宏基因组二代测序与传统病原检测在中性粒细胞减少伴发热白血病患儿中的对比研究

doi:10.12372/jcp.2022.21e1444

摘要/Abstract

摘要：

目的探讨宏基因组二代测序（mNGS）在中性粒细胞减少伴发热（FN）白血病患儿中的应用价值。方法回顾性分析2018年1月1日至2021年7月1日儿科重症监护病房收治的白血病化疗后合并FN患儿的临床资料。根据感染灶分为A组（血流感染组）和B组（肺部感染组）,比较两组mNGS与传统病原检测（TPD）的效能。结果共纳入56例患儿,男27例、女29例,中位年龄4.0（2.0~7.8）岁。A组39例,ALL28例、AML11例;B组17例,ALL10例、AML7例。A组和B组最常见的病原均为曲霉菌、念珠菌和鲍曼不动杆菌。mNGS与TPD检测阳性率的一致性较差（Kappa=0.039）;mNGS检测阳性率（80.4%）明显高于TPD（58.9%）,差异有统计学意义（P=0.023）。A组mNGS对曲霉菌（35.9%对12.8%）、念珠菌（28.2%对10.3%）和鲍曼不动杆菌（28.2%对7.7%）的检测阳性率均高于TPD;B组mNGS对曲霉菌（41.2%对5.9%）的检测阳性率高于TPD,差异均有统计学意义（P<0.05）。mNGS可检测罕见病原,且对混合感染的检出率显著高于TPD,差异有统计学意义（P<0.05）。结论对于初始抗感染治疗失败的白血病合并FN患儿,最常见致病原为曲霉菌、念珠菌、鲍曼不动杆菌。作为TPD的互补手段,mNGS对常见病原检测阳性率更高,对混合感染和罕见病原检测效能突出。

关键词: 宏基因组二代测序, 中性粒细胞减少伴发热, 白血病, 儿童

Abstract:

Objective To investigate the application value of metagenomic next-generation sequencing (mNGS) in leukemia children with febrile neutropenic (FN). Methods The clinical data of leukemia children combined with FN after chemotherapy admitted to the pediatric intensive care unit from January 1, 2018 to July 1, 2021 was retrospectively analyzed. The children were divided into group A (bloodstream infection group) and group B (pulmonary infection group) according to the infection foci, and the efficacy of mNGS and traditional pathogen detection (TPD) in the two groups was compared. Results A total of 56 children (27 boys and 29 girls) were included, with a median age of 4.0 (2.0-7.8) years. There were 39 cases in group A (28 cases of ALL and 11 cases of AML) and 17 cases in group B (10 cases of ALL and 7 cases of AML). The commonest pathogens in group A and B were Aspergillus, Candida and Acinetobacter baumannii. The consistency of positive rate of mNGS and TPD was poor (Kappa=0.039). The mNGS positive rate (80.4%) was significantly higher than TPD (58.9%), and the difference was statistically significant (P=0.023). In group A, the positive rates of mNGS for Aspergillus (35.9% vs. 12.8%), Candida (28.2% vs. 10.3%) and Acinetobacter baumannii (28.2% vs. 7.7%) were higher than those of TPD; in group B, the positive rate of mNGS for Aspergillus (41.2% vs. 5.9%) was higher than that of TPD, and the differences were statistically significant (P<0.05). The mNGS can detect rare pathogens, and the detection rate of mNGS for mixed infection was significantly higher than that of TPD, and the difference was statistically significant (P<0.05). Conclusions In leukemia children with FN who failed in initial antibiotic therapy, the commonest pathogens were Aspergillus, Candida, and Acinetobacter baumannii. As a complementary tool for TPD, mNGS has a higher positive detection rate for common pathogens and outstanding efficacy for mixed infections and rare pathogens.

Key words: metagenomic next-generation sequencing, febrile neutropenic, leukemia, child

康磊, 郭芳, 白新凤, 徐梅先. 宏基因组二代测序与传统病原检测在中性粒细胞减少伴发热白血病患儿中的对比研究[J]. 临床儿科杂志, 2022, 40(7): 539-544.

KANG Lei, GUO Fang, BAI Xinfeng, XU Meixian. Comparative study of metagenomic next-generation sequencing and traditional pathogen detection in leukemia children with febrile neutropenia[J]. Journal of Clinical Pediatrics, 2022, 40(7): 539-544.

