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RMg was 93% sensitive and 81% specific for clinically relevant pathogens compared with routine testing. Forty-eight percent of RMg results informed antimicrobial prescribing changes (22% escalation; 26% deescalation) with escalation based on speciation in 20 out of 24 cases and detection of acquired-resistance genes in 4 out of 24 cases. Fastidious or unexpected organisms were reported in 21 samples, including anaerobes (n\u2009=\u200912), Mycobacterium tuberculosis, Tropheryma whipplei, cytomegalovirus, and Legionella pneumophila ST1326, which was subsequently isolated from the bedside water outlet. Application to consecutive severe community-acquired LRTI cases identified Staphylococcus aureus (two with SCCmec and three with luk F\/S virulence determinants), Streptococcus pyogenes (emm1-M1uk clone), S. dysgalactiae subspecies equisimilis (STG62647A), and Aspergillus fumigatus with multiple treatments and public health impacts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This pilot study illustrates the potential of RMg testing to provide benefits for antimicrobial treatment, infection control, and public health when provided in a real-world critical care setting. Multicenter studies are now required to inform future translation into routine service.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1164\/rccm.202305-0901oc","type":"journal-article","created":{"date-parts":[[2023,11,8]],"date-time":"2023-11-08T10:28:28Z","timestamp":1699439308000},"page":"164-174","update-policy":"https:\/\/doi.org\/10.1164\/crossmarkpolicies","source":"Crossref","is-referenced-by-count":80,"title":["Routine Metagenomics Service for ICU Patients with Respiratory Infection"],"prefix":"10.1093","volume":"209","author":[{"given":"Themoula","family":"Charalampous","sequence":"first","affiliation":[{"name":"Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, School of Immunology and Microbial Sciences and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adela","family":"Alcolea-Medina","sequence":"additional","affiliation":[{"name":"Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, School of Immunology and Microbial Sciences and"},{"name":"Infection Sciences, Synnovis, London, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luke B.","family":"Snell","sequence":"additional","affiliation":[{"name":"Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, School of Immunology and Microbial Sciences and"},{"name":"Department of Infectious Diseases and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Alder","sequence":"additional","affiliation":[{"name":"Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, School of Immunology and Microbial Sciences and"},{"name":"Department of Infectious Diseases and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Tan","sequence":"additional","affiliation":[{"name":"Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, School of Immunology and Microbial Sciences and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom G. 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