Tertiary Care Center In Lebanon Research Articles

The Epidemiology of Syphilis and Co-infection with HIV in a Tertiary Care Center in Lebanon: A Retrospective Review

Introduction: Syphilis is an ancient STI causing a new worldwide outbreak in general and in Lebanon specifically. Methods: We conducted a retrospective chart review to assess the rate of syphilis increase in an infectious diseases clinic in Lebanon from 2006 to 2023. We studied the epidemiology of these cases, stage and treatment response and their association to HIV infection and its control. Results: There was an 862% increase in syphilis cases from 2006 to 2019.Most of our cases were middle aged men living with HIV. Most of them had well-controlled HIV infection with good CD4 counts. Most of the diagnosed cases of syphilis were primary and secondary, responding to penicillin G. Discussion: Our data mostly parallels international data, except for gender distribution. Despite successful treatment of most cases in our clinic, the alarming rise of new cases highlights the urgent need for public health measures to mitigate this epidemic. Conclusion: Inclusive awareness is needed to stop syphilis spread in Lebanon, and more screening is key in identifying new cases early for a successful eradication.

Sex differences among patients with intentional poisoning presenting to the emergency Department at a Tertiary Care Centre in Beirut, Lebanon.

Poisoning poses a worldwide public health challenge and recent data from Lebanon in 2020 revealed that over half patients presenting with acute toxicological exposure intentionally poisoned themselves, primarily with suspected suicidal intent. This study aims to assess sex disparities in intentional toxicological exposures among patients presenting to the Emergency Department, at a tertiary care centre in Lebanon. This was a secondary analysis of an existing toxicological database, including patients aged 6 years and older admitted due to acute overdose from March 2015 to August 2022. A total of 444 cases of intentional poisoning were analysed, with 302 (68.0%) women. The primary cause of intentional poisoning was suspected suicide in both sexes, significantly more common in women (85.1% versus 65.5%, P < 0.001). Specific agents exposed to patients varied by sex; sedatives/hypnotics/antipsychotics, antihistamines, and melitracen/flupentixol were significantly more prevalent in women (P < 0.001) while men showed higher prevalence for ethanol (P = 0.02), stimulants, street drugs and opioids (P < 0.001). Our study underscores substantial sex differences in intentional poisoning cases in Lebanon. Women exhibited a higher likelihood of exposures to sedatives/hypnotics/antipsychotics, antihistamines and melitracen/flupentixol, while stimulant drugs, ethanol, and opioids were prevalent in men. Developing proper and effective sex-specific measures may mitigate potential physical and psychological consequences.

Gram-negative bacterial colonization in the gut: Isolation, characterization, and identification of resistance mechanisms

BackgroundThe gut microbiome is made up of a diverse range of bacteria, especially gram-negative bacteria, and is crucial for human health and illness. There is a great deal of interest in the dynamic interactions between gram-negative bacteria and their host environment, especially considering antibiotic resistance. This work aims to isolate gram-negative bacteria that exist in the gut, identify their species, and use resistance-associated gene analysis to define their resistance mechanisms. MethodsSamples were collected from all patients who had a stool culture at a tertiary care center in Lebanon. Each type of bacteria that was identified from the stool samples was subjected to critical evaluations, and all discovered strains underwent antimicrobial susceptibility testing. Polymerase chain reaction was used to profile the genes for Carbapenem-resistant Enterobacteriaceae (CRE), Extended-spectrum beta-lactamase (ESBL), and that of Pseudomonas aeruginosa strains. ResultsEscherichia coli, Klebsiella species, and Pseudomonas aeruginosa turned out to be the predominant microbiota members. Escherichia coli strains had a high frequency of extended-spectrum beta-lactamase genes, with the most discovered gene being bla CTX-M. Additionally, a considerable percentage of isolates had carbapenemase-resistant Enterobacteriaceae genes, suggesting the rise of multidrug-resistant strains. Multidrug resistance genes, such as bla mexR, bla mexB, and bla mexA, were found in strains of Pseudomonas aeruginosa, highlighting the possible difficulties in treating infections brought on by these bacteria. ConclusionThe findings highlight the critical importance of effective surveillance and response measures to maintain the effectiveness of antibiotics considering the introduction of multidrug resistance genes in Pseudomonas aeruginosa and ESBL and CRE genes in Escherichia coli.

