Microsoft word - european std guidelines july 2010 no codes.doc

European guideline for the management of Chlamydia
trachomatis infections

Revision date:
Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands Laboratory for Medical Microbiology, Maasstad Ziekenhuis, Rotterdam, The Netherlands Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands Outpatients’ Centre for Infectious Venereodermatological Diseases, Vienna, Austria Chelsea Westminster hospital, London, UK 6 Department of Dermatology, Havenziekenhuis, Rotterdam, The Netherlands 7 Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands

Address for correspondence:

E. Lanjouw MD
Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
Tel: +311034580 Fax: +31107033822
E-mail: [email protected]
Summary of recommendations

Table 1. List of recommendations
Only NAATs detecting all known genotypes and variants should be employed for the diagnosis of C. trachomatis infections. Laboratories should participate in (expert) networks for timely communication about genetic variants, less common serovars, and uncommon clinical presentations. For males first-void urine and for females a (self-collected) vaginal swab are the recommended specimens for C. trachomatis testing. C. trachomatis positive rectal specimens from MSM should be further Testing of semen specimens is not recommended. Pooling of urine specimens is not recommended. Confirmatory testing of C. trachomatis-positive samples is not Antibody testing to C. trachomatis is only recommended for the diagnosis of invasive disease, such as LGV and neonatal pneumonia, when NAAT is not possible or not reliable. Laboratories should participate in quality assurance programs, either by their own choice or by national requirements. First choice treatment of uncomplicated urogenital chlamydial infections Alternative treatments are a course of doxycycline, 100 mg two times daily for 7 days, or josamycin, 500-1000 mg two times daily for 7 days, or another macrolide. When infection with M. genitalium is confirmed or suspected, patients should be treated with a short course of azithromycin: 500 mg on day 1, followed by 250 mg on days 2-5. First choice treatment in pregnancy is a single dose of 1 g azithromycin. Alternative treatment is a course of amoxicillin, 500 mg four times daily for 7 days. Erythromycin is not recommended. In high prevalence populations pregnant women should be screened for C. trachomatis infection and, if positive, receive appropriate treatment. First choice treatment of rectal non-LGV chlamydial infections is a course of doxycycline, 100 mg two times daily for 7 days. First choice treatment of rectal LGV infection is a course of doxycycline, Patients tested positive for C. trachomatis should be offered screening for at least hepatitis B, gonorrhoea, syphilis and HIV. Aetiology and transmission

C. trachomatis is an obligate intracellular bacterium that infects over 90 million people each
year by sexual transmission. It is the most common bacterial sexually transmitted infection
worldwide, especially infecting young adults. C. trachomatis belongs to the genus Chlamydia
together with Chlamydia muridarum and Chlamydia suis. Other chlamydiae infecting human
beings, Chlamydophila pneumoniae and Chlamydophila psittaci, have been classified in a
separate genus.1 Three biovars comprising all 15 classical serovars and several additional
serovars and genotypes are recognized within C. trachomatis: the trachoma biovar (serovars
A-C), the urogenital biovar (serovars D-K), and the lymphogranuloma venereum (LGV)
biovar (serovars L1-L3). This guideline only covers urogenital infections caused by the
urogenital and the LGV biovar of C. trachomatis.
Usually transmission takes place by direct mucosal contact between two individuals during
sexual contact or at birth. Occasionally, other ways of transmission (fomites, enemas, sex
toys) may play a role, as has been suggested in the LGV proctitis epidemic. The rate of
transmission between sex partners may be as high as 75%.2 Thus, partner notification and
subsequent treatment are very important.
Clinical features

Urogenital infections in women

 Up to 90% asymptomatic  Cervicitis  Urethritis  Post-coital bleeding  Pelvic inflammatory disease (PID)  Proctitis
Symptoms and signs in women 3,4
 Vaginal discharge  Contact bleeding  Poorly differentiated abdominal pain or lower abdominal pain  Mucopurulent cervical discharge  Cervical friability  Cervical oedema  Endocervical ulcers  Mid cycle spotting  Dysuria
Urogenital infections in men

