Rapid and precise identification of bacteria is crucial in both clinical and environmental microbiology. Traditional Gram staining methods, while foundational in bacterial classification, often suffer from delays and require additional confirmatory tests, raising concerns about the potential for misidentification. To address these limitations, we present a modified KOH string test enhanced with Methylene Blue, aimed at improving the visualization and differentiation of Gram-positive and Gram-negative bacteria. In our study, we analyzed approximately 185 samples collected from hospitals, soil, salt mines, and honeycombs. Initially, we employed conventional Gram staining for preliminary bacterial identification, followed by our modified KOH string test. This innovative procedure involved mixing a drop of 3% KOH with a bacterial colony on a slide. After one minute, the addition of a dye significantly enhanced the visibility of string formation, facilitating the distinction between bacterial types. The results were compelling: 100% of Gram-negative bacteria displayed a visible string, while all Gram-positive bacteria exhibited no string formation. To further validate our findings, selected environmental samples were analyzed using 16S rRNA PCR, reinforcing the effectiveness of our modified KOH string test. This enhanced method is not only cost-effective and straightforward but also reliable, positioning it as an excellent supplementary or alternative approach for bacterial identification. By improving diagnostic accuracy and efficiency, our innovative technique represents a valuable advancement in microbiological applications.

Rapid and reliable identification of bacteria is essential in clinical and environmental microbiology. Gram staining remains a widely used method for preliminary classification; however, it may require additional steps and can be difficult to interpret under certain conditions. To address these limitations, we evaluated a modified potassium hydroxide (KOH) string test incorporating methylene blue to enhance visualization of DNA release and facilitate differentiation between Gram-positive and Gram-negative bacteria. A total of 185 samples from clinical and environmental sources (including hospitals, soil, salt mines and honeycombs) were analysed. Samples were first assessed using Gram staining and subsequently tested using the modified KOH method. In this procedure, a 3% KOH solution was applied to bacterial colonies, followed by the addition of methylene blue to improve visualization of filament formation. All Gram-negative isolates demonstrated visible string formation, while Gram-positive isolates showed no string formation, indicating complete concordance with Gram staining results within the tested dataset. Selected isolates were further examined using 16S rRNA gene analysis to support taxonomic identification. The modified KOH string test provides a rapid, simple and low-cost approach for preliminary bacterial differentiation. While it does not replace conventional or molecular identification methods, it may serve as a useful complementary tool, particularly in resource-limited or high-throughput laboratory settings.

Tuberculosis (TB) and diabetes mellitus (DM) are both highly prevalent in Pakistan. Latent Mycobacterium tuberculosis (Mtb) infection is common however the effect of DM and latent TB infection (LTBI) is less understood. We used RNA arrays to study host transcriptional responses to investigate this. Participants were controls (EC) and with DM, sub-classified to LTBI and DM-LTBI. Host blood transcriptomes were studied using microarrays followed by GO, WikiPathway and reactome pathway analyses. Gene expression compared with EC revealed 187 differentially expressed genes (DEGs) associated with LTBI; 182 DEGs with DM and 13 DEGs with DM-LTBI. In LTBI and DM, downregulation of antigen presentation and upregulation of inflammatory genes was evident whilst in DM, mostly immune related genes were downregulated. Comparison between LTBI-DM and LTBI revealed 321 up- and 12 downregulated DEGs, with upregulated immune response and inflammatory genes whilst a downregulation of genes associated with insulin metabolism and oxidative stress were observed. The impact of uncontrolled hyperglycemia was seen as downregulation in protein synthesis and oxidative phosphorylation in the host. This effect was further enhanced in those with hyperglycemia within the LTBI-DM group. Importantly, our observations of dysregulated pathways observed in diabetic individuals fit with earlier reports. We show that LTBI and DM synergistically increase host inflammatory and metabolic processes whilst reducing innate immunity. Such dysregulation by uncontrolled hyperglyemia highlights increased risk of progression of Mtb infection in this cohort and emphasizes the need for diabetes control in a TB endemic population.

