Clinical, economic, and humanistic burden of community acquired pneumonia in Europe: a systematic literature review

Figures & data

Table 1. PICOS criteria for study selection.

	Inclusion Criteria	Exclusion Criteria
Population	Adults with CAP in the target countries^A	Non-adults (i.e. <18 years old) Persons diagnosed with hospital-acquired pneumonia
Interventions/Comparators	Any or none	Not applicable
Outcomes	Epidemiology: Incidence, prevalence, demographic characteristics, population characteristics (stratified by microbial etiology and serotype to the extent that the data permit) Clinical: Mortality, morbidity (i.e. subsequent clinical impacts) Humanistic burden: quality of life (any instrument) Economic burden: direct medical costs, direct non-medical costs, and societal costs	Outcomes pertaining to persons with hospital-acquired pneumonia
Study design	Any not excluded^B,C	Interventional/clinical trials Non-systematic reviews Editorials, comments, notes Case studies
Data sources		Not applicable
Electronic databases	Articles indexed in Embase or MEDLINE
	Conference abstracts indexed in Embase^D
Search limits	Articles published 2011–2021^E; conference abstracts from 2019–2021	None

^ABelgium, Bulgaria, Czech Republic, Denmark, Germany, Estonia, Ireland, Iceland, Greece, Spain, France, Croatia, Italy, Cyprus, Latvia, Lithuania, Luxembourg, Hungary, Malta, Netherlands, Norway, Austria, Poland, Portugal, Romania, Slovenia, Slovakia, Finland, Sweden, Switzerland, United Kingdom.

^BSystematic literature reviews will be retained separately to hand-check the studies included in those reviews against the studies identified in the present review. Any relevant studies identified in previous systematic literature reviews but not by the present search strategy will be evaluated and retained if applicable.

^CThis search strategy captured published Cochrane reviews.

^DThese databases contain individual records for individual abstracts and conference presentations.

^EThe search excluded records published before the year 2011; although, it is expected that some records published on or after the year 2011 will include information collected before 2011.

Figure 1. PRISMA diagram.

Figure 2. Summary of CAP incidence (per 100,000) by age group and healthcare setting.

Figure 3. Summary of CAP-causative pathogens.

Figure 4. Summary of CAP-associated mortality by country and patient age.

Table 2. Summary of CAP economic studies, per event costs.

Study (Country)	Study Design	Relevant Findings
Marbaix 2018 [14] (Belgium)	Cohort Model: Assessed lifetime risks, consequences, and costs of IPD and CAP associated with PCV13 vaccination for cohort aged 65–75	Per case cost of moderate-risk CAP with inpatient care: €8,501-€15,482 Per case cost of high-risk CAP with inpatient care: €9,359-€17,044 Per case cost of moderate-risk CAP without inpatient care: €867-€866 Per case cost of high-risk CAP without inpatient care: €985-€984
Wolff 2020 [12] (Sweden)	Cohort Model: Assessed lifetime risks, consequences, and costs of IPD and CAP associated with PPV23 or PCV13 vaccination for cohort aged 65–75	5.8 days in the general ward per CAP case at €603 per day 0.25 days in the intensive care unit per CAP case at €1,728 per day
Naoum 2020 [25] (Greece)	Retrospective analysis of electronic medical records	Mean cost per hospitalized CAP patient was €7,407 Mean cost per outpatient CAP patient was €111
Dupuis 2021 [26] (France)	Retrospective claims database analysis of hospitalized CAP patients	Cost of initial hospitalization, 1-year survivors: €18,613 Cost of initial hospitalization, 1-year decedents: €19,834 Cost of subsequent hospitalizations, 1-year survivors: €19,834 Cost of subsequent hospitalizations, 1-year decedents: €14,815
Antunes 2020 [27] (Portugal)	Retrospective claims database analysis of hospitalized CAP patients	Mean cost per hospitalized CAP patient was €2,628
Kaier 2019 [23] (Germany)	Retrospective claims database analysis of hospitalized CAP patients	Mean CAP case cost, CAP not main diagnosis: €26,955 Mean CAP case cost, CAP as main diagnosis: €14,066

Figure 5. Quality of life domain scores after CAP diagnosis.