Diagnostic challenges and outcome of fatty acid oxidation defects in a tertiary care center in Lebanon

BackgroundFatty acid oxidation defects are rare autosomal recessive disorders with variable clinical manifestations and outcome. Early detection by systematic neonatal screening may improve their prognosis. Long-term outcome studies of these disorders in the Middle East and North Africa region are limited. The purpose of this study is to report the diagnostic challenges and outcome of fatty acid oxidation defects in a major tertiary care center in Lebanon, a resource-constrained country in the Middle East.MethodsA retrospective review of charts of all fatty acid oxidation defects sequential patients diagnosed and followed at our center was conducted. Collected data included: parental consanguinity, age at diagnosis, clinical presentation, biochemical profile, confirmatory diagnosis, treatment and outcome. A genotype–phenotype correlation was also performed, when available.ResultsSeven types of fatty acid oxidation defects were identified in a total of 34 patients from 21 families. Most families (79%) were consanguineous (first-degree cousins). The majority were diagnosed when clinically symptomatic (78%), at various ages between 10 days and 19 years (average: 2 years). Follow-up duration spanned between 2 months and 15 years (average: 5 years). The remainder of the patients were detected while still asymptomatic by systematic neonatal screening (9%) or due to positive family history (9%). The most common defect was carnitine transporter deficiency (50%) with an exclusive cardiac presentation related to a founder variant c.981C > T, (p.Arg254*) in the SLC22A5 gene. Medium chain acyl-CoA dehydrogenase deficiency was found in 13% only, which could be explained by the absence of systematic neonatal screening. Rare gene variants were detected in very long chain and multiple acyl-CoA dehydrogenase deficiency. The worse prognosis was observed in very long chain acyl-CoA dehydrogenase deficiency. The overall survival at last follow-up reached 75% with a complete reversal of symptoms with treatment in most patients (63%), despite their late diagnosis.ConclusionsOur experience highlights the diagnostic challenges and outcome of fatty acid oxidation defects in a resource-constrained country with high consanguinity rates. Physicians’ awareness and systematic neonatal screening are key for diagnosis. Larger genotype–phenotype studies are still needed to understand the natural history of these rare diseases and possibly improve their outcome.

Effects of lack of access to cancer medication on survival of patients with lung cancer.

e20585 Background: Lung cancer is the leading cause of cancer-related death. The treatment has evolved with the introduction of immunotherapy. During the economic crisis in Lebanon, cancer medications became unavailable forcing oncologists to adjust treatment protocols. This study aims to assess the effect of medication shortage on the progression-free survival (PFS) of lung cancer patients treated at a tertiary care center in Lebanon. Methods: A retrospective analysis of patients with metastatic NSCLC treated during the period of drug shortage (October 2021-December 2022) as compared to those treated in 2019-2020. The primary end point was progression-free survival (PFS) on first line of therapy and its association with dose density ratio (dose density given/standard dose density). Electronic medical records of 117 patients were reviewed and data of 83 eligible patients were collected and analyzed using IBM SPSS software. Results: The mean age at diagnosis was 68 years. Of the total, 63.5% were male. Additionally, 14.4% of the patients received chemotherapy, 39.7% received immunotherapy, and 42.1% received a combination of chemotherapy and immunotherapy. In total, 49 patients were eligible in the 2019/2020 category. 84% of the patients had the opportunity to receive immunotherapy. In contrast, 25 patients were eligible in the 2021/2022 category, and only 73% of them had the opportunity to receive immunotherapy. The median PFS of the 2019/2020 category was 11.2 months, compared to 5.4 months in 2021-2022 (p-value of 0.339). PFS was studied based on the dose density ratio for immunotherapy. Twenty-two patients received a full immunotherapy dose with a ratio of 1, and their PFS was 5.43 months. Twelve patients received a dose density ratio ranging from 0.01 to 0.50 and had a PFS of 10 months. Twenty-nine patients received a dose density ratio of 0.51-0.99 and had PFS of 12.8 months. Contrary to our initial expectations, we did not observe a statistically significant difference between the dose density of immunotherapy and PFS values with a p-value of 0.107. Conclusions: Despite significant shortages in immunotherapy medications, our study suggests that this has no significant detrimental effect on PFS. This unexpected discovery challenges the conventional notion that full immunotherapy doses are necessary and prompts further exploration of the complex relationship between dosage and treatment outcomes in patients.