 More than 50% asymptomatic  Non-gonococcal urethritis  Epididymitis  Proctitis Symptoms and signs in men 5,6
 Urethral discharge  Burning with micturition  ‘Penile tip irritation’  Watery, viscous excretion (‘morning milker’)  Proctitis
Neonatal infections
Infants born to mothers through an infected birth canal may become colonized and may
develop conjunctivitis and/or pneumonia.7
Complications and sequelae in women 8-10
 PID  Endometritis  Salpingitis  Ectopic pregnancy  Tubal factor infertility  SARA (sexually acquired reactive arthritis)
Approximately 10 percent of women with C. trachomatis infection will develop PID if left
untreated. While PID caused by Neisseria gonorrhoeae infection may be accompanied by
more acute symptoms, PID caused by C. trachomatis infection is associated with a higher rate
of subsequent infertility (level III).11 Early and appropriate therapy has the potential of
significantly reducing the long-term complications of PID.12 Other complications of C.
trachomatis infection consist of sexually acquired reactive arthritis (SARA) or perihepatitis
(Fitz-Hugh-Curtis syndrome), chronic pelvic pain (women), anorectal discharge, and adult
conjunctivitis.
Complications in men

C. trachomatis has also been associated with male infertility (level III) 13-15 and epididymitis
(level III).16-19
Lymphogranuloma venereum

 Caused by the L1-L3 serovars of C. trachomatis  Rarely reported in developed countries before 2004  From 2003 outbreaks were reported in The Netherlands and other developed countries in men who have sex with men (MSM).20-22  The main site of infection: the proctum  Symptoms: o Tenesmus o Constipation o Anorectal pain o Mucopurulent discharge o Diarrhoea
Proctitis was known for many years in MSM as the gay bowel syndrome. LGV was
implicated as a causative agent as early as 1976.23 Since the symptoms of LGV proctitis
closely resemble those of Crohn’s disease, many patients have been mistakenly treated for
Crohn’s disease.24,25 In order to manage this epidemic among MSM, the need for standardized
criteria and procedures as well as guidelines became obvious.26,27
Diagnosis of chlamydial infections

Diagnostic assays

 Nucleic acid amplification techniques (NAATs)  Isolation in cell culture  Enzyme immunoassays (EIA)  Direct fluorescence assays (DFA) Since many studies have shown the superiority of NAATs over other techniques, only
NAATs can be recommended (level I, grade A).28
Assessing performance of NAATs
In evaluating the performance of highly sensitive NAATs a perfect gold-standard has not
been defined and discrepant analysis has been used to reassess the supposedly false-positive
results of the NAATs. Discrepant analysis might introduce a bias towards a higher sensitivity
than can be accounted for.29 Since many studies have been reported, including studies using
highly sensitive NAATs only, it is not likely that this bias will lead to ill advised guidelines
(level I).30
Sampling error, biological variation, local differences, and prevalence of C. trachomatis
infections in populations sampled are more important determinants of performance
evaluations (level IV).
Choice of NAAT
Different manufacturers have developed their own amplification technology platforms.
Although sensitivity and specificity do vary slightly, other factors like cost, hands on time,
combined testing for other agents, degree of automation etc play an important role in
choosing a specific NAAT.31 The latest versions of the NAATs of major manufacturers are all
adequate (level II).32
Diagnostic challenges

 Emergence of LGV among MSM  Emergence of the Swedish C. trachomatis variant
Detecting LGV
LGV proctitis has always been described in textbooks, but due to a very low prevalence is not
always considered in the differential diagnosis of proctitis. All NAATS will detect LGV as C.
trachomatis-positive, but without designating the result as LGV positive. For this purpose,
genotyping is necessary (level II, grade B).

