December 11th, 2016

You Want Guidelines? We Got Guidelines!

"I'm a thoughtful ID doctor who writes guidelines."

“I’m a thoughtful ID doctor who writes guidelines.”

About a million years ago — in other words, probably sometime during my ID fellowship — I asked transplant ID guru Bob Rubin how various ID guidelines came together, including one on antifungal therapy he had just led.

“You lock a bunch of experts in a hotel conference room,” he said. “Provide them plenty of food and coffee. Then you hide the key until they come up with something, especially if there’s a deadline .”

Having participated on a couple of guidelines committees, I can attest that the process has changed just a bit since Bob provided me that memorable story. Conference calls, web-based presentations, and numerous shared documents with extensive “track changes” peppered throughout now dominate the process, along with frequent reminders about grading both the strength of the recommendations and the quality of evidence.

And, since we’re ID doctors, we of course try to outdo each other in obsessive attention to detail — emphasis on obsessive. While everyone makes a big noise about editing and shortening the final document, if that means eliminating one key reference, tell that to its champion — especially if they authored or co-authored the paper. It’s going in!

On the topic of guidelines, you might have noticed that the Infectious Diseases Society of America (IDSA) has been on quite a roll over the past year. They’ve been churning out new guidelines at a blistering pace, often in collaboration with other medical societies. So here’s a look back on IDSA’s hard work over the past 12 months, each one highlighted with at least one notable and/or interesting recommendation, and also (just for bragging rights) the number of references (all thoroughly read, no doubt):

  • CandidiasisLast updated in 2009, these revised guidelines cover diagnosis, prevention, and treatment. A selected key recommendation:  An echinocandin is recommended as initial therapy, with transition to fluconazole if the isolate is susceptible. Number of references:  560 — impressive!
  • Antibiotic Stewardship. The first of its kind! A selected key recommendation: Rapid viral testing for respiratory pathogens is recommended to reduce the use of inappropriate antibiotics. Number of references:  225 — you have to think this will grow in the next iteration.
  • Aspergillosis. Prevention, diagnosis, and treatment of this difficult-to-treat opportunistic infection. A selected key recommendation:  Serum and bronchoalveolar lavage galactomannan can accurately diagnose invasive aspergillosis in high risk patients; the panel disagreed about using PCR. Number of references:   655! Wow, that might be hard to beat.
  • Hospital-acquired and ventilator-associated pneumonia. Retires the term “health-care associated pneumonia”, often abbreviated (and spoken) as “H-CAP” — will be hard for many to break that habit. A selected key recommendation: Duration of therapy should be 7-days (follows the rules!), not 8-15. Number of references:  364. Middle of the pack.
  • Coccidioidomycosis. What a mouthful that fungal disease is, which must be why most people just say “cocci.” A selected key recommendation (actually two this time):  No antifungal treatment for an asymptomatic pulmonary nodule (not even a bit of fluconazole?), while duration of azole therapy for coccidioides meningitis is lifelong. Number of references:  219 — a relatively “low” number, maybe because cocci’s geographic distribution isn’t very wide. Nah, 219 references is still a lot.
  • Treatment of drug-susceptible tuberculosis. The winner for the most number of organizations involved in developing and endorsing these guidelines — I counted 9 (just read the start of the abstract). A selected key recommendation:  Initial adjunctive corticosteroid therapy should not be routinely used in patients with tuberculous pericarditis. Number of references:  531 — would be top of the pack if you added the other TB Guidelines (which are next).
  • Diagnosis of tuberculosis. First update on this topic in 17 years, so long overdue. A selected key recommendation: Use an interferon gamma release assay (IGRA) to assess for latent TB in place of the tuberculin skin test (TST) in most clinical settings. I’m ok with that! Number of references: 241 — hey, it’s just diagnosis after all.
  • Leishmaniasis. Diagnosis and treatment of cutaneous, mucocutaneous, and visceral disease. A selected key recommendation:  Use a reference laboratory to perform culture and PCR in an effort to identify the infecting parasite to the species level, which may have implications for management. Number of references:  503, which exceeds the number of cases of leishmaniasis I have seen by 498.

That’s 8 Guidelines, and a total of 3,298 references. Hard at work, IDSA!

Of course no listing of IDSA Guidelines these days is complete without the invaluable HCV guidelines, which I’ve praised (and use) often. They’ve changed so frequently since their inception that they have their own special site, and aren’t really “published” anywhere else — at least not in a traditional medical journal. On the plus side, this allows the HCV Guidelines greater flexibility, with modifications on an as-needed basis (three times in 2016 alone) for important changes in the field — a nod to the DHHS HIV Guidelines, which have a similar structure. On the minus side, there’s no real peer review, and I’m sure some of the writers of the guidelines (especially those seeking academic promotion) wouldn’t mind a byline discoverable in PubMed.

And they don’t number their references, so someone else has to count. Kind of like guessing the number of pennies in a big jar to win a prize.

Finally, here are some bears playing with a pink balloon. Just because.

5 Responses to “You Want Guidelines? We Got Guidelines!”

  1. Max Voysey says:

    Aren’t there Guidelines on Guidelines?

  2. Louie Katz says:

    GOBSAT= good OLD BOYS sittin’ around a table.

  3. doh says:

    What we really need are updated treatment guidelines for Lyme. The DHHS Agency for Healthcare Research and Quality maintains a National Guidelines Clearinghouse ( In order to be included, “the guideline must have been developed, reviewed, or revised within the past five years”. The IDSA Lyme guidelines date to 2006 so are not included in the Clearinghouse. Instead, guidelines developed by the International Lyme and Associated Diseases Society (ILADS) are the main Lyme treatment guidelines available on the site ( Many Lyme advocacy groups have picked up on this and are stating that the federal government has determined that the IDSA guidelines are obsolete. They have convinced at least one state health department to post the ILADS guidelines ( Help!

    • Paul Sax says:

      I completely agree these are overdue; fortunately, I know that work is ongoing for revising them. I don’t have information about when they’ll be out, though.


  4. Marcos says:

    Guidelines for drug-resistant TB coming out… Sum those references with those on the other TB guidelines. Winner.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.