Comparison of traditional microbiological culture and 16S ...
Comparison of traditional microbiological culture and 16S polymerase chain reaction analyses for identification of preoperative airway colonization for patients undergoing lung resection. Running Title: 16S PCR for detection of airway colonizationAuthors: Samuel H. Howitta,b; Diana Blackshawc; Eustace Fontained ; Ibrahim Hassanc; Ignacio Malagona,ba.Division of Cardiovascular Sciences, University of Manchester, 2nd Floor ERC, Wythenshawe Hospital, Manchester, M23 9LT, UK. b.Department of Cardiothoracic Anaesthesia and Critical Care, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, M23 9LT, UK. c.Department of Microbiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, M23 9LT, UK.d. Department of Thoracic Surgery, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, M23 9LT, UKStudy conducted at: Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, M23 9LT, UKCorresponding authorSamuel Howitt, Academic Surgery Unit, 2nd Floor ERC, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester. UK. M23 9LT. Tel. (0044)161 291 5842. Email samuel.howitt@manchester.ac.ukAbstractPurposePreoperative airway colonization is associated with increased risk of postoperative respiratory complications following lung resection. This study compares the rates of preoperative lower respiratory tract colonization identified by traditional culture and novel 16S polymerase chain reaction (PCR) tests. Materials and MethodsPreoperative sputum and bronchoalveolar lavage (BAL) samples for 49 lung resection patients underwent culture and 16S PCR analyses. Relationships between test results and suspected postoperative respiratory tract infection and hospital length of stay (LOS) were also investigated. ResultsPreoperative BAL cultures were positive for 29 (59.2%) patients (population estimate 95%CI 45.4%-72.9%). 16S PCR tests were positive for 28 (57.1%) patients (population estimate 95%CI 43.2%-71.0%). 17 (34.7%) patients suffered suspected postoperative respiratory tract infection (population estimate 95%CI 21.4%-48.0%). Positive 16S PCR results tended to be associated with longer LOS (median 7.5 days vs 4.0 days for negative, p=0.08) and increased risk of suspected postoperative respiratory tract infection (46.4% for positive vs 19.0% for negative, p=0.07). Conclusions Rates of colonization identified by culture and 16S PCR analyses of BAL samples were similar. Future research should attempt to clarify associations between airway colonization identified by 16S PCR and outcomes. 16S PCR may be useful when stratifying risk of postoperative respiratory complications. 200 wordsKeywords: Thoracic Surgery; Microbiological techniquesFunding StatementThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.IntroductionLung cancer is the leading cause of cancer-related death throughout the world.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GZXJsYXk8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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AG==
ADDIN EN.CITE.DATA [2, 6] Preoperative colonization of the lower respiratory tract is a risk factor for postoperative respiratory tract infection. ADDIN EN.CITE <EndNote><Cite><Author>D’Journo</Author><Year>2011</Year><RecNum>3</RecNum><DisplayText>[7]</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="dfr2zs5phparexepxwcxvdsj2veprtstxr9s">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>D’Journo, Xavier Benoit</author><author>Rolain, Jean Marc</author><author>Doddoli, Christophe</author><author>Raoult, Didier</author><author>Thomas, Pascal Alexandre</author></authors></contributors><titles><title>Airways colonizations in patients undergoing lung cancer surgery</title><secondary-title>European Journal of Cardio-Thoracic Surgery</secondary-title></titles><periodical><full-title>European Journal of Cardio-Thoracic Surgery</full-title></periodical><pages>309-319</pages><volume>40</volume><number>2</number><dates><year>2011</year><pub-dates><date>August 1, 2011</date></pub-dates></dates><urls><related-urls><url>;[7] In previous studies using various methodologies, preoperative bronchial colonization was proven by culture analyses in 20-80% of patients undergoing lung cancer surgery. