At IDWeek 2018, the annual conference for the Infectious Diseases Society of America, I was struck by one simple truth.
We are still talking about washing our hands, or in our professional lingo, hand hygiene.
Hand hygiene is the simplest, most effective way to prevent infection. Most of us know this intuitively, without the science, as we grew up being reminded by our parents and teachers to wash our hands. It simply makes sense. Our hands are the most exposed part of our body and are in constant contact with our non-sterile environment (fecal veneer, anyone?). If someone does not wash their hands in the restroom, we are aghast. Don’t they realize that is a health risk?
This issue even resulted in an #IDWeek2018 Twitter post regarding the excellent hand hygiene in the restrooms.
Consider that, excellent hand hygiene noted by healthcare workers, as compared to what? Their home, hospital or clinic? Where else do they observe more hand washing?
We take those hands and feed ourselves, our loved ones. We provide care, and perform procedures and surgeries (with gloves as further protection, of course). But since 1847, when Semmelweis demonstrated the value of hand washing, we have struggled to have full compliance with hand hygiene in healthcare. In the face of the continual fight against sepsis, still we talk, study, and publish articles on the importance of hand washing.
The simplest thing. Wash your hands. Or now, use the hand sanitizer. Before and after patient care. Before eating, after using the restroom. It takes 15 seconds or less, depending on the method. It is so easy. Session discussions included ideas on how to monitor hand washing – direct observations on the unit? App use for recording hand hygiene opportunities? Technology on badges or door frames? Silent monitoring on sinks? Why on Earth would we still need sessions on achieving adherence with hand hygiene in 2018? Why do we not all simply do what we know is best for the health of ourselves and our patients?
This, my friends, is where sociology, more specifically, sociobehavioral science comes into play.
There may be ample science showing the benefits of handwashing. There are pre-created campaigns for handwashing (5 Moments of Hand Hygiene from WHO), and even specific marketing focused on hand hygiene. Not to mention the seemingly endless amounts of hand sanitizer and sinks with soap that can be found in every hospital.
It turns out that knowing the science and being reminded is simply not enough. A four-hour workshop led by Dr. Julia Syzmczak (University of Pennsylvania) at IDWeek entitled “Changing Hearts and Minds: A Sociobehavioral Approach to Antimicrobial Stewardship and Infection Prevention” focused on the fact that science and education do not necessarily equate to behavioral changes in humans (improved hand hygiene). How we as humans behave in a hospital is subject to the same sociologic pressures as the rest of the world. We are not robots, we are humans. We are subject to the impact of perceptions and perceived culture. And if I learned anything, I learned that culture will beat science EVERY DAY OF THE WEEK when it comes to human behavior.
So, what does this mean for us? Do we stop trying? Do we stop innovating?
No, of course not. But, we need to stop forgetting that the successful implementation of science and best practices carries a wild card with it – humanity.
Medical care is increasingly complex, fast-paced and full of “priorities” for providing state of the art care. The reality is, not everything can be a priority. In a realm of competing priorities, how does a single provider pick which priority is actually most important? Will preventing infection via handwashing always fall at the top of the priority list? Should it?
Where do we go from here? The answer, I believe, is as infectious diseases physicians, healthcare epidemiologists, infection preventionists, healthcare providers and patients, we must give human behavior and sociology, an equitable seat at the table with science.
We need to address the competing priorities, study and understand the behaviors we want to change (not always washing your hands) and why that behavior exists. Then focus our interventions on the behavior itself. Science and education are critical to this role; but can no longer be touted as the holy grail of implementation. We need to consider human nature, the social constructs of our institutions, our organizational ‘culture.’
It is crucial that we embrace the sociologic components of healthcare as we strive to continually provide the best possible care for our patients.
Why? Because in the end, we are all patients.
And as your patient, I want you to wash your hands.
Written by Kelly Cawcutt, MD. Post originally published on Doximity.
Doravirine (DOR) is a novel NNRTI that provides a similar efficacy for the treatment of HIV infection with activity against HIV variants that are resistant to efavirenz (EFV) and rilpivirine (RPV). Doravirine offers a better safety profile without neuropsychiatric adverse effects, minimal drug-drug interactions and is unaffected by food intake and need for an acidic absorption environment. In August, 2018, doravirine was approved by the FDA for use and will be available solely (Pifeltro™) or as a single tablet regimen (Delstrigo™) in combination with lamivudine (3TC) and tenofovir disoproxil fumurate (TDF).
DRIVE-AHEAD2: A randomized, double-blind, phase III trial compared doravirine to another NNRTI, efavirenz. Adults with HIV-1 infection naïve to ART, HIV RNA >1,000 copies/ml, and CD4 >100/mm3 were randomized to receive DOR 100mg with 3TC 300mg/TDF 300mg or EFV 600mg with TDF 300mg/emtricitabine (FTC) 200mg. The primary endpoint of the study measured virologic response with the proportion of patients achieving HIV RNA <40 copies/ml at week 48. Comparisons between each arm were similar, 77% in DOR arm vs. 78% in EFV arm, demonstrating non-inferiority. Clinical adverse events deemed drug-related were reported in 31% of patients in DOR arm and 56% in EFV arm. Dizziness (6.5% DOR vs. 25% EFV) and abnormal dreams (5.6% DOR vs. 14.8% EFV) had the largest variation between the two groups. Only one emergent NNRTI mutation arose to the DOR group, K101K/E mutation, which causes intermediate resistance to RPV and low-level resistance to EFV.
