Browsing by Author "Alali, Muayad"

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    1340. Yield of Repeat Blood Cultures beyond 48 Hours after Negative Initial Cultures in Patients Hospitalized on a Pediatric Hematology/Oncology Unit
    (Oxford University Press, 2022-12-15) Prather, Cassandra S.; Alali, Muayad; Graduate Medical Education, School of Medicine
    Background: Repeat blood cultures (BCxs) beyond 48 hours are often obtained despite negative initial BCxs in hospitalized pediatric hematology/oncology patients. This study seeks to determine the yield of repeat BCxs after negative initial cultures in these patients and to characterize new positive BCxs beyond 48 hours and the clinical contexts in which they were obtained. Methods: A retrospective review utilizing MedMined Inc. Data Mining Surveillance database was conducted on all BCxs obtained on hospitalized patients on the pediatric hematology/oncology unit at Riley Hospital for Children in Indianapolis, IN from January 2015 to February 2021. Exclusion criteria are shown in Fig. 1. Patient episodes in which a new pathogen (or commensal treated by the primary team as a pathogen) was identified on a repeat BCx more than 48 hours after negative initial BCxs were further investigated via electronic medical record review. Results: A total of 1,362 BCx sets were obtained beyond 48 hours in 792 patient hospitalizations, resulting in 303 positive BCxs (Fig. 2). Of these positive cultures, 193 were the same pathogen cultured on day 0 and 74 were contaminant cultures (in 4.0% (23/573) of patient hospitalizations without a positive BCx before 48 hours). Only 36 (2.6%) of positive BCxs beyond 48 hours were determined to be new pathogens, or commensals treated as pathogens, that were not cultured before 48 hours, corresponding to seven patient hospitalizations (1.2% (7/573) of patient hospitalizations without a positive BCx before 48 hours). The majority (6/7) of these patients were neutropenic and on broad spectrum antibiotics when the new positive BCxs were obtained. Fever pattern was prolonged in one patient and recurrent in six. No deaths occurred in these seven patients. All patients with new, true pathogens on BCxs beyond 48 hours (n=5) were either hemodynamically unstable (n=3) or had clinical changes (n=2, mucositis, diarrhea) the day the new positive BCx was drawn. Conclusion: The yield of repeat BCxs beyond 48 hours in hospitalized pediatric hematology/oncology patients with negative initial BCxs is low, while the associated costs are high. Repeat BCxs beyond 48 hours after negative initial cultures need not be obtained in febrile patients that remain hemodynamically stable and without clinical changes.
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    Confounding Histoplasmosis in Hodgkin’s Lymphoma
    (2022-03-24) Zhou, Shannon; Friel, Rylee; Holohan, Maggie; Geers, Erica; Alali, Muayad; Belsky, Jennifer
    Case Description: A 17-year-old, black female was diagnosed with Hodgkin’s Lymphoma (HL), confirmed with lymph node biopsy. Initial infectious workup was negative for Histoplasmosis capsulatum (H. capsulatum), and she was started on routine chemotherapy. After 2 cycles of chemotherapy, routine 18FDG/PET scan demonstrated reduction in previous mediastinal adenopathy, but new areas of adenopathy. Due to concern of disease progression in conjunction with new fevers and dyspnea, she had a biopsy which histologically confirmed H. capsulatum with positive IgG and IgM. She was started on antifungal therapy with dose reduction of chemotherapy. FDG/PET scan 5 weeks into antifungal therapy demonstrated continued FDG uptake in previous H. caspulatum concerning areas, and she was continued on both chemotherapy and antifungal therapy. Radiation to her mediastinal mass and persistent areas of FDG uptake is under discussion. Conclusion: Hodgkin lymphoma (HL) is the most common form of lymphoma and classically presents in late adolescent females as lymphadenopathy. 18FDG/PET scans are used to visualize malignant tissue and aid in staging and end of treatment assessment. We present a case of HL whose case was complicated by concurrent H. capsulatum infection, creating a clinical conundrum regarding treatment. Clinical Significance: Acute H. capsulatum infection can appear as a pulmonary consolidation and/or lymphadenopathy with FDG avidity, making it difficult to discern infection from malignancy. This often results in biopsy, chemotherapy reduction, and ambiguity regarding future radiation therapy. Future research should focus on more FDG sensitive tracers to differentiate malignant tissue from infectious or inflammatory tissue. In addition, immunosuppression in the setting of chemotherapy puts patients at risk for opportunistic infections such as H. capsulatum. Screening for opportunistic disease in endemic areas before initiating chemotherapy should be considered.