Epidemiology and microbiology of catheter-associated urinary tract infections: A 14-year surveillance study at a tertiary care center in Lebanon

BackgroundCatheter-associated urinary tract infections (CAUTIs) are the most common device-associated healthcare-acquired infections and pose a significant burden on patients and healthcare systems worldwide. However, there is a paucity of data on CAUTI epidemiology and microbiology in the Middle East and North Africa (MENA) region, including Lebanon. MethodsThis 14-year retrospective cohort study was conducted at a tertiary care center in Lebanon. It analyzed data on all adult patients diagnosed with CAUTI between January 2009 and December 2022 in intensive care units (ICUs) and between June 2011 and December 2022 in regular units. Incidence rates, urinary catheter utilization ratios, and microbiological profiles were collected and analyzed. ResultsA total of 620 CAUTI cases were identified during the study period. The overall CAUTI rate was 2.4 per 1000 catheter-days, with higher rates in ICUs (3.2 per 1000 catheter-days) compared to regular units (1.4 per 1000 catheter-days). No significant changes in the rates were noted despite implementing many interventions. The most common pathogens were Gram-negative bacteria, with Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae being predominant. Multidrug-resistant organisms represented 48% of all isolates. Enterobacterales were largely extended-spectrum β-lactamase (ESBL) producing, and most Acinetobacter baumannii isolates showed multidrug resistance. ConclusionsThis study provides important insights into CAUTI epidemiology and microbiology in a tertiary care center in Lebanon, addressing the knowledge gap in this area in the MENA region. Despite implementing prevention measures, CAUTI rates remained stable over the 14-year period. The findings highlight the need for continuous improvement in infection prevention practices, diagnostic stewardship, and antimicrobial stewardship, especially given the rising threat of antimicrobial resistance. These results can serve as a guide for the development of targeted preventive strategies to reduce the burden of CAUTIs, particularly in low- and middle-income countries where antimicrobial resistance is a major issue.

The impact of the COVID-19 pandemic on acute appendicitis patients in a tertiary care center in Lebanon

IntroductionWith it becoming a global pandemic, the coronavirus disease of 2019 (COVID-19) imposed public health restraints that hampered patient’s presentation to hospitals. In Lebanon, little is known about the presentation patterns of acute appendicitis (AA) patients among different population groups during the COVID-19. Therefore, this study aims to assess the effects of the COVID-19 pandemic on the rates of cases seen during the pandemic period, the adopted management strategies, and evaluate the patient outcomes compared to presentations from previous years.MethodsThis is a retrospective, observational cohort study with no interventional procedures. All patients presented to our tertiary health care center were diagnosed with AA between February 2019 and February 2021 comprised the study analysis. We divided our patients into the pre-pandemic period cohort March 1st, 2019, till February 29th, 2020, and the pandemic period cohort March 1st 2020 till March 1st 2021.ResultsWe collected data retrospectively from 342 patients: 201 patients presented in the pre-pandemic period and 141 during the pandemic period. Male predominance was seen in both cohorts (51.7% and 58.9% respectively). A decrease in the number of AA cases was seen during the pandemic, however, the duration of symptoms before presentation was similar in both cohorts (p = 0.382) Additionally, the number of complicated appendicitis cases was not different between cohorts. The main imaging modality was CT in both groups with no statistically significant difference in the type of imaging between them (p = 0.398). Further, the predominant treatment modality remained surgery during the pandemic, with no difference between both periods (p = 0.200), and no statistically significant difference in the type of surgery performed as laparoscopic surgery remained the most common surgery type in the pandemic period (p = 0.43). Finally, no extra surgical and post-surgical complications were identified.ConclusionIn conclusion, our study is an example of how the COVID-19 pandemic did not significantly affect patients presenting for AA. Despite the COVID-19-related restrictions, Lebanese patients with worrying symptoms were presenting to the emergency department and the American University of Beirut Medical Center was providing them with the standards of care. Our study mirrors the Lebanese experience and gives an example of a population that focused more on their current symptoms than the fear of acquiring the COVID-19 virus. Further research is needed to assess whether this was the correct approach during these times.

Impact of the Covid-19 Pandemic on the Doctor-Patient Relationship: A Qualitative Study in a Tertiary-Care Centre in Lebanon

Background: The Covid-19 pandemic imposed numerous constraints on medical practice and exacerbated preexisting vulnerabilities in Lebanon’s healthcare system, which was already grappling with instability due to concurrent political and economic crises. This situation had a complex impact on the doctor-patient relationship (DPR), with both negative and positive repercussions. Methods: We conducted semi-structured interviews with physicians from various specialties practicing at a tertiary-care center in Lebanon. Our study aimed to 1) explore the impact of the Covid-19 pandemic on the DPR in Lebanon, and 2) provide recommendations for improving the DPR, healthcare policy, and education. Results: Thematic analysis of the data revealed that the pandemic had varying effects on the DPR. While both physicians and patients seemed to have developed a more favourable perception of the medical profession, communication between them appeared to be challenged by the use of personal protective equipment and patients’ concerns about close contact with physicians. The media played a vital role in educating and raising awareness during the pandemic but lacked organization and ethical standards, leading to anticipated fear and confusion among the society. Telemedicine emerged as an alternative means for communication and remote care but faced several obstacles including inadequate internet infrastructure and disruptions to physicians’ personal lives. Conclusion: Our qualitative study unveiled the multifaceted impact of the Covid-19 pandemic on perceiving the healthcare system, doctor-patient interactions, and the role of telemedicine in Lebanon, among others. These findings underscore the importance of effective communication in enhancing the DPR, the need to address misinformation on social media, and the imperative for systemic improvements to strengthen the resilience of Lebanon’s healthcare system.

