Non-bronchoscopic bronchoalveolar lavage improves respiratory culture accuracy in critically ill patients with suspected pneumonia

SESSION TITLE: Critical Care Posters 9 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2023 12:00 pm - 12:45 pm PURPOSE: Pneumonia is a common cause of death among intubated patients in the intensive care unit (ICU). Diagnosis of pneumonia is challenging in intubated patients due to endotracheal tube colonization and oral flora contamination. Inaccurate respiratory cultures lead to unnecessary and inappropriate antibiotic use, which can be harmful to patients. Non-bronchoscopic bronchoalveolar lavage (NBBL) provides a sterile, alveolar sample for culture that is more cost-effective than traditional bronchoscopy. However, it remains unknown if NBBL is more accurate with less contamination than typical endotracheal aspirate cultures. Hence, we seek to evaluate if routine use of NBBL in ICU patients with suspected pneumonia could improve antibiotic prescribing practices. METHODS: We performed a prospective quality improvement pilot to determine the role of NBBL on the diagnosis of pneumonia in intubated patients. Intubated, adult patients in the medical ICU were enrolled if (1) there was a clinical suspicion for pneumonia (new fever, sputum, increased white blood cell count, infiltrate on chest imaging) and (2) no contraindications to the NBBL procedure (severe hypoxia, coagulopathy, or hemodynamic instability). Patients received concurrent endotracheal aspirate and NBBL cultures performed by a respiratory therapist. The primary outcome was difference in culture positivity between endotracheal aspirate and NBBL. Clinical variables were also collected including: demographic data, severity of illness, and antibiotic administration. RESULTS: 83 patients were enrolled with an average APACHE III score of 92.2. 35 patients (42.2%) had a positive endotracheal aspirate and only 22 (26.5%) had a positive quantitative culture from NBBL. 16 patients (19.3%) had discordant results between endotracheal aspirate and NBBL cultures. Respiratory flora was recovered more commonly in endotracheal aspirate cultures compared with NBBL cultures (58 vs. 39, p= 0.004). 26 (31.3%) had a change in antibiotic therapy after respiratory cultures, including 5 (19.2%) who had discordant results between endotracheal aspirate and NBBL. 2 (2.4%) patients had transient, bloody secretions after NBBL, but there were no major adverse events. CONCLUSIONS: NBBL is a safe and effective method for diagnosing pneumonia in critically ill, intubated patients. In our quality improvement pilot, cultures from NBBL were more accurate compared with those from endotracheal aspirate. Improved respiratory culture specificity will allow for more rapid antibiotic de-escalation and antibiotic stewardship in ICUs. CLINICAL IMPLICATIONS: Routine use of NBBL in intubated patients with suspected pneumonia may reduce respiratory culture contamination compared with endotracheal aspirate and prevent unnecessary antibiotic use as part of a multimodal strategy for antibiotic stewardship in the ICU. DISCLOSURES: No relevant relationships by Margaret Jeng No relevant relationships by Erica Orsini No relevant relationships by Rachel Scheraga No relevant relationships Added 03/31/2023 by Jason Yerke, source=Web Response, value=Shareholder Removed 03/31/2023 by Jason Yerke, source=Web Response No relevant relationships Added 03/31/2023 by Jason Yerke, source=Web Response, value=Shareholder Removed 03/31/2023 by Jason Yerke, source=Web Response No relevant relationships Added 03/31/2023 by Jason Yerke, source=Web Response, value=Shareholder Removed 03/31/2023 by Jason Yerke, source=Web Response No relevant relationships Added 03/31/2023 by Jason Yerke, source=Web Response, value=Shareholder Removed 03/31/2023 by Jason Yerke, source=Web Response