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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2020, Vol. 14 ›› Issue (06) : 657 -664. doi: 10.3877/cma.j.issn.1674-134X.2020.06.002

所属专题： 文献；

临床论著

基因二代测序技术在假体周围感染诊断中的价值
殷晗1, 王大伟1,†(), 李伟1, 苑振峰1, 徐明涛1, 王凯1, 哈承志1, 许笃亮1   
  1. 1. 252000　聊城市人民医院
  • 收稿日期:2020-03-11 出版日期:2020-12-01
  • 通信作者: 王大伟
  • 基金资助:
    聊城市人民医院青年基金(LYQN201912)

Diagnosis value of next-generation sequencing technology in periprosthetic joint infection

Han Yin1, Dawei Wang1,†(), Wei Li1, Zhenfeng Yuan1, Mingtao Xu1, Kai Wang1, Chengzhi Ha1, Duliang Xu1   

  1. 1. Department of joint surgery of the Liaocheng People's Hospital, Liaocheng 252000, China
  • Received:2020-03-11 Published:2020-12-01
  • Corresponding author: Dawei Wang
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引用本文：

殷晗, 王大伟, 李伟, 苑振峰, 徐明涛, 王凯, 哈承志, 许笃亮. 基因二代测序技术在假体周围感染诊断中的价值[J]. 中华关节外科杂志(电子版), 2020, 14(06): 657-664.

Han Yin, Dawei Wang, Wei Li, Zhenfeng Yuan, Mingtao Xu, Kai Wang, Chengzhi Ha, Duliang Xu. Diagnosis value of next-generation sequencing technology in periprosthetic joint infection[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2020, 14(06): 657-664.

目的

通过与细菌培养及血清生物学标志对比，探讨二代测序技术(NGS)对人工关节置换术后假体周围感染(PJI)的诊断价值。

方法

选取2017年7月到2019年12月在聊城市人民医院关节外科因假体周围感染或无菌性松动行关节翻修手术，排除初始关节液无法采集到，通过关节内注射生理盐水获得样本的患者及其他部位存在感染病灶的患者，共纳入患者35人(35例)根据美国肌骨骼感染协会(MSIS)的诊断标准，15例患者纳入感染组，20例患者纳入非感染组。术前两组患者常规检查血沉(ESR)、C反应蛋白(CRP)、降钙素原(PCT)、白介素6(IL-6)及D-二聚体(D-Dimer)。所有患者术前均行关节穿刺，穿刺液检测白细胞计数、白细胞分类、细菌培养及NGS。计算ESR、CRP、PCT、IL-6及D-Dimer的受试者操作特性曲线(ROC)的曲线下面积(AUC)。计算NGS、细菌培养及各项血清学标志物的诊断精确度、敏感性及特异性。

结果

髋关节19例(54.3%)，膝关节16例(45.7%)。男性21例(60.0%)，女性14例(40.0%)，年龄67.0(62.0，74.0)岁。感染组15例患者中NGS结果阳性14例(93.3%)，细菌培养结果阳性7例(46.7%)。非感染组NGS结果阴18例(90.0%)。ESR及D二聚体的AUC分别为0.667和0.572(均为P>0.05)。CRP、IL-6及PCT的AUC分别为0.827、0.767及0.808(均为P<0.01)。NGS、细菌培养、CRP、IL-6及PCT的精确度分别为0.91、0.74、0.77、0.74及0.83。NGS与CRP、IL-6、PCT、细菌培养两两比较，总体检测结果差异有统计学意义(P<0.01)。NGS与CRP、IL-6、PCT、细菌培养两两比较，NGS敏感性更高(P<0.05)。NGS与CRP比较特异性更好(P<0.05)。NGS与IL-6、PCT及细菌培养比较，特异性差异无统计学意义(P>0.05)。

结论

NGS比细菌培养及常用的血清学标志物有更高的精确度及敏感性，在PJI的诊断中具有更大的价值。

关键词: 高通量核苷酸测序, 假体相关感染, 再手术, 诊断, 关节成形术
Objective

To explore the value of next generation sequencing (NGS) in diagnosis of Periprosthetic Joint Infection (PJI) by comparing with bacterial culture and serum biomarker.

Methods

A total of 35 patients (35 cases) who underwent joint revision surgery in department of joint surgery of the Liaocheng People's Hospital from July 2017 to December 2019 were selected. Inclusion criteria: infection or aseptic loosening after prosthesis replacement. Exclusion criteria: the patients whose initial synovial fluid cannot be collected, samples obtained by intra-articular injection of normal saline and patients with infected lesions in other parts. According to the diagnostic criteria of the Muscular Skeletal Infection Society (MSIS), 15 patients were included in the infection group and 20 patients were included in the non-infection group. The patients in both groups routinely received examination of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), interleukin 6 (IL-6), and D-Dimer preoperatively. All the patients were given a joint puncture preoperatively. The synovial fluid was used to detect white blood cell count, white blood cell classification, bacterial culture, and NGS. The area under the curve (AUC) of the receiver operating characteristic curve (ROC) of the ESR, CRP, PCT, IL-6, and D-Dimer was calculated. The diagnostic accuracy, sensitivity, and specificity of NGS, bacterial culture, and various serological markers were also calculated.

