Measles Outbreak in Lebanon: July 2023.

After the beginning of the Syrian crisis, increased rates of infectious diseases were reported. Lebanon, a neighboring country with a major socioeconomic crisis, witnessed a measles outbreak since July 2023, with 519 reported suspected cases. Half of the cases were under 5 y of age, most of them were unvaccinated. The mass displacement of refugees from conflict areas in Syria to Lebanon and the low vaccination coverage have made the situation more challenging. Further efforts are required in Lebanon to address identified gaps to prevent or at least better control future outbreaks.

Epidemiology of pathogens causing acute diarrhea in patients presenting to the emergency departments in 4 hospitals in Lebanon.

Acute diarrhea is a prevalent disease worldwide and a cause of mortality in low and middle-income countries. In previous studies, the causative enteropathogen is found in 38% to 58% of patients, leaving a considerable diagnostic gap. In this study, we intend to determine the pathogenic agents responsible for acute diarrhea in patients presenting to the Emergency Departments of several Lebanese hospitals. A total of 100 stool samples were collected between June 2022 and June 2023 from patients presenting with acute diarrhea to the Emergency Departments. Pathogens were detected by multiplex polymerase chain reaction. The average age for the patients was 53 years old. All patients presented with diarrhea, 15 of them had fever associated. In total, 46 patients were admitted to the hospital (70%), among them 80% received Intravenous antibiotics. Campylobacter was the most common agent detected in 36%, followed by Rotavirus 19%, and Noroviruses 15%. The rest was detected at lower percentages. Bacteria accounted for 49% of cases, viruses for 39%, and parasitic infection 6%. Acute diarrhea epidemiology is understudied in Lebanon. This study is the first Lebanese data about acute diarrhea pathogens. Avoiding overuse of antibiotics in bacterial versus viral infections can be achieved while prevention campaigns can raise awareness about food and water safety at the community level.

Candida glabrata hospital isolate from Lebanon reveals micafungin resistance associated with increased chitin and resistance to a cell-surface-disrupting agent.

OBJECTIVES: This study aimed to identify the resistance mechanisms to micafungin and fluconazole in a clinical isolate of Candida glabrata. METHODS: The isolate was whole-genome sequenced to identify amino acid changes in key proteins involved in antifungal resistance, and the isolate was further characterised by pathogenicity-related phenotypic assays that supported the sequencing results. RESULTS: Amino acid substitutions were detected in 8 of 17 protein candidates. Many of these substitutions were novel, including in CHS3, CHS3B, and KRE5, which are involved in the development of micafungin resistance. Regarding fluconazole resistance, overexpression of efflux pumps was observed. Our isolate did not exhibit an increased virulence potential compared with the control strain; however, a significant increase in chitin content and potential to resist the cell surface disruptant sodium dodecyl sulphate was observed. CONCLUSIONS: This clinical Candida glabrata isolate experienced a change in cell wall architecture, which correlates with the development of micafungin resistance.

Impact of the 4th of August Beirut explosion mass casualty incident on a university hospital microbial Flora.

BACKGROUND: Following the Beirut explosion, our university hospital received at least 350 casualties. Subsequently, infection control standard practices were compromised. Concerns for Multi-Drug Resistant Organisms (MDROs) infections in injured patients and a resulting hospital outbreak were raised. The objectives of the study were to compare the rate of hospital growing MDROs 6 months before and 6 months after the Beirut explosion, to identify emerging microorganisms and to evaluate the change in surgical infection prevention practices. METHODS: This is a retrospective chart review of patients with hospital acquired infections (HAI) admitted to the hospital before and after the Beirut explosion. The study was conducted between February 4, 2020 and January 4, 2021. Excluded patients were those transferred from other hospitals and those with community acquired infections. The primary outcome was to identify the rate of growing MDROs post explosion. The secondary outcomes were identifying antibiotics used for surgical prophylaxis in patients requiring surgeries and patients diagnosed with a HAI. Therefore, patients were divided in three groups. Control group included patients admitted with explosion-related injuries on that same day. Patients admitted and between February 4 and August 4 and diagnosed with HAI were compared to those admitted post August 4 with explosion-related HAI and to patients diagnosed with non-explosion-related HAI between August 4 and January 4, 2021. An estimated rate of 18-22% MDRO was needed to achieve a statistical significance with 80% power and 0.05 α. Pearson Chi square test was used to analyze the primary outcome. RESULTS: A total of 82 patients with 150 cultures were included in this study. Data showed an increase in the rate of MDRO after the explosion with 37.1% of the cultures taken before the explosion and 53.1% after the explosion (p = 0.05). When comparing the types of HAI in both groups, culture sites were significantly different between pre- and post-explosion patients (p = 0.013). However, both groups had similar types of microbes (p = 0.996) with an increase in candida related infections. CONCLUSION: These findings confirmed that the Beirut explosion impact on antimicrobial resistance was similar to combat zone incidence, where an increase in MDROs rate such as Escherichia coli (E.Coli) and Stenotrophomonas maltophilia, in addition to the increase in candida related infections.

