Diagnostic Fiberoptic Bronchoscopy and Protected Brush Culture: MATERIALS AND METHODS
Patients with CAP treated in the Department for Infectious Diseases at Danderyd Hospital were included in the study.
Pilot study: to test the planned bronchoscopy procedure, seven CAP patients received bronchoscopy between October 1985 and December 1986.
Main study: during a ten-month period in 1987, all adult (>=18 years) patients (HIV patients excluded for technical reasons) hos¬pitalized with clinical signs of a community-acquired lower respiratory tract infection and a pulmonary x-ray film showing new infiltrates, or infiltrates resolving after treatment, were included in a study of the etiology and prognosis of CAP.
Repeated samples were obtained from blood and sputum for bacteriologic culture. Sputum was cultured quantitatively after washing and deeming its purulehce. Sputum and urine specimens were also examined for the presence of pneumococcal capsular polysaccharide antigen by coagglutination (Capsular-CoA). Serolog¬ical tests with paired sera were performed for Mycoplasma pneumoniae, Chlamydia psittaci, Legionella species, and respiratory viruses.
The initial antibiotic therapy of the 277 patients in the main study was benzylpenicillin or phenoxymethyl penicillin in 165 (60 per¬cent), ampicillin in 12 (6 percent), a cephalosporin in 44 (16 percent), tetracycline or erythromycin in 30 (11 percent), and other drugs or combinations in the remaining 20 cases.
The case fatality rate in the main study was 4 percent (12 of 277). None of the pilot patients died.
All 277 patients included in this study were evaluated as possible candidates for diagnostic bronchoscopy by the following indications:
(1) Early therapy failure: benzylpenicillin was recommended as the initial treatment except in patients with known allergy to penicillin, in those with a strong suspicion of an atypical pneumonia (M pneumoniae, Chlamydia psittaci or Legionella), in immunocom¬promised patients, and in critically ill patients. If there was no clinical response (persistence of fever and major symptoms) to the initial antibiotic treatment, penicillin or other, within 72 hours, bronchoscopy was to be suggested to the patient before changing the antibiotic therapy. Patients in whom the therapy failure was thought, according to results previously described, to be caused by M pneumoniae or Chlamydia psittaci were excluded.
(2) Late therapy failure: patients with CAP, of known or unknown etiology, who initially seemed to respond to the antibiotic therapy, but who after >72 hours showed signs of therapy failure or relapse.
(3) Before antibiotic therapy: untreated patients, admitted to the hospital during office-hours (ie, at a time when FOB, including the handling of all samples, could be performed) and who were immunocompromised or who had a severe or a recurring pneumonia.
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Informed consent was given by all patients who underwent bronchoscopy. The study procedure was approved by the ethical committee at the Karolinska Institute.