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Tb2s8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [2, 3, 8-11] According to a recent meta-analysis, the risk of postoperative respiratory complications for patients with preoperative airway colonization was around 20% compared with 10% for patients without colonization. ADDIN EN.CITE <EndNote><Cite><Author>D’Journo</Author><Year>2011</Year><RecNum>3</RecNum><DisplayText>[7]</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="dfr2zs5phparexepxwcxvdsj2veprtstxr9s">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>D’Journo, Xavier Benoit</author><author>Rolain, Jean Marc</author><author>Doddoli, Christophe</author><author>Raoult, Didier</author><author>Thomas, Pascal Alexandre</author></authors></contributors><titles><title>Airways colonizations in patients undergoing lung cancer surgery</title><secondary-title>European Journal of Cardio-Thoracic Surgery</secondary-title></titles><periodical><full-title>European Journal of Cardio-Thoracic Surgery</full-title></periodical><pages>309-319</pages><volume>40</volume><number>2</number><dates><year>2011</year><pub-dates><date>August 1, 2011</date></pub-dates></dates><urls><related-urls><url>;[7] However, the association between colonization and postoperative pneumonia remains unclear as the proportion of cases in which organisms responsible for postoperative pneumonia match those identified in preoperative samples ranges from 21% to 85%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1c3NsZXI8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFy
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ADDIN EN.CITE.DATA [10]. Theoretically BAL sampling should allow the identification of organisms from deeper in the bronchial tree than the bronchial brushings technique. Using fibre optic bronchoscopy to guide the sampling would also ensure that samples are taken from both lungs and allow the operator to target areas with signs of inflammation or increased secretion load. These previous studies employed traditional microbiological culturing methods to detect colonization. This methodology often fails to identify fastidious organisms. ADDIN EN.CITE <EndNote><Cite><Author>D’Journo</Author><Year>2011</Year><RecNum>3</RecNum><DisplayText>[7]</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="dfr2zs5phparexepxwcxvdsj2veprtstxr9s">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>D’Journo, Xavier Benoit</author><author>Rolain, Jean Marc</author><author>Doddoli, Christophe</author><author>Raoult, Didier</author><author>Thomas, Pascal Alexandre</author></authors></contributors><titles><title>Airways colonizations in patients undergoing lung cancer surgery</title><secondary-title>European Journal of Cardio-Thoracic Surgery</secondary-title></titles><periodical><full-title>European Journal of Cardio-Thoracic Surgery</full-title></periodical><pages>309-319</pages><volume>40</volume><number>2</number><dates><year>2011</year><pub-dates><date>August 1, 2011</date></pub-dates></dates><urls><related-urls><url>;[7] More sensitive molecular tests such as the 16S PCR which can identify organisms which are difficult to culture may be better suited to the identification of colonization.This prospective, observational study involved the collection of a sputum sample and fibre-optic bronchoscopy guided BAL samples for patients undergoing lung resection surgery (pneumonectomy, lobectomy, bilobectomy or wedge resection). Samples were subjected to microbiological culture and sensitivity analysis and BAL samples were also analysed using 16S polymerase chain reaction (PCR) tests. The study aimed to determine the incidences of preoperative colonization of the lower respiratory tract identified by microbiological culture of sputum and BAL samples and 16S PCR analyses of BAL samples. The incidence of suspected postoperative respiratory tract infection after lung resection surgery was also determined. Having quantified these incidences in our sample, we calculated estimates of the population incidences with 95% confidence intervals (CI). Finally, we investigated the associations between preoperative colonization identified by different methods and treatment for postoperative respiratory tract infection and hospital length of stay (LOS). Materials and MethodsThe study was performed according to R&D approval from our institution and ethical approval from the local National Research Ethics Committee (ref. 15/NM/0069). Adult patients undergoing lung resection surgery defined as pneumonectomy, lobectomy, bilobectomy or wedge resection were considered eligible for the study. Patients taking antimicrobials