DIAGNOSTIC VALUE OF BRONCHOALVEOLAR LAVAGE IN LEUKEMIC AND BONE MARROW TRANSPLANT PATIENTS: THE IMPACT OF ANTIMICROBIAL THERAPY

Main Article Content

John Norman Greene *
Abraham Tareq Yacoub
Dani Thomas
Carol Yuan
Frank Walsh
David Solomon
Skai Schwartz
Arthur Andrews
(*) Corresponding Author:
John Norman Greene | john.greene@moffitt.org

Abstract

Background

Pneumonia carries significant morbidity and mortality in leukemic and bone marrow transplant patient.  The development of pulmonary infiltrates in the setting of such immunocompromise raises concern for both infectious and non-infectious etiologies, some of which are potentially treatabl.  Performing bronchoscopy provides several different options for sampling the lower respiratory tract.  Among these, bronchoalveolar lavage (BAL) is especially effective at collecting samples from the alveoli and has been shown to be associated with less risk than transbonchial biops. We sought to examine the effect of antimicrobial treatment on BAL results in a large study population of leukemic and bone marrow transplant patients.

Subjects and Methods

This retrospective chart review was performed at a single academic cancer center.  A power analysis was performed to determine the appropriate sample size. The patients were selected from those who had undergone an inpatient bronchoscopy in reverse chronological order until 300 patients with either a hematopoietic stem cell transplant or hematologic malignancy were identified.  The exclusion criteria were age <18, a diagnosis of HIV or acquired immune deficiency syndrome (AIDS), or outpatient status.  Electronic medical records were reviewed and data extracted by a single investigator, CY.  Data including age, sex, cancer diagnosis, time from HSCT, leukocyte count, neutropenia in addition to medications were collected.  A normal white blood cell (WBC) count was considered 4,000-12,000/mm3.  Neutropenia was defined as an absolute neutrophil count (ANC) less than 500/mm3.  Medications including antibiotic duration and timing, antifungal use, immunosuppressant use or glucocorticoids were recorded. A positive BAL yield was defined as the culture identification of at least one organism known to be pathogenic in this patient population.  Candida species and coagulase negative staphylocci were considered colonizers The bronchoscopy technique and procedure was similar for each patient, utilizing a Fujinon 470S bronchoscope for every procedure The BAL specimens were collected without suction connected to the bronchoscope prior to a systematic airway survey.  The BAL was performed by instilling two 60cc aliquots of room temperature sterile 0.9% saline followed by slow manual aspiration. Correlates of a positive BAL yield and time on antibiotics were initially analyzed via a chi-square test, or a Fisher’s exact test if the expected count was less than 5.Statistical analyses were performed with Statistical Analysis Software Version 9.3.

Results

A total of 302 patient records were evaluated.  The age range was 18-85 with an average age of 53.5.  Thirty eight percent of the patients were female and 41.8% of the patients had undergone HSCT.  A minority of the patients required mechanical ventilation either at the time of BAL or within 48 hours. One hundred seven of the 297 patients had a positive BAL culture for an overall BAL yield of 36%.  Of the 37 patients on antibiotics for less than 24 hours, including all 4 patients who were not on any antibiotics, twenty-one (56.8%) had a positive BAL culture compared with eighty-five of the 259 (32.8%) patients who had been on antibiotics longer than 24 hours at the time the BAL specimen was obtained and had a positive cultur.  Forty-eight patients were not receiving chemotherapy or immunosupressants, 15 (31.3%) of whom had a positive BAL yield.  One hundred twenty-six patients were on chemotherapy and 32 (25.4%) had a positive BAL culture.  Forty-one patients were not on chemotherapy but were on immunosupressants and 14 (34.1%) had a positive BAL yield.  Eighty patients were on both chemotherapy and immunosupressants and 46 (57.5%) had a positive BAL cultur. There were 64 patients with a normal WBC count and 30 (46.9%) had a positive BAL culture.  Patients with an abnormal WBC or frank neutropenia were less likely to have a positive BAL yield with 39.8% and 27.7% positive yield, respectively. Patients who were on antibiotics for at least 24 hours were significantly less likely to have a positive BAL yield. There was no significant difference in overall distribution of pathogen type.  There was a non-significant trend toward a lower incidence of fungi in those on antibiotics for at least 24 hours. 

