Chest
Volume 132, Issue 2, August 2007, Pages 504-514
Journal home page for Chest

Original Research
Chest Infections
BAL Neutrophils, Serum Procalcitonin, and C-Reactive Protein To Predict Bacterial Infection in the Immunocompromised Host

https://doi.org/10.1378/chest.07-0175Get rights and content

Background

Bacterial pulmonary infection is a common life-threatening complication in immunocompromised patients. The results of BAL cultures are not immediately available, and their microbiological yield might be limited by empiric antibiotic prescriptions. We evaluated clinical signs and symptoms, leukocyte counts, C-reactive protein (CRP) levels, procalcitonin levels, and BAL fluid neutrophil percentages as potential markers for bacterial infection in a cohort of immunocompromised patients with pulmonary complications.

Methods

One hundred seven consecutive patients who had been referred for bronchoscopy due to suspected pulmonary infection were included in this study. Based on clinical, laboratory, radiologic, microbiological, and histologic results, patients were classified as having proven bacterial infection (n = 27), possible bacterial infection (n = 11), and no bacterial infection (n = 69).

Results

Most common underlying conditions were hematologic malignancy (n = 62) and solid organ transplantation (n = 20). Clinical parameters were similar in patients with and without bacterial infection (difference was not significant). The percentage of BAL fluid neutrophils had the highest area under the curve (0.818; 95% confidence interval [CI], 0.700 to 0.935; p < 0.001), followed by absolute neutrophil counts (0.797; 95% CI, 0.678 to 0.916; p < 0.001), procalcitonin level (0.746; 95% CI, 0.602 to 0.889; p = 0.001), and CRP level (0.688; 95% CI, 0.555 to 0.821; p = 0.015) to predict proven bacterial infection (in opposition to no or possible bacterial infection) in the receiver operating characteristic analysis. Conversely, neither infiltrates (p = 0.123) nor leukocyte counts (p = 0.429) were useful in diagnosing bacterial infection. The percentage of BAL fluid neutrophils and procalcitonin level were independent predictors of bacterial infection in the multivariate regression.

Conclusions

Neutrophil percentage in BAL fluid, procalcitonin level, and CRP level might be potentially useful to differentiate bacterial infection from nonbacterial conditions in immunocompromised hosts with pulmonary complications.

Section snippets

Patients

This study was approved by the institutional review board and performed at the University Hospital Basel, a 784-bed tertiary care hospital located in Basel, Switzerland. One hundred seven consecutive hospitalized immunocompromised patients who were referred to the pulmonary division for diagnostic bronchoscopy within a period of 8 months in 2005 were included in this prospective cohort study. Eligibility criteria included the following: (1) immunocompromised state; (2) age > 18 years; (3) a

Baseline Characteristics of Patients

Underlying conditions and baseline characteristics of the 107 patients are presented in Table 1, Table 2. Most common underlying conditions were hematologic malignancies that were treated by high dose chemotherapy alone (n = 29) or combined with allogeneic stem cell transplantation (n = 26) followed by solid organ transplantation (n = 20). Overall, 20 patients (18.7%) had neutropenia at the time of bronchoscopy.

The median length of hospital stay before bronchoscopy was 2 days (interquartile

Discussion

In this study, we found that clinical parameters were not useful for the differential diagnosis of pulmonary complications in immunocompromised patients. In contrast, neutrophilia in the BAL fluid as well as increased serum levels of CRP and procalcitonin were significantly associated with bacterial pulmonary infection. The percentage of neutrophils in BAL fluid showed the best diagnostic accuracy for predicting bacterial infection in the ROC curve analysis, followed by procalcitonin level and

References (57)

  • FJ Herth et al.

    Aspirin does not increase bleeding complications after transbronchial biopsy

    Chest

    (2002)
  • M Estenne et al.

    Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria

    J Heart Lung Transplant

    (2002)
  • CE Metz

    Basic principles of ROC analysis

    Semin Nucl Med

    (1978)
  • A Xaubet et al.

    Pulmonary infiltrates in immunocompromised patients: diagnostic value of telescoping plugged catheter and bronchoalveolar lavage

    Chest

    (1989)
  • S Sharma et al.