at the time of surgery and those unable to provide informed consent for participation were excluded.53 patients presenting to our institution for lung resection surgery consented to participate in the study. One patient was excluded due to being treated with antibiotics preoperatively. All eligible patients provided a sputum sample on the day of their operation. For each patient, BAL samples were taken during fibre optic bronchoscopy which occurs routinely in our institution between induction of anaesthesia and the onset of surgery. The operating surgeon performed one BAL for each lung while the patient was supine using 10mls of normal saline prior to positioning for surgery. All samples were taken before prophylactic antibiotics were administered. All samples were subjected to culture and sensitivity analyses in our institution’s microbiology department. BAL samples were also sent for 16S PCR testing according to the in-house processing protocol at the Public Health England laboratory, Colindale, London.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FZHdhcmRzPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA [13] Samples from three patients were not sent for 16S PCR examination in a deviation from the research protocol in the pathology laboratory. These patients were excluded from the study. Results of the microbiological tests and outcome data were obtained from the hospital pathology database and the case notes respectively. The suspected infection end point was met where suspicion of post-operative respiratory tract infection was documented in the case notes or antibiotics were administered according to hospital protocol for treating respiratory tract infection. LOS was defined as the number of days from surgery to discharge from hospital.Sample size calculationTo estimate the accuracy this study could expect to provide when reporting the rates of positive test results, theoretical 95% confidence intervals (CI) for the population incidences of positive results were calculated. These 95% CIs were based on previously reported incidences of positive BAL culture analyses and were determined using the Wilson score interval method ADDIN EN.CITE <EndNote><Cite><Author>Wilson</Author><Year>1927</Year><RecNum>23</RecNum><DisplayText>[14]</DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="dfr2zs5phparexepxwcxvdsj2veprtstxr9s">23</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wilson, Edwin B.</author></authors></contributors><titles><title>Probable Inference, the Law of Succession, and Statistical Inference</title><secondary-title>Journal of the American Statistical Association</secondary-title></titles><periodical><full-title>Journal of the American Statistical Association</full-title></periodical><pages>209-212</pages><volume>22</volume><number>158</number><dates><year>1927</year></dates><publisher>[American Statistical Association, Taylor & Francis, Ltd.]</publisher><isbn>01621459</isbn><urls><related-urls><url> publication date: Jun., 1927</custom1><electronic-resource-num>10.2307/2276774</electronic-resource-num></record></Cite></EndNote>[14]. The rates of positive BAL cultures in the literature range from 20% PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1c3NsZXI8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFy
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ADDIN EN.CITE.DATA [3]. Assuming a sample size of 50 patients and positive test rates of 20% or 80%, the 95% CIs would be 11%-33% or 67%-89% respectively. The widest possible 95% CI interval would occur if the positive test rate was 50%, in which case the 95% CI would be 37%-63%. Statistical analysis Distributions of non-parametric variables were described using the median and interquartile range (IQR). The 95% CI for the population estimates for the proportions of patients testing positive by each test and the proportion of patients suffering suspected postoperative respiratory tract infections were calculated using the Wilson score interval method ADDIN EN.CITE <EndNote><Cite><Author>Wilson</Author><Year>1927</Year><RecNum>23</RecNum><DisplayText>[14]</DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="dfr2zs5phparexepxwcxvdsj2veprtstxr9s">23</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wilson, Edwin B.