DRIVE-FORWARD3: A randomized, controlled, double-blind, phase III, non-inferiority trial compared doravirine to ritonavir-boosted darunavir, a protease inhibitor. Adults with HIV-1 infection naïve to ART, with plasma HIV RNA >1,000 copies/ml were screened and randomized to receive DOR 100mg or DRV 800mg/RTV 100mg (DRV/r), in combination with either TDF/FTC or ABC/3TC based on investigator choice. The proportion of patients that achieved plasma HIV-1 RNA <50 copies/ml at week 48 defined the primary endpoint of this trial. Doravirine showed non-inferiority to ritonavir boosted darunavir, with 84% in DOR arm vs. 80% in DRV/r arm achieving success with HIV RNA <50c/ml at week 48. Clinical adverse events due to drug therapy were reported in 31% in DOR and 32% in DRV/r group, with diarrhea comprising 5% of DOR patients vs. 13% of DRV/r patients. Lab abnormalities were similar between the two regimens, except LDL-cholesterol increases in <1% of DOR patients vs. 9% of DRV/r patients. Resistance testing was performed in 15 protocol-defined virologic failure (PDVF) patients, and within this group no emergent mutations to DOR were found. One case of resistance was found in a patient that discontinued treatment because of non-compliance at week 24, thus was not included in the PDVF category, encompassing resistance to DOR (V106I, H221Y, F227C) and FTC (M184V).
In the second article, “
Under the coaching of Vintage Ballroom instructor, Rebekah Pasqualetto, three pediatric patients are teaming up with the doctors’ who saved them to put on the biggest performance of their young lives. The dancing isn’t easy. Between school, doctor appointments, and daily lives the girls dedicated two months to learning three styles of dance: Rumba, Merengue, and Country Swing. Each song matches the personality of each child. 11-year old Daisy likes to dance with her friends to the latest pop hits. 12-year old Maura has dance training from previous years of ballet. Even with surgery restrictions, Maura is adamant about performing a trick on the dance floor. 12-year old Raeleigh loves fashion, she is very considerate of others. Raeleigh will be joined on the dance floor by her younger sister Addisyn who suffers from watching Raeleigh undergo treatment.
Dr. Diana Florescu is coordinating the fundraiser with Child Life, Vintage Ballroom, and Nebraska Dance Festival. The organizers of Nebraska Dance Festival – Amanda & Ilya Reyzin and Igor Litvinov – are supporting Child Life Services from University of Nebraska Medical Center! Through their donation, they will share the gift of reading and spread some fun to pediatric patients at Nebraska Medicine. Hospitalization can be a scary and isolating experience for children and teens. Many of the kids are hospitalized for long periods of time – months or even years – due to the severity of their illnesses. Books and games will allow kids to experience normalcy, socialization, and continued growth and development while hospitalized.
During the month rotation a small special project is also conducted and a specialized curriculum/lecture series is conducted. ID fellows are exposed to the infection control literature during a monthly infection control journal club in which they take turns critiquing recent publications along with IPs and faculty. The infection control experience is capped off by attendance of the SHEA/CDC basic course in Hospital Epidemiology. For the ID fellow interested in infection control as a career, opportunity for a third year of Fellowship directed toward specialized training in infection control and hospital epidemiology is encouraged.
Penicillin allergies are 
Once a penicillin allergy is listed in a patient’s record, they are more likely to receive inappropriate broad-spectrum antibiotics – a 
There’s an age-old joke that if a team wants a detailed history on a patient, just consult ID. If our attention to detail is already expected, shouldn’t we feel empowered to take that allergy history and de-label the penicillin allergy? Inpatient allergy consultations are difficult to coordinate when those divisions may be understaffed and allergists are busy with outpatient practices. So how can we capitalize on their expertise when they can’t see the patient in the hospital? Simple: partner with them to create 
In honor of Sir Alexander Fleming and 
Dr. Angela Hewlett has been elected to the Executive Board of the 
Dr. Jasmine Marcelin was awarded the SHEA Race Against Resistance Scholarship, funding provided for a new Antimicrobial Stewardship clincian to learn more about the field. Dr. Marcelin partnered with Physicians Weekly to co-moderate two twitter chats on 
Dr. Susan Swindells was awarded the Department of Medicine Faculty Clinical and Educational Mentoring Award.
Dr. Trevor Van Schooneveld was recently named UNMC College of Medicine Resident Program Director of the Month in September (ID Fellowship Program Director)
Dr. Sara Bares was recently inducted into the UNMC Interprofessional Academy of Educators. She also recently was awarded the ACTG Network Minority HIV Investigator Mentoring Award.
What a terrific group of talented and accomplished individuals. Kudos to our faculty and staff for their continued hard work and dedication to advancing academic Infectious Diseases!
Recent Comments