    Pulmonary complications in adult blood and marrow transplant recipients: autopsy findings

    Chest

    (2005)
  • RM Kotloff et al.

    Pulmonary complications of solid organ and hematopoietic stem cell transplantation

    Am J Respir Crit Care Med

    (2004)
  • B Afessa et al.

    Major complications following hematopoietic stem cell transplantation

    Semin Respir Crit Care Med

    (2006)
  • S Waite et al.

    Acute lung infections in normal and immunocompromised hosts

    Radiol Clin North Am

    (2006)
  • JA Fishman et al.

    Infection in organ-transplant recipients

    N Engl J Med

    (1998)
  • A Rano et al.

    Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures

    Thorax

    (2001)
  • C Cordonnier et al.

    Pulmonary complications occurring after allogeneic bone marrow transplantation: a study of 130 consecutive transplanted patients

    Cancer

    (1986)
  • K Jules-Elysee et al.

    Pulmonary complications in lymphoma patients treated with high-dose therapy autologous bone marrow transplantation

    Am Rev Respir Dis

    (1992)
  • PH Chandrasekar et al.

    Autopsy-identified infections among bone marrow transplant recipients: a clinico-pathologic study of 56 patients: Bone Marrow Transplantation Team

    Bone Marrow Transplant

    (1995)
  • RP Baughman

    The lung in the immunocompromised patient: infectious complications part 1

    Respiration

    (1999)
  • M Tamm

    The lung in the immunocompromised patient: infectious complications part 2

    Respiration

    (1999)
  • L Joos et al.

    Pulmonary infections diagnosed by BAL: a 12-year experience in 1066 immunocompromised patients

    Respir Med

    (2006)
  • DE Stover et al.

    Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host

    Ann Intern Med

    (1984)
  • PA Pizzo

    Fever in immunocompromised patients

    N Engl J Med

    (1999)
  • Cited by (58)

    • Treatment of Community-Acquired Pneumonia in Immunocompromised Adults: A Consensus Statement Regarding Initial Strategies

      2020, Chest
      Citation Excerpt :

      In other institutions, the tests are ordered considering the presence of clinical, radiographic, and immunologic risk factors for specific organisms. Table 731-35 lists microbiologic studies that can be done on BAL or tissue from a transbronchial lung biopsy together with relevant clinical considerations. Question 8: What empirical therapy should be started in hospitalized patients with CAP who are immunocompromised?

    • Personalizing the Management of Pneumonia

      2018, Clinics in Chest Medicine
    • Glucocorticoids and β<inf>2</inf>-agonists regulate the pathologic metabolism of hyaluronic acid in COPD

      2018, Pulmonary Pharmacology and Therapeutics
      Citation Excerpt :

      Diagnostic bronchoscopy was performed, according to standard procedures, under conscious sedation [13]. BAL was performed by 3 repeated installations of 50 ml of 0.9% NaCl [14,15]. Recovered BAL was filtered through a gauze swab, centrifuged (400×g, 10 min) and the cell-free BAL fluid was collected and stored at −80 °C.

    • Acute exacerbations of COPD are associated with increased expression of heparan sulfate and chondroitin sulfate in BAL

      2016, Chest
      Citation Excerpt :

      Cytologic analysis of BAL samples, including differential cell count, was performed.19,22 Microbiologic analysis of BAL samples included appropriate stains, cultures, and polymerase chain reaction for bacteria, mycobacteria, fungi, and Pneumocystis jirovecii.19 Viral infections were also investigated for respiratory viruses such as rhinovirus, herpes simplex virus type 1 and 2, cytomegalovirus, respiratory syncytial virus, and adenovirus, by polymerase chain reaction, culture, or immunofluorescence.19

    View all citing articles on Scopus

    The study was presented in part at the 16th Annual Congress of European Respiratory Society, Munich, 2006 and was honored with the Research Excellence Award in Respiratory Infections.

    Drs. Stolz and Müller have received payments from BRAHMS (the manufacturer of procalcitonin assays) to attend advisory board meetings and speaker engagements, or for research. Drs. Stulz, Gratwohl, and Tamm have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    View full text