2009 CAUTI guidelines - Centers for Disease Control and Prevention

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After determining the GRADE of the evidence base for each outcome of a given intervention orquestion, we calculated the overall GRADE of the evidence base for that intervention orquestion. The overall GRADE was based on the lowest GRADE for the outcomes deemedcritical to making a recommendation.Table 3. Rating the Quality of Evidence Using the GRADE ApproachType ofEvidenceInitialGradeCriteria to DecreaseGradeCriteria to IncreaseGradeOverallQuality GradeRCT High QualitySerious (-1 grade) orvery serious (-2 grades)limitation to study qualityObservationalstudyAny otherevidence(e.g., expertopinion)LowVerylowConsistencyImportant inconsistency(-1 grade)DirectnessSome (-1 grade) or major(-2 grades) uncertaintyabout directnessPrecisionImprecise or sparse data(-1 grade)Publication biasHigh risk of bias (-1grade)Strong associationStrong (+1 grade) orvery strong evidenceof association (+2grades)Dose-responseEvidence of a doseresponsegradient (+1grade)UnmeasuredConfoundersInclusion ofunmeasuredconfoundersincreases themagnitude of effect(+1 grade)HighModerateLowVery lowFormulating RecommendationsNarrative evidence summaries were then drafted by the working group using the evidence andGRADE tables. One summary was written for each theme that emerged under each keyquestion. The working group then used the narrative evidence summaries to develop guidelinerecommendations. Factors determining the strength of a recommendation included 1) thevalues and preferences used to determine which outcomes were "critical," 2) the harms andbenefits that result from weighing the "critical" outcomes, and 3) the overall GRADE of theevidence base for the given intervention or question (Table 4). 33 If weighing the "criticaloutcomes" for a given intervention or question resulted in a "net benefit" or a "net harm," then a"Category I Recommendation" was formulated to strongly recommend for or against the givenintervention respectively. If weighing the "critical outcomes" for a given intervention or questionresulted in a "trade off" between benefits and harms, then a "Category II Recommendation" wasformulated to recommend that providers or institutions consider the intervention when deemedappropriate. If weighing the "critical outcomes" for a given intervention or question resulted in30
an "uncertain trade off" between benefits and harms, then a "No Recommendation" wasformulated to reflect this uncertainty.Table 4. Formulating RecommendationsWeighing Benefits andHICPAC Recommendation Harms for CriticalOutcomesSTRONG (I)WEAK (II)Interventions with net benefitsor net harmsInteventions with trade offsbetween benefits and harmsQuality of EvidenceIA – High to ModerateIB – Low orVery Low (AcceptedPractice)IC – High to Very Low(Regulatory)High to Very LowNo recommendation/unresolved issueUncertain trade offs betweenbenefits and harmsLow to Very LowFor Category I recommendations, levels A and B represent the quality of the evidenceunderlying the recommendation, with A representing high to moderate quality evidence and Brepresenting low quality evidence or, in the case of an established standard (e.g., aseptictechnique, education and training), very low quality to no evidence based on our literaturereview. For IB recommendations, although there may be low to very low quality or even noavailable evidence directly supporting the benefits of the intervention, the theoretical benefitsare clear, and the theoretical risks are marginal. Level C represents practices required by stateor federal regulation, regardless of the quality of evidence. It is important to note that thestrength of a Category IA recommendation is equivalent to that of a Category IB or ICrecommendation; it is only the quality of the evidence underlying the IA recommendation thatmakes it different from a IB.In some instances, multiple recommendations emerged from a single narrative evidencesummary. The new HICPAC categorization scheme for recommendations is provided in Table1, which is reproduced below.Table 1. Modified HICPAC Categorization Scheme for RecommendationsCategory IAA strong recommendation supported by high to moderate quality evidencesuggesting net clinical benefits or harmsCategory IBA strong recommendation supported by low quality evidence suggestingnet clinical benefits or harms or an accepted practice (e.g., aseptictechnique) supported by low to very low quality evidenceCategory IC A strong recommendation required by state or federal regulation.Category IIA weak recommendation supported by any quality evidence suggesting atrade off between clinical benefits and harmsNo recommendation/ Unresolved issue for which there is low to very low quality evidence withunresolved issue uncertain trade offs between benefits and harms31
Page 4 and 5: AcknowledgementHICPAC thanks the fo
Page 6 and 7: AbbreviationsADLAPACHE IIASAASBBUNC
Page 8 and 9: I. Executive SummaryThis guideline
Page 10 and 11: II. Summary of RecommendationsTable
Page 12 and 13: II. Proper Techniques for Urinary C
Page 14 and 15: 1. If obstruction is anticipated, c
Page 16 and 17: a. Procedure-specific guidelines fo
Page 18 and 19: III. Implementation and AuditPriori
Page 20 and 21: IV. Recommendations for Further Res
Page 22 and 23: V. BackgroundUrinary tract infectio
Page 24 and 25: acteriuria inevitably occurs over t
Page 26 and 27: VII. MethodsThis guideline was base
Page 28 and 29: Figure 2: Results of the Study Sele
Page 32 and 33: Category I recommendations are defi
Page 34 and 35: VIII. Evidence ReviewQ1. Who should
Page 36 and 37: Evidence Review Table 1B. What are
Page 38 and 39: Very low-quality evidence suggested
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Page 50 and 51: 15. Jain P, Parada JP, David A, Smi
Page 52 and 53: 44. Chaudhuri P, Vengadasalam D. Ur
Page 54 and 55: 71. Kelleher RE, Meeropol E, Parks
Page 56 and 57: 101. Hirsh DD, Fainstein V, Musher
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Page 62 and 63: 193. Waites KB, Canupp KC, Armstron
Page 64 and 65: 222. Cohen A. A microbiological com
Page 66 and 67: 253. Chavigny KH. The use of polymi

2009 CAUTI guidelines - Centers for Disease Control and Prevention

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