Antimicrobial effects of chlorine dioxide in a hospital setting.

Chlorine dioxide is a powerful disinfectant with strong antibacterial properties. We conducted a study at different sites of the Lebanese American University Medical Center-Rizk Hospital to determine the efficacy of the ECOM air mask in decreasing the particle load. Air cultures were obtained from three different locations, namely the patients' elevator, visitors' elevator and mobile clinic and the number of colonies grown on each type of agar was determined. We also measured particle counts at the three sites both at baseline and after placement of the ECOM air mask. After 7 days of ECOM air mask use, the numbers of colonies grown on all types of media was decreased by 20-100% versus the baseline values. The counts of particles of different diameters (0.3, 0.5 and 5 µm) were decreased at all three sampled sites. This study highlighted the efficacy of the ECOM air mask. The utility of the gaseous form of ClO2 as an antiseptic in the hospital setting appears promising.

Lower odds of COVID-19-related mortality in hospitalised patients with type II diabetes mellitus: A single-centre study.

BACKGROUND: COVID-19 infection in patients with type 2 diabetes mellitus (T2DM) -a chronic illness in Lebanon-is not well described. METHODS: This was a single-centre retrospective observational study of 491 patients, including 152 patients with T2DM, who were hospitalised for COVID-19 between 20 August 2020 and 21 April 2021. Data on clinical characteristics, laboratory and radiological findings and outcomes were collected from the electronic medical records. Clinical characteristics and in-hospital mortality between patients with and without T2DM infected with COVID-19 using multivariate analysis were compared. RESULTS: Patients with T2DM were significantly older than those without T2DM (mean age, 68.7 vs. 60.3 years). Patients with T2DM were more likely to present with a body temperature of <38.3°C (83.9% vs. 69.9%) and less likely to present with chest pain (3.9% vs. 9.1%) and sore throat (2.0% vs. 6.8%). Patients with T2DM were more likely to be hypertensive (76.35% vs. 41%) and dyslipidaemic (58.6% vs. 25.7%) and had more frequent underlying coronary artery disease (33.6% vs. 12.4%). The rates of patients with creatinine levels of ≥1.17 mg/L and troponin T levels of ≥4 ng/dL were higher in the T2DM group than in the non-T2DM group (30.4% vs. 15% and 93.3% vs. 83.1%, respectively). Patients with T2DM were more likely to be admitted to the intensive care unit (ICU) (34.2% vs. 22.1%), require invasive ventilation (18.4% vs. 10.3%) and receive vasopressors (16.4% vs. 10.0%). Increasing age and the use of invasive ventilation and vasopressors were associated with higher odds of mortality (odds ratio (OR), 1.08, 9.95 and 19.83, respectively), whereas longer ICU stay was associated with lower odds of mortality (OR, 0.38). The odds of mortality were lower in the T2DM group than in the non-T2DM group (OR, 0.27). CONCLUSION: Among patients hospitalised for COVID-19, those with T2DM were older, presented with milder symptoms and had more comorbidities and higher troponin T levels compared with those without T2DM. Despite the worse clinical course, the patients with T2DM had lower odds of mortality than those without T2DM.

Evolution of COVID-19 infection characteristics in a Lebanese cohort of inpatients during different pandemic periods.

