Article type
Abstract
"Background
The nature of infectious diseases poses several specific challenges to developing guidelines. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) is addressing them on a daily basis in developing its guidelines.
Objectives and methods
Our aim is to discuss some of the issues commonly encountered by the ESCMID guidelines subcommittee when applying the GRADE approach, and reflecting on implementation.
Results
We grouped specific considerations into four categories – with examples:
1)Defining “PICO” questions:
-how do we define “P”: by patient (e.g. immunocompromised)? By site of infection? by diagnosis (suspected vs proven infection)? by pathogen? by resistance to antimicrobial?
-How do we define “O”: outcome of the affected patient? Transmission of the pathogen to its contacts? Which surrogate correlates of cure/protection can we safely assume?
-How do we define “I”? the example of antimicrobial stewardship
2)Assessing the evidence
-Is evidence generated in one setting (with e.g. specific incidence/prevalence of disease) relevant to other settings?
-How reliable are diagnostic tests, especially for emerging infections (e.g. COVID-19 at the beginning of the pandemic)?
-How quickly does evidence age, considering the changing epidemiology?
3)Evidence-to-decision framework
-Do specific subgroups of patients (e.g. immunocompromised) always deserve specific recommendations?
-How can we tailor recommendations to the level of resistance?
-How often do we need to update recommendations, based on changed epidemiology?
-How can we factor social consideration (e.g. HIV stigma, vaccine hesitancy) in the ETD framework?
-How “strong” (=mandatory) are strong recommendations in this setting?
4)Other considreations
-Setting the scope: patient-level, community-level, or international/global perspective?
-Implementation: how all the above affect implementation?
-Evidence in neglected diseases: how can we use indirect evidence to develop recommendations?
-Conflicts of interest: does antimicrobial resistance pose special challenges in defining what constitute a conflict?
Conclusions
We propose a set of special considerations for guidelines in infectious diseases. These have direct relevance to patients, as inappropriate recommendations, rigidly applied, might pose a danger not only to patients but to their contacts and, more generally, to whole populations.
"
The nature of infectious diseases poses several specific challenges to developing guidelines. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) is addressing them on a daily basis in developing its guidelines.
Objectives and methods
Our aim is to discuss some of the issues commonly encountered by the ESCMID guidelines subcommittee when applying the GRADE approach, and reflecting on implementation.
Results
We grouped specific considerations into four categories – with examples:
1)Defining “PICO” questions:
-how do we define “P”: by patient (e.g. immunocompromised)? By site of infection? by diagnosis (suspected vs proven infection)? by pathogen? by resistance to antimicrobial?
-How do we define “O”: outcome of the affected patient? Transmission of the pathogen to its contacts? Which surrogate correlates of cure/protection can we safely assume?
-How do we define “I”? the example of antimicrobial stewardship
2)Assessing the evidence
-Is evidence generated in one setting (with e.g. specific incidence/prevalence of disease) relevant to other settings?
-How reliable are diagnostic tests, especially for emerging infections (e.g. COVID-19 at the beginning of the pandemic)?
-How quickly does evidence age, considering the changing epidemiology?
3)Evidence-to-decision framework
-Do specific subgroups of patients (e.g. immunocompromised) always deserve specific recommendations?
-How can we tailor recommendations to the level of resistance?
-How often do we need to update recommendations, based on changed epidemiology?
-How can we factor social consideration (e.g. HIV stigma, vaccine hesitancy) in the ETD framework?
-How “strong” (=mandatory) are strong recommendations in this setting?
4)Other considreations
-Setting the scope: patient-level, community-level, or international/global perspective?
-Implementation: how all the above affect implementation?
-Evidence in neglected diseases: how can we use indirect evidence to develop recommendations?
-Conflicts of interest: does antimicrobial resistance pose special challenges in defining what constitute a conflict?
Conclusions
We propose a set of special considerations for guidelines in infectious diseases. These have direct relevance to patients, as inappropriate recommendations, rigidly applied, might pose a danger not only to patients but to their contacts and, more generally, to whole populations.
"