</author></authors></contributors><titles><title>Probable Inference, the Law of Succession, and Statistical Inference</title><secondary-title>Journal of the American Statistical Association</secondary-title></titles><periodical><full-title>Journal of the American Statistical Association</full-title></periodical><pages>209-212</pages><volume>22</volume><number>158</number><dates><year>1927</year></dates><publisher>[American Statistical Association, Taylor & Francis, Ltd.]</publisher><isbn>01621459</isbn><urls><related-urls><url> publication date: Jun., 1927</custom1><electronic-resource-num>10.2307/2276774</electronic-resource-num></record></Cite></EndNote>[14]. The results of each patient’s BAL test results were cross tabulated to allow comparison. Comparison of LOS for different groups was performed using the Wilcoxon rank sum test. Comparisons of proportions suffering suspected postoperative respiratory tract infection were performed using Fisher’s exact test due to the low number of outcomes.ResultsData from 49 patients were included in the analyses. The median (IQR) age of patients was 69 (34-74) years. 28 (57.1%) of patients were female and the most commonly performed procedure was a lobectomy (n=34). Further details including patient co-morbidities can be found in Table 2. The median (IQR) LOS in hospital was 4.0 (3.0-8.0) days. One patient died prior to discharge from hospital. The death was related to a postoperative pneumonia and subsequent respiratory failure. 17 patients (34.7%) suffered a suspected respiratory tract infection postoperatively. The 95% CI for the estimate of the incidence of suspected postoperative respiratory tract infection in this institution’s lung resection population was 22.9%-48.7%. Sputum samples were not analysed in five cases due to the samples not complying with the laboratory specimen acceptance policy. Culture analyses identified organisms in 43 of the 44 sputum samples analysed. As sputum samples had passed through the upper respiratory tract, samples which identified only “normal upper respiratory tract flora” were classified as negative (n=32). Sputum cultures identified specific organisms in 11 patients but in four of these cases the organism was Candida albicans which was considered to represent upper respiratory tract colonization.The results of all test performed on the BAL samples are shown in Table 3. As BALs were taken directly from deep in the bronchial tree through a newly inserted endotracheal tube, BAL samples which identified “normal upper respiratory tract flora” were classified as positive – they were considered to represent true colonization of the lower respiratory tract. BAL culture was positive for 29 (59.2%) patients. In 18 of these patients “normal upper respiratory tract flora” were identified in the BAL sample. 16S PCR analysis of BAL samples identified bacterial RNA in 28 (57.1%) of the 49 patients (Table 4). The organisms most commonly identified by PCR analyses (Table 5) were Haemophilus Influenzae (n=6), Prevotella sp. (n=6) and Streptococcus sp. (n=6). The calculated 95%CIs for the incidences of positive BAL culture and positive BAL PCR in this patient population were 45.2%-71.8% and 43.3%-70.0% respectively. There was agreement between the results of both testing methods in 38 (77.6%) patients (Table 3). The 95% CI for the proportion of patients in whom the tests agreed was 64.1-87.0%. In six cases, culture identified organisms in patients with negative PCR analyses (including fungal pathogens in two patients) and in five cases, PCR was positive while culture was negative (Tables 3 and 4). In 7 cases the bacteria identified on culture were sensitive to cefuroxime (our institution’s prophylactic antibiotic). Fungal pathogens were not covered by the antimicrobial prophylaxis provided in our institution. Samples identifying “normal respiratory tract flora” were not subjected to antibiotic sensitivity testing. The outcomes for patients grouped according to the results of their BAL culture and 16S PCR tests are shown in Table 5. No difference in outcomes achieved statistical significance although it should be noted that the study was only powered to compare the incidences of positive test results and not to allow comparisons of the test’s accuracy when predicting postoperative infection.The sensitivity and specificity for the BAL culture when identifying those who would develop as suspected postoperative respiratory tract infection were 0.65 and 0.44 respectively. The equivalent values for the sensitivity and specificity of the 16S PCR test were 0.76 and 0.53. DiscussionTraditional