This study aims to describe COVID-19 patients characteristics, laboratory and imaging results, and the different outcomes of patients admitted to the Lebanese American University Medical Center-Rizk Hospital over a period of 9 months. In this observational retrospective study, data were obtained from electronic medical records of 491 male and female patients from the ages of 17 to 97. Analysis of the patients was performed in 3 periods: August 2020 to October 20 November 202020 to January 2021 and February 2021 to April 2021 corresponding with 3 waves of newly diagnosed cases during this period. The sample showed a male predominance with an average age of 63. The average hospitalization length was 10.1 days. The majority of patients were discharged to quarantine. The distribution of hospitalized cases was significantly correlated to the monthly distribution of newly COVID-19 cases in Lebanon. There was no significant difference in patient's characteristics between the 3 periods of the study (gender, age, body mass index, smoking, and medical conditions). Clinical presentations of the patients varied between the 3 periods. Similarly, the course and outcome of infection varied. Patients received less oxygen during period 1, while more patients were cured during period 3. This study presents the first Lebanese cohort of COVID-19 patients with their medical background, clinical presentation, laboratory results, radiological findings and course of infection with its outcome. It also shows how the relations between the medical manifestation of the COVID-19 pandemic and the socio-political measures of infection control are deeply intertwined.

The Prevalence and Risk Factors of Acute Kidney Injury during Colistin Therapy: A Retrospective Cohort Study from Lebanon.

INTRODUCTION: The current study aimed to determine the prevalence, risk factors, and stages of severity of acute kidney injury (AKI) caused by colistimethate sodium (CMS) treatment in patients diagnosed with systemic antibiotic-resistant Gram-negative bacterial infections. The predictors of all-cause mortality in this patient population were also examined. METHODS: This retrospective cohort study included patients who were admitted to a university-affiliated hospital and acute tertiary care referral center in Beirut, Lebanon between January 2015 and December 2018 and underwent CMS treatment for a period of 48 h or more. RESULTS: The study sample included 298 adult patients, of which 46.3% (n = 138/298) developed AKI (assessed using the Kidney Disease Improving Global Outcomes (KDIGO) criteria). Of these, 37.7% (n = 51/138) were diagnosed with stage 1 AKI, 23.9% with stage 2 (n = 33/138), and 38.4% with stage 3 (n = 53/138). Nephrotoxicity was reversed in 87.5% of AKI patients who survived until hospital discharge. Independent risk factors for AKI included patient age ≥ 75 years (aOR = 1.854; 95% CI: 1.060-3.241; p-value = 0.03); underlying chronic kidney disease (aOR = 4.849; 95% CI: 2.618-9.264; p-value < 0.0001); and concomitant use of vasopressors (aOR = 4.305; 95% CI: 2.517-7.456; p-value < 0.0001). Multivariate analysis showed that the predictors of severe AKI (stage 2 or 3) included baseline hypoalbuminemia (aOR = 2.542; 95% CI: 1.000-6.564; p-value = 0.05); concomitant use of vasopressors (aOR = 6.396; 95% CI: 2.741-15.87; p-value < 0.0001); and CMS days of therapy (DOT) prior to development of AKI ≥ 7 days (aOR = 4.728; 95% CI: 2.069-11.60; p-value < 0.0001). All-cause mortality was recorded in 51.3% of patients (n = 153/298), and this was significantly higher in patients with AKI (76.8%; n = 106/138) compared to those without (29.4%; n = 47/160; OR = 7.964; 95% CI: 4.727-13.417; p-value < 0.0001). Independent predictors of all-cause mortality included a baseline Charlson comorbidity index score ≥5 (aOR = 4.514; 95% CI: 2.443-8.530; p-value < 0.0001); concomitant use of vasopressors (aOR = 7.76; 95% CI: 4.238-14.56; p-value < 0.0001); and CMS-induced AKI (aOR = 4.117; 95% CI: 2.231-7.695; p-value < 0.0001). CONCLUSIONS: The findings of this study suggest that old age, history of chronic kidney disease, and concomitant vasopressor treatment are all independent predictors of CMS-induced AKI. The risk of developing severe AKI significantly increases with CMS DOT. Understanding the risk factors of nephrotoxicity is essential for improving prognosis and treatment outcomes.

Cryptococcal meningitis post-covid-19 infection: Immunomodulation, a double-edged sword.

Cryptococcal meningitis is an opportunistic infection associated with altered immunity. Immunomodulatory agent use in severe coronavirus disease 2019 (COVID-19) may predispose such infections. Here, we present a 75-year-old male patient who presented with fever and altered general status after severe COVID-19 infection and developed cryptococcal meningitis. Opportunistic infection may arise from the use of immunomodulation in severe COVID-19, especially in the elderly population. This article describes the case and extensively reviews cryptococcal disease post-COVID-19 literature, highlighting the risk from immunosuppressive treatment.

The Cholera Outbreak in Lebanon: October 2022.

