Article Text

Original research
Consideration of antimicrobial resistance and contextual factors in infectious disease guidelines: a systematic survey
  1. Rosa Stalteri Mastrangelo1,2,
  2. Nancy Santesso1,3,
  3. Antonio Bognanni1,
  4. Andrea Darzi1,3,
  5. Samer Karam1,3,
  6. Thomas Piggott1,3,
  7. Tejan Baldeh3,
  8. Finn Schünemann3,4,
  9. Matthew Ventresca1,
  10. Gian Paolo Morgano1,
  11. Lorenzo Moja5,
  12. Mark Loeb1,
  13. Holger Schunemann1,3,4
  1. 1Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
  2. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  3. 3Michael G. DeGroote Cochrane Canada and MacGRADE Centres, McMaster University, Hamilton, Ontario, Canada
  4. 4Institut für Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
  5. 5Department of Health Product Policy and Standards, World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Holger Schunemann; holger.schunemann{at}


Objectives Guidelines that include antimicrobial recommendations should explicitly consider contextual factors that influence antimicrobial resistance and their downstream effects on resistance selection. The objectives were to analyse (1) how, and to what extent, tuberculosis, gonorrhoea and respiratory tract infection guidelines are considering antimicrobial resistance; (2) are of acceptable quality and (3) if they can be easily contextualised to fit the needs of specific populations and health systems.

Methods We conducted a systematic review and searched Ovid MEDLINE and Embase from 1 January 2007 to 7 June 2019 for tuberculosis, gonorrhoea and respiratory tract infection guidelines published in English. We also searched guideline databases, key websites and reference lists. We identified guidelines and recommendations that considered contextual factors including antimicrobial resistance, values, resource use, equity, acceptability and feasibility. We assessed quality of the guidelines using the Appraisal of Guidelines for Research and Evaluation II tool focusing on the domains scope and purpose, rigour of development, and editorial independence.

Results We screened 10 365 records, of which 74 guidelines met inclusion criteria. Of these guidelines, 39% (n=29/74) met acceptable quality scores. Approximately two-thirds of recommendations considered antimicrobial resistance at the population and/or outcome level. Five of the 29 guidelines reported all factors required for recommendation contextualisation. Equity was the least considered across guidelines.

Discussion Relatively few guidelines for highly prevalent infectious diseases are considering resistance at a local level, and many do not consider contextual factors necessary for appropriate antimicrobial use. Improving the quality of guidelines targeting specific regional areas is required.

PROSPERO registration number CRD42020145235.

  • Antimicrobial resistance
  • tuberculosis
  • gonorrhoea
  • respiratory tract infections
  • guidelines
  • recommendations
  • contexts

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.

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  • Contributors RSM, HS, NS, ML and TP designed the study protocol. RSM coordinated the study. RSM, AB, AD, GPM, MV, SK and TB assessed eligibility of records at title and abstract. RSM, AD and MV searched for unpublished guidelines in key websites. RSM, AB, AD, GPM, MV, and SK assessed eligibility of full text articles. RSM, AB, AD, FS, GPM, MV and SK extracted data and performed quality assessment using the AGREE II tool. NS and HS settled disputes. RSM analysed and interpreted the data with HS, NS and ML. RSM and HS drafted the manuscript, with writing contributions from NS, ML and LM. All authors interpreted and make edits to the manuscript.

  • Funding Michael G. DeGroote Cochrane Canada and McMaster GRADE centres.

  • Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.