How Do Specific Nutritional Interventions (e.g., Enteral Nutrition, Protein Supplementation, Micronutrient Support) Affect Mortality, Length of Hospital Stay, and Recovery in Patients with Pneumonia? : A Systematic Review
Keywords:
Pneumonia, enteral nutrition, protein supplementation, mortality, length of stay, nutritional support, critical illnessAbstract
Introduction: Pneumonia remains a leading cause of morbidity and mortality worldwide, with malnutrition significantly exacerbating poor clinical outcomes. Despite growing interest in nutritional interventions, evidence regarding their specific effects on mortality, hospital stay, and recovery in pneumonia patients remains heterogeneous and inconclusive.
Methods: This systematic review synthesized evidence from 57 studies evaluating nutritional interventions in pneumonia patients, including 12 randomized controlled trials, 6 systematic reviews/meta-analyses, and 39 observational studies. Studies were screened based on predefined criteria including primary pneumonia diagnosis, specific nutritional interventions, relevant clinical outcomes, and adult populations. Data extraction encompassed intervention characteristics, patient demographics, comparator groups, mortality, length of stay, and recovery indicators.
Results: Early enteral nutrition initiated within 24-48 hours significantly reduced mortality (OR 0.45, 95% CI 0.21-0.95, p=0.038) and shortened hospital LOS by 3.54 days (p<0.00001). Each 30g/day increase in protein intake was associated with 24% reduced 60-day mortality (OR 0.76, p<0.001). Enteral nutrition demonstrated superior outcomes compared to parenteral nutrition across mortality (13.8% vs 27.1%, p=0.003), LOS (18.0 vs 28.0 days, p<0.05), and complication rates. High-protein feeding (1.8-2.2 g/kg/d) significantly attenuated muscle atrophy (13.97% vs 18.96%, p<0.001). Individualized nutritional programs reduced readmission by 77% (p=0.03) in malnourished elderly.
Discussion: Nutritional interventions demonstrate clinically meaningful benefits when appropriately timed, dosed, and delivered via enteral routes. Heterogeneity in mortality findings reflects differential effects of intervention timing, nutritional adequacy thresholds, and baseline nutritional risk.
Conclusion: Early enteral nutrition with adequate protein delivery should be standard care in hospitalized pneumonia patients. Future research should focus on optimal protein dosing, immunonutrition strategies, and post-discharge nutritional rehabilitation.
References
A. Baumgartner, Flavia Hasenboehler, Jennifer Cantone, L. Hersberger, Annika Bargetzi, L. Bargetzi, N. Kaegi-Braun, et al. “Effect of Nutritional Support in Patients with Lower Respiratory Tract Infection: Secondary Analysis of a Randomized Clinical Trial.” Clinical Nutrition, 2020.
A. Flores-López, G. Quiroz-Olguín, A. González-Garay, and Aurora E. Serralde-Zúñiga. “It Is Not Just about Prescription. A Cohort Study of the Impact of Enteral Nutrition on Mortality of Hospitalized Patients with COVID-19.” Nutrición Hospitalaria, 2023.
Adam M. Deane, R. Dhaliwal, Andrew G. Day, E. Ridley, A. Davies, D. Heyland, Deane Adam, et al. “Comparisons Between Intragastric and Small Intestinal Delivery of Enteral Nutrition in the Critically Ill: A Systematic Review and Meta-Analysis.” Critical Care, 2013.
C. Uno, K. Maeda, H. Wakabayashi, S. Nishioka, N. Ogawa, Takayuki Okamoto, Kengo Hoyano, and R. Momosaki. “Nutritional Status Change and Activities of Daily Living in Elderly Pneumonia Patients Admitted to Acute Care Hospital: A Retrospective Cohort Study from the Japan Rehabilitation Nutrition Database.” Nutrition (Burbank, Los Angeles County, Calif.), 2019.
