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Despite marked improvements in antibiotic therapy, the accurate diagnosis and treatment of bacterial lower respiratory tract infection remain a challenge. The bronchoscopic protected specimen brush and bronchoscopic bronchoalveolar lavage combined with quantitative bacterial cultures can provide sensitive and relatively specific information about lower airway flora. Both of these methods require strict observance of the required protocol, careful processing of the obtained specimens, and the absence of prior antibiotic therapy to obtain best results. These procedures are also of some utility in sickle cell acute chest syndrome, bronchiectasis, and in the immunocompromised host.

Bronchoalveolar lavage (BAL) is quite useful in the diagnosis of nonbacterial lung infections, especially in immunocompromised patients, and recent studies have suggested that BAL may be useful in the diagnosis of bacterial pneumonia as well. Because previous studies indicated that bronchoscopic aspirates are usually contaminated by oropharyngeal flora, we anticipated that BAL fluid would also likely be contaminated. Therefore, the purpose of this study was to perform quantitative bacterial cultures on BAL fluids obtained from eight normal subjects. Prior to each procedure, saline was aspirated through the bronchoscope and submitted for culture. A protected brush catheter (PBC) specimen was obtained from each subject's right middle lobe, and then a BAL specimen was obtained from the same location. All specimens were quantitatively cultured for aerobic and anaerobic organisms. In addition, lidocaine concentrations were measured in the BAL fluids and the PBC specimens. Six of the eight bronchoscope cultures were sterile. Seven of the eight PBC specimens were sterile and one yielded less than 10(3) cfu/ml of normal oropharyngeal flora. One BAL fluid specimen was sterile and seven yielded from one to four bacterial strains each; however, quantitation revealed less than 10(4) cfu/ml in all specimens. Lidocaine concentrations (mean +/- 1 SD) were as follows: PBC specimen, 0.81 microgram/ml (+/- 0.62); BAL fluid specimen, 62.6 micrograms/ml (+/- 43). We conclude that BAL fluid obtained from normal subjects is frequently contaminated by oropharyngeal bacterial flora.(ABSTRACT TRUNCATED AT 250 WORDS)

We prospectively compared the usefulness of a bronchoscopic protected catheter technique with the results from sputum cultures in the evaluation of moxalactam, a new beta-lactam antibiotic. The significance of a given isolate on protected catheter culture was determined by quantitative bacteriology. 32 patients with community-acquired pneumonia were enrolled in the study and 31 grew common lower respiratory tract pathogens from their protected catheter specimen. The most common single pathogens recovered were Streptococcus pneumoniae (11 patients) and Haemophilus influenzae (2). Mixed flora, predominantly anaerobes, were isolated from 15 patients, and 3 patients had mixed aerobic infections. All seven bacteremic cases had the identical organism isolated from the protected catheter specimen, confirming the accuracy of the technique. Comparisons with sputum cultures showed that the predominant organism on sputum culture was the same as that obtained from the protected catheter culture in only 13% of the cases. Sputum cultures revealed either no pathogen or a different pathogen in 23 cases, and no sputum could be obtained in 4. Compared to cultures of expectorated sputum, we found the protected catheter bronchoscopic culture technique to have the following advantages in the bacteriologic evaluation of moxalactam: 1) greater accuracy and sensitivity in bacteremic patients; 2) accurate delineation of the bacteriology of infections; and 3) a higher percentage of patients with evaluable bacteriology leading to greater efficiency during the investigation.