Abstract
BackgroundThe development of evidence-based clinical practice guidelines has gained wide acceptance in high-income countries and reputable international organizations. Whereas this approach may be a desirable standard, challenges remain in low-income settings with limited capacity and resources for evidence synthesis and guideline development. We present our experience using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for the recent revision of the Kenyan pediatric clinical guidelines focusing on antibiotic treatment of pneumonia.MethodsA team of health professionals, many with minimal prior experience conducting systematic reviews, carried out evidence synthesis for structured clinical questions. Summaries were compiled and distributed to a panel of clinicians, academicians and policy-makers to generate recommendations based on best available research evidence and locally-relevant contextual factors.ResultsWe reviewed six eligible articles on non-severe and 13 on severe/very severe pneumonia. Moderate quality evidence suggesting similar clinical outcomes comparing amoxicillin and cotrimoxazole for non-severe pneumonia received a strong recommendation against adopting amoxicillin. The panel voted strongly against amoxicillin for severe pneumonia over benzyl penicillin despite moderate quality evidence suggesting clinical equivalence between the two and additional factors favoring amoxicillin. Very low quality evidence suggesting ceftriaxone was as effective as the standard benzyl penicillin plus gentamicin for very severe pneumonia received a strong recommendation supporting the standard treatment.ConclusionsAlthough this exercise may have fallen short of the rigorous requirements recommended by the developers of GRADE, it was arguably an improvement on previous attempts at guideline development in low-income countries and offers valuable lessons for future similar exercises where resources and locally-generated evidence are scarce.
Highlights
The development of evidence-based clinical practice guidelines has gained wide acceptance in highincome countries and reputable international organizations
The World Health Organization (WHO), after criticisms of its guideline development procedures [4], recently adopted the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [5] expecting it to be used for all new technical advice [6]
The GRADE approach, acknowledging that evidence alone is inadequate for making recommendations, directs that local contextual factors be taken into account when producing recommendations
Summary
The development of evidence-based clinical practice guidelines has gained wide acceptance in highincome countries and reputable international organizations Whereas this approach may be a desirable standard, challenges remain in low-income settings with limited capacity and resources for evidence synthesis and guideline development. Key treatment recommendations for children without HIV infection are largely unchanged since their first launch over twenty years ago and concerns have been expressed over their current and future appropriateness [12]. Perhaps linked to such concerns there is evidence of poor guideline adherence revealing possible preferences for ‘stronger’ (broader spectrum, non-beta-lactam) antibiotics [13]. We illustrate such compromises here both to indicate where sharing resources, capacity and prior work may be helpful and because they raise the question of whether or not what we describe, as an illustration of what may be possible in low income settings, is a ‘GRADE-compliant’ process
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