Efficiency of pragmatic search strategies to update clinical guidelines recommendations.

BACKGROUND: A major challenge in updating clinical guidelines is to efficiently identify new, relevant evidence. We evaluated the efficiency and feasibility of two new approaches: the development of restrictive search strategies using PubMed Clinical Queries for MEDLINE and the use of the PLUS (McMaster Premium Literature Service) database. METHODS: We evaluated a random sample of recommendations from a national guideline development program and identified the references that would potentially trigger an update (key references) using an exhaustive approach. We designed restrictive search strategies using the minimum number of Medical Subject Headings (MeSH) terms and text words required from the original exhaustive search strategies and applying broad and narrow filters. We developed PLUS search strategies, matching Medical Subject Headings (MeSH) and Systematized Nomenclature of Medicine (SNOMED) terms with guideline topics. We compared the number of key references retrieved by these approaches with those retrieved by the exhaustive approach. RESULTS: The restrictive approach retrieved 68.1 % fewer references than the exhaustive approach (12,486 versus 39,136), and identified 89.9 % (62/69) of key references and 88 % (22/25) of recommendation updates. The use of PLUS retrieved 88.5 % fewer references than the exhaustive approach (4,486 versus 39,136) and identified substantially fewer key references (18/69, 26.1 %) and fewer recommendation updates (10/25, 40 %). CONCLUSIONS: The proposed restrictive approach is a highly efficient and feasible method to identify new evidence that triggers a recommendation update. Searching only in the PLUS database proved to be a suboptimal approach and suggests the need for topic-specific tailoring.

[Use of levofloxacin in the hospital]. / Utilización hospitalaria de levofloxacino.

Levofloxacin is a new, recently commercialized fluoroquinolone. We aimed to assess the use of levofloxacin after its inclusion in the hospital drug guide. In a prospective observational study, patients treated with levofloxacin in a university hospital were selected from July 2000 to June 2001. Using a structured questionnaire, data were recorded on patients' demographic characteristics and comorbidities, indications for levofloxacin use and previous use of other antibiotics. In addition, the adherence to the instructions for use as recommended by the antibiotic subcommittee of the hospital, and the use of other alternative antibiotics were analyzed. Ninety-seven patients were treated [mean age 67 years; range 17-93; 64 men], of whom 83 (85.6%) had comorbidity and 51 (52.6%) a possible allergy to the betalactam antibiotics. The treatment began after the use of other antibiotics in 47 (48.5%) patients. The main clinical indications were pneumonia (54; 55.7%) and acute exacerbation of chronic bronchitis (25; 25.8%). The use of other antibiotics was possible in 56 (57.7%) patients, and levofloxacin was only used according to the recommended indications in 41 (42.3%). Levofloxacin is mainly used in the treatment of patients with respiratory infections, those who are allergic to the betalactam antibiotics and those previously treated with other antibiotics; however, in many cases, the use of other antibiotics may still be possible. As part of the antibiotic policy, it is necessary to define the indications of use for new antibiotics introduced in the hospital and surveillance studies need to be developed.

Quality of tuberculosis guidelines: urgent need for improvement.

SETTING: Clinical practice guidelines have been developed for many disorders, but their quality varies greatly and does not always reach an acceptable standard. No evaluation of clinical practice guidelines on tuberculosis (TB) has been carried out to date. OBJECTIVE: To identify and assess the quality of TB guidelines. DESIGN: We systematically searched documents published from January 1998 to May 2008 in Medline and the Turning Research into Practice (TRIP) database and in clearing houses and on websites of scientific societies. Three appraisers evaluated each guideline using the AGREE (Appraisal of Guidelines, Research and Evaluation) instrument. A standardised score was calculated separately for each of the six domains. RESULTS: A total of 36 guidelines for TB were identified, and after appraisal good overall agreement was observed among the three evaluators. Results revealed that quality was acceptable in two domains but had serious shortcomings in the other four. A slight improvement in quality was observed in documents published in 2005 or later. After global assessment, 18 documents were considered 'recommended with provisos' and only two documents 'strongly recommended' for use in clinical practice. CONCLUSION: The methodological quality of TB guidelines was disappointingly low. All guideline developers should adhere to instruments such as AGREE to produce documents of optimal quality.