Infectious causes of fever of unknown origin in developing countries: An international ID-IRI study

Background

Fever of unknown origin (FUO) in developing countries is an important dilemma and further research is needed to elucidate the infectious causes of FUO.

Methods

A multi-center study for infectious causes of FUO in lower middle-income countries (LMIC) and low-income countries (LIC) was conducted between January 1, 2018 and January 1, 2023. In total, 15 participating centers from seven different countries provided the data, which were collected through the Infectious Diseases-International Research Initiative platform. Only adult patients with confirmed infection as the cause of FUO were included in the study. The severity parameters were quick Sequential Organ Failure Assessment (qSOFA) ≥2, intensive care unit (ICU) admission, vasopressor use, and invasive mechanical ventilation (IMV).

Results

A total of 160 patients with infectious FUO were included in the study. Overall, 148 (92.5%) patients had community-acquired infections and 12 (7.5%) had hospital-acquired infections. The most common infectious syndromes were tuberculosis (TB) (n=27, 16.9%), infective endocarditis (n=25, 15.6%), malaria (n=21, 13.1%), brucellosis (n=15, 9.4%), and typhoid fever (n=9, 5.6%). Plasmodium falciparum, Mycobacterium tuberculosis, Brucellae, Staphylococcus aureus, Salmonella typhi, and Rickettsiae were the leading infectious agents in this study. A total of 56 (35.0%) cases had invasive procedures for diagnosis. The mean qSOFA score was 0.76±0.94 {median (interquartile range [IQR]): 0 (0-1)}. ICU admission (n=26, 16.2%), vasopressor use (n=14, 8.8%), and IMV (n=10, 6.3%) were not rare. Overall, 38 (23.8%) patients had at least one of the severity parameters. The mortality rate was 15 (9.4%), and the mortality was attributable to the infection causing FUO in 12 (7.5%) patients.

Conclusions

In LMIC and LIC, tuberculosis and cardiac infections were the most severe and the leading infections causing FUO.

Prospective analysis of febrile neutropenia patients with bacteraemia: the results of an international ID-IRI study

OBJECTIVES

Bacteraemia during the course of neutropenia is often fatal. We aimed to identify factors predicting mortality to have an insight into better clinical management.

METHODS

The study has a prospective, observational design using pooled data from febrile neutropenia patients with bacteraemia in 41 centres in 16 countries. Polymicrobial bacteraemias were excluded. It was performed through the Infectious Diseases-International Research Initiative platform between 17 March 2021 and June 2021. Univariate analysis followed by a multivariate binary logistic regression model was used to determine independent predictors of 30-d in-hospital mortality (sensitivity, 81.2%; specificity, 65%).

RESULTS

A total of 431 patients were enrolled, and 85 (19.7%) died. Haematological malignancies were detected in 361 (83.7%) patients. Escherichia coli (n = 117, 27.1%), Klebsiellae (n = 95, 22% %), Pseudomonadaceae (n = 63, 14.6%), Coagulase-negative Staphylococci (n = 57, 13.2%), Staphylococcus aureus (n = 30, 7%), and Enterococci (n = 21, 4.9%) were the common pathogens. Meropenem and piperacillin-tazobactam susceptibility, among the isolated pathogens, were only 66.1% and 53.6%, respectively. Pulse rate (odds ratio [OR], 1.018; 95% confidence interval [CI], 1.002-1.034), quick SOFA score (OR, 2.857; 95% CI, 2.120-3.851), inappropriate antimicrobial treatment (OR, 1.774; 95% CI, 1.011-3.851), Gram-negative bacteraemia (OR, 2.894; 95% CI, 1.437-5.825), bacteraemia of non-urinary origin (OR, 11.262; 95% CI, 1.368-92.720), and advancing age (OR, 1.017; 95% CI, 1.001-1.034) were independent predictors of mortality. Bacteraemia in our neutropenic patient population had distinctive characteristics. The severity of infection and the way to control it with appropriate antimicrobials, and local epidemiological data, came forward.