*Adapted from a report by Andrade et al. (2017).

Table 3. Previous reviews of CAP burden in Europe.

Study	Years Covered	Key Findings
Welte et al. (2012) [8]	1990 to 2007	Incidence varied by country, age, gender; higher in persons aged ≥65 years old and in men Streptococcus pneumoniae was the most common etiology Mortality (<1% to 48%) was associated with older age, co-morbidities, and CAP severity CAP was associated with high rates of hospitalization and length of hospital stay
Alimi et al. (2017) [29]	1999 to 2016	25% of CAP cases in Europe had a viral etiology 13% of CAP cases were due specifically to influenza, rhinoviruses, and coronaviruses
Torres et al. (2018) [30]	2000 to 2016	Overall incidence was 68–7000 per 100,000; hospitalized cases: 16–3581 per 100,000 Incidence increased with age and (for pneumococcal CAP) comorbidities Most cases (30%–78%) were caused by serotypes covered by PCV13 vaccine
Ferreira-Coimbra et al. (2020) [31]*	Not Reported	Incidence varied considerably among countries, but direct assessment is hindered by differences in reporting and case selection from epidemiological studies CAP is responsible for at least 23,000 deaths annually in Europe Streptococcus pneumoniae was the most common etiology in all treatment settings (outpatient, general ward, and ICU)

*Ferreira-Coimbra et al. (2020) was a comprehensive qualitative synthesis and not a systematic review. The study also included non-European countries.

Marbaix S, Peetermans WE, Verhaegen J, et al. Cost-effectiveness of PCV13 vaccination in Belgian adults aged 65-84 years at elevated risk of pneumococcal infection. PLoS One. 2018;13(7):e0199427. doi: 10.1371/journal.pone.0199427

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Wolff E, Storsaeter J, Örtqvist Å, et al. Cost-effectiveness of pneumococcal vaccination for elderly in Sweden. Vaccine. Jul 6 2020;38(32):4988–4995. doi: 10.1016/j.vaccine.2020.05.072

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Naoum P, Athanasakis K, Kyriopoulos I, et al. Community acquired pneumonia: a cost-of-illness analysis in Greece. Rural Remote Health. 2020 Jun;20(2):5400. doi: 10.22605/rrh5400

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Dupuis C, Sabra A, Patrier J, et al. Burden of pneumococcal pneumonia requiring ICU admission in France: 1-year prognosis, resources use, and costs. Crit Care. 2021/1/Oct 2021;25(1):24. doi: 10.1186/s13054-020-03442-z

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Antunes C, Pereira M, Rodrigues L, et al. Hospitalization direct cost of adults with community-acquired pneumonia in Portugal from 2000 to 2009. Pulmonology. 2020 Sep;26(5):264–267. doi: 10.1016/j.pulmoe.2020.02.013

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Kaier K, Heister T, Götting T, et al. Measuring the in-hospital costs of Pseudomonas aeruginosa pneumonia: methodology and results from a German teaching hospital. BMC Infect Dis. Dec 3 2019;19(1):1028. doi: 10.1186/s12879-019-4660-5

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Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012 Jan;67(1):71–79. doi: 10.1136/thx.2009.129502

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Alimi Y, Lim WS, Lansbury L, et al. Systematic review of respiratory viral pathogens identified in adults with community-acquired pneumonia in Europe. J Clin Virol. 2017 Oct;95:26–35.

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Torres A, Cillóniz C, Blasi F, et al. Burden of pneumococcal community-acquired pneumonia in adults across Europe: a literature review. Respir med. 2018 Apr;137:6–13.

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Ferreira-Coimbra J, Sarda C, Rello J. Burden of community-acquired pneumonia and unmet clinical needs. Adv Ther. 2020 Apr;37(4):1302–1318. doi: 10.1007/s12325-020-01248-7

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