Detecting variants
Possible variants:
 Plasmid free strains  Plasmid mutant strains Most commercially available NAATs only detect one target, either the cryptic plasmid, the
major outer membrane protein gene (MOMP), or rRNA. Thus, NAATs are prone to erroneous
results in case of genetic alterations. The plasmid occurs in an average copy number of 4.0
plasmids per chromosome 33 and is highly conserved.34 Therefore, the plasmid is an attractive
target for NAATs. However, NAATs based only on plasmid sequences will not detect
plasmid free C. trachomatis variants. It is not clear if this constitutes a real problem, since
only a few reports exist on the occurrence of plasmid free strains. Although all genes located
on the plasmid are transcribed during infection 35, three groups reported the isolation of a
strain lacking the plasmid.36-38 Matsumoto et al. indeed showed that plasmid free strains can
be isolated from clinical specimens using special cloning techniques and that these strains
may survive.39 Thus, the plasmid is not essential for survival. One group studied a series of 40
specimens from high risk patients with various nucleic acid assays and concluded that 9
specimens contained no plasmid sequences.40 Further analysis comparing these specimens
with C. trachomatis type strains showed they were genetically similar.41 However,
confirmation of these results has not been reported (level III).
An unexpected 25% decrease in the prevalence of C. trachomatis infections triggered Ripa
and Nilsson to study the cause. They reported a new variant of C. trachomatis with a 377 base
pair deletion in the plasmid, exactly at the target sequence of several commercial NAATs.42,43
Later it became clear that laboratories relying on these NAATs missed between 20% and 65%
of C. trachomatis infections.44 A real-time PCR assay for detection of the Swedish variant has
been developed 45 and subsequent analysis showed that this strain has to date only rarely been
encountered outside of the Scandinavian countries. Laboratories need to choose a NAAT
capable of detecting the Swedish variant (level I, grade A).
It is recommended that laboratories participate in quality assurance programs, including
monitoring systems, to detect genetic variants and uncommon clinical presentations (level II,
grade B).
Expert networks
Both the experience with LGV and with the Swedish variant show the added value of expert
networks like the European Surveillance of Sexually Transmitted Infections (ESSTI), for
quickly assessing new findings and for notifying professionals in Europe and the rest of the
world.21,46 It is recommended that laboratories participate in (expert) networks for timely
communication about genetic variants and uncommon clinical presentations (level II, grade
B).
Choice of specimen

Until recently different types of specimens were recommended for screening programs and
clinical settings. This is no longer the case.

Type of specimen of first choice


The sensitivity of testing male first-void urine is 85-95%.30,47 The concordance of different
NAATs is highest for symptomatic men. Also, the acceptability by men of first-void urine
specimens is generally good.48 First-void urine should be used to diagnose chlamydial
infections in men (level I, grade A).
For females, the sensitivity of testing first-void urine is slightly lower than that for males: 80-
90%.30 Self-collected vaginal swabs provide an acceptable alternative.49-56 Also, self-collected
vaginal swabs are well accepted by women.57 The difference in sensitivities between tests on
specimens from various sites is likely to be the result of the difference in bacterial load in
these specimens.58 Self-collected vaginal swabs should be used to diagnose chlamydial
infections in women (level I, grade A).
Pap-smears provide an attractive type of specimen for epidemiological purposes using already
available specimens. Although several procedures have been described to optimize
performance of detection of C. trachomatis in Pap-smears 59, they cannot be recommended
for specific screening programmes, nor for diagnostic purposes (level II).
Other types of specimen
Pharyngeal and conjunctival specimens
Due to the low bacterial load NAATs are the test of choice for adult and infant pharyngeal
specimens if indicated.60 Although the bacterial load in neonatal conjunctivitis is probably
higher, NAATs still show a higher sensitivity compared to non-amplification assays. NAATs
have now been adequately validated for these specimens (level II).61-64
Rectal specimens
Isolation in cell culture and enzyme immunoassays are not suited for rectal specimens, due to
toxicity of the specimens and extensive cross-reactions, respectively.
The specificity of current commercial NAATs seems adequate, although laboratories
employing these assays should recognize that specificity is less than 95% and confirmation by
another assay might be appropriate (level II).63-65 In MSM, positive rectal specimens should
be genotyped for LGV (level II, grade B).66
Semen specimens
Up to 10% of semen specimens might contain inhibitors for NAATs. However, a good
correlation exists between first-void urine positivity and semen positivity.67-69
Therefore, testing of semen specimens is not recommended (level II, grade B).