INTRODUCTION:Infection with Mycobacterium tuberculosis (MTB) may result in active tuberculosis (TB), bacterial clearance, or asymptomatic latent infection (LTBi). During the COVID-19 pandemic, interactions between MTB and SARS-CoV-2 infections were coincident in high TB burden countries such as Pakistan. The impact of LTBi on COVID-19 is not well understood. Here we investigated the association of LTBi with COVID-19 and its severity by determining cellular activation to MTB, IgG antibody responses and expression of genes associated with host immunity. METHODS:Age and sex matched Healthy Controls (HC, n = 147) and COVID-19 patients (n = 128) were recruited in this cross-sectional study. COVID-19 was categorized as ambulatory (n = 103) or hospitalized (n = 25) disease. LTBi was determined using the X.DOT-TB ELISpot assay. RT-PCR based mRNA levels of IFN-γ, IFN-α, IL-6, IL-10, OAS1, MAVS, SOCS1 and SOCS3 were determined in PBMCs. IgG to SARS-CoV-2 and rubella virus were measured. RESULTS:We found that 18% of COVID-19 patients and 32% of HC were LTBi positive (p < 0.0001). All COVID-19 LTBi positive cases had ambulatory disease. Logistic regression analysis revealed individuals with LTBi to have a 54% lower risk of COVID-19. The frequency of MTB-specific IFN-γ producing T cells was lower in COVID-19 patients than in HC LTBi positive individuals (p = 0.0095). The presence of a BCG scar was not associated with the occurrence of COVID-19. Levels of IgG antibodies to SARS-CoV-2 were raised in COVID-19 cases but did not differ by LTBi status in HC or COVID-19 groups. IgG levels to rubella virus were similar regardless of LTBi status in control and patient groups. COVID-19 cases displayed higher expression of mRNA levels of MAVS, OAS-1, and SOCS3 (p < 0.05). Further, OAS-1 expression was raised in LTBi positive COVID-19 group as compared to the LTBi positive HC group (p = 0.019). CONCLUSIONS:We observed that T cell reactivity to MTB was associated with milder COVID-19. Reduced severity of COVID-19 and higher OAS-1 gene expression in COVID-19 LTBi positive individuals suggest a protective effect in these individuals. Further studies are required to investigate the combined impact of MTB and SARS-CoV-2 infections in the host.

There is no denying the fact that violence against children is one of the issues that needs to be addressed, as it is directly related to the well-being of children in Pakistan. Therefore, this study assumes the extent of various forms of violence against children in Pakistan, how these may be dealt with, and the legal remedies for these issues. Children from other classes of society in Pakistan are exposed to this social ill of child abuse. The pattern of child abuses in Pakistan, its causes, prevalence, protection strategies, and legal responses are all called out in this study. A mixed qualitative and quantitative research approach which included the use of surveys focus group discussions and secondary data was used. Facts and figures collected show that the nature of abuse includes physical, sexual, psychological, neglect, etc which is common in most given communities where the majority of people are poor, there is a soft legal structure, and cultural practices of abuse are rather common. Laws on child protection are rarely enforced where such laws exist despite commitments and even within societies reporting such abuse is often viewed negatively. The study seeks to deploy better community-based primary prevention approaches, changes in the law, and health education campaigns. Policymakers should be alerted to the present research as it seeks to address deficiencies in preventative approaches and legislation that exist in Pakistan.

Background: Colistin is a last-resort antibiotic used against infections caused by multidrug-resistant gram-negative organisms, particularly carbapenem-resistant strains. Rising resistance to colistin is a significant global concern. To address this, an Antimicrobial Stewardship (AMS) Program was introduced in our hospital, including pre-authorization protocols for colistin use. Objective: To evaluate the prevalence of colistin-resistant organisms and determine the impact of AMS implementation on their occurrence and associated clinical outcomes. Methods: We conducted a quasi-experimental study at a tertiary care hospital in Pakistan, comparing data from 18 months before and after AMS implementation. Adult patients (>18 years) with confirmed infections due to colistin-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, or Acinetobacter spp. were included. Clinical and microbiological data were analyzed to assess differences in organism prevalence, mortality, and hospital stay duration. Results: A total of 121 patients met inclusion criteria, with 45 (37.2%) in the pre-AMS period and 76 (62.8%) in the post-AMS period. Klebsiella pneumoniae was the most frequently isolated organism in both groups. The overall in-hospital mortality rate was 34%, and the average length of stay was approximately 20 days, with no significant differences between periods. Despite AMS implementation, colistin resistance prevalence did not decline. Conclusion: While the AMS facilitated better identification and documentation of colistin-resistant infections, it did not significantly reduce their prevalence or associated mortality. Strengthened stewardship measures, continuous compliance monitoring, and alternative therapeutic strategies are needed to curb rising colistin resistance in high-burden settings.