Conclusion

It is common clinical practice to perform BAL in leukemic and bone marrow transplant patients with unexplained new lung infiltrates.  This study supports the practice of obtaining a BAL specimen within 24 hours of antimicrobial therapy in leukemic and HSCT patients with unexplained new lung infiltrates, a population that is universally on antimicrobials at the time of BAL. 


Downloads month by month

Downloads

Download data is not yet available.

Article Details

Author Biography

John Norman Greene, Section Chief, Division of Infectious Diseases and Tropical Medicine - Moffitt Cancer Center, Tampa FL Professor of Medicine

BIOGRAPHICAL SKETCH

Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2.
Follow this format for each person.  DO NOT EXCEED FOUR PAGES.

 

NAME

John N. Greene MD FACP

POSITION TITLE

 

Professor, Division of Infectious Disease & International Medicine

 

eRA COMMONS USER NAME (credential, e.g., agency login)

 

EDUCATION/TRAINING  (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.)

INSTITUTION AND LOCATION

DEGREE

(if applicable)

MM/YY

FIELD OF STUDY

College of William and Mary, Williamsburg, Virginia

BS

1982

Biology and Psychology

University of South Florida College of Medicine,

Tampa, Florida

MD

1986

Medicine

University of South Florida College of Medicine, Tampa, Florida

Residency

1986-1989

Internal Medicine

University of South Florida College of Medicine, Tampa, Florida

Fellowship

1989-1991

Infectious Disease

     

A.        Personal Statement

Dr. John N. Greene received his medical degree from the University of South Florida College of Medicine, Tampa, Florida.  He is a Professor of Medicine and currently the Section Chief, Division of Infectious Diseases and Tropical Medicine and Senior Member of the Blood & Marrow Transplant department at Moffitt Cancer Center, Tampa, FL.  He is affiliated with numerous committees, community outreach projects, associations, and boards.  He is an accomplished speaker and writer, having published over 166 manuscripts in peer reviewed journals and has been a speaker for over 160 invited presentations.  He has written and published one book, and written over 30 chapters in other books.  Dr. Greene has been a mentor to hundreds of medical students throughout his career and has taken many students with him on his yearly medical mission trips to third world countries

 

B.        Positions and Honors

 

1994-present               “Moffitt Angel” Award (Patients’ Family Request).

1996-present               Citation, “The Best Doctors in America: Southeast Region.”

1997                                        Physician of the Year, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL

1998                                        “Doctor of the Day”, Florida Senate, Tallahassee, FL

2003                                        Nomination for “Outstanding Sophomore Instructor” by the graduating class, University                                                                                of South Florida College of Medicine, Tampa, FL

2003                                        “The Leonard Tow 2003 Humanism in Medicine” Award, “In Recognition of Exemplary                                                                              Compassion, Competence and Respect in the Delivery of Care,” The Arnold P. Gold

                                                            Foundation.

2005                      Election to the Gold Humanism Honor Society in Recognition of Exemplary Service to Others

2006                      USF Department of Internal Medicine Faculty Award for H. Lee Moffitt Resident Teaching Award.      

2007-2008             Selected by peers “Best Doctors in America® 2007-2008”

2008-2009                               Biographical candidate representing industry in the Who’s Who Among Executives and                                                                              Professionals “Honors Edition”

2009-2010                               Selected by peers “Best Doctors in America® 2009-2010”

2010-2011                               Who’s Who of Executives Professionals and Entrepreneurs 2010-2011

C.        Selected Peer-reviewed Publications

Marela Velez, Beata Casanas, John N. Greene*, Jose Morey, Dominick Mastroianni, Richard Oehler – Pasteurella multocida Infections in Cancer Patients - Asian Biomedicine Vol. 4 No. 3 June 2010; 449-455

 