1379. Evaluation of Cardiovascular Disease Risk among People Living with HIV in Lebanon

Abstract Background Since the introduction of antiretroviral therapy (ART), People Living with HIV (PLHIV) have become more prone to developing chronic illnesses, such as cardiovascular diseases (CVD), than to suffer from AIDS related conditions. The global burden of CVD associated with HIV has tripled over the last two decades, especially in low/middle income countries. Scarce data exist on the prevalence of CVD and CVD risk factors among PLHIV in the Middle East and North Africa (MENA) region. Therefore, we aim to examine the prevalence of CVD risk factors and calculate the CV risk in a cohort of PLHIV in Lebanon. Methods This is a retrospective chart review conducted between 2018 and 2023 at an HIV clinic in a tertiary care center in Lebanon. The study population includes adult subjects receiving ART and with at least 6 months of undetectable viral loads. Data included demographics, laboratory values, HIV-specific data, and review of traditional CVD risk factors. Atherosclerotic Cardiovascular Disease (ASCVD) risk score was calculated using the American College of Cardiology Risk Estimator Plus, to estimate patients’ 10-year risk for developing ASCVD. Descriptive statistics were implemented to summarize the cohort’s characteristics and the prevalence of CVD risk factors. Results A total of 85 HIV-infected subjects were included in the analysis. Subjects’ characteristics are summarized in table 1. The majority were males (89.4%), and the mean age was 43.31±12.28 years. The prevalence of smoking, alcohol consumption, and illicit drug use was 70.6%, 54.1%, and 20%, respectively. The mean BMI was 26.1±5 kg/m². Additionally, 20.2 % of subjects had dyslipidemia, 6% had diabetes, and 15.5% had hypertension. The mean current CD4 cell count was 687.83 ±356 cells/ml. The cohort had a mean ASCVD risk score of 8.8%, higher than that of age-matched population (mean ASCVD risk score of US firefighters aged 40-44 years is 1.8%). Conclusion This study shows the prevalence of traditional CVD risk factors among PLHIV receiving effective ART in Lebanon. The cohort mean ASCVD risk score indicates an intermediate risk for developing CVD over the next decade. in the MENA region, we need larger studies to inform on the prevalence of CVD among PLHIV, and to develop guidelines to mitigate the risk. Disclosures All Authors: No reported disclosures

2583. Antimicrobial Resistance Profile of Mycobacterium simiae and Treatment Trends from a Tertiary Care Center in Lebanon

Abstract Background Mycobacterium simiae is a rare non-tuberculous mycobacterium (NTM) that is most identified in some Middle Eastern countries. It is unclear why this NTM is geographically restricted. The pathogen can either be a mere colonizer or cause significant morbidity. Patients with M. simiae infection require prolonged treatment with a combination of 3 antimicrobials. Drug resistance among M. simiae isolates can complicate the course of treatment. However, the correlation between in vitro resistance and clinical response is unknown. We aimed to report the susceptibility profile of M. simiae isolates from our institution and the prescribed treatments. Methods We conducted a retrospective study of M. simiae isolates from the American University of Beirut Medical Center (AUBMC) over 19 years. All isolates were cultured at AUBMC using the Lowenstein-Jensen media and the BacT/ALERT system then referred for speciation and susceptibility testing at Mayo Clinic, MN, USA. Results We included 72 isolates that underwent susceptibility testing from 59 patients. Most isolates were obtained from sputum samples (61.1%) and the rest from bronchoalveolar lavages (BAL). The highest rates of susceptibility were to clarithromycin (84.7%) and amikacin (73.6%). All isolates were resistant to ciprofloxacin, streptomycin, doxycycline, and minocycline (Graph 1). Median minimal inhibitory concentrations (MIC) for clarithromycin and amikacin for susceptible isolates were 8 and 16 mcg/mL respectively. Clofazimine susceptibility was performed on only 16 isolates, 10 of which had an MIC ≤ 0.06 mcg/mL and the highest was 0.25 mcg/mL. Empiric antimicrobial therapy was given to 30% of patients but was inappropriate in 80% of cases. Targeted therapy was given to 40.9% of patients. Most received triple therapy with clarithromycin (95.8%) and clofazimine (41.7%) being the most common agents. The median duration of treatment was 12 months with the longest duration being 11 years. Microbiologic cure was achieved in 73.9% of the 23 patients who underwent repeated testing. Susceptibility of Mycobacterium simiae isolates according to the CLSI breakpoints. TMP-SMX, trimethoprim-sulfamethoxazole. *Clofazimine was not included in this graph as there is no consensus on breakpoints for susceptibility for NTM. All our isolates had MICs ≤ 0.25 mcg/mL which is lower than breakpoints used in other studies. Conclusion M. simiae exhibits resistance to most available antimycobacterial agents. Further research is needed to understand resistance mechanisms of this organism and correlate in vitro and in vivo findings. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

