摘要
目的 应用宏基因组二代测序(mNGS)分析不同类型免疫抑制合并重症肺炎患者的病原体分布特点,为临床治疗提供依据.方法 2021年1月—2022年1月郑州大学第一附属医院诊治免疫抑制合并重症肺炎患者113例,根据免疫抑制类型分为长期使用激素或免疫抑制剂组(长期组)71例和其他类型组(其他组)42例,2组均行纤维支气管镜检查,收集支气管肺泡灌洗液行mNGS检测,分析2组病原体感染类型及病原体分布特点.73例患者根据mNGS结果调整抗感染治疗方案,观察治疗结局.结果 2组肺部混合感染均常见,长期组mNGS检出的细菌、真菌、病毒分别主要为鲍曼不动杆菌、耶氏肺孢子菌、人类疱疹病毒4型;其他组mNGS检出的细菌、真菌、病毒分别主要为鲍曼不动杆菌、曲霉菌、人类疱疹病毒1型.长期组病毒+真菌检出率(25.4％)高于其他组(7.1％)(x2=4.499,P=0.034),细菌+真菌、细菌+真菌+病毒检出率(7.0％、19.7％)均低于其他组(21.4％、38.1％)(x2=4.527,P=0.033;x2=4.135,P=0.043),细菌+病毒检出率(9.9％)与其他组(9.5％)比较差异无统计学意义(x2=0.007,P=0.935),单病原体(细菌、真菌、病毒、非典型病原体)检出率(11.3％、14.1％、1.4％、2.8％)与其他组(11.9％、2.4％、0、2.4％)比较差异均无统计学意义(x2=0.005,P=0.945;x2=2.232,P=0.135;x2=0.587,P=0.443;x2=0.021,P=0.886).长期组耶氏肺孢子菌检出率(46.7％)高于其他组(28.0％)(x2=5.130,P=0.023),鲍曼不动杆菌、肺炎克雷伯菌检出率(11.3％、5.6％)均低于其他组(23.5％、14.7％)(x2=25.230,P＜0.001;x2=26.440,P＜0.001).73 例患者根据 mNGS 结果调整抗感染治疗方案后好转出院48例,病情恶化自动出院20例,死亡5例.结论 不同类型免疫抑制合并重症肺炎患者常见感染类型均为混合感染;与其他免疫抑制类型相比,长期使用激素或免疫抑制剂患者感染耶氏肺孢子菌的风险较高,感染鲍曼不动杆菌和肺炎克雷伯菌的风险较低.
Abstract
Objective To analyze the distribution characteristics of pathogens in severe pneumonia patients with different types of immunosuppression using metagenomic next-generation sequencing(mNGS),and to provide a basis for clinical treatment.Methods From January 2021 to January 2022,113 patients with immunosuppression-associated severe pneumonia were treated in the First Affiliated Hospital of Zhengzhou University,among whom 71 patients had the history of long-term glucocorticoid or immunosuppressant therapy(long-term group)and the other 42 patients had other types of immunosuppression(other-type group).Both groups were performed fiberoptic bronchoscopy examination,and the bronchoalveolar lavage fluid samples were harvested for mNGS to analyze the pathogen infection types and distribution characteristics.The anti-infective therapy regimen was adjusted based on mNGS results in 73 patients,and the outcomes were observed.Results Mixed lung infections were common in both groups,with Acinetobacter baumannii,Pneumocystis jirovecii,and Human Herpesvirus 4 as the bacteria,fungi,and viruses detected by mNGS in long-term group,and Acinetobacter baumannii,Aspergillus,and Human Herpesvirus 1 in other-type group.The detection rate of viruses+fungi was higher in long-term group(25.4％)than that in other-type group(7.1％)(x2=4.499,P=0.034),the detection rates of bacteria+fungi and bacteria+fungi+viruses were lower in long-term group(7.0％,19.7％)than those in other-type group(21.4％,38.1％)(x2=4.527,P=0.033;x2=4.135,P=0.043),there were no significant differences in the detection rates of bacteria+viruses,single pathogens(bacteria,viruses,fungi,atypical pathogens)between long-term group(9.9％,11.3％,14.1％,1.4％,2.8％)and other-type group(9.5％,11.9％,2.4％,0,2.4％)(x2=0.007,P=0.935;x2=0.005,P=0.945;x2=2.232,P=0.135;x2=0.587,P=0.443;x2=0.021,P=0.886).The detection rate of Pneumocystis jirovecii was higher in long-term group(46.67％)than that in other-type group(28.0％)(x2=5.130,P-0.023),while the detection rates of Acinetobacter baumannii and Klebsiella pneumoniae were lower in long-term group(11.3％,5.6％)than those in other-type group(23.5％,14.7％)(x2=25.230,P＜0.001;x2=26.440,P＜0.001).Among these 73 patients,48 patients were discharged after showing improvement by adjustment of anti-infective therapy regimen based on mNGS results,20 patients were discharged due to disease deterioration,and 5 resulted in death.Conclusions Mixed infections are common in severe pneumonia patients with different types of immunosuppression.Compared to other types of immunosuppression,long-time use of glucocorticoid or immunosuppressants has a lower risk of infection with Acinetobacter baumannii and Klebsiella pneumoniae,but a higher risk of Pneumocystis jirovecii infection.
NETL
NSTL
万方数据