Pham T, Greene JN*, Sandin RL, Vincent AL, Messina J. – A Chronic Nodular Hand and Forearm Lesion  - Infectious Diseases in Clinical Practices “Images in ID – What’s Your Diagnosis? – Vol. 18, No. 4, July 2010; 261-263

 

Knapp CF, Tucci VT, Keeler JA, Sandin RL, Greene JN*, - Primary Cutaneous Acremonium Infection in a Neutropenic Patient After Trauma – Infectious Diseases in Clinical Practices  – Vol. 18, No. 4, July 2010; 277-278

 

Choudhry A, Tucci V, Greene JN*, - Disseminated Bipolaris Infection – Review Article:  Infectious Diseases in Clinical Practices Vol. 18, No. 5, September 2010; 296-298

 

Li, Y, Greene JN, Sandin RL, - “Recurrent Soft Tissue Infection Seventy Years After Initial Trauma”.  – Images in ID – What’s the Diagnosis?  Infectious Diseases in Clinical Practice, November 2010:18:389-391

 

Greene JN – Prevention of Infections in Patients with Hematologic Malignancies – The spectrum of infections is changing as microbes take advantage of neutropenia – National Comprehensive Cancer Network (NCCN) 5th Annual Congress:  Hematologic Malignancies 2010, pages 30-33

 

Rivera, RJ, Alrabaa, SF, List, A, Greene, JN*.,  “Successful Treatment of Refractory Disseminated Mycobacterium Abscessus infection using Gamma Interferon” – Case Report - Infections Diseases in Clinical Practices –  Vol. 19, Issue 2,  March 2011;142-145

 

Prince MD, Suber JS, Aya-ay ML, Cone Jr. JD, Greene JN, Smith Jr. DJ, Smith PD, - “Prosthesis Salvage in Breast Reconstruction Patients with Periprosthetic Infection and Exposure” Plas. Reconstr. Surg. 129: 42, June 2012

 

Lortholary O, Obenga G, Biswa P, Cailott D, Chachaty E, Bienvenu AL, Cornet M, Greene JN, Herbert R, Lacroix C, Grenouillet F, Raad I, Sitbon K, Troke P; the French Mycoses Study Group – An International, Retrospective Analysis of 73 Cases of Invasive Fusariosis Treated  with Voriconazole – Antimicrobial Agents Chemotherapy, Vol. 54, No. 10, Oct. 2011, p. 4446-4450

 

Stein, M, Palumbo, B., Letson, DG, Bui, MM, Sandin, RL, Greene, JN – Case Report – “A Case of Coccidioides Synovitis of the Knee Presents Clinically as Pigmented Villonodular Synovitis” Infectious Diseases in Clinical Practice.  (1)6:439-441, November 2011

 

Osterndorf B., Oehler RL, Greene JN – Case Report “Human Staphylococcus intermedius Infection in a Patient with Post-radiation Changes – Infectious Diseases in Clinical Practices 19(6);426-427, November 2011

 

Prince MD, Suber JS, Aya-Ay ML, Cone JD Jr, Greene JN, Smith DJ Jr, Smith PD. Prosthesis salvage in breast reconstruction patients with periprosthetic infection and exposure. Plast Reconstr Surg. 2012 Jan;129(1):42-8. PubMed PMID: 22186499.

Manry, Matthew; Cox, Jennifer; Casanas, Beata; Quilitz, Rod; Greene, John N.  Rituximab-Associated Occurrence of Disseminated Miliary Tuberculosis Infectious Diseases in Clinical Practice. 20(1):82-84, January 2012.

 

Givins P, Velez AP, Sandin RL, Quilitz RE, Greene JN* – Development of Enteroviral Meningoencephalitis Following Rituximab Treatment for Non-Hodgkin’s Lymphoma - Infectious Diseases in Clinical Practice  - July 2012;20(4):291-293

 

Casanas BC, Kass J, Pathak A, Tucci V, Payor A, Vincent AL, Greene JN*, Sandin RL, - 1 Non-gastrointestinal Aeromonas Hydrophilia Infections in Cancer Patients –  Infectious Diseases in Clinical Practice – July 2012;20(4):268-271

D.        Research Support

None

Most read articles by the same author(s)