GRADE is a systematic approach to guideline development that has been described in detail elsewhere [2,39].The IDSA adopt- ed GRADE in 2008. In the GRADE system, the guideline panel assigns each recommendation with separate ratings for the un- derlying quality of evidence supporting the recommendation and for the strength with which the recommendation is made (Figure 1). Data from randomized controlled trials begin as “high” quality, and data from observational studies begin as “low” quality. However, the panel may judge that specific fea- tures of the data warrant decreasing or increasing the quality of evidence rating, and GRADE provides guidance on how such factors should be weighed [39]. The strength assigned to a recommendation chiefly re flects the panel’s con fidence that the benefits of following the recommendation are likely to out- weigh potential harms. While the quality of evidence is an im- portant factor in choosing recommendation strength, it is not prescriptive.
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