Cheng Liu, Li He, Jin Hui Zhang, JiangShan He, Lin Tian, and Xiangde Zheng. “Impact of High-Protein Enteral Nutrition on Muscle Preservation in Mechanically Ventilated Patients with Severe Pneumonia: A Randomized Controlled Trial.” Journal of Health, Population and Nutrition, 2024.
D. Heyland, K. Stephens, A. Day, and S. McClave. “The Success of Enteral Nutrition and ICU-Acquired Infections: A Multicenter Observational Study.” Clinical Nutrition, 2011.
D. Lakdawalla, J. Snider, D. Perlroth, C. LaVallee, M. Linthicum, T. Philipson, J. Partridge, and P. Wischmeyer. “Can Oral Nutritional Supplements Improve Medicare Patient Outcomes in the Hospital?” Forum for Health Economics & Policy, 2014.
D. Min, Min Cai, and Min Chen. “Comparison of the Effect Between Enteral Nutrition and Parenteral Nutrition Among Elderly Patients with Critical Pulmonary Infection,” 2017.
D. Sousa-Catita, C. Godinho, P. Mascarenhas, F. Quaresma, and J. Fonseca. “The Effects Of An Intensive Rehabilitation Program On The Nutritional And Functional Status Of Post Covid-19 Pneumonia Patients.” Clinical Nutrition ESPEN, 2023.
———. “The Effects of an Intensive Rehabilitation Program on the Nutritional and Functional Status of Post-COVID-19 Pneumonia Patients.” Nutrients, 2022.
D. Yeh, C. Cropano, S. Quraishi, Eva Fuentes, H. Kaafarani, Jarone Lee, Yuchiao Chang, and G. Velmahos. “Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes.” Nutrition in Clinical Practice, 2017.
E. Choi, D. Park, and Jinkyeong Park. “Calorie Intake of Enteral Nutrition and Clinical Outcomes in Acutely Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials.” JPEN - Journal of Parenteral and Enteral Nutrition, 2015.
Elizabeth Pérez-Cruz, Salvador Ortiz-Gutiérrez, J. Castañón-González, Y. Luna-Camacho, and J. Garduño-López. “Effectiveness and Tolerance of Enteral Nutrition in Critically Ill Patients with COVID-19.” British Journal of Nutrition, 2024.
F. Tian, Xuejin Gao, Chao Wu, Li Zhang, Xianfeng Xia, and Xinying Wang. “Initial Energy Supplementation in Critically Ill Patients Receiving Enteral Nutrition: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” Asia Pacific Journal of Clinical Nutrition, 2015.
Feng Tian, Philippa T. Heighes, M. J. Allingstrup, and G. Doig. “Early Enteral Nutrition Provided Within 24 Hours of ICU Admission: A Meta-Analysis of Randomized Controlled Trials*.” Critical Care Medicine, 2018.
Fengchan Xi, Xingwei Xu, Shanjun Tan, T. Gao, Jialiang Shi, Yanxi Kong, Wen-kui Yu, Jie‐shou Li, and Ning Li. “Efficacy and Safety of Pectin-Supplemented Enteral Nutrition in Intensive Care: A Randomized Controlled Trial.” Asia Pacific Journal of Clinical Nutrition, 2017.
G. Elke, E. Kuhnt, M. Ragaller, D. Schädler, I. Frerichs, F. Brunkhorst, M. Löffler, K. Reinhart, N. Weiler, and For the German Competence Network Sepsis. “Enteral Nutrition Is Associated with Improved Outcome in Patients with Severe Sepsis.” Medizinische Klinik - Intensivmedizin Und Notfallmedizin, 2013.
G. Elke, Miao Wang, N. Weiler, A. Day, and D. Heyland. “Close to Recommended Caloric and Protein Intake by Enteral Nutrition Is Associated with Better Clinical Outcome of Critically Ill Septic Patients: Secondary Analysis of a Large International Nutrition Database.” Critical Care, 2014.
