Quality assessment of clinical practice guidelines for sepsis and variations in recommendations

To provide a clinical reference, we assessed the quality of clinical practice guidelines (CPGs) for sepsis management in adults and compared their key recommendations. Relevant CPGs for adult sepsis management were identified through searches of electronic databases, guideline repositories, and professional societies from January 1, 2018, to March 1, 2025. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument and the Appraisal of Guidelines for Research and Evaluation-Recommendation Excellence (AGREE-REX) were used to evaluate the methodological quality of CPGs and the quality of recommendations. Key recommendations were comprehensively extracted and compared. A total of 11 CPGs were included. The median (interquartile range [IQR]) scores for AGREE II domain were: scope and purpose, 88.89% (77.78–94.44%); stakeholder involvement, 83.33% (50.00–88.89%); rigor of development, 58.33% (50.00–83.33%); clarity of presentation, 94.40% (88.89–94.44%); applicability, 45.83% (33.33–66.67%); and editorial independence, 66.67% (58.33–91.67%). The AGREE-REX assessment indicated clinical applicability at 70.83% (63.89–83.33%), implementability at 58.33% (47.92–64.58%), and values and preferences at 30.21% (25.00–39.58%). In total, 552 key recommendations were extracted. Among guidelines utilizing the GRADE system, the proportion of evidence categorized as low (Grade C; n = 97, 40.93%) and very low quality (Grade D; n = 66, 27.85%) was substantially higher than that of high (Grade A; n = 15, 6.33%) and moderate-quality (Grade B; n = 59, 24.89%) evidence. Furthermore, weak recommendations (n = 168, 70.89%) were markedly more prevalent than strong recommendations (n = 69, 29.11%). Although guidelines for sepsis diagnosis were generally consistent, evidence gaps in hemodynamic management and antibiotic use led to controversial recommendations. Treatment strategies for sepsis vary across guidelines and remain inconsistent. The quality of CPGs for sepsis management requires improvement, particularly in applicability and values and preferences. Future CPG developers should adhere strictly to standardized methodologies and focus on enhancing the dissemination and implementation of guidelines. In this study, we lay the foundation for future guideline development, aiming to synthesize evidence-based insights for clinical decision-making.