SARS-CoV-2 infection modulates innate and adaptive immunity and likely impacts outcomes of infections such as Mycobacterium tuberculosis (MTB). We investigated the association between COVID-19 and latent tuberculosis infection (LTBi), studying viral and mycobacterial antigen-stimulated responses in those with and without a history of COVID-19. We studied healthy Controls and COVID-19 convalescent subjects. Participants were screened for LTBi using an interferon-gamma release assay (IGRA). SARS-CoV-2 Spike- and MTB H37Rv-sonicate -stimulated cytokines from peripheral blood mononuclear cells (PBMCs) were measured. Spike-induced IFN-γ (p = 0.03), IL-6 (p = 0.018) and IL-2 (p = 0.04) levels were reduced in COVID-19 as compared with Controls. Within Controls, Spike induced higher cytokine levels in IGRA positive participants (p < 0.05). MTB-induced IFN-γ (0.003), IL-2 (p = 0.0021), IL-6 (p = 0.002), TNF-α (p = 0.02), and IL-10 (p = 0.04) levels were lowered in COVID-19. MTB- stimulated higher levels of proinflammatory cytokines were found in IGRA-positive Controls. Between IGRA positive participants, the COVID-19 group displayed lower Spike and MTB induced IFN-γ (0.003), IL-6 (0.0037), IL-2 (0.001), and TNF-α (0.005) levels. Further, MTB-induced IL-6/IL-10 and TNF-α/IL-10 ratios were higher in COVID-IGRA positive participants. Reduced SARS-CoV-2 and MTB activation of inflammatory cytokines reflects downregulated immunity after COVID-19. Further studies are required to assess whether LTBi and COVID-19 increase the risk of progression to tuberculosis.

Purpose: Colistin resistant Acinetobacter baumannii poses a growing challenge in neonatal intensive care units (NICUs) due to the emergence of plasmid-mediated Mobile Colistin Resistance (mcr) genes that can rapidly spread among neonates. This pioneering study conducted a comprehensive analysis of mcr-1, mcr-2, mcr-3, mcr-4, and mcr-5 genes in A. baumannii strains isolated from NICU. Notably, this investigation marks the first of its kind in this setting. In addition to genotypic analyses, the study incorporated phenotypic assays to identify the most effective method for detecting colistin resistance in these A. baumannii strains. Methods: In the genotypic investigation, DNA was extracted from strains of colistin-resistant A. baumannii, collected from the NICU of a local hospital of Islamabad, Pakistan. The specific set of primers for each mcr gene was used to detect their presence. Various phenotypic methods such as, disc diffusion, broth macro dilution, Minimum Inhibitory Concentration (MIC), disc elusion and colistin agar methods were performed using predetermined calculations for phenotypic studies. Results:The study confirms the distribution of the mcr-1 gene among the eight strains, which contributes 62% of the total number, whereas mcr-2, 3, 4 and 5 genes were not detected in all strains. Based on phenotypic analysis, A. baumannii had shown resistance against colistin at < 2µg/mL. In contrast, MIC varies from strain to strain. Conclusions: The horizontal transfer of the mcr-1 gene is responsible for developing resistance against colistin among A. baumannii in neonates. All phenotypic methods adopted in this study generated the same results, so the method selection depends upon individual comfort. However, we propose that the colistin agar method offers multiple advantages over other methods as it is more economical, easy to perform, multiple samples can be assessed simultaneously, and fewer calculations are involved for colistin resistance determination and finding out clinical breakpoints.

Pakistan has been a hub of several HIV outbreaks over the last 2 decades, with four major outbreaks being registered since 2018. There has been a recent rise in HIV infections, especially in high-risk populations, mainly consisting of people who inject drugs, men who have sex with men, prisoners, the transgender women community, and female sex workers. Consistently poor infection control practices, unregulated unsafe blood transfusion, questionable ethical practices by healthcare providers, and a general lack of awareness are the main drivers of recent HIV outbreaks, with these issues exacerbated by the presence of untrained health care providers. To stop the spread of HIV systemically and sustainably, aggressive measures need to be taken at all levels by all concerned stakeholders that not only deal with building up testing, tracing, and treatment capabilities but also address underlying grassroots problems that have largely been ignored to date.