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    Febrile Neutropenia in Children: Etiologies, Outcomes, and Risk Factors with Prolonged Fever
    (Lidsen, 2020-02) Alali, Muayad; David, Michael Z.; Ham, Sandra A.; Danziger-Isakov, L. A.; Bartlett, Allison H.; Petty, Lindsay; Pisano, Jennifer; Pediatrics, School of Medicine
    Most studies of children with prolonged fever and neutropenia (PFN) have focused on invasive fungal disease (IFD) as the etiology of fever and not on other causes. Data are lacking regarding risk factors and adverse outcomes in pediatric cancer patients with PFN compared with those whose fevers resolve more rapidly. Retrospective medical record review was performed for all cancer patients with febrile neutropenia (FN) in the pediatric oncology unit at University of Chicago Medicine Comer Children’s Hospital from March 2009 to July 2016. Resolving febrile neutropenia (RFN), lasting less than 96 hours, and PFN episodes (≥ 96 hours) were compared to identify risk factors and outcomes associated with PFN. A total of 572 FN episodes were identified in 265 patients. PFN occurred in 119 (21%) FN episodes (50 patients) and RFN occurred in 453 (79%) FN episodes (215 patients). In multivariable analysis, autologous stem cell transplant (odds ratio [OR] 6.5, P <0.001), fever >39°C at the time of presentation (OR 2.4, P<0.01) and absolute monocyte count (AMC) <100 cells/m3 (OR 2.7, P=<0.01) were independently associated with PFN. Pneumonia, neutropenic enterocolitis and IFD were more common etiologies of fever in PFN compared with RFN. Patients with PFN were more likely to be admitted to the pediatric intensive care unit [OR 3, (95%CI, 1.66%-5.28%), P<0.001] and had a trend toward higher 30-day mortality [OR 3.8, (95%CI, 0.52%-29.32%), P=0.07]. Patients with PFN are at increased risk for serious illness and death. A better understanding of the etiologies of PFN other than IFD is needed to be able to appropriately diagnose and treat this high-risk group.
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    High frequency of viridians group streptococci bacteremia in pediatric neuroblastoma high-risk patients during induction chemotherapy
    (Springer Nature, 2023-04-06) El Kebbi, Ola; Prather, Cassandra S.; Elmuti, Lena; Khalifeh, Malak; Alali, Muayad; Pediatrics, School of Medicine
    Existing literature on febrile neutropenia (FN) has categorized patients with acute leukemia or those undergoing allogeneic stem cell transplantation (SCT) as being high risk for severe infection, bacteremia, and poor outcomes. Comprehensive studies of infection risk in pediatric high-risk neuroblastoma (NB-HR) during induction chemotherapy are limited, and mostly merged within the solid tumor (ST) group. Therefore, it is unclear whether infectious complications and outcomes for NB-HR are the same as in other ST groups. We conducted a retrospective medical record review of pediatric FN patients in a single center from March 2009 to December 2016. FN episodes were categorized into five groups based on underlying diagnosis (acute myelogenous leukemia (AML), acute lymphocytic leukemia (ALL), NB-HR during induction chemotherapy, other solid tumors, and SCT). Comparative analyses of infectious complications between patients with NB-HR and those with other types of cancer diagnoses were performed. A total of 667 FN episodes (FNEs) were identified in 230 patients. FNEs occurred in 82 episodes with NB-HR. Bloodstream infection (BSI) occurred in 145 (21.7%) of total FN episodes. The most isolated organisms were the viridians group streptococci (VGS) (25%). NB-HR patients have higher rates of VGS bacteremia (OR 0.15, 95% [CI 0.04, 0.56]) and are more likely to be admitted to the Pediatric Intensive Care Unit (PICU) compared to patients with other solid tumors (OR 0.36, 95% [CI 0.15, 0.84]). Interestingly, there is no difference in VGS rates between patients with NB-HR and those with AML despite the fact that NB-HR patients do not receive a cytosine arabinoside (AraC)-based regimen. This large neuroblastoma cohort showed that patients with NB-HR during induction chemotherapy are at higher risk for VGS bacteremia and PICU admissions compared with patients with other solid tumors. Further prospective studies are needed to investigate infection-related complications in this high-risk group and to improve morbidity and mortality.
