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Table 1 Early management measures and impact on mortality in severe community-acquired pneumonia and its complications

From: Severe community-acquired pneumonia: timely management measures in the first 24 hours

Intervention

Patient population

Number of patients

Number with pneumoniaa

Mortality reduction

Mortality definition

Risk (95 % CI)

Evidence quality

Selected reference

CAP severity assessment tools to guide management

Severe CAP in hospital

348

348 with CAP

Yes

Hospital

Adjusted OR 0.24 (0.09–0.67)

Low; before-and-after study

[27]

Guideline-concordant antibiotics

CAP in hospital

1288

1288 with CAP

Yes

Hospital mortality

Adjusted OR 0.55 (0.30–0.90)

Low; observational study

[39]

Macrolide combination treatment

Severe CAP in ICUs

8872

8872 with CAP

Yes

Hospital, ICU, 28-day or 30-day

RR 0.84 (0.71–1.00)

Moderate; systematic review of observational studies

[48]

Early antibiotics within 1 hour

Sepsis and septic shock

11,017

Data not available

Uncertain

Hospital or 28-day

OR 0.68 (0.42–1.12)

Moderate; systematic review of observational studies

[56]

Early antibiotics after septic shock

Septic shock

2154

838

Yes

Hospital

Adjusted OR 0.89 (0.88–0.91) per hour earlier

Low; observational study

[55]

Early goal-directed therapy

Septic shock

4201

1278

Uncertain

90-day

OR 0.99 (0.86–1.15)

High; systematic review of RCTs

[66]

High-flow nasal cannula

PaO2/FIO2 ≤ 300 mmHg

310

254 (197 with CAP)

Yes

90-day

HR 0.50 (0.25–0.99)

High; RCT

[71]

Low tidal volumes and plateau pressures

ARDS with PaO2/FIO2 ≤ 300 mmHg

861

69

Yes

Hospital

RR 0.78 (0.65–0.93)

High; RCT

[76]

High positive-end expiratory pressure

ARDS with PaO2/FIO2 ≤ 200 mmHg

2299

1145

Yes

Hospital

Adjusted RR 0.90 (0.81–1.00)

Moderate; systematic review of RCTs; conflicting results with other systematic reviews

[79]

Low driving pressure

ARDS with PaO2/FIO2 ≤ 300 mmHg

3562

1314b

Yes

Hospital at 60 days

RR 0.71 (0.66–0.76) for each 1-SD decrease in driving pressure

Moderate; systematic review of RCTs of different objectives and methods

[77]

Neuromuscular blockade

ARDS with PaO2/FIO2 < 150 mmHg

339

262 (130 with CAP)

Yes

90-day

Adjusted HR 0.68 (0.48–0.98)

High; RCT

[81]

Prone positioning

ARDS with PaO2/FIO2 < 150 mmHg

466

281

Yes

28-day

HR 0.39 (0.25–0.63)

High; RCT

[83]

Corticosteroids

Severe CAP according to severity assessment tools

388

388 with CAP

Uncertain

Varies between RCTs

RR 0.39 (0.20–0.77)

Moderate; systematic review of RCTs; conflicting results with other systematic reviews

[87]

Care bundles

CAP in hospital

2118

2118 with CAP

Yes

30-day

Adjusted OR 0.59 (0.37–0.95)

Low; before-and-after study

[97]

  1. aNumbers include all forms of pneumonia, including CAP and hospital-acquired pneumonia. Number of CAP patients is stated where available
  2. bA total of 1314 out of 3449 patients had pneumonia (specific data on pneumonia were not available from one study of 113 patients [106])
  3. CI confidence interval, OR odds ratio, RCT randomised controlled trial, PaO 2 partial pressure of arterial oxygen, FIO 2 fraction of inspired oxygen, HR hazard ratio, ARDS acute respiratory distress syndrome, RR risk ratio, SD standard deviation, CAP community-acquired pneumonia