Economic evaluation of community acquired pneumonia management strategies: A systematic review of literature

Autoři: Marufa Sultana aff001;  Abdur Razzaque Sarker aff003;  Nausad Ali aff004;  Raisul Akram aff003;  Lisa Gold aff002
Působiště autorů: Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh aff001;  Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, Victoria, Australia aff002;  Health Economics and Financing Research, Bangladesh Institute of Development Studies (BIDS), Dhaka, Bangladesh aff003;  Health Systems and Population Studies Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh aff004
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224170



Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity worldwide. Efficient use of resources is fundamental for best use of money among the available and novel treatment options for the management of pneumonia. The objective of this study was to systematically review the economic analysis of management strategies of pneumonia.


A systematic search was performed using Academic Search Complete, MEDLINE, EconLit, Global health, MEDLINE complete and Embase databases using specific subject headings or key words in May 2018 without restricting publication year. All search results were recorded and any type of economic evaluation for management of CAP was included for detailed review. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for quality appraisal.


Nineteen studies met the inclusion criteria; ten studies were trial based, five conducted analysis using model based techniques and the rest of the studies were either based on observational, record review or pre-post intervention studies. Most of the studies conducted cost-effectiveness analysis (n = 15) and compared different combinations of antimicrobials. Most were based on developed countries (n = 17), considered adult age groups (n = 16) and used a provider perspective (n = 14). Nine studies reported dominant alternatives (lower cost with higher benefit). Sensitivity analysis was performed by the majority of studies (n = 15). Fourteen studies were assessed as either being excellent, very good or good quality, with no relationship found between publication year and study quality. Methodological variation, type of microbial used, perspective, costs and outcome measures limit the compatibility among the results of the included studies.


Economic evaluation of interventions for management of CAP to date supports cost-effectiveness of studied interventions. However, evidence relates largely to antimicrobials choice in older populations in developed countries. Parallel economic evaluation of different management strategies of CAP is recommended for both developed and developing countries to support rigorous and robust comparative economic analysis within health care systems.

PROSPERO registration no: CRD42018097174

Klíčová slova:

Antibiotics – Cost-effectiveness analysis – Database searching – Drug administration – Economics – Health economics – Hospitals – Pneumonia


1. Prina E, Ranzani OT, Torres A. Community-acquired pneumonia. Lancet. 2015;386: 1097–1108. doi: 10.1016/S0140-6736(15)60733-4 26277247

2. Gutiérrez F, Masiá M, Mirete C, Soldán B, Carlos Rodríguez J, Padilla S, et al. The influence of age and gender on the population-based incidence of community-acquired pneumonia caused by different microbial pathogens. J Infect. 2006;53: 166–174. doi: 10.1016/j.jinf.2005.11.006 16375972

3. Arnold FW, Wiemken TL, Peyrani P, Ramirez JA, Brock GN. Mortality differences among hospitalized patients with community-acquired pneumonia in three world regions: Results from the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study. Respir Med. 2013;107: 1101–1111. doi: 10.1016/j.rmed.2013.04.003 23660396

4. Murray CJL, Barber RM, Foreman KJ, Ozgoren AA, Abd-Allah F, Abera SF, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition. Lancet. 2015;386: 2145–2191. doi: 10.1016/S0140-6736(15)61340-X 26321261

5. Drijkoningen JJC, Rohde GGU. Pneumococcal infection in adults: burden of disease. Clin Microbiol Infect. 2014;20: 45–51. doi: 10.1111/1469-0691.12461 24313448

6. Song JH, Thamlikitkul V, Hsueh PR. Clinical and economic burden of community-acquired pneumonia amongst adults in the Asia-Pacific region. Int J Antimicrob Agents. 2011;38: 108–117. doi: 10.1016/j.ijantimicag.2011.02.017 21683553

7. Rozenbaum MH, Mangen MJJ, Huijts SM, van der Werf TS, Postma MJ. Incidence, direct costs and duration of hospitalization of patients hospitalized with community acquired pneumonia: A nationwide retrospective claims database analysis. Vaccine. 2015;33: 3193–3199. doi: 10.1016/j.vaccine.2015.05.001 25981488

8. WHO. Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses [Internet]. Guidelines for the management of common illnesses. Geneva, Switzerland; 2013.

9. Madhi SA, Levine OS, Hajjeh R, Mansoor OD, Cherian T. Vaccines to prevent pneumonia and improve child survival. Bull World Health Organ. 2008;86: 365–372. doi: 10.2471/BLT.07.044503 18545739

10. Saha S, Hasan M, Kim L, Farrar JL, Hossain B, Islam M, et al. Epidemiology and risk factors for pneumonia severity and mortality in Bangladeshi children <5 years of age before 10-valent pneumococcal conjugate vaccine introduction. BMC Public Health. 2016;16: 1–12. doi: 10.1186/s12889-015-2639-8 26728978

11. Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA, Pneumonia Guidelines Committee of the BTS Standards of CareCommittee.2009. BTS guidelines for the management of communityacquired pneumonia in adults: update 2009. Thorax. 2009; 64: (Suppl 3):iii1–iii55.

