Treatment Guidelines for Nosocomial Pneumonia: Agreeing to Disagree

CONSENSUS CONFERENCES TO GENERATE TREATMENT guidelines for specific infectious diseases or syndromes seem to be something of a growth industry. In this issue of The Canadian JoumaL of Infectious Diseases we are presented with another, this one on the initial antimicrobial treatment of nosocomial pneumonia (pages 317-321). To begin to sort out how to make optimal use of these particular guidelines, we should first consider what requirements underly the development of a meaningful consensus of lhis kind. First, we need a diagnosis clearly enough defined that consensus seekers can agree to it and guideline users can recognize it. If the case definition is vague or subjective, even the best treatment guidelines cannot ensure uniform standards of care. Second, it is helpful ii the usual microbial etiology of lhe diagnosis in question is known and is reasonably unifom1 in different places and at different times. Third, lhere should be good compara tive data regarding efficacy and cost for potential treatment regimens, so lhat recommendations can be both specific and justifiable . Without this, while guidelines may, at best. represent lhe distilled wisdom of the shared experience of experts, they risk being merely codified bias. When lhese requirements are met, guidelines can make an important contribution to educating physicians a bout appropriate management of infectious diseases . The Canadian Treatment Guidelines for Sexually Transmitted Diseases is an example of a consensus document which is both useful and a uthori tative, in which lhe diagnostic entities are well-defined, the respons ible pathogens are known and generally consistent in kind and antimicrobial susceptibility, and which has good comparative data of treatment efficacy and cost benefit to support specific antimicrobial recommenda tions (1). An examination of the recommended a ntimicrobial