Gurasees S Chawla, M. Fazzari, Sarah W. Baron, A. Assa, Laurel Mohrmann, S. Chekuri, and J. Katz. “S1430 Early Enteral Nutrition Reduces In-Hospital Mortality of Critically Ill COVID-19 Patients.” American Journal of Gastroenterology, 2021.
Haina Cai, Yang Wang, Zejun Cai, Yuqing Lin, and Qinghong Xu. “Nutrition Intervention in the Management of Novel Coronavirus Pneumonia Patients.” Open Life Sciences, 2022.
Hanan Elkalawy, Pavan Sekhar, Mona Fayad, Mohammed Barrima, and Mohammad Abdullah. “EFFECT OF STANDARD VS HIGH-PROTEIN ENTERAL FEEDING ON RECTUS FEMORIS MUSCLE MASS IN MECHANICALLY VENTILATED ICU PATIENTS: A PROSPECTIVE OBSERVATIONAL COHORT STUDY.” Chest, 2023.
Hong Sun, K. Li, Qian Yang, H. Ren, Xiandong Liu, and Xiaowei Bao. “Effect of Different Methods of Applying Enteral Nutritional Support Methods in Elderly Patients with Severe Pneumonia,” 2020.
I. Feldblum, Larisa German, H. Castel, I. Harman-boehm, and D. Shahar. “Individualized Nutritional Intervention During and After Hospitalization: The Nutrition Intervention Study Clinical Trial.” Journal of The American Geriatrics Society, 2011.
J. Kutsogiannis, C. Alberda, L. Gramlich, Naomi E. Cahill, Miao Wang, A. Day, R. Dhaliwal, and D. Heyland. “Early Use of Supplemental Parenteral Nutrition in Critically Ill Patients: Results of an International Multicenter Observational Study*.” Critical Care Medicine, 2011.
Jie Liu, Xin Chen, Lanyan Wang, Hongyang Li, Jianfei Chen, Yonglin Tang, and Yan Li. “The Research on the Effect of Nutritional Stage-Based Care Intervention in Elderly Patients with Severe Pneumonia.” Alternative Therapies in Health and Medicine, 2024.
Jose Henrique Silvah, Cristiane Maria Mártires de Lima, C. Nicoletti, Ana Carolina Barbosa, Gizela Pedroso Junqueira, S. F. da Cunha, and J. Marchini. “Protein Provision and Lower Mortality in Critically Ill Patients with COVID-19.” Clinical Nutrition ESPEN, 2021.
Jungwon Cho, Ahreum Shin, and Chami Im. “Rapid Advancement of Enteral Nutrition and in-Hospital Mortality in Critically Ill Adults: A Retrospective Cohort Study.” JPEN - Journal of Parenteral and Enteral Nutrition, 2024.
K. Krylov, S. Sviridov, I. Vedenina, and M. Rubanes. “The Effects of Supplementary Nutrition Support (Sns) on the Physical and Functional Recovery of Covid-19 Patients.” Clinical Nutrition ESPEN, 2021.
Kye-Wol Park, Heekwon Son, Jihoon Kim, Myoung-Hee Kim, and E. J. Choi. “The Effects of Early Enteral Nutrition in Patients: A Role of Nutrition Support Team,” 2016.
L. Ortiz-Reyes, Yuchiao Chang, S. Quraishi, Liyang Yu, H. Kaafarani, M. D. de Moya, D. King, P. Fagenholz, G. Velmahos, and D. Yeh. “Early Enteral Nutrition Adequacy Mitigates the Neutrophil–Lymphocyte Ratio Improving Clinical Outcomes in Critically Ill Surgical Patients.” Nutrition in Clinical Practice, 2018.
Livia Dainelli, Silvia Delgado, Raffaele Lagravinese, Giuseppe Massimo Paradiso, and Miroslaw Perlinski. “Early Versus Late Enteral Nutrition in US COVID-19 Patients: A Systematic Literature Review and Meta-Analysis.” Clinical Nutrition Open Science, 2023.
