Infectious Disease

Many IDSA “sturdy” suggestions are based mostly on inferior high quality proof, the evaluation suggests

February 04, 2021

2 min read

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File and Rodriguez do not report any relevant financial information.

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Nearly half of the recommendations rated “strong” in 17 current Infectious Diseases Society of America clinical practice guidelines are based on inferior quality evidence, an analysis found.

Still, “Physicians should continue to trust IDSA guidelines as they always have”. Ryan Rodriguez, PharmD, BCPS, Healio said he was a clinical associate professor at the University of Illinois in the Chicago Department of Pharmacy Practice.

Ryan Rodriguez

“The IDSA guideline panelists are clinical experts, and the GRADE methodology is an international standard in guideline development. However, when reviewing and applying guideline recommendations, clinicians should consider the level of evidence to support each recommendation, ”he said.

Rodriguez and colleagues noted that IDSA introduced the GRADE system – the acronym stands for Grading of Recommendations Assessment, Development and Evaluation – in 2008 and has been using it since 2010 to create guidelines that measure the strength of recommendations (SOR ) and take into account the Quality of Evidence (QOE).

Thomas File Jr.

In their paper, they said one of the determinants of SOR was the QOE behind it – “classified as high, moderate, low, or very low based on confidence in the effect estimate.”

“GRADE initially identifies a range of pieces of evidence as high or low QOE when it is from randomized controlled trials or observational studies,” they wrote. “This initial QOE classification can then be improved by a notch or two based on factors such as high efficiency, dose-response gradient, or some residual confusion effect that further supports the effect of a treatment. The QOE classification can also be downgraded by a notch or two due to the risk of bias, inconsistencies, indirectness, inaccuracy, or publication bias. “

Rodriguez and colleagues evaluated the relationship between strength of recommendation (SOR) and quality of evidence (QOE) for 17 current IDSA guidelines published since 2010 that used the GRADE methodology, including guidelines for candidiasis, infectious diarrhea, aspergillosis, and the implementation of an antimicrobial Stewardship program. Among other things, they analyzed the frequency of discordances between SOR and QOE pairings.

Their analysis comprised a total of 1,042 recommendations. The most common SOR was strong (71.8%; n = 748) while the most common QOE was rated low (48.6%; n = 506). Within the strong recommendations, 47.1% (n = 352) disagreed with the QOE.

IDSA Immediate Past President and Editor of the Infectious Disease News Thomas File Jr., MD, MSc, FIDSA, Healio said that IDSA welcomes feedback on its guidelines and that guideline development and the GRADE methodology itself is “an evolving process”.

“To me, this means not so much criticism, but an understanding that when we make decisions about treating patients, we try to find the best evidence available,” he said. “This paper recognizes that the best evidence available is often not robust or of a high level. Even so, we do what is best for the patient under the circumstances. “

File says IDSA will prioritize improving its policy development over the next 5 years and recruiting new staff, including methodologists, to help.

Rodriguez said the researchers were surprised that treatment recommendations for infectious diseases were more likely to be mismatched than prevention or diagnostic recommendations, noting that treatment recommendations are often the decisions doctors make most often with their patients.

“These results can underscore the importance of physicians being familiar with the underlying evidence for guideline recommendations they are acting on,” said Rodriguez.

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