Title: How to tailor recommendations on the treatment of multi-drug resistant Gram-negative infections at country level integrating antibiotic stewardship principles within the GRADE-ADOLOPMENT framework.
Anti-microbial resistance (AMR) in the last decade has become one of the most critical public health emergencies and causes an estimated 35,000 deaths in the European Union/European Economic Area each year. In particular, multi-drug resistant gram-negative bacteria accounts for the majority of infections and deaths in Europe, with Italy among one of the most impacted countries in Europe.
There are many international guidelines on AMR but often they have low quality evidence and cannot be tailored to a local context. The epidemiology of AMR and availability of resources, in terms of diagnostic capacity and antibiotics, vary among countries and what works for one country is not always appropriate for another.
In 2021 the Italian Medicine Agency (AIFA), appointed a working group to support its main scientific committee to optimise the use of antibiotics in Italy. A short-term objective was the rapid development of recommendations for the treatment of infections caused by multidrug resistant bacteria (MDB) in both hospitals and primary care settings. This article describes the process of the working group on the development of international evidence-based guidance documents on treating infections caused by MDB by using the GRADE-ADOLOPMENT Framework methodology and integrating antibiotic stewardship principles. The GRADE-ADOLOPMENT Framework was preferred as it allowed for the “adoption, adaption and update of existing recommendations to specific settings without performing de novo systematics review and grading the evidence”.
The process and development of the guidelines was completed in 6 months. The process resulted in the adoption of 64 recommendations, the adaption of 27 recommendations and the rejection of nine potential recommendations. The final result consisted of 62 recommendations (11 strong, 23 conditional, 25 good practice and three for further research) and was divided into two documents. One for primary care physicians and the other targeting infectious disease specialists and prescribers working in hospital settings.
Through the process it showed how the GRADE-ADOLOPMENT Framework was an effective and efficient method to produce MDB recommendations that can be tailored to a specific country or region, specifically in places where they do not have the time, resources or expertise to perform systematic reviews.
In conclusion, the implementation of evidence-based recommendations that have been tailored with local epidemiology and availability of drugs and diagnostics in mind should, as per the article, "be considered one of the core actions in promoting appropriate antibiotic use and contributing to the global fight against AMR”.
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