CONCLUSIONS

Local antibiotic susceptibility profiles should be integrated into therapeutic recommendations, and infection control and prevention measures should be prioritised in this era of rapidly increasing antibiotic resistance.

Classical fever of unknown origin in 21 countries with different economic development: an international ID-IRI study

Fever of unknown origin (FUO) is a serious challenge for physicians. The aim of the present study was to consider epidemiology and dynamics of FUO in countries with different economic development. The data of FUO patients hospitalized/followed between 1st July 2016 and 1st July 2021 were collected retrospectively and submitted from referral centers in 21 countries through ID-IRI clinical research platform. The countries were categorized into developing (low-income (LI) and lower middle-income (LMI) economies) and developed countries (upper middle-income (UMI) and high-income (HI) economies). This research included 788 patients. FUO diagnoses were as follows: infections (51.6%; n = 407), neoplasms (11.4%, n = 90), collagen vascular disorders (9.3%, n = 73), undiagnosed (20.1%, n = 158), miscellaneous diseases (7.7%, n = 60). The most common infections were tuberculosis (n = 45, 5.7%), brucellosis (n = 39, 4.9%), rickettsiosis (n = 23, 2.9%), HIV infection (n = 20, 2.5%), and typhoid fever (n = 13, 1.6%). Cardiovascular infections (n = 56, 7.1%) were the most common infectious syndromes. Only collagen vascular disorders were reported significantly more from developed countries (RR = 2.00, 95% CI: 1.19-3.38). FUO had similar characteristics in LI/LMI and UMI/HI countries including the portion of undiagnosed cases (OR, 95% CI; 0.87 (0.65-1.15)), death attributed to FUO (RR = 0.87, 95% CI: 0.65-1.15, p-value = 0.3355), and the mean duration until diagnosis (p = 0.9663). Various aspects of FUO cannot be determined by the economic development solely. Other development indices can be considered in future analyses. Physicians in different countries should be equally prepared for FUO patients.

Carbapenem-Resistant Enterobacteriaceae (CRE) among Children with Cancer: Predictors of Mortality and Treatment Outcome

Carbapenem-resistant Enterobacteriaceae (CRE) is an important emerging threat among pediatric cancer patients, with a high mortality rate. This retrospective study included all pediatric cancer patients with (CRE) bloodstream infections (BSIs) at a children's cancer hospital in Egypt (2013-2017). Two hundred and fifty-four pediatric cancer patients with CRE BSI were identified; 74% had hematological malignancies, and 26% had solid tumors. Acute myeloid leukemia was the most common hematological malignancy (50%). The main clinical features for acquiring CRE-BSI were previous antibiotics exposure (90%), profound neutropenia (84%), prolonged steroid use (45%), previous colonization with a resistant pathogen (35%), ICU admission within 90 days (28%), and central venous catheter use (24%). E. coli was the most common isolated pathogen (56%), followed by Klebsiella pneumoniae (37%). All isolates were resistant to carbapenem with an MIC < 4-8 μg/mL in 100 (45%) and >8 μg/mL in 153 (55%). The overall mortality rate was 57%, and 30 day mortality was reported in 30%. Upon multivariate analysis, for the patients with Klebsiella pneumoniae BSI, carbapenem resistance with an MIC > 8 μg/mL and associated typhlitis or pneumonia were predictors of poor outcome. In conclusion, CRE-BSI is a major threat among pediatric cancer patients in limited resource countries with limited options for treatment. Antimicrobial stewardship for early detection through routine screening, adequate empirical treatment, and timely adequate therapy may impact the outcome for such high-risk patient groups.

Outcome and safety of colistin usage in pediatric cancer patients with carbapenem-resistant enterobacteriaceae bacteremia at children cancer hospital Egypt

Background

Carbapenem resistant Enterobacteriacae (CRE) bloodstream infection (BSI) causes complicated infections, especially in immunocompromised patients. This study aimed to assess the renal toxicity and the efficacy of therapy with colistin in a cohort of pediatric cancer patients with BSIs due to CRE and sensitivity to colistin.