2582. Real-World Analysis of the Outcomes of Patients Treated with Ceftazidime-Avibactam

Abstract Background Ceftazidime-avibactam (CAZAVI) is a novel β-lactam/β-lactamase inhibitor combination with activity against Pseudomonas aeruginosa and some carbapenem-resistant Enterobacterales. CAZAVI has been particularly useful as a carbapenem-sparing strategy to mitigate the selection pressure observed with carbapenems. We aim to perform a real-world analysis of patients treated with CAZAVI for various clinical indications at a tertiary care center in Lebanon. Methods This is a retrospective study conducted at the American University of Beirut Medical Center from 2019-21. We excluded patients who were less than 18 years old, received CAZAVI for less than 48 hours, had severe COVID-19 infection, received more than three courses of CAZAVI, and patients on palliative care before CAZAVI treatment. Data were collected from electronic medical records. The primary endpoint was unfavorable outcome defined as death or incomplete clinical response. Results A total of 301 patients were included contributing 373 infection episodes. The median age was 66 years, with 48% of patients being male, and 55% having a high Charlson Comorbidity Index (CCI) of ≥ 5. A large proportion of patients had been admitted to the intensive care unit and had received antibiotics for more than 48 hours during the preceding 30 days. The majority of infection episodes were hospital-acquired (66%). The most common indication for CAZAVI was respiratory infection (44%) followed by bacteremia (9%). Clinical cultures were positive in 44% of episodes distributed as Enterobacterales 64%, P. aeruginosa 10%, and polymicrobial 26%. Clinical success was 66% and microbiological success was 52%. Mortality was 32%, 65% of which was directly attributable to the infection. The primary endpoint was achieved in 38% of episodes. Multivariate analysis of independent predictors of unfavorable outcome is shown in the Table. Independent Predictors of Unfavorable Outcomes in Patients Receiving CAZAVI Conclusion Results from this highly morbid patient population suggest a good overall response to CAZAVI therapy. The presence of multiple infection sites is an important predictor of unfavorable outcome. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

2584. Predictors of Clinically Significant Infection in Patients with Mycobacterium simiae Isolated from Respiratory Samples: a Retrospective Study from a Tertiary Care Center in Lebanon

Abstract Background Mycobacterium simiae is a rare slow-growing, non-tuberculous mycobacterium (NTM). It is predominant in Middle Eastern countries like Israel, Iran and Lebanon and is the most isolated NTM spp. at our institution (40%). Little is known about its reservoirs, pathogenesis, risk factors and indications for treatment. Methods We retrospectively studied patients with respiratory cultures showing M. simiae at the American University of Beirut Medical Center (AUBMC) over 19 years. We used the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) criteria to define NTM lung disease. Samples were cultured at AUBMC using Lowenstein-Jensen media and the BacT/ALERT system. NTM isolates were referred for speciation and susceptibility testing at Mayo Clinic, MN, USA. Results We identified 72 isolates from 66 patients. Most were obtained from sputum samples (57.6%), the rest from bronchoalveolar lavages (BAL). Acid-fast bacilli smear was positive in 27% of samples with no difference between sputum and BAL. The median age of patients was 64 years and 51.5% were females. Bronchiectasis (34.5%), chronic obstructive pulmonary disease (27.3%) and immunosuppression (33.3%) were common (Table 1). As per the ATS/IDSA criteria, 67.9% of patients had NTM lung disease. The most common symptoms were cough (83.3%) and sputum production (74.5%). All patients except 2 had abnormal findings on CT imaging like nodules (58.5%), tree in bud aspect (45.3%) and bronchiectasis (24.5%). Among those, 55.6% had abnormal CT findings preceding the M. simiae isolation. Bronchiectasis was more common in those who satisfied the ATS/IDSA criteria versus those who did not (38.9% vs 20.0%). Otherwise, we found no significant differences between both groups (Table 2). Treatment was given to 88.9% of patients who satisfied the NTM lung disease and 42.1% of those who did not (p&amp;lt; 0.001) with a median duration of 12 months. Of those with available follow-up, relapse was reported in 24% of cases. Characteristics of patients with M. simiae isolated from respiratory samples. BMI, body mass index, COPD, chronic obstructive pulmonary disease, AFB, acid-fast bacilli. *Median(Interquartile range) **Composite variable including hematologic malignancy, solid organ malignancy, hematopoietic transplantation, solid organ transplant, chronic steroids treatment, and active chemotherapy. Clinical and radiological differences between patients with M. simiae lung disease and those colonized according to the ATS/IDSA criteria. BMI, body mass index, COPD, chronic obstructive pulmonary disease. *Median (Interquartile range) Conclusion M. simiae is a significant cause of NTM lung disease at our institution with a high rate of relapse. Further research is required to understand its geographic restriction, predisposing factors, and identify patients at risk for clinically significant infection. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