Pooling of urine specimens
To reduce the workload and/or cost, laboratories might want to pool urine specimens.
Depending on the prevalence calculations can be made on cost and benefits. However, female
urine might contain inhibitors 70,71, that could cause false-negative results in other specimens
from the pool. In addition, most NAATs are neither FDA cleared nor CE marked for using
pooled specimens. Therefore, in the era of automated high-throughput equipment and
considering the need for unambiguous identification and tracking of specimens, as well as the
need for reduction of human errors, pooling of urine cannot be recommended (level II, grade
B).72
Sampling error
First portions of urine have a higher bacterial load than second and third portions. Thus, first-
void urine should be used.73 Voiding interval seems not to effect diagnostic performance.74
Early morning urine seems not to be more sensitive than urine at the time of visit.75 Thus,
male urines can be collected at the time of the visit (level II).
Hormonal levels

Hormonal levels have been suggested to influence C. trachomatis detection by NAATs.
Factors involved are:
 Bacterial load (increase or decrease)  Presence of inhibitors (increase or decrease) Bacterial load seems to increase with time after the last menstrual bleeding, while the
presence of inhibitors in urine seems to be maximal three weeks after the last menstrual
bleeding.70,76 Thus, the optimal period for taking vaginal swabs seems to be four weeks after
the last menstrual bleeding (level III).
Inhibition

In some studies differences between NAATs have been observed 77, but this has not been
confirmed in other studies. Urine from pregnant women might contain inhibitors, as well as
urine taken in the third week after menstrual bleeding.70,71 It is likely that hormones play a
role in this inhibition. Various solutions (e.g. freezing, boiling or diluting the specimens) have
been suggested to deal with inhibition, but none of these is generally applicable nor generally
accepted.
Another concern (competitive inhibition) is raised by the use of duplex or multiplex assays
detecting more than one target. If one of the targets is present in excess, other targets may be
reported false-negative.78,79 In these cases, the use of monoplex assays is needed to achieve
the desired sensitivity (level II).
Confirmatory testing

Several strategies have been evaluated for confirmatory testing. One could use the same
specimen, a second specimen taken at the same time, or a new specimen. Also, one could
repeat the original test or one could use a different test.
Using a second platform for confirmatory testing can only be implemented when the second
platform is at least as sensitive as the initial platform.80 After all, using a less sensitive test
would reduce the overall sensitivity to the level of the least sensitive test.
For specimens with a high bacterial load all types of confirmatory testing will be positive and,
therefore, confirmatory testing is unnecessary and expensive. For specimens with a low
bacterial load as can be expected in low prevalence populations or in screening programs of
asymptomatic individuals, confirmatory testing will confirm 80-90% depending on the initial
test and the confirmatory procedure. More rigorous testing shows that the assumption that
non-confirmed specimens are negative is wrong. Thus, confirmatory testing of specimens
with a low bacterial load does not solve the issue of true positivity and is therefore not
recommended (level II, grade B).81 Proficiency testing and laboratory accreditation seem
more appropriate ways to assure a high quality of laboratory results (level II).
Serology

In general, only invasive disease will lead to antibody levels useful for diagnostic purposes.
Chlamydial serology

 Only synthetic peptide-based EIAs show no cross-reactions  Duration of antibody-positivity is not known.  No value in the diagnosis of uncomplicated cervicitis and urethritis.82  Limited value in the diagnosis of ascending infections.83-85  Limited value for infertility workup.86  LGV: high titres (IgG and/or IgA) can be diagnostic.20,25,87,88  Neonatal pneumonia: IgM can be diagnostic.7 Especially when direct detection by NAAT is not possible or not reliable, antibody testing to
C. trachomatis may be helpful in the diagnosis of invasive disease, such as LGV involving
the lymph nodes and neonatal pneumonia (level I, grade A).
Quality assurance
As mentioned in the paragraph on confirmatory testing, quality assurance is important to
guarantee correct test results of high quality. For blood products, a working group was
convened dealing with NAAT validation and standardisation, reference standards, proficiency
testing , and external assessment of laboratory performance to assure quality of testing and
safety of products across all laboratories.89 In general for NAATs procedures have been
developed to assure quality.90,91 Diagnostic procedures for C. trachomatis are not different
from other diagnostic procedures. Performance problems can be detected, that would remain
undetected following manufacturer’s instructions only.92 Laboratories should participate in
quality assurance programs, either by their own choice or by national requirements (level I,
grade A).