Patients and Methods

This was an observational, prospective cohort study from May 2017 to October 2017 in Children's Cancer Hospital Egypt 57,357. All patients who had blood stream infections due to CRE receiving intravenous colistin were prospectively enrolled. We used a standardized case form to record patient characteristics, including age, sex, weight, underlying comorbidities, type of infection, causative organism, and antibiotic susceptibility testing. Daily doses, duration of colistin therapy, and co-administered antibiotics (aminoglycosides, vancomycin) were collected. Furthermore, clinical and microbiological responses to treatment were reported. The dosing schedule was based on a loading dose of 5 MU and a 5-MU twice-daily divided maintenance dose, titrated on renal function. Clinical cure, bacteriological clearance, and daily serum creatinine were recorded.

Results

One hundred and forty-one Blood Stream infectious episodes mainly due to Klebsiella Species (pneumoniae and Oxytoca) (27%) and Escherichia coli (68%) were analyzed. All strains were susceptible to colistin with Minimum inhibitory concentration (MICs) of 0.19-1.5 mg/L. Patients were predominantly females (69%), with a mean age of 7 years. It was used as a combination therapy with carbapenems (69.2%) or aminoglycosides (80%). The median duration of treatment was 9 days (Range 1-50 days). Clinical and microbiological cure was observed in 110 cases (80%). Acute kidney injury developed during five treatment courses (4%) in which colistin was used in combination with amikacin. No renal replacement therapy was required and subsided within 7 days from colistin discontinuation.

Conclusions

Our study showed that colistin had a high efficacy without significant renal toxicity in severe infections due to CRE Gram-negative bacteria.

Analyzing central-line associated bloodstream infection prevention bundles in 22 countries: The results of ID-IRI survey

BACKGROUND

Because central line-associated bloodstream infections (CLABSIs) are a significant complication of central venous access, it is critical to prevent CLABSIs through the use of central line bundles. The purpose of this study was to take a snapshot of central venous access bundles in various countries.

METHODS

The participants in intensive care units (ICUs) completed a questionnaire that included information about the health center, infection control procedures, and central line maintenance. The countries were divided into 2 groups: those with a low or low-middle income and those with an upper-middle or high income.

RESULTS

Forty-three participants from 22 countries (46 hospitals, 85 ICUs) responded to the survey. Eight (17.4%) hospitals had no surveillance system for CLABSI. Approximately 7.1 % (n = 6) ICUs had no CLABSI bundle. Twenty ICUs (23.5%) had no dedicated checklist. The percentage of using ultrasonography during catheter insertion, transparent semi-permeable dressings, needleless connectors and single-use sterile pre-filled ready to use 0.9% NaCl were significantly higher in countries with higher and middle-higher income (P < .05).

CONCLUSIONS

Our study demonstrated that there are significant differences in the central line bundles between low/low-middle income countries and upper-middle/high-income countries. Additional measures should be taken to address inequity in the management of vascular access in resource-limited countries.

COVID-19-Associated Pulmonary Fungal Infection among Pediatric Cancer Patients, a Single Center Experience

Patients with COVID-19 are at risk of developing secondary complications such as invasive pulmonary aspergillosis and mucormycosis. This is a retrospective study including all cancer children diagnosed with COVID-19-associated pulmonary fungal infection (CAPFI) during the period 2020–2021. A total of 200 patients were diagnosed with COVID-19, out of which 21 (10%) patients were diagnosed with CAPFI, 19 patients (90%) with COVID-aspergillosis (CAPA), and 2 (10%) patients with COVID-mucormycosis (CAM). Patients with CAPFI were classified using the “2020 ECMM/ISHAM consensus criteria”; proven in 2 (10%) patients, probable in 12 (57%), and possible in 7 (33%) patients. Although the hematological malignancy patients were already on antifungal prophylaxis, breakthrough fungal infection was reported in 16/21 (75%), 14 (65%) patients had CAPA while on echinocandin prophylaxis, while 2 (10%) patients had CAM while on voriconazole prophylaxis. Overall mortality was reported in 8 patients (38%) while CAPFI-attributable mortality was reported in 4 patients (20%). In conclusion, clinicians caring for pediatric cancer patients with COVID-19 should consider invasive pulmonary fungal infection, even if they are on antifungal prophylaxis, especially with worsening of the clinical chest condition. A better understanding of risk factors for adverse outcomes may improve clinical management in these patients.

