Objective To systematically analyze prognostic factors in acute fibrinous and organizing pneumonia (AFOP) and provide evidence for optimizing clinical management strategies for improved patient outcomes. Methods We searched the Medline, Web of Science, CNKI and Wanfang databases to identify studies that met predefined criteria, from which we extracted individual patient data (IPD). Clinical characteristics were compared among groups (Survival without recurrence, Survival with recurrence, Death, Lung transplantation) using univariate analysis. Additionally, the Random Forest model was employed to assess the importance of factors associated with these prognostic outcomes. Results IPD, which were extracted from 179 patients across 130 studies, were analyzed. Intergroup comparisons revealed that the death group exhibited the highest rate of combined antibiotic-glucocorticoid therapy, with the earliest glucocorticoid initiation, highest doses, yet shortest treatment duration, a profile likely reflecting confounding by indication due to more rapidly progressive disease. After excluding hyper-acute cases, restricted cubic spline (RCS) analysis further suggested that earlier initiation of corticosteroid therapy (within 0-15 days) was associated with a lower risk of death. Diagnostic delay was also significantly associated with poor outcomes (P=0.015). The average diagnostic delay was significantly higher in the death group than the survival without recurrence group (42.4 days vs. 26.2 days). Hematologic diseases were the most frequent comorbidity among both survivors and non-survivors, occurring more often in the death group (39.5%, 15/38) than in the survival group (14.7%, 17/116). Random Forest analysis identified the treatment regimens as the most significant predictors of prognosis, likely reflects confounding by indication, followed by diagnostic delay, age, duration of corticosteroid maintenance, and time from symptom onset to corticosteroid therapy.Conclusion The treatment regimen, diagnostic delay, and timing of therapeutic intervention are key factors influencing AFOP prognosis. These findings suggest that clinical practice should focus on shortening the diagnostic delay to achieve prompt diagnosis and initiate glucocorticoid therapy accordingly. However, treatment regimens must be individualized based on the patient's age, underlying diseases, and disease severity.

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