Therapy

Uncomplicated urogenital C. trachomatis infections
Although the natural course of infection has not been studied in great detail, it is assumed that
many infections will clear spontaneously over time.93 Some infections may proceed into a
chronic persistent state.94 Since sequelae might be severe, treatment is recommended.
Resistance, although infrequently reported to date, may occur in C. trachomatis and is
associated with treatment failure.95,96 The incidence of resistance is unknown, but estimated
very low. Thus, therapy is initiated empirically. A recent meta-analysis revealed that a single
dose of azithromycin and a 7-day course of doxycycline are equally effective (level I, grade
A).97 Treatment compliance is of major concern and has been shown to be substantially
higher in case of a single dose of azithromycin, in both patients 98 and their partners 99,100
(level I). Alternatively, josamycin has been used with success in some countries (level II,
grade B).101
First choice treatment of uncomplicated urogenital infections consists of one of the following
(level I, grade A):
 Single dose of 1 g azithromycin  Course of doxycycline, 100 mg two times daily for 7 days Alternative treatment (level II, grade B):
 Course of josamycin, 500-1000 mg two times daily for 7 days  Course of another macrolide in an appropriate dosage
Please note that this recommendation is only valid in case of an infection with C. trachomatis
as a single agent. In case of concurrent STIs, see below.
Therapy in pregnancy
C. trachomatis infections also occur during pregnancy. Infection is associated with premature
labour, preterm birth, and neonatal conjunctivitis and pneumonitis.102,103 The choice of drugs
for treatment is important because of their possible adverse effects on foetal development and
pregnancy outcome. Recently, a meta-analysis comprising 587 pregnant women reported
equivalent efficacy of azithromycin, erythromycin, and amoxicillin. Side-effects were
however, significantly less in the azithromycin group than in the erythromycin group. There
were no differences in pregnancy outcome.104 In some studies, erythromycin is less
efficacious than azithromycin and amoxicillin.105 The positive effect of treatment on
pregnancy outcome even suggests screening and treatment of all pregnant women.106 In
countries where the drug is available, josamycin seems safe and efficacious and might also be
considered.107,108 First choice treatment in pregnancy is a single dose of 1 g azithromycin.
Alternative treatment is a course of amoxicillin, 500 mg four times daily for 7 days.
Erythromycin is not recommended (level I, grade A).
In high prevalence populations (e.g. > 5%) pregnant women should be screened for C.
trachomatis infection and, if positive, receive appropriate treatment (level II, grade B).
Rectal infection with LGV and non-LGV C. trachomatis

In some reports a higher failure rate of the standard single dose of azithromycin has been
described in rectal chlamydial infections. The reason for this observation is not clear.109
Usually a distinction between rectal non-LGV chlamydial infections and rectal LGV
chlamydial infections is not made. Recently, evidence for treatment recommendations has
been examined 110,111 and a new guideline for rectal LGV infection has been published.27
Doxycycline (100 mg two times daily for 21 days) remains the treatment of choice (level III,
grade B).
First choice for treatment of rectal non-LGV chlamydial infections is a course of doxycycline,
100 mg two times daily for 7 days (level III, grade B).111
Therapy failure
Limited data exist on alternative therapy in case of therapy failure. A repeated course or a
longer course (10-14 days) with doxycycline or a macrolide has been suggested, but evidence
is lacking (level IV). Resistance has been shown rarely 95,96, but therapy failure might also be
caused by persistence of chlamydial strains. Probably, the most common reason for therapy
failure is re-infection from an untreated partner (level II).112 An interesting suggestion is the
combined use of rifampicin and a macrolide.113-116 Further studies are needed.

Concurrent STIs

Men and women having a diagnosis of C. trachomatis infection should be offered a complete
workup for other STIs. C. trachomatis infection is a risk factor for the acquisition or
transmission of HIV and other STIs. Patients should be offered screening for at least hepatitis
B, gonorrhoea, syphilis, and HIV (level I, grade A).117,118 Mycoplasma genitalium is a
sexually transmitted pathogen causing clinical disease similar to C. trachomatis, including
PID.119,120 An association with long-term sequelae has not been established yet. If facilities
are available, patients may be offered screening for M. genitalium as well. This is particularly
important in patients with persistent or recurrent disease (level II).120 Recently, data were
presented indicating that a single dose of 1 g azithromycin may lead to macrolide resistance in
M. genitalium.121,122 When infection with M. genitalium is confirmed or suspected, patients
should not be treated with a single dose of 1 g azithromycin, but with a short course of
azithromycin: 500 mg on day 1 followed by 250 mg on days 2-5 (level III, grade C).123
Complications

