mNGS在基于CURB-65风险分层社区获得性 肺炎的诊治及评估预后中的价值

The Value of Metagenomic Next-Generation Sequencing (mNGS) in the Diagnosis, Treatment and Prognostic Evaluation of Community-Acquired Pneumonia Based on CURB-65 Risk Stratification

摘要: 目的：探讨宏基因组二代测序(mNGS)在基于CURB-65风险分层的社区获得性肺炎(CAP)患者的诊断、指导抗感染治疗以及评估预后中的应用价值。方法：回顾性纳入2020年12月~2025年12月安徽医科大学呼吸与危重症医学科收治的120例CAP患者，根据CURB-65评分分为低危组(n = 65)和高危组(n = 55)。收集两组基线特征、实验室指标、mNGS与常规病原学检测结果、抗感染方案调整及临床转归数据，采用统计学方法比较组间差异，分析mNGS在不同CURB-65风险分层组内的诊治和评估预后价值。结果：高危组平均年龄(74.0 ± 7.5岁)、基础疾病比例(83.6%)及白细胞水平、中性粒细胞、降钙素原水平显著高于低危组(P < 0.05)，淋巴细胞水平显著低于低危组。mNGS阳性率(94.55% vs 64.62%)、常规培养阳性率(50.91% vs 30.77%)、混合感染比例(65.45% vs 30.77%)及抗生素调整率(54.55% vs 32.31%)在高危组均显著更高(P < 0.01)。mNGS共检出病原体253例，以鲍曼不动杆菌、肺炎克雷伯菌为主；常规检测检出病原体81例，以白色假丝酵母、肺炎克雷伯菌为主，mNGS对特殊病原体的检出更具优势。两组病原体类型分布存在显著差异(χ² = 10.299, P = 0.016)，高危组真菌占比(69.49%)显著高于低危组(30.51%)。高危组不良转归率(54.55%)高于低危组(6.15%)，在常规培养阴性的高危组患者中，mNGS可以显著改善不良转归率(P = 0.028)。多因素Logistic回归显示CURB-65分组是不良转归的独立预测因素(OR = 13.46, 95% CI [3.54~51.17], P < 0.001)。根据mNGS调整抗感染方案后，预后有差异但无统计学意义(OR = 0.533, 95% CI [0.22~1.32], P = 0.174)。结论：不同CURB-65风险分层CAP患者的mNGS诊断阳性率及其指导抗感染方案调整率存在显著差异，mNGS在高危组病原学诊断中优势突出，可作为常规病原学检测阴性的补充，提高诊断阳性率并指导抗感染方案调整，有效改善预后。

Abstract: Objective: To investigate the clinical value of metagenomic next-generation sequencing (mNGS) in the diagnosis, guidance of anti-infective therapy, and prognostic evaluation of patients with community-acquired pneumonia (CAP) stratified by CURB-65 risk. Methods: A total of 120 patients with CAP admitted to the Department of Respiratory and Critical Care Medicine, Anhui Medical University from December 2020 to December 2025 were retrospectively enrolled. According to the CURB-65 score, the patients were divided into the low-risk group (n = 65) and the high-risk group (n = 55). Baseline characteristics, laboratory parameters, results of mNGS and conventional etiological tests, adjustments of antimicrobial regimens, and clinical outcome data were collected from both groups. Statistical analyses were performed to compare differences between the two groups and to evaluate the value of mNGS in the diagnosis, treatment, and prognostic assessment among patients with different CURB-65 risk stratifications. Results: Compared with the low-risk group, the high-risk group had a significantly higher mean age (74.0 ± 7.5 years), proportion of underlying comorbidities (83.6%), white blood cell count, neutrophil count, and procalcitonin level (all P < 0.05), while the lymphocyte count was significantly lower. The positive rate of mNGS (94.55% vs 64.62%), positive rate of conventional culture (50.91% vs 30.77%), proportion of mixed infections (65.45% vs 30.77%), and antibiotic adjustment rate (54.55% vs 32.31%) were significantly higher in the high-risk group (all P < 0.01). A total of 253 pathogens were detected by mNGS, mainly Acinetobacter baumannii and Klebsiella pneumoniae; 81 pathogens were detected by conventional tests, mainly Candida albicans and Klebsiella pneumoniae. mNGS exhibited superior performance in detecting special pathogens. There was a significant difference in the distribution of pathogen types between the two groups (χ² = 10.299, P = 0.016), with the proportion of fungi in the high-risk group (69.49%) being significantly higher than that in the low-risk group (30.51%). The adverse outcome rate was higher in the high-risk group (54.55%) than in the low-risk group (6.15%). Among high-risk patients with negative conventional culture, mNGS significantly improved the adverse outcome rate (P = 0.028). Multivariate logistic regression analysis revealed that CURB-65 stratification was an independent predictor of adverse outcomes (OR = 13.46, 95%CI [3.54~51.17], P < 0.001). There was a difference in prognosis after adjusting antimicrobial regimens according to mNGS, but this difference was not statistically significant (OR = 0.533, 95%CI [0.22~1.32], P = 0.174). Conclusion: Significant differences exist in the diagnostic positive rate of mNGS and the rate of antimicrobial regimen adjustment guided by mNGS among CAP patients with different CURB-65 risk stratifications. mNGS exhibits prominent advantages in etiological diagnosis of the high-risk group, and can serve as a supplement to negative conventional etiological tests to improve the diagnostic yield, guide the adjustment of antimicrobial regimens, and effectively improve patient prognosis.