CHALLENGES OF THE GRADE CLASSIFICATION IN DEVELOPING THE IDSA ASPERGILLUS GUIDELINES

Thomas F. Patterson

Abstract: 

Guidelines for the treatment of invasive aspergillosis have become important tools for practitioners 
managing patients with these infections. Grading of Recommendations, Assessment, Development and 
Evaluation (GRADE) is a systematic approach to guideline development that has also been used in meta-analyses 
and reviews to provide a transparent and consistent framework to develop clinical guidelines so 
that recommendations can be compared and analyzed. The IDSA/HIVMA adopted GRADE in 2008. In the 
GRADE system, the guideline panel assigns each recommendation with separate ratings for the underlying 
quality of evidence supporting the recommendation and for the strength with which the recommendation is 
made. Data from randomized controlled trials begin as “high” quality, and data from observational studies 
begin as “low” quality. However, the panel may judge that specific features of the data warrant decreasing 
or increasing the quality of evidence rating, and GRADE provides guidance on how such factors should 
be weighed. The strength assigned to a recommendation reflects the panel’s confidence that the benefits 
of following the recommendation are likely to outweigh potential harms and are categorized as “weak’ or 
“strong’. While the quality of evidence is an important factor in choosing recommendation strength, it is not 
prescriptive. Challenges for these criteria for guideline development in invasive aspergillosis are several, 
including the lack of extensive randomized clinical trial data, few comparative data for diagnostic strategies, 
antifungal drugs and treatment strategies and many areas in which expert opinion forms the basis of clinical 
practice decisions. These challenges are compounded by a heterogeneous group of clinical conditions 
ranging from rapidly lethal disease in highly immunocompromised patients to saprophytic colonization or 
allergic manifestations of disease. These difficulties are further complicated by diverse clinical populations 
at risk for these infections. Key areas in which limited data exist include management strategies, including 
combination therapies as well as specific approaches in infections that have not been extensively studied, 
among others. Despite these limitations, guidelines can be developed using GRADE which are beneficial to 
patient management

2016

Full conference title: 

7th Advances Against Aspergillosis