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Rigby I, Michelen M, Cheng V, Dagens A, Dahmash D, Lipworth S, Harriss E, Cai E, Balan V, Oti A, Joseph R, Groves H, Hart P, Jacob S, Blumberg L, Horby PW, Sigfrid L. Preparing for pandemics: a systematic review of pandemic influenza clinical management guidelines. BMC Med 2022; 20:425. [PMID: 36345005 PMCID: PMC9640791 DOI: 10.1186/s12916-022-02616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has highlighted the importance of evidence-based clinical decision-making. Clinical management guidelines (CMGs) may help reduce morbidity and mortality by improving the quality of clinical decisions. This systematic review aims to evaluate the availability, inclusivity, and quality of pandemic influenza CMGs, to identify gaps that can be addressed to strengthen pandemic preparedness in this area. METHODS Ovid Medline, Ovid Embase, TRIP (Turning Research Into Practice), and Guideline Central were searched systematically from January 2008 to 23rd June 2022, complemented by a grey literature search till 16th June 2022. Pandemic influenza CMGs including supportive care or empirical treatment recommendations were included. Two reviewers independently extracted data from the included studies and assessed their quality using AGREE II (Appraisal of Guidelines for Research & Evaluation). The findings are presented narratively. RESULTS Forty-eight CMGs were included. They were produced in high- (42%, 20/48), upper-middle- (40%, 19/48), and lower-middle (8%, 4/48) income countries, or by international organisations (10%, 5/48). Most CMGs (81%, 39/48) were over 5 years old. Guidelines included treatment recommendations for children (75%, 36/48), pregnant women (54%, 26/48), people with immunosuppression (33%, 16/48), and older adults (29%, 14/48). Many CMGs were of low quality (median overall score: 3 out of 7 (range 1-7). All recommended oseltamivir; recommendations for other neuraminidase inhibitors and supportive care were limited and at times contradictory. Only 56% (27/48) and 27% (13/48) addressed oxygen and fluid therapy, respectively. CONCLUSIONS Our data highlights the limited availability of up-to-date pandemic influenza CMGs globally. Of those identified, many were limited in scope and quality and several lacked recommendations for specific at-risk populations. Recommendations on supportive care, the mainstay of treatment, were limited and heterogeneous. The most recent guideline highlighted that the evidence-base to support antiviral treatment recommendations is still limited. There is an urgent need for trials into treatment and supportive care strategies including for different risk populations. New evidence should be incorporated into globally accessible guidelines, to benefit patient outcomes. A 'living guideline' framework is recommended and further research into guideline implementation in different resourced settings, particularly low- and middle-income countries.
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Affiliation(s)
- Ishmeala Rigby
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Melina Michelen
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Vincent Cheng
- Bristol Medical School, University of Bristol, Bristol, BS8 1TL, UK
| | - Andrew Dagens
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Dania Dahmash
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Samuel Lipworth
- Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, OX3 9DU, UK
| | - Erhui Cai
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Valeria Balan
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Alexandra Oti
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB2 1TN, UK
| | | | | | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Lucille Blumberg
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Peter W Horby
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK
| | - Louise Sigfrid
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, OX3 7LG, UK.
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