Incremental value of a gut microbiome score (M-score) for predicting stroke-associated pneumonia beyond the clinical A2DS2 score: A nested case–control study

Zhang, Yidan and Dong, Qi and Li, Wenbin (2026) Incremental value of a gut microbiome score (M-score) for predicting stroke-associated pneumonia beyond the clinical A2DS2 score: A nested case–control study. ACTA MICROBIOLOGICA ET IMMUNOLOGICA HUNGARICA, 73 (2). pp. 235-244. ISSN 1217-8950

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Abstract

Stroke-associated pneumonia (SAP) is a major complication of acute ischemic stroke. The brain–gut–lung axis suggests that post-stroke gut dysbiosis may offer independent risk information beyond clinical scores like A 2 DS 2 . The aim of this study was to evaluate the incremental predictive value of early post-stroke gut microbiome biomarkers for SAP and to construct a simplified microbiome risk score (M-score). In a prospective nested case–control study, we identified 63 SAP cases from a cohort of 551 patients with acute ischemic stroke and stool samples were collected 24–72 h post-admission. Cases were matched 1:2 (age, sex) to 126 controls. Gut microbiota was profiled via 16S rRNA sequencing. Three differentially abundant genera (prevalence ≥20%, FDR q < 0.10) were used to construct an M-score via bootstrapped regression. Independent associations were assessed with conditional logistic regression. Incremental value over the A 2 DS 2 score was evaluated using AUC, continuous net reclassification improvement (NRI), and the Brier score. SAP cases exhibited reduced α -diversity and distinct β -diversity (both P < 0.01). Cases had higher Enterococcus and Streptococcus and lower Faecalibacterium levels (all q < 0.05). The M-score was independently associated with SAP (adjusted OR per 1-SD: 1.76, 95% CI: 1.30–2.39, P = 0.001). Adding the M-score to A 2 DS 2 significantly improved prediction: AUC increased from 0.76 to 0.84 (ΔAUC = 0.08, P = 0.009), NRI was 0.31 (95% CI: 0.12–0.51), and the Brier score decreased from 0.18 to 0.16. Results were robust in sensitivity analyses. A gut microbiome score based on three genera provides significant independent and incremental predictive value for SAP over the A 2 DS 2 score, enabling more precise early risk stratification after stroke.

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