Blood Stream Infections in COVID-19 Patients From a Tertiary Care Center in Lebanon: Causative Pathogens and Rates of Multi-Drug Resistant Organisms

ObjectiveTo report the microbiological profile of the pathogens implicated in blood stream infections (BSI) in hospitalized coronavirus disease 2019 (COVID-19) patients and to examine the risk factors associated with multidrug-resistant organisms (MDROs) causing BSI. Patients and MethodsBetween March 2020 and September 2021, 1647 patients were hospitalized with COVID-19 at the American University of Beirut. From 85 patients, 299 positive blood cultures were reported to the Infection Control and Prevention Program. The BSI was defined as 1 positive blood culture for bacterial or fungal pathogens. The following organisms were considered MDROs: methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp, carbapenem-resistant Enterobacterales spp., carbapenem-resistant Pseudomonas aeruginosa, MDR Acinetobacter baumannii only susceptible to colistin or tigecycline, and Candida auris. ResultsWe identified 99 true positive BSI events. Gram-negative bacteria accounted for 38.4 %, followed by Gram-positive bacteria (37.4%), and fungi (24.2%). The most isolated species were Candida spp. (23%), 3 of which were C. auris, followed by Enterobacterales spp. (13%), Enterococcus spp. (12%), S. aureus (9%), P. aeruginosa (9%), and A. baumannii (3%). The MDROs represented 26% of the events. The overall mortality rate was 78%. The time to acquisition of BSI in patients with MDROs was significantly longer compared with that of non-MDROs (20.2 days vs 11.2 days). And there was a significantly shorter time from acquisition of BSI to mortality between MDROs and non-MDROs (1.5 vs 8.3 days). ConclusionRigorous infection prevention and control measures and antimicrobial stewardship are important to prevent antimicrobial resistance progression, especially in low-resource settings.

Characteristics and management of patients with substance use disorders referred to a consultation-liaison psychiatry service in Lebanon

BackgroundThis study explores the characteristics and management of individuals with substance use disorders (SUDs) who were referred to the consultation-liaison psychiatry (CLP) service in a tertiary care center in Lebanon. As part of the Consultation-Liaison at the American University of Beirut (CLAUB) analysis, we conducted a retrospective record review of patients referred to our CLP service between February 2019 and May 2020. We assessed differences between SUD and non-SUD consults using chi-square analysis, Fisher’s exact test, or Mann–Whitney U test, as appropriate.ResultsOf 1475 patients, 278 (18.8%) received a diagnosis of SUD. They were mostly males (73.7%) with an average age of 38.8 years. The most used substances were alcohol (60%) and cannabis (28.4%). Compared to non-SUD consults, patients with SUDs were more likely to be males (odds ratio OR = 3.18, p < 0.001) and to get intubated during admission (OR = 1.81, p = 0.048). Predictors of intensive care unit admission in patients with alcohol use disorder included pulmonary or endocrinological disease, benzodiazepine use disorder, and days until CLP referral.ConclusionsThe results of this study highlight the high prevalence of alcohol use among individuals with SUD referred to the CLP service. Additionally, they underscore the limited treatment avenues available in this part of the world. The institution of a comprehensive CLP service is crucial to address the unmet needs of patients with SUDs who present to a general hospital setting.

