May 2018 (1/3): It's time to ditch the yellow gowns, y'all

Discontinuing contact precautions for patients with MRSA and VRE was associated with a 20% reduction in non-infectious adverse events with no corresponding increase in infections. This should come as no surprise to anyone who has worked in the hospital - patients who are on contact isolation are seen less frequently and cared for less attentively by their physicians, nurses, and other healthcare workers. This paper adds to the growing body of literature published in last few years showing that MRSA and VRE contact precautions can be safely discontinued. Let's also remember that the original studies recommending contact precautions examined intervention bundles, in which contact precautions were rolled out at the same time as more meaningful interventions, like measures to improve handwashing; we have relatively little evidence that contact precautions alone prevent MDR infections. Getting rid of contact precautions wherever their efficacy has not been proven has the potential to not only save money but also directly benefit patient care. 29745356

In the US and Canada, about 4% of TB case contacts go on to develop active tuberculosis; of these, 75% are diagnosed in the first 3 months after the index case is diagnosed, and 92% are diagnosed in the first year. Put another way, if a TB case contact in the US has already gone over a year without developing active TB, their future risk of developing active TB at that point is less than one percent. A caveat to that statement is that the duration of followup for the contacts in this study was five years from the diagnosis of TB in the index patient - so it would not capture risk of late progression from LTBI to active TB disease. 29767733

The addition of procalcitonin to the workup of lower respiratory tract infections did not reduce antibiotic prescribing in medical centers that already had high adherence to antibiotic prescribing guidelines for LRTI. I mention the preexisting good stewardship of antibiotics in the centers studied because the results of this study contrast with those of prior RTCs done at institutions where antibiotics were being overprescribed; in those studies, it was helpful in reducing antibiotic use, and in some studies even improved mortality (likely due to a reduction in side effects/harms of unnecessary antibiotic therapy). Everyone in the academic ID world has strong opinions about the use of procalcitonin; it's either totally revolutionary or a total waste of money. I personally only ever use it as an anxiolytic for my colleagues; that is, I wouldn't trust the PTC to make decisions about starting or stopping antibiotic therapy, but I do think it can be a useful way to convince primary teams to stop antibiotics that you've already decided aren't necessary. 29781385

The presence of a GNR with resistance to an antibiotic in any of a patient's cultures from the preceding 12mo is highly specific (92%) for the presence of resistance to that antibiotic in the patient's present gram-negative bacteremia (PPV: 66%). Put another way, if you have a patient with a gram-negative bacteremia, don't start them on an antibiotic that any of their cultured GNRs had resistance to in the preceding year. 2881124