M. Cangelosi, H. R. Auerbach, and Joshua T. Cohen. “A Clinical and Economic Evaluation of Enteral Nutrition.” Current Medical Research and Opinion, 2011.
M. Coruja, L. C. Antunes, V. Leotti, and T. Steemburgo. “Nutrition Adequacy in the Late Period of the Acute Phase Is Associated with a Lower Risk of 30-Day Mortality in Critically Ill Patients: A Prospective Cohort Study.” Nutrition in Clinical Practice, 2024.
M. Scarcella, R. Commissari, S. Cappanera, E. Sensi, M. Scimmi, B. Tiri, and E. De Robertis. “SARS-COV2 CRITICALLY ILL PAZIENTS: FOCUS ON NUTRITION.” Nutrition (Burbank, Los Angeles County, Calif.), 2021.
Marilyn Oliveros, Cacia Riquelme, Belén Cornejo, Yosselyn Vargas, and C. Alvarado. “Evaluación Del Soporte Nutricional Intensivo En Pacientes Con Neumonía Grave Por COVID-19.” Revista Chilena de Nutricíon, 2022.
Max Melchers, Anoek Jacqueline Hubertine Hermans, Suzanne Belia Hulsen, Imre Willemijn Kehinde Kouw, and Arthur Raymond Hubert van Zanten. “Individualised Energy and Protein Targets Achieved During Intensive Care Admission Are Associated with Lower Mortality in Mechanically Ventilated COVID-19 Patients: The COFEED-19 Study.” Clinical Nutrition, 2023.
N. D. Altıntaş, K. Aydın, M. Türkoğlu, O. Abbasoğlu, and A. Topeli. “Effect of Enteral Versus Parenteral Nutrition on Outcome of Medical Patients Requiring Mechanical Ventilation.” Nutrition in Clinical Practice, 2011.
N. Hansen, D. Faurholt-Jepsen, C. K. Ryrsø, M. H. Hegelund, A. Dungu, A. Sejdic, B. L. Madsen, and J. Andersen. “The Effect of Protein-Based Nutritional Supplementation During and After Hospital Stay in Patients with Community Acquired Pneumonia,” 2020.
Na Gyeong Lee, Hye Jin Kim, Ji Gyeong Kang, Do Hyeon Jeon, M. Kwak, and So‐Hyun Nam. “Effects of Nutritional Status and Support on the Survival of COVID-19 Patients in a Single Tertiary-Center Intensive Care Unit in Korea: A Case-Control Study.” Annals of Clinical Nutrition and Metabolism, 2023.
O. Ojo, O. Ojo, Qianqian Feng, J. Boateng, Xiaohua Wang, J. Brooke, and A. Adegboye. “The Effects of Enteral Nutrition in Critically Ill Patients with COVID-19: A Systematic Review and Meta-Analysis.” Nutrients, 2022.
P. J. Alvarez. “Intervención Nutricional Precoz En Ancianos Con Neumonía Adquirida En La Comunidad,” 2019.
P. Singer, R. Anbar, J. Cohen, Haim Shapiro, M. Shalita-Chesner, S. Lev, E. Grozovski, M. Theilla, S. Frishman, and Z. Madar. “The Tight Calorie Control Study (TICACOS): A Prospective, Randomized, Controlled Pilot Study of Nutritional Support in Critically Ill Patients.” Intensive Care Medicine, 2011.
P. Wischmeyer, M. Hasselmann, C. Kummerlen, R. Kozar, D. Kutsogiannis, C. Karvellas, B. Besecker, et al. “A Randomized Trial of Supplemental Parenteral Nutrition in Underweight and Overweight Critically Ill Patients: The TOP-UP Pilot Trial.” Critical Care, 2017.
Pei-Hsin Yang, Meng-Chih Lin, Yi-Ying Liu, Chia-Lun Lee, and N. Chang. “Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial.” International Journal of Environmental Research and Public Health, 2019.
