Introduction
Methods
Data source and study selection
Data extraction
Data synthesis and data analysis
Results
Literature search
Study characteristics
Series no. | References author, year of publish | Study design | Country | Total no. of patients | Causes of immunosuppression | Method of PCP diagnosis | Definition of adjunctive corticosteroids use |
---|---|---|---|---|---|---|---|
1 | Pareja, 1998 | Retrospective single center | USA | 30 | Organ transplantation = 13; longterm immunosuppressive therapy = 9; Chemotherapy for malignancy = 8 | Morphological | ≥ 60 mg prednisone daily equivalent |
2 | Delclaux, 1999 | Retrospective two center | France | 31 | Hematologic malignancy = 24; vasculitis = 3; solid tumor = 2; other = 2 | Morphological (demonstration of typical organism in specimens BALF) | 1. De novo therapy (for patients who did not receive previous CS): oral prednisone > 1 mg/kg/day or iv methylprednisolone 240 mg for 3 days- > 120 mg for 3 days- > 60 mg for 3 days or longer 2. Rescue therapy(for patients already receiving CS): corticosteroid increased at least 300% of the baseline |
3 | Zahar, 2002 | Retrospective two center | France | 39 | Malignancy: hematological malignancies = 28 Solid tumor = 7; nonmalignant hematological diseases = 4 | Positive results for cytological tests or direct fluorescent antibody staining for PCP in sputum or BALF | 240 mg/day for 3 days, with the dosage then tapered during the next 10 days, until no therapy was given |
4 | Pagano, 2002 | Retrospective multicenter | Italy | 55 | Malignant hematological diseases: on-Hodgkin’s lymphoma = 18 Acute lymphoblastic leukemia = 10 Acute myeloid leukemia = 8; chronic myeloid leukemia = 5 | Microbiologically (positive visualization, mAbs, or PCR of PC in sputum or BALF) and/or histologically documented | Methylprednisolone (50–80 mg/day) |
5 | Roblot, 2003 | Retrospective multicenter | France | 60 | Hematologic malignancies: non-Hodgkin’s malignant lymphoma = 18 Chronic lymphocytic leukemia = 13; acute leukemia = 10 Multiple myeloma = 5; Waldenstro¨m’s diseases = 4; chronic myeloid leukemia = 4 Myelodysplasia = 3; Hodgkin’s diseases = 2; thrombopenia = 1 | Microbiological evidence of PC in BALF (silver and eosin þ methylene blue stainings and/or immunostaining using monoclonal antibodies) | Dose and duration of adjunctive corticosteroids use was not detailed reported |
6 | Bollee, 2007 | Retrospective single center | France | 56 | Cancer: hematologic malignancies = 44; solid tumors = 12 | PCP with Giemsa staining and/or immunofluorescence with human monoclonal anti-Pneumocystis cyst antibodies in BALF or sputum | 1 mg/kg of prednisone (or equivalent) per day or in a 30-mg increase in the daily prednisone dosage |
7 | Aoki, 2009 | Retrospective single center | Japan | 25 | Collagen vascular diseases | Elevated concentration of plasma 1,3-d-glucan, and positive PCR test for PCP in sputum | Dose and duration of adjunctive corticosteroids use was not detailed reported |
8 | Matsumura, 2011 | Retrospective multicenter | Japan | 82 | Inflammatory diseases = 50; solid malignancies = 17 Hematological malignancies = 12; transplantations = 6 | Diagnosed with PCP by PCR | Dose and duration of adjunctive corticosteroids use was not detailed reported |
