Abstract Objective: To assess the quality of recommendations from 161 CPGs using AGREE-REX-D (Appraisal of Guidelines REsearch and Evaluation – Recommendations Excellence Draft). Design: Cross-sectional study Setting: International CPG community. Participants: 322 international CPG developers, users, and researchers Intervention: Participants were assigned to appraise one of 161 CPGs selected for the study using the AGREE-REX prototype tool Main outcome measures: AGREE-REX-D scores of 161 CPGs (7-point scale, maximum 7). Results: Recommendations from 161 CPGs were appraised by 322 participants using the AGREE-REX-D. CPGs were developed by 70 different organizations. The total overall average score of the CPG recommendations was 4.23 (standard deviation (SD)=1.14). AGREE-REX-D items that scored the highest were (mean; SD): Evidence (5.51; 1.14), Clinical relevance (5.95; SD 0.8), and Patients/population relevance (4.87; SD 1.33), while the lowest scores were observed for the Policy values (3.44; SD 1.53), Local applicability (3,56; SD 1.47) and Resources, tools and capacity (3.49; SD 1.44) items. CPGs developed by government-supported organizations and developed in the UK and Canada had significantly higher recommendation quality scores with the AGREE-REX-D tool (p<0.05) than their comparators. Conclusions. We found that there is significant room for improvement of some CPGs such as the considerations of patient/population values, policy values, local applicability and resources, tools and capacity. These findings may be considered a baseline upon which to measure future improvements in the quality of CPGs.