Qianqian Zhou, Liqin Zhang, Xiandong Wang, Quan-gang Wang, Dongquan Zhang, and Yuan Yuan. “Clinical Efficacy of Nutrition Support Therapy Combined with Antibiotics in the Patients of Community-Acquired Pneumonia and Its Influence on Serum Pct and Crp.” Pakistan Journal of Pharmaceutical Sciences, 2019.
R. Chada, S. Chidrawar, A. Siddiqua, R. Medanki, S. A. Omer, and B. Nagalla. “Tailoring Nutrition Therapy Amid the Covid-19 Pandemic: Does It Work?” Clinical Nutrition ESPEN, 2021.
R. Chada, S. Chidrawar, A. Siddiqua, R. Medanki, Syeda Amena Omer, and B. Nagalla. “Tailoring Nutrition Therapy Amid the COVID-19 Pandemic: Does It Work?” Clinical Nutrition ESPEN, 2021.
R. Griffiths. “Nutrition for Critically Ill Patients: How Much Is Enough?” Journal of the American Medical Association (JAMA), 2012.
R. Koretz. “JPEN Journal Club 20. Confirmation Bias.” JPEN - Journal of Parenteral and Enteral Nutrition, 2016.
S. C. Omar, R. H. M. Zaini, Isma Syarina Binti Ismail, Wan Mohd Nazaruddin Wan Hassan, Praveena Seevaunnamtum, and C. M. Che Hussin. “A Randomized Study of an Evaluation of Trigona Honey as Immunonutrition Among Ventilated Pneumonia Patients in Intensive Care Unit.” Anaesthesia, Pain &Amp; Intensive Care, 2022.
S. Gomes, C. Carvalho, F. Borges, and A. Ramos. “The Impact of Early Protein Intake and Nutritional Status in Critically Ill Patients,” 2020.
S. Mikkelsen, Karen Hougaard Frost, Emma Mølgaard Engelbreth, L. Nilsson, Karen Marie Peilicke, R. Tobberup, L. Skadhauge, H. Rasmussen, and M. Holst. “Are Nutritional Sufficiency of ≥75% Energy and Protein Requirements Relevant Targets in Patients at Nutritional Risk? - A One Month Follow-up Study.” Clinical Nutrition ESPEN, 2023.
S. Sviridov, K. Krylov, I. Vedenina, and Rubenas Mohan. “The Effects of Oral Nutritional Support on the Ability of the COVID-19 Patients to Recover: A Prospective, Open, Multicenter, Comparative in Two Groups, Observational Study.” Clinical Nutrition and Metabolism, 2021.
Sheila Martínez Iturriaga. “Nutritional Approach in Patients Hospitalized with Covid-19.” Nutrición Clínica y Dietética Hospitalaria, 2020.
Sheng Wu, Jian Lou, Peng Xu, R. Luo, and Libin Li. “Early Enteral Nutrition Improves the Outcome of Critically Ill Patients with COVID-19: A Retrospective Study.” Asia Pacific Journal of Clinical Nutrition, 2021.
Y. Honda, Ryo Momosaki, and Naoshi Ogata. “Nasogastric Tube Feeding Versus Total Parenteral Nutrition in Older Dysphagic Patients with Pneumonia: Retrospective Cohort Study.” The Journal of Nutrition, Health & Aging, 2020.
Y. Sharma, A. Mangoni, C. Horwood, and Campbell Thompson. “Association Between Multivitamin Use on Admission and Clinical Outcomes in Patients Hospitalised with Community-Acquired Pneumonia: A Case—Cohort Study.” Nutrients, 2024.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Bayu Anggara H (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors publishing here keep copyright but grant the journal first publication rights, under a Creative Commons Attribution-NonCommercial 4.0 License. They can distribute their work non-exclusively elsewhere with an acknowledgment of its first publication in this journal. Posting the work online before and during submission for earlier and greater citation is encouraged, reflecting Open Access benefits.
