These results are comparable with our data in that S pneumoniae is the main organism involved in CAP We agree with Ortqvist et al that bronchoscopy can be performed without major risks and that it is a useful tool in the severely ill patient and also in the moderately ill patient who cannot produce a sputum specimen. In 12 of our patients, we could not obtain sputum, and in 18 patients the sputum culture yielded normal flora. When the sputum culture was positive, the same organism was always cultured in the BAL fluid sample. However, the sensitivity of sputum culture was only 20 percent.
Cultures of fiberoptic bronchoscopy aspirates are not suitable for diagnosis because of contamination of the bronchoscope with normal flora in the upper airways. To overcome this problem, we performed quantitative cultures in order to delineate infection from colonization. We selected 103 cfu/ml as the cutoff point for TPC cultures according to previous published data.’ The optimal cutoff point for BAL cultures has not been established yet. This issue has been addressed recently by several investigators. Thorpe et al studied 15 patients with “clinically active bacterial pneumonia” and 13 of these patients had a BAL culture containing over 105 cfu/ml. However, the population with pneumonia was not well defined in this study; it included patients with nosocomial pneumonia and also patients with mechanical ventilation-associated pneumonia.