culture analyses of sputum samples identified organisms in all but one patient. Sputum samples which revealed “normal upper respiratory tract flora” were classified as negative because the organisms are likely to have entered the sputum as it passed through the upper airway during expectoration. As the majority of colonization occurs through micro-aspiration of upper respiratory tract secretions ADDIN EN.CITE <EndNote><Cite><Author>Dickson</Author><Year>2015</Year><RecNum>21</RecNum><DisplayText>[15]</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="dfr2zs5phparexepxwcxvdsj2veprtstxr9s">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dickson, Robert P.</author><author>Huffnagle, Gary B.</author></authors></contributors><titles><title>The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease</title><secondary-title>PLOS Pathogens</secondary-title></titles><periodical><full-title>PLOS Pathogens</full-title></periodical><pages>e1004923</pages><volume>11</volume><number>7</number><dates><year>2015</year></dates><publisher>Public Library of Science</publisher><urls><related-urls><url>;[15] most colonising organisms will be upper airway commensals. 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ADDIN EN.CITE.DATA [2, 9, 10, 12]. However, this classification is somewhat subjective, particularly in the cohort of high risk patients studied. Therefore, in this study, identification of any organism in samples taken directly from the lower respiratory tract resulted in a positive test result. Thus the incidence of colonization was similar to those found in other studies which included all organisms when defining colonization.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Tb2s8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [3, 8] Further work could investigate the relative significance of colonization by specific pathogens when identifying patients at risk of adverse outcomes. That was outside the scope of this study.Another reason for the higher incidence of colonization identified in our study may be the sampling technique employed. Use of fibre optic bronchoscopy to guide the BALs ensured that samples were taken from sites where the clinician performing the procedure saw most inflammation and secretions in each lung. Use of BAL also ensured that pathogens from deeper in the bronchial tree than those obtainable by bronchial swabbing and brushing were sampled.While the proportions of patients testing positive using each method were almost identical, there was only agreement between the tests in around three quarters of the patients. While our study was not powered to detect correlation between positive tests and adverse outcomes, there were non-statistically significant trends for positive PCR results but not culture results being associated with suspected postoperative respiratory tract infection and longer LOS. This difference should be investigated further in larger studies and differences between outcomes of those with colonization identified by each method should be quantified. Seven of the nine specific bacteria identified in preoperative cultures were sensitive to our institution’s antibiotic prophylaxis. However, when considering all potentially pathogenic organisms cultured from the preoperative samples (including fungi), our institution’s antimicrobial prophylaxis only covered 63.6% of the organisms identified. The antibiotic sensitivities of the organisms identified only by PCR analysis were not determined and neither were those of the “normal upper respiratory tract flora” bacteria. The relevance of antibiotic sensitivities of colonizing organisms is debatable as it is not possible to justify administration of prophylaxis to cover all colonising agents especially in the era of increasing antibiotic resistance. However, although there is no proven link between organisms identified as preoperative colonizers and those responsible for postoperative infections it seems prudent to ensure antibiotic prophylaxis covers the most frequently pathogenic organisms identified in the preoperative samples.Among the organisms detected by PCR in patients where culture analyses revealed no growth or only normal upper respiratory tract flora, Prevotella, Streptococcus and Veillonella species were the most common. Other PCR-identified organisms not specifically identified by culture analysis included Neisseria cinerea and Neisseria meningtidis, Haemophilus