos Pereira Gomes, MD, Emergency Department, Hospital das Clínicas da Faculdade de Medicina, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255–5° and s. 5023, 05403–010 São Paulo (SP), Brazil; e-mail: jcpgomes@uol.com.br



Chest. 2000;118(6):1739-1746. doi:10.1378/chest.118.6.1739
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Background: Pneumonia is responsible for 50% of antibiotics prescribed in ICUs. Treatment failure, ie, absence of improvement or clinical deterioration under antibiotic therapy, presents a dilemma to physicians. BAL is an invasive method validated for etiologic diagnosis in pneumonia.

Study objective: To evaluate in ICU patients the impact of BAL in the etiologic diagnosis, treatment, and outcome of pneumonia with treatment failure.

Design: Prospective clinical study.

Setting: Nonsurgical, medical ICU of a university hospital in Brazil.

Patients and participants: Sixty-two episodes of pneumonia treated for at least 72 h without clinical improvement in 53 patients hospitalized for diverse clinical emergencies. Mean duration of hospitalization was 14.2 days. Mean duration of previous antibiotic therapy was 11.4 days.

Interventions: Bronchoscopy and BAL were performed in each episode. BAL fluid was cultivated for aerobic and anaerobic bacteria; the cutoff considered positive was 104 cfu/mL; 103 cfu/mL was also analyzed if under treatment. Pneumocystis carinii, fungi, Legionella spp, and Mycobacterium spp were also researched.

Measurements and results: Fifty-eight of 62 BAL were performed under antibiotics. The results showed positivity in 45 of 62 (72.6%); 42 of the 45 positive episodes (93.3%) had > 104 cfu/mL. The three cases with between 103 and 104 cfu/mL were considered positive and were treated according to BAL cultures. The main agents were Acinetobacter baumannii (37.1%), Pseudomonas aeruginosa (17.7%), and methicillin-resistant Staphylococcus aureus (MRSA; 16.1%); 46.7% of the episodes (21 of 45) were polymicrobial. BAL results directed a change of therapy in 34 episodes (54.8%). Overall mortality was 43.5%. There was no difference in mortality among positives, negatives, and patients who changed therapy guided by BAL culture.

Conclusions: (1) BAL fluid examination was positive in 45 of 62 episodes (72.6%), with 58 of 62 BAL performed under antibiotics. This suggests that BAL may be a sensitive diagnostic method for treatment failures of clinically diagnosed pneumonias, even if performed under antibiotics; (2) the main pathogens in our study were A baumannii, P aeruginosa, and MRSA, and approximately 45% of infections were polymicrobial; (3) BAL culture results directed a change of therapy in 75.6% of positive episodes (34 of 45) and in 54.8% of all episodes of treatment failure (34 of 62); and (4) there was no difference in mortality among positives, negatives, and patients who changed therapy guided by BAL culture.


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