The clinical application of metagenomic next-generation sequencing for invasive pulmonary aspergillosis in neutropenic patients: a multicenter retrospective study in the ICU.

BACKGROUND: Early initiation of targeted antifungal therapy is critical for improving outcomes in neutropenic patients with invasive pulmonary aspergillosis (IPA) in the intensive care unit (ICU). Although metagenomic next-generation sequencing (mNGS) is valuable for pathogen detection, its clinical value in IPA patients with neutropenia remains unclear. METHODS: This multicenter retrospective study included patients clinically diagnosed with invasive pulmonary aspergillosis (IPA). All patients underwent both conventional microbiological tests (CMTs) and metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF). Based on neutrophil status, patients were stratified into neutropenic and non-neutropenic groups and further divided into mNGS-guided and CMT-guided groups according to the antifungal treatment strategy. RESULTS: mNGS demonstrated higher pathogen detection rate than conventional microbiological tests (CMTs) in both neutropenic and non-neutropenic patients with invasive pulmonary aspergillosis (IPA). It also identified a broader pathogen spectrum and a higher proportion of mixed infections. Overall, IPA patients in the mNGS-guided group had lower 28-day mortality compared with the CMT-guided group (23.17% vs. 43.75%, P = 0.04). Multivariate analysis indicated that mNGS-guided therapy was associated with reduced 28-day mortality (adjusted OR = 0.329, 95% CI: 0.111-0.974, P = 0.045). A significant interaction between treatment strategy and neutrophil status was observed (adjusted P = 0.002). In subgroup analysis, the survival benefit of mNGS-guided therapy was mainly observed in neutropenic IPA patients, who achieved higher rates of appropriate antifungal therapy and lower mortality, whereas no significant intergroup difference was found among non-neutropenic IPA patients. CONCLUSION: mNGS-guided antifungal therapy significantly reduced 28-day mortality in neutropenic IPA patients, whereas no clear effect was observed in non-neutropenic patients. These findings highlight the potential clinical value of mNGS in guiding antifungal therapy in neutropenic IPA patients.