influenzae, Streptococcus parasanguinis, Brevunidmonas, Escherichia coli and Shigella. The majority of these organisms are fastidious and the ability of 16S PCR to identify them is a potential advantage over traditional culturing techniques and the clinical relevance of these largely commensal organisms should be the focus of future investigations. Suspected rather than proven respiratory tract infection was chosen as our endpoint. This decision was made to ensure all patients who suffered important complications postoperatively were recognised. In a previous study, where multiple respiratory tract samples were taken from patients with clear clinical signs of respiratory tract infection immediately prior to starting antibiotic therapy, organisms were only identified in 40% of patients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1c3NsZXI8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFy
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ADDIN EN.CITE.DATA [16] Therefore, in order to ensure all patients who suffered a postoperative respiratory tract infection were identified, suspicion rather than microbiological proof of infection was used as the end point. LimitationsThis study was not blinded as it was considered unethical to withhold information concerning the organisms present in patients’ lungs around the time of their surgery. Therefore the initiation of antibiotics may have been influenced by the presence of positive microbiological results. This was more likely for culture analyses of sputum and BAL samples where specific organisms were identified as the results were typically available within 2 days. Positive 16S PCR results are less likely to have influenced treatments as the mean time to result availability was 5 days. In this study the PCR analyses were conducted off site with a delay of around 5 days between the samples being taken and the results being received, whereas the culture analyses typically gave results within 48 hours. The delay in receiving the PCR results is likely to limit their clinical utility. The cost of each BAL test at ?160 was also ten times higher than the conventional culture analysis. However, as new molecular identification technologies become cheaper and deliver results more quickly they may become better suited to the detection of preoperative airway colonization than traditional cultures. This can only happen if their clinical validity can be demonstrated. Future work should use a larger sample to clarify the relationship between positive PCR results in preoperative BAL samples and clinical outcomes. ConclusionThis study has shown that 16S PCR analyses identify colonizing bacteria in a similar proportion of preoperative BAL samples as traditional culture. This study should lead to a larger study to compare the rates of adverse outcomes in groups of patients who are found to have preoperative lower airway colonization by 16S PCR and traditional culture analyses.Declaration of interests: noneTable 1 – Incidence of preoperative colonization identified in previous studiesAuthorMethodPercentage with positive cultureSchusler OPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2h1c3NsZXI8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFy
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ADDIN EN.CITE.DATA [10]BAL bronchoscopy34%*Howitt SBAL bronchoscopy59%* Only includes potential pathogenic organisms Table 2 – Patient characteristicsCharacteristicValueAge, years ,median (Interquartile range)69 (34-74)Female gender, n (%)28 (57.1)BMI, kg/m2, median (Interquartile range)26.5 (23.9-29.6)Smoking Status, n (%) Current12 (24.5) Ex31 (63.2) Never6 (12.2)Ischaemic Heart Disease, n (%)9 (18.4)COPD, n (%)15 (30.1)Hypertension, n (%)25 (51.0)Cerebrovascular Disease, n (%)4 (8.2)Peripheral Vascular Disease, n (%)3 (6.1)Operation, n (%) Perelman Procedure 1 (2.0) Wedge Resection10 (20.4) Segmentectomy4 (8.2) Lobectomy34 (69.3)Table 3 – Agreement between results of testing methods Test and result (N)16S PCR + (28) 16S PCR – (21)Culture + (29)236Culture – (20)515Table 4 – Organisms identified from BAL samplesPatient NumberCulture resultPCR result1Moraxella catarrhalisMoraxella catarrhalis3No growthStreptococcus sp.4Haemophilus influenzaeHaemophilus influenza, Neisseria cinerea and Neisseria menigitidis6Moraxella catarrhalisMoraxella catarrhalis7No growthStreptococcus sp.8Scedosporium apiospermumNo DNA10Normal upper respiratory tract floraPrevotella