Experience developing national evidence-based clinical guidelines for childhood pneumonia in a low-income setting - making the GRADE?

A team of health professionals, many with minimal prior experience conducting systematic reviews, carried out evidence synthesis for structured clinical questions. Summaries were compiled and distributed to a panel of clinicians, academicians and policy-makers to generate recommendations based on best available research evidence and locally-relevant contextual factors.We reviewed six eligible articles on non-severe and 13 on severe/very severe pneumonia. Moderate quality evidence suggesting similar clinical outcomes comparing amoxicillin and cotrimoxazole for non-severe pneumonia received a strong recommendation against adopting amoxicillin. The panel voted strongly against amoxicillin for severe pneumonia over benzyl penicillin despite moderate quality evidence suggesting clinical equivalence between the two and additional factors favoring amoxicillin. Very low quality evidence suggesting ceftriaxone was as effective as the standard benzyl penicillin plus gentamicin for very severe pneumonia received a strong recommendation supporting the standard treatment.Although this exercise may have fallen short of the rigorous requirements recommended by the developers of GRADE, it was arguably an improvement on previous attempts at guideline development in low-income countries and offers valuable lessons for future similar exercises where resources and locally-generated evidence are scarce.The approach to developing clinical practice guidelines has become increasingly formal over the last two decades. Requirements now span rigor in evidence appraisal to incorporation of user preferences. As a result developed countries have invested substantially in national institutes to develop guidelines (National Institute for Health and Clinical Excellence [1],; Agency for Healthcare Research and Quality [2], Norwegian Knowledge Centre for the Health Services [3] etc). The World Health Organization (WHO), after criticisms of its guideline development procedures [4], recently adopted th