9 | Moon, 2011 | Retrospective single center | Korea | 88 | Solid-organ transplant = 26; hematologic malignancy = 26 Non-hematologic malignancy = 12; interstitial lung disease = 9 Connective tissue disease = 7; others = 8 | Diagnosis was based on a positive result in the direct immunofluorescence assay for PCP | At least 40 mg prednisone twice daily for 5 days |
10 | Kim, 2014 | Retrospective multicenter | Korea | 173 | Hematologic malignancy = 81; solid tumors = 38 Organ transplantations = 17; others = 37 | Positive direct fluorescent antibody (DFA) or PCR results from a sputum or BAL fluid sample | Dose and duration of adjunctive corticosteroids use was not detailed reported |
11 | Kofteridis, 2014 | Retrospective single center | Greece | 62 | Malignant hematological disease = 31; solid tumor = 16 Chronic inflammatory disease = 15 | Positive results of direct fluorescent antibody staining for PCP in samples of induced sputum or BALF | Dose and duration of adjunctive corticosteroids use was not detailed reported |
12 | Weng, 2016 | Retrospective multicenter | China | 82 | CTD = 65; organ transplant = 3; hematologic malignancy = 3; solid tumor = 4 | PCR or methenamine silver stain of samples from BALF, aspirate or sputum | Dose and duration of adjunctive corticosteroids use was not detailed reported |
13 | Kotani, 2017 | retrospective single center | Japan | 20 | Rheumatoid arthritis or CTD = 9; renal transplant = 7; other = 4 | By fluorescent antibody staining using induced sputum or BALF | Methylprednisolone was dependent on the prior dosage of steroids and any underlying diseases |
14 | Wieruszewski, 2018 | Retrospective single center | USA | 332 | Hematologic malignancy = 162; bone marrow transplantation = 26 Inflammatory of connective tissue disease = 100 Solid organ tumor = 61; solid organ transplantation = 20 | A Positive single-copy PCP PCR or smear from a respiratory specimen | Corticosteroids within 48 h |
15 | Inoue, 2019 | Retrospective multicenter | Japan | 1299 | After transplantation = 34; solid tumor = 245 Malignancy of lymphoid tissue = 160; rheumatoid arthritis = 257 Connective tissue disease = 80 | Based on records | Adjunctive corticosteroids were defined < 250 mg/day corticosteroids or high dose pulse steroid therapy which refers to the administration of 250 mg prednisone equivalent a day for one or a few days (usually less than 5 days) |
16 | Liu, 2019 | Retrospective single center | China | 84 | Hematologic malignancy = 29; autoimmune diseases = 21 Solid cancers = 17; solid organ transplantation = 7 | Quantitative real-time PCR | Adjunctive steroids were high dose (≥ 1 mg/kg/day) |
Series no. | References author, year of publish | Study design | Country | Hospital or centers | Study period | Total no. of patients | Major outcome reported | Mortality | No CAT mortality | CAT mortality | Cases of hypoxemic respiratory dysfunction (hypoxemia: PaO2 < 70 mmHg on room air; respiratory failure: PaO2 ≤ 60 mmHg on room air) | Mortality in respiratory failure PCP | Mortality in hypoxic PCP and no CAT | Mortality in hypoxic PCP and with CAT |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Pareja, 1998 | Retrospective single center | USA | 1 tertiary care urban teaching hospital | 1989–1995 | 30 | In-hospital mortality | 12/30 (40%) | 5/14 (36%) | 7/16 (44%) | 21/30 (70%, hypoxemia) | 12/21 (57.1%) | 4/9 (44.4%) | 8/12 (66.7%) |
2 | Delclaux, 1999 | Retrospective two center | France | 2 medical ICUs | 1988–1996 | 31 | ICU mortality | 13/31 (42%) | 4/8 (50%) | 9/23 (39%) | 31/31 (100%, respiratory failure) | 13/31 (42%) | 4/8 (50%) | 9/23 (39%) |
