The clinical utility of bronchoalveolar lavage galactomannan result stewardship within a tertiary medical system

Abstract

Our Transplant Infectious Disease (TID) program implemented monitoring of all elevated bronchoalveolar lavage (BAL) galactomannan (GM) results as a quality improvement (QI) project. Twenty-four hours after a positive result, a standardized email is sent to the primary providers if the GM result is unaccounted for based on clinical documentation. We performed a real-world, retrospective study to examine the impact of this intervention over one year (2022-2023) as well as the impact of an elevated BAL GM result on clinical decision-making. We captured the number of positive GM results that triggered notification of the primary team, and the number of times a single positive galactomannan triggered initiation or change of systemic antifungal therapy. We included 55 cases of BAL GM > 1.0. In seventeen cases (31%), a single positive BAL GM result triggered the initiation of antifungal therapy. Most of these cases met criteria for probable IPA. The TID team contacted the primary team for 14 cases (25%) of elevated BAL galactomannan antigens which led to a new start or change in antifungal regimen. Voriconazole was the most common definitive antifungal agent chosen. Though elevated BAL GM results were impactful in introducing or changing antifungal regimens, we identified a possible knowledge gap in the interpretation of elevated galactomannan results among clinical staff. Our study suggests that there may be value in the diagnostic stewardship and monitoring of BAL galactomannan results by infectious diseases clinicians.