In recent years, Lebanon has been struggling with a socioeconomic crisis exacerbated by population displacement after the Syrian crisis, which put a significant burden on its healthcare system. An additional challenge has been the response to a cholera outbreak- a deadly waterborne disease transmitted through the fecal-oral route that usually manifests as severe watery diarrhea and can rapidly progress to death. After reports of a cholera outbreak in Syria were disclosed in September 2022, the Northern Governorate of Lebanon too began reporting cases immediately after, and the first case was confirmed on October 6, 2022. The outbreak rapidly spread to other parts of the country. As of December 9, 2022, a total of 5105 suspected cholera cases with 23 associated deaths were reported across Lebanon. An estimated 45% of these cases were of children and adolescents below the age of 15 years. With the start of the vaccination campaign, awareness programs emphasizing adequate sanitation and clean water sources have become an urgent need.

Effect of combination of prophylactic or therapeutic anticoagulation with aspirin on the outcomes of hospitalized COVID-19 patients: An observational retrospective study.

Regimens for managing thromboembolic complications of COVID-19 are still not very well established. The present study compares the clinical characteristics and outcomes of patients hospitalized with COVID-19 receiving different anticoagulation regimens with and without aspirin. This is a retrospective observational study of 491 patients hospitalized for COVID-19 from August 2020 to April 2021. Data regarding clinical characteristics, laboratory findings, and outcomes of patients receiving different anticoagulation with and without aspirin regimens was collected, according to which 5 patient groups were defined: received no anticoagulation (NAA), prophylactic anticoagulation with (PA) or without aspirin (PAA) and therapeutic anticoagulation with (TA) or without aspirin (TAA). The average age was highest in the TAA group. Desaturation was highest in the TA and TAA groups. Diabetes, hypertension, dyslipidemia and coronary artery disease were the most prevalent in aspirin groups (PAA and TAA) as was heart failure in the TA and TAA groups and cancer in the TA and PAA groups. Elevated troponin was observed in the PAA and TAA groups. TA and TAA patients received oxygen therapy, needed ICU admission overall, and required invasive ventilation and vasopressors the most. Prophylactic anticoagulation groups (PA and PAA) had the highest patient survival rates. Patients with severe COVID-19 infections were more likely to receive higher, therapeutic, anticoagulation doses. Aspirin was given to patients with preexisting comorbidities, but it had no statistically significant impact on the outcomes of the different groups. Groups receiving prophylactic anticoagulation had the best survival outcomes.

Liver manifestations in COVID-19 patients: A review article.

The coronavirus disease 2019 (COVID-19) initially presented as a disease that affected the lungs. Then, studies revealed that it intricately affected disparate organs in the human body, with the liver being one of the most affected organs. This review aimed to assess the association between COVID-19 and liver function, shedding light on its clinical implication. However, its exact pathophysiology remains unclear, involving many factors, such as active viral replication in the liver cells, direct cytotoxic effects of the virus on the liver or adverse reactions to viral antigens. Liver symptoms are mild-to-moderate transaminase elevation. In some patients, with underlying liver disease, more serious outcomes are observed. Thus, liver function should be meticulously considered in patients with COVID-19.

COVID-19 infection and seroconversion rates in healthcare workers in Lebanon: An observational study.

Coronavirus disease 2019 (COVID-19) infection is a recent pandemic. Healthcare workers (HCW) are at high risk of acquiring the infection and transmitting it to others. Seroprevalence for COVID-19 among HCW varies between countries, hospitals in the same country and even among different departments in the same hospital. In this study, we aim to determine the prevalence of severe acute respiratory syndrome coronavirus 2 antibodies and the seroconversion among the HCW in our hospital. A total of 203 HCW were included. The rate of conversion to seropositive was 19.7% in total, with a rate of 13.4% in female versus 25% in male. The seropositivity in the House keeping group was 83%, followed by 45% in the COVID Floor while the seropositivity in the Anesthesia was 4% and the Infection Control 0%. The highest seropositivity rate in the COVID floor, and in the intensive care unit was explained by the long time spent with the patients. While in the inhalation team and the anesthesia, the lower rates of seropositivity was due to the N95 mask wearing the whole time. Seropositivity for COVID-19 in HCW is a major public health concern. Policies should be implemented to better protect HCWs.

Perception of the Lebanese Adults about Vaccination: A Survey.