3 | Zahar, 2002 | Retrospective two center | France | 2 medical ICUs | 1989–1999 | 39 | 30-day mortality | 13/39 (33%) | 3/8 (38%) | 10/31 (32%) | 39/39 (100%, respiratory failure) | 13/3 (33%) | 3/8 (38%) | 10/31 (32%) |
4 | Pagano, 2002 | Retrospective multicenter | Italy | 52 hematology divisions | 1990–1999 | 55 | 30-day mortality | 20/55 (36%) | 12/33 (36%) | 8/22 (36%) | 39/55 (71%, hypoxemia) | N/A | N/A | N/A |
5 | Roblot, 2003 | Retrospective multicenter | France | 11 infectious diseases units | 1995–1999 | 60 | 30-day mortality | 20/60 (33%) | 5/25 (20%) | 15/35 (43%) | N/A | N/A | N/A | N/A |
6 | Bollee, 2007 | Retrospective single center | France | 1 adult cancer center | 2001–2006 | 56 | In-hospital mortality | 11/56 (20%) | 9/35 (26%) | 2/21 (10%) | 56/56 (100%, hypoxemia) | 11/56 (20%) | 9/35 (26%) | 2/21 (10%) |
7 | Aoki, 2009 | Retrospective single center | Japan | 1 university hospital | 2000–2007 | 25 | In-hospital mortality | 11/25 (44%) | 4/12 (33%) | 7/13 (54%) | 25/25 (100%, hypoxemia) | 11/25 (44%) | 4/12 (33%) | 7/13 (54%) |
8 | Matsumura, 2011 | Retrospective multicenter | Japan | 2 university hospital | 2005–2010 | 82 | 30-day mortality | 20/82 (24%) | 4/22 (18%) | 16/60 (27%) | 57/82 (70%, hypoxemia) | 18/57 (32%) | N/A | N/A |
9 | Moon, 2011 | Retrospective single center | Korea | 1 university hospital | 2007–2010 | 88 | 30-day mortality | 28/88 (32%) | 10/29 (35%) | 18/59 (31%) | 54/88 (61%, respiratory failure) | 28/54 (52%) | 10/17 (59%) | 18/37 (49%) |
10 | Kim, 2014 | Retrospective multicenter | Korea | 2 tertiary care university hospitals | 2004–2011 | 173 | In-hospital mortality | 62/173 (36%) | 0/21 (0%) | 62/152 (41%) | 88/173 (51%, respiratory failure) | N/A | N/A | N/A |
11 | Kofteridis, 2014 | Retrospective single center | Greece | 1 university hospital | 2004–2013 | 62 | In-hospital mortality | 18/62 (29%) | 3/12 (25%) | 15/50 (30%) | 12/62 (19%, hypoxemia) | N/A | N/A | N/A |
12 | Weng, 2016 | Retrospective multicenter | China | 4 ICUs from 2 centers | 2012–2015 | 82 | ICU mortality | 62/82 (76%) | 14/18 (78%) | 48/64 (75%) | 82/82 (100%, respiratory failure) | 62/82 (76%) | 14/18 (78%) | 48/64 (75%) |
13 | Kotani, 2017 | Retrospective single center | Japan | 1 ICU | 2008–2012 | 20 | In-hospital mortality | 4/20 (20%) | 1/11 (9%) | 3/9 (33%) | N/A | N/A | N/A | N/A |
14 | Wieruszewski, 2018 | Retrospective single center | USA | 1 teaching hospital | 2006–2016 | 332 | 30-day mortality | 74/332 (23%) | 6/74 (9%) | 68/258 (26%) | N/A | N/A | N/A | N/A |
15 | Inoue, 2019 | Retrospective multicenter | Japan | Nationwide records study | 2010–2016 | 1299 | 60-day mortality | 247/1299 (19%) | 34/159 (21%) | 213/1140 (19%) | 737/1299 (57%, respiratory failure) | 189/737 (26%) | 26/71 (37%) | 163/661 (25%) |
16 | Liu, 2019 | Retrospective single center | China | 1 medical center | 2015–2016 | 84 | 60-day mortality | 39/84 (46%) | 16/41 (39%) | 23/43 (53%) | 57/84 (68%, respiratory failure) | N/A | N/A | N/A |
Total | 1998 ~ 2019 | 16 retrospective 8 single center 8 multi center | From 7 countries | 1 nationwide data 8 hospital wide data 4 ICU wide data 3 ward wide data | 1989–2016 | 2518 | 2 for ICU mortality 6 for in-hospital mortality 6 for 30-day mortality 2 for 60-day mortality | 654/2518 (26%) | 130/522 (25%) | 524/1996 (26%) | 6 with hypoxemia (3 with CAT use reported) 7 with respiratory failure (5 with CAT use reported) | 339/1040 (33%) | 74/178 (42%) | 265/862 (31%) |