图/表 5

表1

表2

表3

表4

表5

参考文献 22

[1]	Bispo JAB, Pinheiro PS, Kobetz EK. Epidemiology and etiology of leukemia and lymphoma[J]. Cold Spring Harb Perspect Med, 2020, 10(6): a034819. doi: 10.1101/cshperspect.a034819
[2]	Lin X, Wang J, Huang X, et al. Global, regional, and national burdens of leukemia from 1990 to 2017: a systematic analysis of the global burden of disease 2017 study[J]. Aging (Albany NY), 2021, 13(7): 10468-10489.
[3]	Mishra K, Kumar S, Ninawe S, et al. The clinical profile, management, and outcome of febrile neutropenia in acute myeloid leukemia from resource constraint settings[J]. Ther Adv Infect Dis, 2021, 8: 20499361211036592.
[4]	Nucci M. How I treat febrile neutropenia mediterr[J]. Mediterr J Hematol Infect Dis, 2021, 13(1): e2021025. doi: 10.4084/mjhid.2021.025
[5]	Martinez-Nadal G, Puerta-Alcalde P, Gudiol C, et al. Inappropriate empirical antibiotic treatment in high-risk neutropenic patients with bacteremia in the eraof multidrug resistance[J]. Clin Infect Dis, 2020, 70(6): 1068-1074. doi: 10.1093/cid/ciz319 pmid: 31321410
[6]	Gu W, Deng X, Lee M, et al. Rapid pathogen detection by metagenomic next-generation sequencing of infected body fluids[J]. Nat Med, 2021, 27(1): 115-124. doi: 10.1038/s41591-020-1105-z
[7]	马彩霞, 陈镜龙, 陆泳, 等. 肺泡灌洗液宏基因组测序在儿童重症肺炎支原体肺炎混合感染中的诊断价值[J]. 临床儿科杂志, 2020, 38(12): 891-895.
[8]	中华医学会检验医学分会临床微生物学组, 中华医学会微生物学与免疫学分会临床微生物学组, 中国医疗保健国际交流促进会临床微生物与感染分会. 宏基因组高通量测序技术应用于感染性疾病病原检测中国专家共识[J]. 中华检验医学杂志, 2021, 44(2): 107-120.
[9]	Tang W, Zhang Y, Luo C, et al. Clinical Application of metagenomic next-generation sequencing for suspected infections in patients with primary immunodeficiency disease[J]. Front Immunol, 2021, 12: 696403. doi: 10.3389/fimmu.2021.696403
[10]	Kanda Y, Kimura SI, Iino M, et al. D-Index-Guided early antifungal therapy versus empiric antifungal therapy for persistent febrile neutropenia: a randomized controlled noninferiority trial[J]. J Clin Oncol, 2020, 38(8): 815-822.
[11]	中华医学会血液学分会, 中国医师协会血液科医师分会. 中国中性粒细胞缺乏伴发热患者抗菌药物临床应用指南(2020年版)[J]. 中华血液学杂志, 2020, 41(12): 969-978.
[12]	Gu W, Deng X, Lee M, et al. Rapid pathogen detection by metagenomic next-generation sequencing of infected body fluids[J]. Nat Med, 2021, 27(1): 115-124. doi: 10.1038/s41591-020-1105-z
[13]	Pagano L, Caira M, Candoni A, et al. The epidemiology of fungal infections in patients with hematologic malignancies: the SEIFEM-2004 study[J]. Haematologica, 2006, 91(8): 1068-1075.
[14]	Lionakis MS, Iliev ID, Hohl TM. Tobias M Hohl. Immunity against fungi[J]. JCI Insight, 2017, 2(11): e93156. doi: 10.1172/jci.insight.93156
[15]	Lionakis MS, Netea MG, Holland SM. Mendelian genetics of human susceptibility to fungal infection[J]. Cold Spring Harb Perspect Med, 2014, 4(6): a019638. doi: 10.1101/cshperspect.a019638
[16]	Lass-Florl C. Diagnosing fungal infections in haematology patients-another case of less is more in the clinical setting?[J]. Clin Microbiol Infect, 2017, 23(12): 896-897. doi: 10.1016/j.cmi.2017.05.022
[17]	El-Mahallawy HA, Hassan SS, El-Wakil M, et al. Increasing antimierobial resistance monitored in surveillance analysis of blood stream infections in febrile neutropenic pediatric oneology patients[J]. Asian Pac J Cancer Prev, 2015, 16(14): 5691-5695. doi: 10.7314/APJCP.2015.16.14.5691
[18]	Kochanek M, Schalk E, von Bergwelt-Baildon M, et al. Management of sepsis in eutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO)[J]. Ann Hematol, 2019, 98(5): 1051-1069. doi: 10.1007/s00277-019-03622-0
[19]	Li N, Cai Q, Miao Q, et al. High-throughput metagenomics for identification of pathogens in the clinical settings[J]. Small Methods, 2021, 5(1): 2000792. doi: 10.1002/smtd.202000792
[20]	Zheng Y, Qiu X, Wang T, et al. The Diagnostic value of metagenomic next-generation sequencing in lower respiratory tract infection[J]. Front Cell Infect Microbiol, 2021, 11: 694756. doi: 10.3389/fcimb.2021.694756
[21]	Fang X, Mei Q, Fan X,et al. Diagnostic value of metagenomic next-generation sequencing for the detection of pathogens in bronchoalveolar lavage fluid in ventilator-associated pneumonia patientsl[J]. Front Microbiol, 2020, 11: 599756. doi: 10.3389/fmicb.2020.599756
[22]	Fontana L, Strasfeld L. Respiratory virus infections of the stem cell transplant recipient and the hematologic malignancy patient[J]. Infect Dis Clin North Am, 2019, 33(2): 523-544. doi: 10.1016/j.idc.2019.02.004