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Crimean-Congo haemorrhagic fever (CCHF) is a widely distributed and potentially fatal tick-borne viral disease with no licensed specific treatments or vaccines. In 2019, WHO published an advanced draft of a research and development roadmap for CCHF that prioritised the development and deployment of the medical countermeasures most needed by CCHF-affected countries. This Personal View presents updated CCHF research and development priorities and is the product of broad consultation with a working group of 20 leading experts in 2023-24. The strategic goals, milestones, and timelines have been revised and expanded to reflect scientific advances since 2019, including the identification of antibodies with therapeutic potential and the progression of four vaccine candidates through phase 1 clinical trials. This update emphasises the need for a One Health approach to manage CCHF, from integrated crosssectoral surveillance to novel interventions that target ticks and their vertebrate hosts to reduce CCHF virus transmission to humans. The overarching vision for rapid diagnostics and specific therapeutics by 2028, followed by options to limit CCHF virus transmission and control disease by 2030, is deliberately ambitious and will only be achieved through coordinated international action from affected countries, funders, scientists, product developers, manufacturers, regulators, national authorities, and policy makers.

Purpose : Colistin-resistant Acinetobacter baumannii (CRAB) poses a growing challenge in neonatal intensive care units (NICUs) due to the emergence of plasmid-mediated Mobile Colistin Resistance (mcr) genes that can rapidly spread among neonates. This pioneering study conducted a comprehensive analysis of mcr-1, mcr-2, mcr-3, mcr-4, and mcr-5 genes in A. baumannii strains isolated from a Pakistani NICU. Notably, this investigation marks the first of its kind in this setting. In addition to genotypic analyses, the study incorporated phenotypic assays to identify the most effective method for detecting colistin resistance in these A. baumannii strains. The research also encompassed the examination of A. baumannii blood isolates exhibiting low to mid-level colistin resistance during an outbreak in a tertiary care hospital. Methods: In the genotypic investigation, DNA was extracted from strains of colistin-resistant A. baumannii, collected from the NICU of the local hospital of Islamabad, Pakistan. The specific set of primers for each mcr gene was used to detect their presence. Various phenotypic methods such as; disc diffusion, broth macro dilution, Minimum Inhibition Concentration (MIC), disc elusion and colistin agar methods were performed using predetermined calculations for phenotypic studies. Results: The study confirms the distribution of the mcr-1 gene among the eight strains, which contributes 66 % of the total number, whereas mcr-2, 3, 4 and 5 genes were not detected in all strains. Based on phenotypic analysis, A. baumannii had shown resistance against colistin at < 2µg/mL. In contrast, MIC varies from strain to strain. Conclusions: The horizontal transfer of the mcr-1 gene is responsible for developing resistance against colistin among A. baumannii in neonates. All phenotypic methods adopted in this study generated the same results, so the method selection depends upon individual comfort. However, we propose that the colistin agar method offers multiple advantages over other methods as it is more economical, easy to perform, multiple samples can be assessed simultaneously and fewer calculations are involved for colistin resistance determination and finding out clinical breakpoints.

This retrospective cohort study aims to describe the clinical characteristics and outcomes and assess risk factors for mortality across the epidemic waves in hospitalized COVID-19 patients in a major tertiary-care center in Pakistan. A total of 5368 patients with COVID-19, hospitalized between March 2020 and April 2022 were included. The median age was 58 years (IQR: 44-69), 41% were females, and the overall mortality was 12%. Comparative analysis of COVID-19 waves showed that the proportion of patients aged ≥ 60 years was highest during the post-wave 4 period (61.4%) and Wave 4 (Delta) (50%) (p < 0.001). Male predominance decreased from 65.2% in Wave 2 to 44.2% in Wave 5 (Omicron) (p < 0.001). Mortality rate was lowest at 9.4% in wave 5 and highest at 21.6% in the post-wave 4 period (p = 0.041). In multivariable analysis for risk factors of mortality, acute respiratory distress syndrome (ARDS) was most strongly associated with mortality (aOR 22.98, 95% CI 15.28-34.55, p < 0.001), followed by need for mechanical ventilation (aOR 6.81, 95% CI 5.13-9.05, p < 0.001). Other significant risk factors included acute kidney injury (aOR 3.05, 95% CI 2.38-3.91, p < 0.001), stroke (aOR 2.40, 95% CI 1.26-4.60, p = 0.008), pulmonary embolism (OR 2.07, 95% CI 1.28-3.35, p = 0.003), and age ≥ 60 years (aOR 2.45, 95% CI 1.95-3.09, p < 0.001). Enoxaparin use was associated with lower mortality odds (aOR 0.45, 95% CI 0.35-0.60, p < 0.001. Patients hospitalized during Wave 4 (aOR 2.22, 95% CI 1.39-3.56, p < 0.001) and the post-wave 4 period (aOR 2.82, 95% CI 1.37-5.80, p = 0.005) had higher mortality odds compared to other waves. The study identifies higher mortality risk in patients admitted in Delta wave and post-wave, aged ≥ 60 years, and with respiratory and renal complications, and lower risk with anticoagulation during COVID-19 waves.

