MH Kollef, PR Eisenberg, MF Ohlendorf and MR Wick
Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.

The purpose of this study was to determine the accuracy of elevated concentrations of endotoxin in bronchoalveolar lavage (BAL) fluid for the diagnosis of gram-negative pneumonia. Sixty-three hospitalized adults underwent 71 evaluations with BAL using quantitative cultures for suspected lung infection. A cutoff value of > 5 EU/ml for the concentration of endotoxin in BAL fluid yielded the best operating characteristics for the diagnosis of gram-negative pneumonia (sensitivity, 100%; specificity, 75.0%; area under receiver operating characteristic [ROC] curve, 0.88). Good diagnostic agreement was found between elevated concentrations of endotoxin in BAL fluid and microbiologically confirmed gram-negative pneumonia (kappa statistic, 0.64; concordance 83.1%). Gram stain examination of BAL fluid for the presence of gram-negative bacteria yielded inferior operating characteristics (sensitivity, 63.2%; specificity, 75.0%; area under ROC curve, 0.69). Poor diagnostic agreement was observed between BAL fluid Gram stain results and microbiologically confirmed gram-negative pneumonia (kappa statistic, 0.35; concordance, 71.8%). These findings suggest that a concentration of endotoxin in BAL fluid > 5 EU/ml is superior to Gram stain examination for the rapid identification of patients with gram-negative pneumonia.

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