INTRODUCTION: With the continuous spread and emergence of transmissible diseases, focusing on preventive measures is essential to decrease their incidence and spread. In addition to behavioral measures, vaccination is an optimal way to protect the population and eradicate infectious diseases. The majority are aware of children's vaccinations, while many might not know that adult vaccinations are also essential. OBJECTIVES: This study aims to understand the perception of Lebanese adults towards vaccination and their knowledge and awareness of its importance. This is a national cross-sectional study, conducted between January 2020 and January 2021. RESULTS: the data were collected from 1023 subjects, the majority being Lebanese, previously healthy, and with a graduate or post-graduate level of education. Out of these participants, 44.9% were advised to take vaccines, half of them by healthcare workers. The most common vaccine received during adult life is the Flu vaccine. Overall, 25.6% of the participants were unaware that they needed vaccines and 27.9% thought it is not indicated. Participants' knowledge about vaccination is variable. In total, 39.4% agree or are uncertain whether vaccines contain harmful chemicals and 48.4% believe that vaccines will trigger diseases. The level of education and occupation significantly enhances knowledge about vaccination. Some participants 27.3% are concerned about the vaccine's side effects. The group of young participants, graduates, and nonsmokers think that the vaccine is a necessity and had a positive attitude towards vaccination. CONCLUSIONS: Many Lebanese lack knowledge about adult vaccination protection and its benefits in the community. It is essential that the country's health ministry department collaborate with the healthcare system to launch awareness campaigns about adult vaccination in the country to overcome the barriers and ensure better coverage.

Characterization and susceptibility of non-albicans Candida isolated from various clinical specimens in Lebanese hospitals.

Background: Invasive fungal infections have presented a challenge in treatment. In the past, it was known that the frontrunner in such infections is Candida albicans with little emphasis placed on non-albicans Candida species (NAC). Studies worldwide have shown a rise in fungal infections attributed to non-albicans Candida species. The aim of this study is to describe the epidemiology of NAC infections along with an overview of resistance in Lebanese hospitals. Methods: This is a two-year observational multi-central descriptive study. Between September 2016 and May of 2018, a total of 1000 isolates were collected from 10 different hospitals distributed all over the country. For the culture, Sabouraud Dextrose Agar was used. Antifungal Susceptibility was evaluated by determining the Minimum Inhibitory Concentration (MIC) in broth (microdilution) of the different antifungal treatments. Results: Out of the 1000 collected isolates, Candida glabrata, being the most isolated species (40.8%), followed by Candida tropicalis: 231(23.1%), Candida parapsilosis: 103(10.3%), and other NAC species at lower percentage. Most of these isolates (88.67%) were susceptible to posaconazole, 98.22% were susceptible to micafungin, and 10% were susceptible to caspofungin. Conclusion: The change of etiology of fungal infections involving a significant increase in NAC cases is alarming due to the different antifungal susceptibility patterns and the lack of local guidelines to guide the treatment. In this context, proper identification of such organisms is of utmost importance. The data presented here can help in establishing guidelines for the treatment of candida infections to decrease morbidity and mortality. Future surveillance data are needed.

Limiting the Spread of Multidrug-Resistant Bacteria in Low-to-Middle-Income Countries: One Size Does Not Fit All.

The spread of multidrug-resistant organisms (MDRO) is associated with additional costs as well as higher morbidity and mortality rates. Risk factors related to the spread of MDRO can be classified into four categories: bacterial, host-related, organizational, and epidemiological. Faced with the severity of the MDRO predicament and its individual and collective consequences, many scientific societies have developed recommendations to help healthcare teams control the spread of MDROs. These international recommendations include a series of control measures based on surveillance cultures and the application of barrier measures, ranging from patients' being isolated in single rooms, to the reinforcement of hand hygiene and implementation of additional contact precautions, to the cohorting of colonized patients in a dedicated unit with or without a dedicated staff. In addition, most policies include the application of an antimicrobial stewardship program. Applying international policies to control the spread of MDROs presents several challenges, particularly in low-to-middle-income countries (LMICs). Through a review of the literature, this work evaluates the real risks of dissemination linked to MDROs and proposes an alternative policy that caters to the means of LMICs. Indeed, sufficient evidence exists to support the theory that high compliance with hand hygiene and antimicrobial stewardship reduces the risk of MDRO transmission. LMICs would therefore be better off adopting such low-cost policies without necessarily having to implement costly isolation protocols or impose additional contact precautions.