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Fungal Diagnostic Stewardship in Bronchoscopy Specimens for Immunocompetent Patients in the Intensive Care Unit

      Abstract

      Objective

      To evaluate the diagnostic yield of fungal smears and cultures from bronchial lavage and wash specimens obtained from immunocompetent patients in the intensive care unit (ICU) because respiratory tract samples from patients in the ICU often undergo extensive microbiological testing.

      Patients and Methods

      In total, we enrolled 112 immunocompetent adult patients treated in the medical and surgical ICU between July 1, 2016, and June 30, 2017. We evaluated whether the results of fungal smears and cultures of specimens obtained from bronchoscopy and bronchoalveolar lavage changed patient care.

      Results

      In total, 131 bronchoscopic specimens and 31 bronchoalveolar lavage specimens were tested for fungi. Cultures were held for an estimated 4680 culture-days. Two results changed patient therapy. In both cases, other routine tests provided the same information as fungal culture before these results were returned.

      Conclusion

      In immunocompetent, critically ill patients, fungal culture of respiratory tract specimens does not add diagnostic value. Routine fungal culture of respiratory tract specimens should be discouraged in this population.

      Abbreviations and Acronyms:

      ICU (intensive care unit), IQR (interquartile range)
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      Linked Article

      • Candida Bronchitis and Mucus Plugging
        Mayo Clinic ProceedingsVol. 95Issue 4
        • Preview
          Although obtaining fungal cultures from bronchoscopy samples rarely changed therapy, the study by Shah et al1 did not show whether such patients would benefit from antifungal drug treatment. Infectious Diseases Society of America guidelines2 state that "[g]rowth of Candida from respiratory secretions usually indicates colonization and rarely requires treatment with antifungal therapy." Following those guidelines, therapy will not be given. In my experience, Candida sometimes causes chronic bronchitis, which improves with antifungal drug therapy,3 and Candida can contribute to mucus plugging and atelectasis.
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      • In reply — Candida Bronchitis and Mucus Plugging
        Mayo Clinic ProceedingsVol. 95Issue 4
        • Preview
          We thank Dr Johnson for his feedback.1 We agree that change of therapy vs benefit of therapy could not be assessed by our retrospective design. Regarding the comments on bronchiectasis, the role of antifungal agents in this population has not been thoroughly studied. Some retrospective studies, such as the letter writer's own, suggest that there may be benefit of researching this further in a prospective manner, but the preponderance of evidence is insufficient to recommend routinely treating Candida in respiratory infections outside of an appropriately monitored clinical trial.
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