melaninogenica and Prevotella denticola12Normal upper respiratory tract floraVeillonella sp15Haem influenzaeHaemophilus influenzae16No growthclosest to Escherichia coli and Shigella17Normal upper respiratory tract floraStreptococcus sp.21Pseudomonas aeruginosaPseudomonas aeruginosa23Normal upper respiratory tract floraHaemophilus influenzae and Prevotella sp.24Aspergillus fumigatus complexNo DNA25Normal upper respiratory tract floraPrevotella sp. and Veillonella sp.26Haemophilus influenzaeHaemophilus influenzae27Normal upper respiratory tract floraStreptococcus sp.30Normal upper respiratory tract floraStreptococcus parasanguinis31Normal upper respiratory tract floraNo DNA32Normal upper respiratory tract floraNo DNA33Normal upper respiratory tract floraStreptococcus sp.34Candida albicansNo DNA35Haemophilus influenzaeHaemophilus influenzae36No growthBrevundimonas sp.37Normal upper respiratory tract floraNo DNA40Normal upper respiratory tract floraVeillonella sp.41Normal upper respiratory tract floraEscherichia, Shigella, Klebsiella and Prevotella42Normal upper respiratory tract floraGanulicatella adiacens43No growthStreptococcus sp.44Normal upper respiratory tract floraPrevotella sp.49Stenotrophomonas maltophiliaStenotrophomonas maltophilia51Normal upper respiratory tract floraStreptococcus parasanguinis52Normal upper respiratory tract floraVeillonella sp. and Prevotella sp.53Haemophilus InfluenzaeHaemophilus influenzaeTable 5 – Outcomes for patients according to BAL sample analysisTest result (N)Treatment for chest infection (%)LOS, days, median (IQR)Culture + (29)11 (37.9)5.0 (3.0-8.0)Culture – (20)6 (30.0)4.0 (3.0-7.5)16S PCR + (28) 13 (46.4)7.5 (3.0-9.5)16S PCR – (21)4 (19.0)4.0 (3.0-5.0)References ADDIN EN.REFLIST 1. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015; 136:E359-3862. Schussler O, Alifano M, Dermine H, et al. Postoperative pneumonia after major lung resection. Am J Respir Crit Care Med 2006; 173:1161-11693. Belda J, Cavalcanti M, Ferrer M, et al. Bronchial colonization and postoperative respiratory infections in patients undergoing lung cancer surgery. Chest 2005; 128:1571-15794. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128-11375. Doddoli C, Barlesi F, Trousse D, et al. One hundred consecutive pneumonectomies after induction therapy for non-small cell lung cancer: an uncertain balance between risks and benefits. J Thorac Cardiovasc Surg 2005; 130:416-4256. Watanabe S, Asamura H, Suzuki K, et al. Recent results of postoperative mortality for surgical resections in lung cancer. Ann Thorac Surg 2004; 78:999-1002; discussion 1002-10037. D’Journo XB, Rolain JM, Doddoli C, et al. Airways colonizations in patients undergoing lung cancer surgery. European Journal of Cardio-Thoracic Surgery 2011; 40:309-3198. Sok M, Dragas AZ, Erzen J, et al. Sources of pathogens causing pleuropulmonary infections after lung cancer resection. Eur J Cardiothorac Surg 2002; 22:23-27; discussion 27-299. Yamada Y, Sekine Y, Suzuki H, et al. Trends of bacterial colonisation and the risk of postoperative pneumonia in lung cancer patients with chronic obstructive pulmonary disease. Eur J Cardiothorac Surg 2010; 37:752-75710. Dancewicz M, Szymankiewicz M, Bella M, et al. [Bronchial bacterial colonization in patients with lung cancer]. Pneumonol Alergol Pol 2009; 77:242-24711. Wansbrough-Jones MH, Nelson A, New L, et al. Bronchoalveolar lavage in the prediction of post-thoracotomy chest infection. European Journal of Cardio-Thoracic Surgery 1991; 5:433-434; discussion 43512. Oor JE, Daniels JMA, Debets-Ossenkopp YJ, et al. Bronchial colonization and complications after lung cancer surgery. Langenbeck's Archives of Surgery 2016; 401:885-89213. Edwards KJ, Logan JM, Langham S, et al. Utility of real-time amplification of selected 16S rRNA gene sequences as a tool for detection and identification of microbial signatures directly from clinical samples. J Med Microbiol 2012; 61:645-65214. Wilson EB. Probable Inference, the Law of Succession, and Statistical Inference. Journal of the American Statistical Association 1927; 22:209-21215. Dickson RP, Huffnagle GB. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLOS Pathogens 2015; 11:e100492316. Llitjos JF, Amara M, Benzarti A, et al. Prior antimicrobial therapy duration influences causative pathogens identification in ventilator-associated pneumonia. J Crit Care 2017 ................
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