Strength of Recommendation and Quality of Evidence for Recommendations in Current Infectious Diseases Society of America Guidelines

Background: Grading of Recommendations Assessment, Development, and Evaluation (GRADE) is a systematic approach to grading strength of recommendation (SOR) and quality of evidence (QOE) for guideline recommendations. We aimed to assess the relationship between SOR and QOE in current Infectious Diseases Society of America (IDSA) guidelines. Methods: In this cross-sectional analysis, we analyzed the frequency of SOR-QOE pairings, including discordance (defined as strong SOR based on expert opinion, very low, or low QOE) for GRADEd recommendations in IDSA guidelines published since 2010. Data for each recommendation were extracted on SOR, QOE, the domain of disease management (one or more of diagnosis, treatment, prevention, and other categories), and relevance to drug or nondrug treatment. Results: Seventeen eligible guidelines provided 1042 unique GRADEd recommendations (n = 237, 711, 76, and 73 pertaining to diagnosis, treatment, prevention, and other domains, respectively; n = 574 and 137 pertaining to drug and nondrug treatment). Overall, the most common SOR was strong (71.8%; n = 748) and the most common QOE was low (48.6%; n = 506). Among all strong recommendations, 47.1% (n = 352) demonstrated discordance with QOE. By domain, strong recommendations were discordant in 36.6%, 51.4%, 29.3%, and 58.1% of recommendations pertaining to diagnosis, treatment, prevention, and other domains, respectively. Similarly, 50.7% and 54.0% of strong recommendations related to drug and nondrug treatment were discordant, respectively. We identified 39.6% of discordant recommendations to be consistent with good practice statements, which are recommended to be labeled as such without formal GRADEd designations of SOR or QOE. Conclusions: Among all IDSA guideline recommendations with strong SOR, approximately half were discordant with QOE, and this frequency varied across strata of domains of disease management.