12. Ayieko P, Akumu AO, Griffiths UK, English M. The economic burden of inpatient paediatric care in Kenya: Household and provider costs for treatment of pneumonia, malaria and meningitis. Cost Eff Resour Alloc. 2009;7: 1–13. doi: 10.1186/1478-7547-7-1 19133149

13. Chola L, Robberstad B. Estimating average inpatient and outpatient costs and childhood pneumonia and diarrhoea treatment costs in an urban health centre in Zambia. Cost Eff Resour Alloc. 2009;7: 16. doi: 10.1186/1478-7547-7-16 19845966

14. Madsen HO, Hanehøj M, Das AR, Moses PD, Rose W, Puliyel M, et al. Costing of severe pneumonia in hospitalized infants and children aged 2–36 months, at a secondary and tertiary level hospital of a not-for-profit organization. Trop Med Int Heal. 2009;14: 1315–1322. doi: 10.1111/j.1365-3156.2009.02374.x 19719464

15. Sadruddin S, Shehzad S, Bari A, Khan A, Ul-Haque I, Khan A, et al. Household costs for treatment of severe pneumonia in Pakistan. Am J Trop Med Hyg. 2012;87: 137–143. doi: 10.4269/ajtmh.2012.12-0242 23136289

16. Mihalopoulos C, Chatterton ML. Economic evaluations of interventions designed to prevent mental disorders: A systematic review. Early Interv Psychiatry. 2015;9: 85–92. doi: 10.1111/eip.12156 24962626

17. Aguiar PM, Lima TM, Storpirtis S. Systematic review of the economic evaluations of novel therapeutic agents in multiple myeloma: What is the reporting quality? J Clin Pharm Ther. 2016;41: 189–197. doi: 10.1111/jcpt.12384 27009796

18. Oosterhoff M, van der Maas ME, Steuten LMG. A systematic review of health economic evaluations of diagnostic biomarkers. Appl Health Econ Health Policy. 2016;14: 51–65. doi: 10.1007/s40258-015-0198-x 26334528

19. Hope SF, Webster J, Trieu K, Pillay A, Ieremia M, Bell C, et al. A systematic review of economic evaluations of population-based sodium reduction interventions. PLoS One. 2017;12: 1–22. doi: 10.1371/journal.pone.0173600 28355231

20. Chisholm D, Evans DB. Economic evaluation in health: saving money or improving care? J Med Econ. 2007;10: 325–337. doi: 10.3111/13696990701605235

21. Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6. doi: 10.1371/journal.pmed.1000097 19621072

22. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0: updated February 2011. The Cochrane Collaboration;2011; Available:

23. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated health economic evaluation reporting standards (CHEERS)-explanation and elaboration: A report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Heal. 2013;16: 231–250. doi: 10.1016/j.jval.2013.02.002 23538175

24. Palfreyman SJ, Stone PW. A systematic review of economic evaluations assessing interventions aimed at preventing or treating pressure ulcers. Int J Nurs Stud. 2015;52: 769–788. doi: 10.1016/j.ijnurstu.2014.06.004 25012958

25. Hasali MAA, Ibrahim MIM, Sulaiman SAS, Ahmad Z, Hasali JBA. A clinical and economic study of community-acquired pneumonia between single versus combination therapy. Pharm World Sci. 2005;27: 249–53. doi: 10.1007/s11096-004-7039-6 16096896

26. Kortz TB, Herzel B, Marseille E, Kahn JG. Bubble continuous positive airway pressure in the treatment of severe paediatric pneumonia in Malawi: A cost-effectiveness analysis. BMJ Open. 2017;7. doi: 10.1136/bmjopen-2016-015344 28698327

27. Samsa GP, Matchar DB, Harnett J, Wilson J. A cost-minimization analysis comparing azithromycin-based and levofloxacin-based protocols for the treatment of patients hospitalized with community-acquired pneumonia: Results from the CAP-IN trial. Chest. 2005;128: 3246–3254. doi: 10.1378/chest.128.5.3246 16304269

28. van Werkhoven CH, Postma DF, Mangen M-JJ, Oosterheert JJ, Bonten MJM. Cost-effectiveness of antibiotic treatment strategies for community-acquired pneumonia: results from a cluster randomized cross-over trial. BMC Infect Dis. 2017;17: 52. doi: 10.1186/s12879-016-2179-6 28068956

29. Van Barlingen HJJ, Nuijten MJC, Volmer T, Sanderson DJ, Lacey LF. Model to evaluate the cost-effectiveness of different antibiotics in the management of acute bacterial exacerbations of chronic bronchitis in Germany. J Med Econ. 1998;1: 201–218. doi: 10.3111/199801201218

30. Barlow G, Nathwani D, Williams F, Ogston S, Winter J, Jones M, et al. Reducing door-to-antibiotic time in community-acquired pneumonia: Controlled before-and-after evaluation and cost-effectiveness analysis. Thorax. 2007;62: 67–74. doi: 10.1136/thx.2005.056689 16928714

31. Dietrich ES, Joseph U, Vogel E, Howaldt S, Kullmann K-H, Frank EDD U.. Cost-Effectiveness of Ceftriaxone 1 g vs Second-Generation Cephalosporins in the Treatment of Pneumonia in General Medical Wards in Germany. Infection. 1999;16: 74–80.

