Vissichelli N C, Miller K, McCarty J M, Roberts C H, Stevens M P, De La Cruz O
Department of Internal Medicine, Virginia Commonwealth University Health System, Department of Infectious Diseases, Richmond, VA, United States.
Department of Internal Medicine, Virginia Commonwealth University Health System, Department of Pulmonary Critical Care Medicine, Richmond, VA, United States.
Infect Prev Pract. 2019 Dec;1(3):100029. doi: 10.1016/j.infpip.2019.100029. Epub 2019 Dec 3.
Pulmonary complications cause significant morbidity and mortality after allogeneic hematopoietic stem cell transplant (AHSCT). Bronchoscopy with targeted bronchoalveolar lavage (BAL) is often used in AHSCT patients with suspected lower respiratory tract infection (LRTI) to help guide management.
To evaluate how positive BAL results change antimicrobial management of AHSCT recipients with suspected LRTI.
We performed a retrospective review of BAL results from January 2014 to July 2016 for 54 AHSCT recipients. A positive BAL was determined by culture, multiplex polymerase chain reaction (PCR), galactomannan antigen (AGA), and cytology.
BAL was positive for infectious etiologies in 63%, and antimicrobials were adjusted in 48/54 (89%) of patients. Antibacterial escalation was predicted by a positive BAL bacterial culture (OR 7.61, =0.017). Antibiotic de-escalation was more likely with an elevated AGA (OR 3.86, =0.035). Antiviral initiation was more likely with positive BAL multiplex PCR (OR 17.33, =0.010). Antifungals were more likely to be escalated or changed with an elevated AGA (OR 4.33, =0.020). The patients with a negative BAL were more likely to be started on steroids (OR 0.19, = 0.043).
BAL was helpful to determine the etiology of pulmonary complications and optimize antimicrobials. The addition of AGA and multiplex PCR to standard BAL significantly impacted de-escalating antibiotics and adjusting antifungals to provide adequate coverage. The association with an elevated AGA with antibacterial de-escalation highlights a new role for BAL in antimicrobial optimization.
异基因造血干细胞移植（AHSCT）后肺部并发症会导致显著的发病率和死亡率。对于疑似下呼吸道感染（LRTI）的AHSCT患者，常采用支气管镜检查及靶向支气管肺泡灌洗（BAL）来指导治疗。
评估BAL结果呈阳性如何改变疑似LRTI的AHSCT受者的抗菌治疗方案。
我们对2014年1月至2016年7月期间54例AHSCT受者的BAL结果进行了回顾性分析。通过培养、多重聚合酶链反应（PCR）、半乳甘露聚糖抗原（AGA）和细胞学检查确定BAL结果为阳性。
63%的患者BAL结果显示存在感染病因，48/54（89%）的患者调整了抗菌药物。BAL细菌培养结果呈阳性可预测抗菌药物升级（比值比7.61，P = 0.017）。AGA升高时更有可能进行抗菌药物降阶梯治疗（比值比3.86，P = 0.035）。BAL多重PCR结果呈阳性时更有可能开始抗病毒治疗（比值比17.33，P = 0.010）。AGA升高时更有可能升级或更换抗真菌药物（比值比4.33，P = 0.020）。BAL结果为阴性的患者更有可能开始使用类固醇药物（比值比0.19，P = 0.043）。
BAL有助于确定肺部并发症的病因并优化抗菌药物治疗。在标准BAL检查中加入AGA和多重PCR显著影响了抗菌药物的降阶梯治疗以及抗真菌药物的调整，以提供足够的覆盖范围。AGA升高与抗菌药物降阶梯治疗之间的关联凸显了BAL在抗菌药物优化方面的新作用。