Characteristics, Treatment Complexity, and Outcome of Mixed-Phenotype Acute Leukemia in Children in a Low–Middle-Income Country

Background

Mixed-phenotype acute leukemia (MPAL) in children is an uncommon subtype of acute leukemia that cannot be definitively assigned to a specific lineage. There is no consensus on the best approach to therapy. Management is more complex in low–middle-income countries (LMICs).

Aim

To evaluate the clinicopathological characteristics and outcomes of patients with MPAL in a developing country.

Patients and Methods

A retrospective descriptive study of 42 pediatric patients newly diagnosed with MPAL from July 2007 until December 2017.

Results

The immunophenotyping was T/Myeloid in 24 patients (57.1%) and B/Myeloid in 16 (38.1%). Three subjects had MLL gene rearrangement, two had Philadelphia-positive chromosomes, and eight had FMS-like tyrosine kinase 3 (FLT3-ITD) internal tandem duplication (FLT3-ITD) with a ratio &gt;0.4. Two subjects died before starting chemotherapy. Ten patients (25%) received acute lymphoblastic leukemia (ALL) induction, and all achieved complete remission (CR) with no induction deaths and no shift of therapy. Thirty patients (75%) started therapy with acute myeloid leukemia (AML) induction: five (16.6%) died during induction, 17 (56.7%) achieved CR, and 10 patients received maintenance ALL therapy after ending AML treatment. Four of the eight patients with induction failure were switched to ALL therapy. The 5-year event-free survival (EFS) and overall survival (OS) rates were 56.7% [standard error (SE): 8.1%] and 61% (SE: 8%), while the cumulative incidence of relapse was 21.7% (SE: 6.7%), with a median follow-up duration of 5.8 years. Patients treated with ALL-directed therapy had a 5-year EFS rate of 111 70% (SE: 14%) and OS rate of 78.8% (SE: 13%). Patients treated with ALL-directed therapy had a 5-year EFS rate of 70% (SE: 14.5%) and OS rate of 78.8% (SE: 13%). FLT3-ITD mutation showed a significantly lower 5-year EFS rate of 28.6% (SE: 17%) vs. 75% (SE: 9%) for the wild type, p = 0.032. Undernourished patients with a body mass index (BMI) z-score ≤-2 at presentation had a significantly lower 5-year EFS rate of 20% (SE: 17%) compared to 61.8% (SE: 8%) for patients with BMI z-score &gt;-2, p = 0.015.

Conclusion

This study supports ALL-directed therapy for pediatric MPAL in a setting of LMIC. Given the poor outcome of FLT3-ITD, the role of FLT3 inhibitor needs to be explored in this subset of cases.

Vaccine hesitancy and refusal among parents: An international ID-IRI survey

INTRODUCTION

Although vaccines are the safest and most effective means to prevent and control infectious diseases, the increasing rate of vaccine hesitancy and refusal (VHR) has become a worldwide concern. We aimed to find opinions of parents on vaccinating their children and contribute to available literature in order to support the fight against vaccine refusal by investigating the reasons for VHR on a global scale.

METHODOLOGY

In this international cross-sectional multicenter study conducted by the Infectious Diseases International Research Initiative (ID-IRI), a questionnaire consisting of 20 questions was used to determine parents' attitudes towards vaccination of their children.