32. Dresser LD, Niederman MS, Paladino JA. Cost-effectiveness of gatifloxacin vs ceftriaxone with a macrolide for the treatment of community-acquired pneumonia. Chest. 2001;119: 1439–1448. doi: 10.1378/chest.119.5.1439 11348951

33. Bhavnani SM, Ambrose PG. Cost-effectiveness of oral gemifloxacin versus intravenous ceftriaxone followed by oral cefuroxime with/without a macrolide for the treatment of hospitalized patients with community-acquired pneumonia. Diagn Microbiol Infect Dis. 2008;60: 59–64. doi: 10.1016/j.diagmicrobio.2007.07.006 17889491

34. Caldwell JW, Singh S, Johnson RH. Clinical and economic evaluation of subsequent infection following intravenous ciprofloxacin or imipenem therapy in hospitalized patients with severe pneumonia. J Antimicrob Chemother. 1999;43: 129–134. 10225583

35. Bahadori K, Quon BS, Doyle-Waters MM, Marra C, Fitzgerald JM. A systematic review of economic evaluations of therapy in asthma. J Asthma Allergy. 2010;3: 33–42. 21437038

36. Drummond MF, Becker DL, Hux M, Chancellor JVM, Duprat-Lomon I, Kubin R, et al. An economic evaluation of sequential IV/po moxifloxacin therapy compared to IV/po co-amoxiclav with or without clarithromycin in the treatment of community-acquired pneumonia. Chest. 2003;124: 526–535. doi: 10.1378/chest.124.2.526 12907538

37. Lloyd A, Holman A, Evers T. A cost-minimisation analysis comparing moxifloxacin with levofloxacin plus ceftriaxone for the treatment of patients with community-acquired pneumonia in Germany: results from the MOTIV trial. Curr Med Res Opin. 2008;24: 1279–1284. doi: 10.1185/030079908X280400 18358083

38. Paladino JA, Gudgel LD, Forrest A, Niederman MS. Cost-effectiveness of IV-to-oral switch therapy: Azithromycin vs cefuroxime with or without erythromycin for the treatment of community-acquired pneumonia. Chest. 2002;122: 1271–1279. doi: 10.1378/chest.122.4.1271 12377852

39. Edwards SJ, Wordsworth S, Clarke MJ. Treating pneumonia in critical care in the United Kingdom following failure of initial antibiotic: a cost-utility analysis comparing meropenem with piperacillin / tazobactam. Eur J Health Econ. 2012; 181–192. doi: 10.1007/s10198-011-0296-0 21243514

40. Frei BCR, Burgess DS. Cost-effectiveness of 4 empiric antimicrobial regimens in patients with community-acquired pneumonia. 2005;

41. Grau S, Lozano V, Valladares A, Cavanillas R, Xie Y, Nocea G. Antibiotic expected effectiveness and cost under real life microbiology: Evaluation of ertapenem and ceftriaxone in the treatment of community-acquired pneumonia for elderly patients in Spain. Clin Outcomes Res. 2014;6: 83–92. doi: 10.2147/ceor.s55265 24611019

42. Martin M, Moore L, Quilici S, Decramer M, Simoens S. A cost-effectiveness analysis of antimicrobial treatment of community-acquired pneumonia taking into account resistance in Belgium. Curr Med Res Opin. 2008;24: 737–751. doi: 10.1185/030079908X273336 18230196

43. Rittenhouse BE, Stinnett AA, Dulisse B, Henke CJ, Potter L, Parasuraman B, et al. An economic evaluation of levofloxacin versus cefuroxime axetil in the outpatient treatment of adults with community-acquired pneumonia. Am J Manag Care. 2000;6: 381–389. 10977438

44. Lee KKC, Wan MHS, Fan BSK, Chau MWY, Lee VWY. A cost-minimisation analysis comparing different antibiotic regimens used in treating all-cause bacterial pneumonia in Hong Kong. J Med Econ. 2009;12: 46–55. doi: 10.3111/13696990902840227 19450064

45. Alouki K, Delisle H, Bermudez-Tamayo C, Johri M. Lifestyle interventions to prevent etype 2 diabetes: a systematic review of economic evaluation studies. J Diabetes Res. 2016;2016: 2159890. doi: 10.1155/2016/2159890 26885527

46. Steel A, Sundberg T, Reid R, Ward L, Bishop FL, Leach M, et al. Osteopathic manipulative treatment: A systematic review and critical appraisal of comparative effectiveness and health economics research. Musculoskelet Sci Pract. 2017;27: 165–175. doi: 10.1016/j.math.2016.10.067 27852531

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