Jason Yerke, BCCCP, PharmD
Medical ICU Clinical Pharmacy Specialist
Cleveland Clinic Foundation
Cleveland, Ohio
Disclosure information not submitted.
Rachel Scheraga, MD
Assistant Professor of Molecular Medicine
Respiratory Institute, Cleveland Clinic, United States
Disclosure information not submitted.
Title: One Center’s Successful Experience with Antibiotic De-escalation Based on Alveolar Cultures
INTRODUCTION/HYPOTHESIS: Antibiotics are frequently used in critically ill patients, leading to nosocomial infections, nephrotoxicity, and hypersensitivity reactions. Non-bronchoscopic bronchoalveolar lavage (NBBL) provides a tool to culture the alveolar space with less contamination than endotracheal aspirate. We designed a quality improvement project at the Cleveland Clinic to demonstrate the safety and efficacy of NBBL compared to endotracheal aspirate in order to reduce antibiotic use in the intensive care unit (ICU). Additionally, we wanted to determine if the remnant sample could be used to study the immune mechanisms of lung injury at our center.
Methods: Patients were enrolled from the Medical Intensive Care Unit (MICU) if (1) they were mechanically ventilated and (2) there was clinical suspicion of pneumonia. Concurrent NBBL and endotracheal aspirate were performed by a respiratory therapist with a Ballard Mini-BAL Sampling Catheter. Cultures were considered positive if there was growth of bacteria, other than respiratory flora, on blood agar media. For quantitative cultures, a threshold of at least 104 colony forming units was used for a positive culture. The remnant bronchoalveolar fluid was microscopically examined.
Results: 20 patients were enrolled with an average APACHE III score of 87.7. 8 patients (40%) had a positive endotracheal aspirate and only 5 (25%) had a positive quantitative culture from NBBL. Based on NBBL culture results, 8 (40%) had a change in antibiotic therapy, including 5 (25%) with antibiotics discontinued within 72 hours of NBBL. There were no safety issues or complications in any patients. On microscopic analysis, we found macrophages, neutrophils, and lymphocytes characteristic of immune cells in the bronchoalveolar space.
Conclusion: NBBL is a safe and effective method to obtain bronchoalveolar samples in critically ill patients. Here we show that NBBL can help tailor antibiotic therapy as part of a multimodal strategy for antibiotic stewardship in the ICU. In addition to the clinical benefits of NBBL, lower respiratory tract samples can be an invaluable resource to study immune mechanisms in pulmonary infection associated lung injury.