Bacterial respiratory infections in patients with COVID-19: A retrospective study from a tertiary care center in Lebanon

BackgroundDespite multiple reports of increased incidence of bacterial respiratory tract infections following COVID-19 globally, the microbiology is not yet fully elucidated. In this study, we describe the microbiology of bacterial infections and the prevalence of multidrug resistant organisms (MDROs) in hospitalized COVID-19 patients with community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP) which includes both non-ventilated hospital acquired pneumonia (NVHAP) and ventilator-associated pneumonia (VAP). To our knowledge, this is the first study that compares the microbiology of VAP and NVHAP in COVID-19 patients. MethodsThis is a longitudinal retrospective cohort study conducted at the American University of Beirut Medical Center (AUBMC), a tertiary-care centre in Lebanon. Adult patients with confirmed COVID-19 and concurrent bacterial respiratory infections with an identifiable causative organism who were hospitalized between March 2020 and September 2021 were included. Bacterial isolates identified in hospital-acquired pneumonia (HAP) were divided into 3 groups based on the time of acquisition of pneumonia after admission: hospital day 3–14, 15–28 and 29–42. ResultsOut of 1674 patients admitted with COVID-19, 159 (9.5%) developed one or more respiratory infections with an identifiable causative organism. Overall, Gram-negative bacteria were predominant (84%) and Stenotrophomonas maltophilia was the most common pathogen, particularly in HAP. Among 231 obtained isolates, 59 (26%) were MDROs, seen in higher proportion in HAP, especially among patients with prolonged hospital stay (> 4 weeks). Non-fermenter Gram-negative bacilli (NFGNB) (OR = 3.52, p-value<0.001), particularly S. maltophilia (OR = 3.24, p-value = 0.02), were significantly more implicated in VAP compared to NVHAP. ConclusionsNFGNB particularly S. maltophilia were significantly associated with COVID-19 VAP. A high rate of bacterial resistance (25%), especially among Gram-negative bacteria, was found which may compromise patients’ outcomes and has important implications in guiding therapeutic decisions in COVID-19 patients who acquire bacterial respiratory infections.

Outcomes of critically ill COVID-19 patients boarding in the emergency department of a tertiary care center in a developing country: a retrospective cohort study

BackgroundBoarding of critically ill patients in the emergency department (ED) has long been known to compromise patient care and affect outcomes. During the COVID-19 pandemic, multiple hospitals worldwide experienced overcrowded emergency rooms. Large influx of patients outnumbered hospital beds and required prolonged length of stay (LOS) in the ED. Our aim was to assess the ED LOS effect on mortality and morbidity, in addition to the predictors of in-hospital mortality, intubation, and complications of critically ill COVID-19 ED boarder patients.MethodsThis was a retrospective cohort study, investigating 145 COVID-19-positive adult patients who were critically ill, required intensive care unit (ICU), and boarded in the ED of a tertiary care center in Lebanon. Data on patients who boarded in the emergency from January 1, 2020, till January 31, 2021, was gathered and studied.ResultsOverall, 66% of patients died, 60% required intubation, and 88% developed complications. Multiple risk factors were associated with mortality naming age above 65 years, vasopressor use, severe COVID pneumonia findings on CT chest, chemotherapy treatment in the previous year, cardiovascular diseases, chronic kidney diseases, prolonged ED LOS, and low SaO2 < 95% on triage. In addition, our study showed that staying long hours in the ED increased the risk of developing complications.ConclusionTo conclude, all efforts need to be drawn to re-establish mitigation strategies and models of critical care delivery in the ED to alleviate the burden of critical boarders during pandemics, thus decreasing morbidity and mortality rates. Lessons from this pandemic should raise concern for complications seen in ED ICU boarders and allow the promotion of health measures optimizing resource allocation in future pandemic crises.

Comparing emergency department visits 10-year apart at a tertiary care center in Lebanon.

Presentations to the emergency department (ED) are growing worldwide. With the increasing risk factors of non-communicable disease (NCD) and communicable diseases (CD) in low- and middle-income countries, it is crucial to understand how ED presentations are changing with time to meet patients' needs and allocate acute care resources. The aim of this study is to compare the changes in patient and diseases characteristics over 2 time periods 10 year apart at the largest tertiary care center in Lebanon. This was a retrospective descriptive study of patients presenting to the ED at a large tertiary care center in 2009/2010 and 2018/2019. The discharge diagnoses were coded into Clinical Classification Software codes. We used descriptive statistics, odds ratios (OR), and non-parametric test to compare the different diagnoses. The total number of ED visits increased by 33% from 2009/2010 to 2018/2019. The highest increase rate was among patients older than 65 years (2.6%), whereas the percentage of pediatric patients decreased from 30.8% to 25.3%. ED presentations shifted from NCD to CD. A shift in the discharge diagnoses was also noted within age groups, specifically a shift in cardiovascular diseases to a younger age. Our study suggests that the role of the ED is changing and moving towards treating the aging population and CD. There is a need to invest and mitigate CD, better allocate resources to accommodate the aging population, focus on awareness campaigns targeting early detection of cardiovascular diseases and modifying its risk factors.

