The Role of Guidelines in ID Treatment

Segment Description: Jason Gallagher, PharmD, FCCP, FIDSA, BCPS, clinical professor at Temple University College of Pharmacy and editor-in-chief of Contagion®, weighs in on the role of guidelines in ID treatment.

Interview Transcript (modified slightly for readability):

Contagion®: What is the role of official guidelines for prescribing in ID? And do you see them as rules, recommendations or something in between?

Gallagher: Guidelines are important. In infectious diseases, I feel like we're always waiting for guidelines to be revised for lots of different reasons, but one is: organisms change. Our diagnostics change. Everything can change. I feel like if you follow the literature, you know what the guidelines should say. And then you're waiting and waiting and waiting for that to occur so that people can implement those in practice. I have a couple of passionate feelings about that, I would say: why wait, when you know the literature and see where things are going, that's the time to implement change, and not wait and see what a society does.

But the other one is that we really take guidelines too far. Guidelines are meant not to be rules, they're meant to be guidance, it's right there in the name, guidelines guide, they’re not hard and fast rules. And unfortunately, they almost become weaponized after they come out in the United States where sometimes payers then use them and say, if it's not in the guideline, we're not going to use it, or pay for it. Or regulators can use it as well to say these are the agents that you should be using and that we recognize as what should be used for that condition. And I think that's really problematic. They really are not designed to be that way.

And guidelines also generally report the level of evidence that recommendations come from. Some of those are high levels of evidence, and some of them are low levels of evidence. And if both the high and low level of evidence come out into a guideline that is seen as a hard and fast rule, that's really a mistake. So, I think that as useful as they are, and I do think that they are useful, we tend to take it too far. And they’re a recommendation, the recommendations are, obviously hopefully evidence based, and should be a best practice but shouldn't be the only practice. There's exceptions to every rule.