PID remains one of the most important sequelae of sexually transmitted infections (STIs),
resulting in severe morbidity and acting as the economic justification for STI screening
programmes. Early and appropriate therapy has the potential to significantly reduce the long-
term complications of PID, and evidence-based guidelines provide advice on the management
of pelvic infection including the use of appropriate antimicrobial regimens.12
Several pathogens that may play a role in the aetiology of PID should be covered by empiric
therapy: N. gonorrhoeae, C. trachomatis, M. genitalium, and anaerobes.12,124
Partner notification

There is a wide difference in practicing partner notification between countries.125 Besides
scientific aspects, legal and privacy aspects are important. They differ from country to
country. Also, no data are available to recommend a look-back period. Human studies on the
duration of genital C. trachomatis infections have shown that chlamydia clearance increases
over time, with approximately half of infections spontaneously resolving one year after
initial chlamydia testing.126 However, practical restrictions will usually limit a look-back
period to approximately two months. Overall, 50-80% of partners may be reached. The higher
rates were associated with various enhancements to basic referral instructions, especially if
patients were offered additional counselling or medications for their partners.127,128 Expedited
partner therapy or patient-delivered partner therapy might be an efficient way to treat partners
129, but is not always permitted by law.130 Major concerns are the unsupervised administration
of prescription drugs, lack of monitoring of therapeutic effect, side-effects, and allergies, the
lack of opportunity to test for C. trachomatis or other STIs, as well as the lack of onwards
partner notification, and safe sex education. In the UK, one-third of the professionals is
strongly opposed.131,132 It is, however, well accepted by patients and partners.132,133
Given the wide differences between countries, no definitive recommendation can be given.
Follow-up

NAATS cannot discriminate between live and dead microorganisms. Up until 4-6 weeks after
therapy a test result may still be positive, based on remnants of microorganisms that have not
been cleared by the host. Therefore, a test of cure is not recommended. Since a previous C.
trachomatis infection is a risk factor for future STIs, a control visit after 3 months can be
considered (level II).72,117
Acknowledgement

The authors acknowledge the members of the IUSTI / WHO European STI Guidelines
Editorial Board for their valuable comments.

IUSTI / WHO European STI Guidelines Editorial Board:
Keith Radcliffe (Editor-in-Chief), Karen Babayan, Simon Barton, Michel Janier, Jorgen Skov
Jensen, Lali Khotenashvili, Marita van de Laar, Willem van der Meijden, Harald Moi,
Martino Neumann, Raj Patel, Angela Robinson, Jonathan Ross, Jackie Sherrard, Magnus
Unemo.


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Appendix 1

The last version of the IUSTI guideline for chlamydial infection was published in 2001.134
Since then, the guidelines editorial board has decided to introduce evidence-based guidelines
for all Sexually Transmitted Infections (STI), including chlamydial infections. Here we
present the revised version of the guideline, produced according to the protocol approved by
the IUSTI STI Guidelines Editorial Board and an evidence-based approach. This guideline is
intended to be used by any clinician having to deal with one or more aspects of Chlamydia
trachomatis infections.
Search Strategy
The guideline for management of C. trachomatis infections was written after a literature
search in the Medline, Embase, and Cochrane databases for English-language articles
published between January 1999 and December 2008. For this purpose a well established
algorithm developed by the Dutch Institute for Healthcare Improvement (CBO) was used.135
This algorithm guarantees inclusion of most if not all major publications on this topic. The
resulting database of publications was extended with searches on specific topics and existing
guidelines.12,27,72,117,134
The level of evidence was assigned according to table 2 and the grading of recommendations
according to table 3.




Appendix 2

Table 2. Levels of evidence
Evidence obtained from meta-analysis of randomised controlled trials Evidence obtained from at least one randomised controlled trial Evidence obtained from at least one well designed study without randomisation Evidence obtained from at least one other type of well designed quasi- Evidence obtained from well designed non-experimental descriptive studies, correlation studies, and case control studies Evidence obtained from expert committee reports or opinions and/or clinical Evidence levels Requires at least one randomised control trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation Evidence levels Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality Declarations of interest
None declared.

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