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    P-1606. Utilizing Diagnostic Stewardship to Help Increase the Yield and Clinical Value of Broad Range PCR Testing at a Tertiary Children’s Hospital
    (Oxford University Press, 2025-01-29) Fortna, Sarah; Alali, Muayad; Prabhudas-Strycker, Kirsten; Mellencamp, Kagan A.; Boyd, LaKeisha; Goings, Michael; Khan, Haseeba; Fahey, Mackenzie; Samaro, Matthew; Schneider, Jack G.; Graduate Medical Education, School of Medicine
    Background: Broad range PCR testing (BR-PCR) in various clinical samples has the ability to provide timely diagnoses that cannot always be made through conventional testing (CT), yet its diagnostic yield and clinical impact have been variable, especially by specimen type. As such, we developed an ID-physician led diagnostic stewardship approval protocol to help optimize test usage. Methods: We conducted a single-center, retrospective pre/post study to assess the impact of an ID-led diagnostic stewardship approval protocol for BR-PCR testing. All clinical specimen types obtained for BR-PCR at Riley Hospital for Children were evaluated between 10/1/2019 to 4/30/2022 (pre-intervention) and 5/1/2022-12/31/2023 (post-intervention). Clinical relevancy of BR-PCR results was determined after review from two ID physician experts and compared between the two time periods, along with clinical impact and overall cost savings. Results: A total of 931 BR-PCR tests were sent from 238 specimens collected from 175 patients in the pre-intervention period, while 208 BR-PCR tests were sent from 65 specimens collected from 65 patients in the post-intervention period. Clinical relevancy of results was determined to be 30.7% and 56.9% for pre-and post-intervention periods, respectively (p< 0.001). 23.1% of post intervention results led to a change in clinical management, compared to 12.6% in the pre-intervention period (p=0.035). Bronchial lavage (BAL) was the most common specimen type with 52.9% of results being clinically relevant post-intervention, compared to 29.6% in the pre-intervention period; p=0.068). Results that led to a clinical change in management were also slightly higher but non-significant for BALs post-intervention (11.8% vs 9.9% pre intervention; p=0.816). Overall cost savings post-intervention was estimated to be $200,000. Conclusion: Use of an ID-physician led diagnostic stewardship approval protocol led to an overall improvement in clinical utility for BR-PCR testing at our institution and was influenced by specimen type. Prospective, multi-center studies are needed to determine which specimen types, diagnoses, and potential diagnostic stewardship measures will help increase the yield and clinical value of BR-PCR testing.
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    Recurrent Serratia marcescens osteomyelitis eight years after a contaminated open fracture: a case report and review of the literature
    (AME, 2024) Mayhew, Jonathan A.; Christenson, John C.; Alali, Muayad; Pediatrics, School of Medicine
    Background: Serratia marcescens (S. marcescens) is an unusual cause of osteomyelitis. Infection may develop following open trauma, intravenous drug abuse, or in the presence of hardware, but osteoarticular infections outside of this context are atypical in the absence of immunodeficiency. Rarely, a chronic indolent infection may develop after open trauma with disease recurrence years after the initial injury. Case description: We present the case of a 16-year-old male with extensive left lower extremity osteomyelitis secondary to S. marcescens eight years after an open fracture to this leg was complicated by an infection with the same organism. Suboptimal therapy of his initial infection may have contributed to persistent, latent disease before recurrence years later. Evaluation for immunodeficiency was negative and he responded well to ciprofloxacin antibiotic therapy. Conclusions: S. marcescens infection may complicate open fractures, and, if not adequately treated, a chronic, indolent infection may result, with disease recurrence years later. We stress the importance of adequate therapy for infectious complications following open fractures and discuss virulence factors of S. marcescens that may allow this organism to evade the immune system and survive subclinically within a host. The optimal therapy of S. marcescens osteomyelitis is not established and further studies are needed to best guide the therapeutic approach.