BACKGROUND: The study assessed whether a “7-1-7” timeliness metric for screening and TB preventive therapy (TPT) could be implemented for household contacts (HHCs) of index patients with bacteriologically confirmed pulmonary TB under routine programmatic settings in Kenya.METHODS: A longitudinal cohort study conducted among index patients and their HHCs in 12 health facilities, Kiambu County, Kenya.RESULTS: Between January and June 2023, 95% of 508 index patients had their HHCs line-listed within 7 days of initiating anti-TB treatment (“First 7”). In 68% of 1,115 HHCs, screening outcomes were ascertained within 1 day of line-listing (“Next 1”). In 65% of 1,105 HHCs eligible for further evaluation, anti-TB treatment, TPT or a decision for no drugs was made within 7 days of screening (“Second 7”). Altogether, 62% of screened HHCs started TPT during the “7-1-7” period compared with 58% in a historical cohort. Main barriers to TPT uptake were HHCs not consulting clinicians, HHCs being unwilling to initiate TPT and drug shortages. Healthcare workers felt that a timeliness metric was valuable for streamlining HHC management and proposed “3-5-7” as a workable alternative.CONCLUSIONS: The national TB programme must generate awareness about TPT, ensure uninterrupted drug supplies and assess whether the “3-5-7” metric can be operationalised.

Introduction: Influenza is a serious underestimated viral infection in Pakistan and influenza vaccination and vaccination awareness are low. The current work aimed to develop consensus on influenza epidemiology, prevention, vaccination, and awareness in Pakistan. Methodology: A systematic literature search was conducted to develop recommendations on influenza vaccines in Pakistan. Experts' feedback was incorporated using the modified Delphi method. A three-step process was used, with 18 experts from different specialties from Pakistan who participated in voting rounds to achieve a minimum 75% agreement level. Results: Pakistan has a low-immunization-rate and is susceptible to serious influenza outbreaks and influenza-related complications. Influenza circulates year-round in Pakistan but peaks during January and February. The subtype A/H1N1 is predominant. The experts urged vaccination in all individuals ≥ 6 months of age and with no contraindications. They highlighted special considerations for those with comorbidities and specific conditions. The experts agreed that the inactivated influenza vaccine is safe and efficient in pregnant women, immunocompromised, and comorbid respiratory and cardiovascular patients. Finally, the experts recommended conducting promotional and educational programs to raise awareness on influenza and vaccination. Conclusions: This is the first regional consensus on influenza and influenza vaccination in Pakistan with experts’ recommendations to increase influenza vaccination and decrease influenza cases and its associated detrimental effects.