RESULTS

Four thousand and twenty-nine (4,029) parents were included in the study and 2,863 (78.1%) were females. The overall VHR rate of the parents was found to be 13.7%. Nineteen-point three percent (19.3%) of the parents did not fully comply with the vaccination programs. The VHR rate was higher in high-income (HI) countries. Our study has shown that parents with disabled children and immunocompromised children, with low education levels, and those who use social media networks as sources of information for childhood immunizations had higher VHR rates (p < 0.05 for all).

CONCLUSIONS

Seemingly all factors leading to VHR are related to training of the community and the sources of training. Thus, it is necessary to develop strategies at a global level and provide reliable knowledge to combat VHR.

Prognostic impact of CT severity score in childhood cancer with SARS-CoV-2

Background

CT chest severity score (CTSS) is a semi-quantitative measure done to correlate the severity of the pulmonary involvement on the CT with the severity of the disease.

The objectives of this study are to describe chest CT criteria and CTSS of the COVID-19 infection in pediatric oncology patients, to find a cut-off value of CTSS that can differentiate mild COVID-19 cases that can be managed at home and moderate to severe cases that need hospital care.

A retrospective cohort study was conducted on 64 pediatric oncology patients with confirmed COVID-19 infection between 1 April and 30 November 2020. They were classified clinically into mild, moderate, and severe groups. CT findings were evaluated for lung involvement and CTSS was calculated and range from 0 (clear lung) to 20 (all lung lobes were affected).

Results

Overall, 89% of patients had hematological malignancies and 92% were under active oncology treatment. The main CT findings were ground-glass opacity (70%) and consolidation patches (62.5%). In total, 85% of patients had bilateral lung involvement, ROC curve  showed that the area under the curve of CTSS for diagnosing severe type was 0.842 (95% CI 0.737–0.948). The CTSS cut-off of 6.5 had 90.9% sensitivity and 69% specificity, with 41.7% positive predictive value (PPV) and 96.9% negative predictive value (NPV). According to the Kaplan–Meier analysis, mortality risk was higher in patients with CT score > 7 than in those with CTSS < 7.

Conclusion

Pediatric oncology patients, especially those with hematological malignancies, are more vulnerable to COVID-19 infection. Chest CT severity score > 6.5 (about 35% lung involvement) can be used as a predictor of the need for hospitalization.

Profiles of multidrug-resistant organisms among patients with bacteremia in intensive care units: an international ID-IRI survey

Evaluating trends in antibiotic resistance is a requisite. The study aimed to analyze the profile of multidrug-resistant organisms (MDROs) among hospitalized patients with bacteremia in intensive care units (ICUs) in a large geographical area. This is a 1-month cross-sectional survey for blood-borne pathogens in 57 ICUs from 24 countries with different income levels: lower-middle-income (LMI), upper-middle-income (UMI), and high-income (HI) countries. Multidrug-resistant (MDR), extensively drug-resistant (XDR), or pan-drug-resistant isolates were searched. Logistic regression analysis determined resistance predictors among MDROs. Community-acquired infections were comparable to hospital-acquired infections particularly in LMI (94/202; 46.5% vs 108/202; 53.5%). Although MDR (65.1%; 502/771) and XDR (4.9%; 38/771) were common, no pan-drug-resistant isolate was recovered. In total, 32.1% of MDR were Klebsiella pneumoniae, and 55.3% of XDR were Acinetobacter baumannii. The highest MDR and XDR rates were in UMI and LMI, respectively, with no XDR revealed from HI. Predictors of MDR acquisition were male gender (OR, 12.11; 95% CI, 3.025-15.585) and the hospital-acquired origin of bacteremia (OR, 2.643; 95%CI, 1.462-3.894), and XDR acquisition was due to bacteremia in UMI (OR, 3.344; 95%CI, 1.189-5.626) and admission to medical-surgical ICUs (OR, 1.481; 95% CI, 1.076-2.037). We confirm the urgent need to expand stewardship activities to community settings especially in LMI, with more paid attention to the drugs with a higher potential for resistance. Empowering microbiology laboratories and reports to direct prescribing decisions should be prioritized. Supporting stewardship in ICUs, the mixed medical-surgical ones in particular, is warranted.