项目	A组(n=39)		统计量	P	B组(n=17)		统计量	P
项目	ALL(n=28)	AML(n=11)	统计量	P	ALL(n=10)	AML(n=7)	统计量	P
男性[n(%)]	16(57.1)	6(54.5)	χ²=0.00	1.000	3(30.0)	2(28.6)	—	0.686¹⁾
年龄 [M(P₂₅~P₇₅)]/岁	5.0 (3.0~7.0)	10.0 (2.0~12.0)	Z=1.33	0.182	3.5 (2.0~4.0)	0.8 (0.7~3.0)	Z=1.88	0.061
脓毒性休克[n(%)]	8(28.6)	1(9.1)	χ²=0.77	0.380	0(0.0)	0(0.0)	—	—
肺出血[n(%)]	3(10.7)	1(9.1)	—	1.000¹⁾	2(20.0)	0(0.0)	—	0.485¹⁾
ARDS[n(%)]	0(0.0)	0(0.0)	—	—	1(10.0)	2(28.6)	—	0.537¹⁾
存活[n(%)]	20(71.4)	10(90.9)	χ²=0.77	0.380	9(90.0)	6(85.7)	—	1.000¹⁾
SOFA评分 [M(P₂₅~P₇₅)]/分	6.0 (4.0~8.0)	7.0 (5.0~8.0)	Z=0.68	0.498	6(3~8)	5(2~8)	Z=0.45	0.656
ANC [M(P₂₅~P₇₅)]×10⁹/L	0.0 (0.0~0.1)	0.0 (0.0~0.1)	Z=1.21	0.225	0.1 (0.0~0.1)	0.1 (0.0~0.2)	Z=0.30	0.768
CRP [M(P₂₅~P₇₅)]/mg·L^-1	146.5 (57.0~231.0)	111.0 (99.0~195.0)	Z=0.19	0.851	62.5 (40.0~152.0)	102.0 (54.0~161.0)	Z=1.08	0.282
PCT [M(P₂₅~P₇₅)]/μg·L^-1	1.5 (0.2~8.3)	0.3 (0.2~1.6)	Z=1.37	0.169	0.8 (0.4~1.4)	0.2 (0.1~1.2)	Z=1.43	0.143
mNGS延迟天数 [M(P₂₅~P₇₅)]/d	10.0 (5.3~13.8)	9.0 (5.0~12.0)	Z=0.71	0.481	13.5 (4.5~24.3)	12.0 (9.0~13.0)	Z=0.49	0.624

病原	A组(n=39)		合计	B组(n=17)		合计
病原	ALL(n=28)	AML(n=11)	合计	ALL(n=10)	AML(n=7)	合计
革兰阴性菌
鲍曼不动杆菌	9(32.1)	3(27.3)	12	3(30.0)	2(28.6)	5
肺炎克雷伯菌	6(21.4)	1(9.1)	7	0(0.0)	1(14.3)	1
铜绿假单胞菌	4(14.3)	0(0.0)	4	0(0.0)	2(28.6)	2
大肠埃希氏菌	2(7.1)	1(9.1)	3	0(0.0)	0(0.0)	0
嗜麦芽窄食单胞菌	3(10.7)	0(0.0)	3	0(0.0)	0(0.0)	0
其他阴性菌	3(10.7)	1(9.1)	4	1(10.0)	1(14.3)	2
革兰阳性菌
肺炎链球菌	3(10.7)	0(0.0)	3	0(0.0)	3(42.9)	3
屎肠球菌	1(3.6)	0(0.0)	1	0(0.0)	3(42.9)	3
金黄色葡萄球菌	1(3.6)	1(9.1)	2	1(10.0)	0(0.0)	1
其他阳性菌	0(0.0)	0(0.0)	0	1(10.0)	0(0.0)	1
真菌
曲霉菌	11(39.3)	4(36.4)	15	6(60.0)	2(28.6)	8
念珠菌	9(32.1)	3(27.3)	12	2(20.0)	2(28.6)	4
肺孢子菌	0(0.0)	1(9.1)	1	0(0.0)	2(28.6)	2
毛霉菌	2(7.1)	1(9.1)	3	0(0.0)	0(0.0)	0
毛孢子菌	0(0.0)	0(0.0)	0	0(0.0)	1(14.3)	1
病毒
EBV	3(10.7)	0(0.0)	3	0(0.0)	1(14.3)	1
CMV	2(7.1)	0(0.0)	2	0(0.0)	0(0.0)	0
腺病毒	1(3.6)	0(0.0)	1	0(0.0)	0(0.0)	0

病原体种类	mNGS	TPD	Kappa	P
0	11（19.6）	23（41.1）	0.039	0.023
1	16（28.6）	21（37.5）	0.000	0.424
≥2	29（51.8）	12（21.4）	0.055	0.002