Pakistan has low HIV prevalence (0·1%), with incidence on the rise and marginalised key populations bearing the brunt.1WHO Eastern Mediterranean RegionHIV in the WHO eastern mediterranean region.https://www.emro.who.int/asd/about/hiv-situation-region.htmlDate accessed: January 21, 2024Google Scholar Alarmingly, incidence is slowly rising in the general population. We believe that in Pakistan, the main reasons for continued spread of HIV are flawed preventive strategies, stigma, a major reliance on external funding for disease control and treatment, the disproportionate role of non-governmental organisations (NGOs), and a warped perception of accountability at different levels. An intricate relation exists between stigma and outcomes of HIV/AIDS control measures, including treatment adherence, and the role of HIV NGOs in Pakistan. In Pakistan's HIV prevention sector, most community work related to HIV and key populations has been delegated to NGOs, which rely mostly on foreign aid and respond to incentives created by international actors. Additionally, NGOs often leverage perceived cultural differences between at-risk groups to secure funding and maintain their position as brokers of funding primarily controlled by international donors.2Qureshi A Stigma and strategy in Pakistan's HIV prevention sector.J R Anthropol Inst. 2022; 28: 1177-1191Crossref Scopus (3) Google Scholar NGOs also reportedly use practices that inadvertently reinforce existing biases.3Bano M Partnerships and the good-governance agenda: improving service delivery through state–NGO collaborations.Voluntas. 2019; 30: 1270-1283Crossref Scopus (19) Google Scholar The pressure to meet deliverables without adequate monitoring further compromises the reliability of the reported key performance indicators.4Farooq LS Beyond good intentions: questioning the "leaving no one behind" agenda in global development, evidence from Pakistan.Community Dev J. 2021; 57: 469-486Crossref Scopus (2) Google Scholar Because the HIV response in Pakistan heavily relies on NGOs and external donor funding, a constrained level of political commitment exists, with a relatively low priority assigned to HIV within the national agenda. Marginalised communities with HIV in Pakistan are less likely to seek health care when needed and, as such, stigma leads to delayed diagnosis and subsequent undetected spread of HIV.5Donnelly LR Bailey L Jessani A Postnikoff J Kerston P Brondani M Stigma experiences in marginalized people living with HIV seeking health services and resources in Canada.J Assoc Nurses AIDS Care. 2016; 27: 768-783Crossref PubMed Scopus (0) Google Scholar There are 74 antiretroviral therapy centres in the country, functioning as easily identifiable, standalone clinics with clearly labelled signage (figure). People using such facilities, and even doctors providing services at these centres, can easily be identified by local community members. The overt lack of integration of HIV care into regular health systems is perpetuating stigma, driving away those who are most in need of screening and treatment, and contributing to the eventual failure of the strategy. This is also an infringement on the confidentiality rights of people using such centres. Given these challenges, an appraisal is needed to review the factors that are hindering the control of HIV/AIDS in Pakistan. Crucial components needed for the HIV continuum of care include addressing high-risk behaviours, instituting preventive measures in key populations, promoting health-seeking behaviours, and integrating services for key populations into general health systems. Appropriate, easily accessible screening and treatment facilities should be made readily available as part of routine medical services. This must be linked with ongoing education of physicians and other health-care workers, community education, and engagement to prevent the escalation of the HIV epidemic in Pakistan. Lastly, for long-term success, it is imperative to explore more sustainable and diversified alternative approaches to over-reliance on NGOs and external funds. We declare no competing interests.

PWD can develop infections with a prolonged course and complications more frequently. Chronic low-grade inflammation and reduced cytokine responses lead to metabolic derangement. Uncommon infections like mucormycosis and malignant otitis externa occur predominantly in PWD. Diabetes is one of the main risk factors for severe COVID-19 disease. Thirty percent of people with liver cirrhosis have type-2 diabetes. The urinary tract is the most affected site of infection in PWD. Globally, 5% of tuberculosis (TB) cases are attributable to diabetes. Foot infections are the leading cause of lower limb amputation in PWD. It is recommended to start an antibiotic that is initially empirical. Given the risk of antimicrobial resistance, it is mandatory to limit the use of antibiotics for infected wounds. It is important to note that no data support the use of systemic or topical antimicrobials to improve uninfected foot ulcers or preventing an infection.

OBJECTIVE:To investigate the diagnostic performance of bronchoscopy in patients with coronavirus disease 2019 infection.METHODS:The systematic review was conducted in April 2021 and comprised search of published articles and preprint servers for original articles assessing diagnostic performance of bronchoscopy in patients with suspected coronavirus disease 2019 infection. The primary outcome of interest was diagnostic sensitivity of bronchoalveolar lavage in the patients. The quality of each study was assessed using the Quality Assessment, Data Abstraction and Synthesis-2 tool.RESULTS:Of the 29 full-text articles assessed for eligibility, 4(13.8%) were included collectively comprising 209 patients who had undergone bronchoalveolar lavage. Mean sensitivity of bronchoalveolar lavage was 83.5% ± 10.63 (range: 68.2-940%). Overall, the 4 studies had an unclear or low risk of bias.CONCLUSIONS:Limited data suggested that bronchoscopy with bronchoalveolar lavage did not have reliably higher diagnostic sensitivity than that reported for either nasopharyngeal or oropharyngeal swabs.