Overview and outcome of mucormycosis among children with cancer: Report from the Children's Cancer Hospital Egypt

Mucormycosis represents a real challenge in immunocompromised patients. This study aimed to describe the clinical characteristics, treatment outcome and infection-related mortality in our patients at the Children's Cancer Hospital 57357, Cairo, Egypt. This is a retrospective study during the period 2007-2017. Data analysis included demographic data, risk factors, diagnostic workup, treatment and outcome. During the study period, 45 patients developed proven mucormycosis according to EORTC/MSG criteria (2008). Ninety percentof cases were of haematological malignancies. Liposomal amphotericin B was the mainstay of treatment. Posaconazole was used as secondary prophylaxis in 35% of cases. Combination antifungal was used in three cases with progressive mucormycosis. Surgical intervention was achievable in 50% of cases. Therapy was successful in 35 patients (66%). Complications related to mucormycosis were seen in five cases with disfigurement and perforated hard palate. Chemotherapy delay with subsequent relapse of primary malignancy was reported in one case. Mucormycosis-related mortality was 33% (15 cases). Mucormycosis is a major cause of mortality among patients with haematological malignancies. Early diagnosis of Mucormycosis infection, with rapid initiation of appropriate antifungal therapy and surgical intervention, whenever feasible, is the backbone of mucormycosis treatment.

1534. Prevalence and Outcome of Neutropenic Enterocolitis Among Pediatric Acute Myeloid Leukemia Patients: A Developing Country Experience

Background

Neutropenic enterocolitis (NEC) is a life-threatening disease with substantial morbidity and mortality, seen primarily in patients with hematologic malignancies. The frequency of NEC has increased with the widespread use of chemotherapeutic agents such as the taxanes, which cause severe gastrointestinal mucositis.

Methods

This was a retrospective study at the National Cancer Institute, Cairo University. The computerized records were screened for ultrasound or computerized tomographic scan requests for abdominal pain for all acute myeloid pediatrics inpatients (2012–2016). Retrospective case note analysis was used to collect clinical data for patients with features of Typhlitis. D 30 morbrtality was reported.

Results

The incidence of NEC among our inpatients was 24% (49/203). Forty-three children had radiologically confirmed typhlitis, and six had clinical features alone. Most (93%) patients were profoundly neutropenic (ANC <100). All of the patients were subjected to conservative management. All of them needed ICU admission. Eighteen children had a variable period of bowel rest, including 12 patients who were supported with total parenteral nutrition. Three patients had laparotomy that revealed extensive colonic bowel necrosis (1), perforated bowel loop (1), and a perforated appendix (1).Two out of three cases of Laparotomy were diagnosed with Mucormycosis. 30-Days mortality was 44.8% (22/49).Relapsing typhlitis in subsequent courses was observed in 6/27 (22%) patients. Fulminant Gram-negative sepsis without surgical intervention was the leading cause of death in this cohort.

Conclusion

The diagnosis of typhlitis was based on clinical features, supported by radiologic evidence in almost half of the study group. Surgical intervention should be reserved for specific complications or where another surgical pathologic condition cannot reasonably be ruled out. Though rare, fungal infection should be suspected specially in cases with worsening signs of typhlitis despite broad antimicrobial coverage.

Disclosures

All authors: No reported disclosures.

2437. Colistin Usage, Do We Need to Worry About Its Toxicity Among Children With Cancer?

Background

Gram-negative bacteria susceptible only to colistin are emerging causes of complicated infections especially in the immunocompromised patients, reviving interest in the use of colistin. The purpose of this study was to test the renal toxicity along with efficacy of a salvage therapy with a colistin among pediatric cancer patients in our hospital.

