Q&A: ‘WikiGuidelines’ collaborative tackles infective endocarditis
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Key takeaways:
- Infective endocarditis is increasingly linked to injection drug use.
- A group of researchers reviewed almost 600 articles on the illness and came away with one recommendation.
The “WikiGuidelines” collaborative has published its second clinical practice guideline, stating that oral transitional therapy is at least as effective as IV-only therapy in treating bacterial infective endocarditis in adults.
The researchers behind WikiGuidelines say they are developing infectious disease clinical practice recommendations that are based on strong evidence and can “standardize clinical care with the humility of uncertainty.”
“WikiGuidelines seek to provide clinical practice guidelines with a pragmatic focus that are broadly applicable to ‘real world,’ practical settings, including outside of academic medical centers,” the group’s charter says.
They crowdsource their topics, asking members via email and on social media which guidelines they should cover next. They published their first consensus statement — on the management of pyogenic osteomyelitis in adults — last year.
Infective endocarditis (IE) is an uncommon bacterial infection of the heart that is increasingly associated with injection drug use. Other risk factors include heart valve disease or previous heart valve surgery and congenital heart disease, according to the American Heart Association.
For the new guidelines, 51 researchers from 10 countries reviewed 587 articles and found that doctors have been diagnosing and managing IE mostly based on “historical practice and small, outdated, observational studies” with low-quality evidence.
One exception was the use of oral step-down antibiotics for IE, which has been supported by multiple trials, including the POET trial.
We reached out to Emily G. McDonald, MD, MSc, a physician at McGill University Health Centre in Montreal and member of the WikiGuidelines board of directors and steering committee, to ask about the new guidance, how WikiGuidelines operates, what the group will investigate next and whether its members are trying to change how guidelines are constructed (they are).
Healio: Does the one consensus statement in the paper — that oral transitional therapy is at least as effective as IV-only therapy for IE — conflict with any existing guidelines?
McDonald: It is not a matter of it conflicting; we specifically highlight the evidence in favor of this option. There is a lot of inertia to overcome [because] this is a big change to practice.
Healio: Should physicians change their practice based on your guidance? Should they already have changed it based on the three randomized trials?
McDonald: Yes, and yes! Some patients can truly benefit from this approach, and we should be considering it.
Healio: There are 16 unanswered questions about IE in the paper, including questions about diagnosing it. IE is not a new illness. Why is there such a lack of high-quality data, and what type of evidence is missing that could help answer the other 16 questions the group came up with?
McDonald: IE is a very old infection, and many standards of practice in ID are based on historical practice. It takes courage to call out a lack of evidence, to demand stronger evidence and to go against the way things have always been done. Also, running clinical trials is costly, and there are far more barriers to conducting research than there ought to be. We need more prospective, controlled trials to answer the other questions.
Healio: Will some of them be answered soon?
McDonald: Yes! There are several important practice-changing clinical trials currently underway that will answer some of these questions. The results are eagerly awaited.
Healio: This is the second consensus statement issued by the group following last year’s guidance on pyogenic osteomyelitis in adults. Are WikiGuidelines intended to be living documents? Will they be updated as new information comes in?
McDonald: Yes! WikiGuidelines are living documents and are updated on our website when new practice-changing evidence is published. We just submitted an update to the osteomyelitis guideline for peer review.
Healio: Are you trying to change how guidelines are currently constructed?
McDonald: We are absolutely trying to change how guidelines are constructed. We want the members who participate in the guidelines to be more representative of the clinicians who use them. We want guideline recommendations to be based on strong evidence and not just expert opinion. When opinions diverge, we present different options and outline the harms and benefits. We want guidelines to be useful in a variety of practice settings — urban, rural, developed and developing countries.
Healio: Did you have any contact with the Infectious Diseases Society of America during this process, or about WikiGuidelines in general?
McDonald: Not personally, no — not about WikiGuidelines. I can't speak for all co-authors. Because some IDSA members are colleagues or research associates, we naturally interact professionally.
Healio: Have you crowdsourced your next topic?
McDonald: Yes, we have. We are currently drafting a guideline for persons who inject drugs and another for urinary tract infections.
Healio: Is there anything you personally would like to see the group tackle next?
McDonald: I'm excited about the urinary tract infection guideline, and I'm a participating member this time around. There is a lot of inappropriate use of antibiotics in the treatment of asymptomatic urinary tract infections, and so I'm hoping we address that.
References:
- Heart.org. Infective endocarditis. https://www.heart.org/en/health-topics/infective-endocarditis. Last reviewed March 4, 2021. Accessed Aug. 7, 2023.
- McDonald EG, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.26366.
- Spellberg B, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.11321.
- WikiGuidelines. WikiGuidelines Charter. Last edited Nov. 10, 2022. Accessed Aug. 1, 2023. https://www.wikiguidelines.com/en/charter.