Utilization of patient portals: a cross-sectional study investigating associations with mobile app quality

BackgroundMobile apps facilitate patients’ access to portals and interaction with their healthcare providers. The COVID-19 pandemic accelerated this trend globally, but little evidence exists on patient portal usage in the Middle East, where internet access and digital literacy are limited. Our study aimed to explore how users utilize a patient portal through its related mobile app (MyChart by EPIC).MethodsWe conducted a cross-sectional survey of MyChart users, recruited from a tertiary care center in Lebanon. We collected MyChart usage patterns, perceived outcomes, and app quality, based on the Mobile Application Rating Scale (user version, uMARS), and sociodemographic factors. We examined associations between app usage, app quality, and sociodemographic factors using Pearson’s correlations, Chi-square, ANOVA, and t-tests.Results428 users completed the survey; they were primarily female (63%), aged 41.3 ± 15.6 years, with a higher education level (87%) and a relatively high crowding index of 1.4 ± 0.6. Most of the sample was in good and very good health (78%) and had no chronic illnesses (67%), and accessed the portal through MyChart once a month or less (76%). The most frequently used features were accessing health records (98%), scheduling appointments (67%), and messaging physicians (56%). According to uMARS completers (n = 200), the objective quality score was 3.8 ± 0.5, and the subjective quality was 3.6 ± 0.7. No significant association was found between overall app usage and the mobile app quality measured via uMARS. Moreover, app use frequency was negatively associated with education, socioeconomic status, and perceived health status. On the other hand, app use was positively related to having chronic conditions, the number of physician visits and subjective app quality.ConclusionThe patient portal usage was not associated with app quality but with some of the participants’ demographic factors. The app offers a user-friendly, good-quality interface to patient health records and physicians, appreciated chiefly by users with relatively low socioeconomic status and education. While this is encouraging, more research is needed to capture the usage patterns and perceptions of male patients and those with even lower education and socioeconomic status, to make patient portals more inclusive.

Small Bowel Capsule Endoscopy: Benefits of Rereading Rather than Repeating—A Single Blinded Randomized Study

Abstract Objectives Small bowel capsule endoscopy (SBCE) technology detects small bowel lesions. Many factors affect its sensitivity. SBCE is also costly, and patients might not be able to repeat the test when results are equivocal. Instead of repeating the test, reading the results by two endoscopists might provide a better or a cheaper option in the right settings. We studied the sensitivity of SBCE when read by two different physicians and checked if, rather than repeating the examination, rereading the results improved its sensitivity. Furthermore, we studied the effect of small bowel transit time (SBTT) on the diagnostic yield. Materials and Methods A retrospective cohort study on capsule endoscopies was conducted between 2018 and 2019 in a tertiary care center in Lebanon. A total of 42 patients with anemia or obscure gastrointestinal bleed were included for SBCE after a negative evaluation with upper and lower gastrointestinal (GI) endoscopy. Two specialists read the results. The second physician was blinded from the first reader's results. We compared the sensitivity of the two readings. SBTT correlation with the diagnostic yield was calculated. Results Out of 42 patients, 18 tested positive in the first reading and 31 in the second reading. The diagnostic yield increased from 43 to 74% (p = 0.0043). Among the 33 patients who had a documented SBTT, longer SBTT correlated with a higher diagnostic yield (odds ratio [OR] &gt; 1), but no statistical significance was demonstrated. Conclusion Within the limitations of this study, we found that rereading capsule endoscopy can be more cost-effective than repeating the test.

Predicting missed delirium diagnosis in a tertiary care center: the Consultation-Liaison at the American University of Beirut (CLAUB) analysis

Abstract Background Delirium is a very common occurrence in hospital settings and is frequently missed by the primary care team. It remains, however, poorly studied in the Middle East despite abundant global reports. In this study, we aimed to estimate the prevalence of missed delirium diagnosis in a tertiary care center in Lebanon and investigate potential predictors of this missed diagnosis. This was a retrospective study of adult patients admitted to the American University of Beirut Medical Center between March 2019 and December 2019 and assessed by the consultation-liaison psychiatry (CLP) team. The primary endpoint was the rate of missed delirium diagnosis among CLP consultations. Relevant statistical tests were performed to assess the association between the missed diagnosis of delirium and characteristics of patients. Results Five hundred fifty-three patients were included with a mean age of 69.19 ± 14.79 years. 86.13% of the patients received a delirium diagnosis by the CLP team that had been missed prior to the CLP referral. A missed delirium diagnosis was more likely to be found in patients with a history of depression (OR = 24, p &lt; 0.01) and a longer hospital stay [in days] (OR = 1.04, p = 0.04). Conclusion The alarmingly high prevalence of missed delirium diagnosis is the first evidence of its kind in the Middle East. This urges the implementation of educational interventions to increase the detection of delirium among healthcare providers and ultimately improve patient outcomes.