Methods

A prospective, observational, cohort study was performed from May 2017 to October 2017 in Children’s cancer hospital Egypt 57357. All patients who had Blood Stream Infections due to COS Gram-negative bacteria and received intravenous Colistin were prospectively enrolled. A standardized case form was used to record patient characteristics, including age, sex, weight, underlying comorbidities, type of infection, causative organism and in vitro susceptibility, daily doses and duration of colistin therapy, cumulative dose of colistin, co-administered antibiotics, nephrotoxic agents, and clinical and microbiological responses to therapy, daily serum creatinine clearance, and estimated creatinine clearance were recorded.

Results

One hundred and Thirty-four Blood Stream infectious episodes due to Klebsiella species (pneumoniae and Oxytoca) (32%), and E. coli (68%) were analyzed. All strains were fully susceptible to colistin, with MICs of 0.19–1.5 mg/L. It was employed as combination therapy with carbapenems (69.2%) or aminoglycosides (30.8%). Median duration of treatment was 9 days (range 1–50 days). Clinical and Microbiological cure was observed in 107 cases (80%). Acute kidney injury developed during 5 treatment courses (4%)in combination with Amikacin. No renal replacement therapy was required and subsided within 7 days from Colistin discontinuation. No correlation was found between variation in serum creatinine level (from base line to peak) and daily and cumulative doses of CMS.

Conclusion

Our study shows that in severe infections due to COS Gram-negative bacteria, Colistin had a high efficacy, without significant renal toxicity. Looking into the failure of microbiological cure, we need to further study the possibility of increasing the Colistin with cautious monitoring of renal functions, and Therapeutic Drug monitoring. Furthermore, the bacterial isolates should be studied at the genetic level for resistance.

Disclosures

All authors: No reported disclosures.

Development of the joint Children’s Cancer Hospital Egypt (CCHE-57357) Dana-Farber Boston Children’s Hospital Pediatric Oncology Fellowship Program

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Background: Children diagnosed with cancer in low- and middle-income countries (LMIC) have markedly inferior outcomes compared to those in high income countries. While some of these issues can be resource availability, a major problem is the quality of training and traditional methods of clinical practice where decision making is centered on the most senior person on the team. To ensure real change, highly-trained locally based specialists with a strong emphasis on problem-solving and critical thinking using evidence-based approaches are needed. Methods: The Children’s Cancer Hospital Egypt (CCHE-57357) and Dana-Farber Boston Children’s Hospital (DFBCH) at Harvard Medical School developed a 30 month pediatric oncology fellowship training program following the American Academy of Pediatrics fellowship guidelines. The primary objective of the program was to implement a shared education model to develop highly educated physicians who are able to follow evidence-based approaches and who are committed to sustained practice in LMIC. Results: DFBCH staff provide ongoing education to the fellows through visits to CCHE-57357 every 2-3 months, weekly video sessions with the fellows for case presentation and journal clubs, and weekly conference calls with the fellowship program staff to ensure that the goals and objectives for each fellow and the program are met. Each of the current 15 fellows spend 6 weeks/year in Boston participating in evidence-based multi-disciplinary based rounds; the remainder of the curriculum takes place at CCHE-57357 and incorporates an array of individual, small group and e-learning modules specifically created for the program. Three classes of fellows have been enrolled and the senior class will graduate in the spring of 2017. Conclusions: Training of fellows following the same standards and methods as those applied to North American candidates is feasible and has the potential to advance the quality of education and expertise in LMIC. By focusing on the education of the next generation of clinicians, the opportunity to implement many of the important principles of clinical care can be realized.

Investigation and Management of a Rhizomucor Outbreak in a Pediatric Cancer Hospital in Egypt

We describe an outbreak of mucormycosis in a pediatric oncology hospital during December 2010 and the measures taken to stop it. The outbreak began with two consecutive cases of laboratory-documented mucormycosis infections within 1 week. Investigations to track the source were conducted immediately. Air plate cultures from machines and ducts supplying patients' rooms revealed the growth of Rhizomucor. Of five affected patients, all had acute leukemia and three were histopathologically proven. All patients were treated with liposomal amphotericin B after mucormycosis was diagnosed. Posaconazole was used as a secondary prophylaxis in one case. Three patients died.