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Levels of evidence supporting European and American community-acquired pneumonia guidelines

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European Journal of Clinical Microbiology & Infectious Diseases Aims and scope Submit manuscript

Abstract

Optimal clinical decisions should be supported by clinical practice guidelines (CPG) based on evidence generated from randomized clinical trials (RCT). We aimed to evaluate the class and level of evidence (LOE) supporting the international community-acquired pneumonia (CAP) guidelines and their variation over time. The 2019 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) and the 2011 European Respiratory Society/European Society Clinical Microbiology Infectious Diseases (ERS/ESCMID) CPG and its immediate predecessors (2007 and 2005) were evaluated. The number of recommendations and distribution as LOE A (supported by multiple RCT or a single, large RCT), B (supported by data from a single RCT or observational studies) and C (expert opinion, case studies, or standard of care) was identified. Overall, recommendations for diagnosis, management, and prevention were graded as strong in 51.4%, 62.9%, and 23.5% in spite that they were supported by LOE A in 5.7%, 11.1%, and 52.9%, respectively. In the 2019 ATS/IDSA guidelines (39 recommendations), 7.7% (n = 3) recommendations were classified as LOE A, 30.8% (n = 12) as LOE B, and 61.5% (24%) as LOE C. Across the 2011 ERS/ESCMID guidelines (68 recommendations), 21.2% (n = 14) recommendations were classified as LOE A, 4.6% (n = 3) as LOE B, and 74.2% (n = 49) as LOE C. When comparing with prior versions, the proportion of recommendations that were LOE A did not significantly increase in ERS/ESCMID (21.2% vs 20%) and decreased in ATS/IDSA (7.7% vs 32.0%). In conclusion, large randomized trials or network meta-analysis including comparison of regimens to identify high probability of best cure and mortality is an unmet clinical need on CAP.

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Abbreviations

ATS:

American Thoracic Society

ARDS:

Acute respiratory distress syndrome

CAP:

Community acquired pneumonia

COPD:

Chronic obstructive pulmonary disease

CPG:

Clinical practice guidelines

ERS:

European Respiratory Society

ESCMID:

European Society of Clinical Microbiology and Infectious Diseases

IDSA:

Infectious Diseases Society of America

LOE:

Level of evidence

NMA:

Network meta-analysis

MA:

Meta-analysis

RCT:

Randomized controlled trial

SR:

Systematic review

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Acknowledgements

Authors appreciate comments from Maria Teresa Martin, Microbiology Department, Vall d’Hebron University Hospital who helped to improve the final manuscript.

Funding

This work was funded in part by CIBERES, Instituto Salud Carlos III, Madrid, Spain (Fondos FEDER) (CB06–06-036).

Author information

Authors and Affiliations

  1. Internal Medicine Department, Centro Hospitalar Universitario do Porto, Largo do Prof. Abel Salazar, 4099-001, Porto, Portugal

    João Ferreira-Coimbra

  2. CIBER de Enfermedades Respiratorias, CIBERES, Instituto de Salud Carlos III, Barcelona, Spain

    Sofía Tejada & Jordi Rello

  3. Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d’Hebron Institut of Research (VHIR), Barcelona, Spain

    Sofía Tejada & Jordi Rello

  4. Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, Rome, Italy

    Laura Campogiani

  5. Clinical Research in ICU, Anesthesiology Department, CHU Nîmes, University Montpellier, Montpellier, France

    Jordi Rello

Authors
  1. João Ferreira-Coimbra
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  2. Sofía Tejada
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  3. Laura Campogiani
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  4. Jordi Rello
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Contributions

JR and JFC designed the study. The recommendations were abstracted by a single reviewer (JFC) and validated by two other reviewers (LC and STM). JFC analyzed data and write the first manuscript draft. All authors approved the final version of the manuscript. JFC takes full responsibility for the integrity of the reported data.

Corresponding author

Correspondence to João Ferreira-Coimbra.

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Competing interests

Dr. Rello has served as consultant and in the speakers’ bureau for Nzbriva, MSD, Pfizer & Astellas. The remaining authors have no conflicts of interest to declare.

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Ferreira-Coimbra, J., Tejada, S., Campogiani, L. et al. Levels of evidence supporting European and American community-acquired pneumonia guidelines. Eur J Clin Microbiol Infect Dis 39, 1159–1167 (2020). https://doi.org/10.1007/s10096-020-03833-8

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  • DOI: https://doi.org/10.1007/s10096-020-03833-8

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