Results

Nineteen cases of hip joints (54.3%) and 16 cases of knee joints (45.7%) were included. There were 21 males (60.0%) and 14 females (40.0%), age was 67.0(62.0, 74.0) years. Fourteen cases were positive for NGS (93.3%) and seven cases were positive for bacterial culture (46.7%) in the infection group. NGS results were negative in 18 cases (90.0%) in the non-infected group. The AUCs of ESR and D-Dimer were 0.667 and 0.572, respectively (both P values>0.05). The AUC of CRP, IL-6 and PCT were 0.827, 0.767 and 0.808, respectively (all P<0.01). The accuracy of NGS, bacterial culture, CRP, IL-6 and PCT were 0.91, 0.74, 0.77, 0.74 and 0.83, respectively. When comparing NGS with CRP, IL-6, PCT, and bacterial culture, the difference in overall test results were statistically significant (P<0.01). NGS compared with CRP, IL-6, PCT and bacterial culture, the sensitivity of NGS was higher (P<0.05). Compared with CRP, the specificity of NGS was higher (P<0.05). Compared with IL-6, PCT and bacterial culture, the specificity of NGS was not statistically significant (P>0.05).

Conclusion

NGS has higher accuracy and sensitivity than bacterial culture and commonly used serological markers, and has greater value in diagnosis of PJI.

Key words: High-throughput nucleotide sequencing, Prosthesis-related infections, Reoperation, Diagnosis, Arthroplasty
图1 患者选择流程图
表1 两组患者基本特征
项目 总体 感染组 非感染组 统计值 P值
例数 35 15 20    
年龄[岁，M(P25，P75)] 67.0(62.0，74.0) 67(63.0，69.5) 68.5(62.0，74.0) - 0.458a
性别[例(%)]          
  男 21(60.0) 10(66.7) 11(55.0)    
  女 14(40.0) 5(33.3) 9(45.0) - 0.728b
身体质量指数[kg/m2，(±s)] 27.2±2.3 26.9±2.4 27.4±2.1 t＝-0.604 >0.05
累及关节[例(%)]          
  髋 19(54.3) 7(46.7) 12(60.0)    
  膝 16(45.7) 8(53.3) 8(40.0) - 0.506b
图2 感染组与非感染组检测指标对比。图A为CRP(C反应蛋白)检测结果，两组差异有统计学意义(P＝0.001)；图B为ESR(血沉)检测结果，两组差异无统计学意义(P>0.05)；图C为IL-6(白介素-6)检测结果，两组差异有统计学意义(P＝0.007)；图D为PCT(降钙素原)检测结果，两组差异有统计学意义(P＝0.001)；图E为D-dimer(D二聚体)检测结果，两组差异无统计学意义(P>0.05)；图F为NGS(二代测序)及细菌培养结果，两种结果在感染组及非感染组的差异有统计学意义(NGS：P<0.001，细菌培养：P＝0.011)；culture-细菌培养
表2 两组NGS、细菌培养及血清标志物检测结果
项目 感染组 非感染组 P值
例数 15 20  
CRP蛋白[mg/dl，M(P25，P75)] 18.30(8.90，32.20) 5.65(3.73，10.75) 0.001a
ESR(mm/h) 32.33(11.67，50.47) 17.23(1255，22.82) 0.099a
IL-6[ng/L，M(P25，P75)] 16.82(9.54，37.59) 8.42(3.26，15.45) 0.007a
PCT[μg/L，M(P25，P75)] 3.54(0.26，4.84) 0.21(0.12，0.29) 0.001a
D-二聚体[mg/L，M(P25，P75)] 0.63(0.18，1.87) 0.54(0.22，0.93) 0.479a
NGS[例(%)]     <0.001b
  阳性 14(93.33) 2(10.00)  
  阴性 1(6.67) 18(90.00)  
培养[例(%)]     0.011b
  阳性 7(46.67) 1(5.00)  
  阴性 8(53.33) 19(95.00)  
图3 CRP(C-反应蛋白)、IL-6(白介素-6)及PCT(降钙素原)的ROC曲线(受试者操作特征曲线)
表4 CRP、ESR、IL-6、PCT及D-dimer的AUC及Cut off值
  AUC SE P值 95% CI cut off值
CRP 0.827 0.069 0.001 (0.692，0.961) 11.20
ESR 0.667 0.107 0.096 (0.457，0.876) 26.50
IL-6 0.767 0.081 0.008 (0.608，0.926) 23.05
PCT 0.808 0.085 0.002 (0.642，0.774) 2.29
D-二聚体 0.572 0.103 0.474 (0.369，0.889) 1.02
表5 CRP、IL-6、PCT、NGS及细菌培养的诊断能力
  FP TP TN FN P值 ACC Sen P值 Spe P值 PPV NPV ＋LR -LR
CRP 3 10 17 5 <0.01* 0.77 0.67 <0.05* 0.85 <0.05* 0.77 0.77 4.44 0.39
IL6 1 7 19 8 <0.01* 0.74 0.47 <0.05* 0.95 >0.05* 0.88 0.70 9.33 0.56
PCT 1 10 19 5 <0.01* 0.83 0.67 <0.05* 0.95 >0.05* 0.91 0.79 13.33 0.35
NGS 2 14 18 1 - 0.91 0.93 - 0.90 - 0.88 0.95 9.33 0.07
细菌培养 1 7 19 8 <0.01* 0.74 0.47 <0.05* 0.95 >0.05* 0.88 0.70 9.33 0.56
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