Breaking barriers: Assessing pre-exposure prophylaxis awareness and willingness to use in the Lebanese community.

BACKGROUND: In the evolving HIV landscape, the Middle East and Northern Africa (MENA) grapples with data gaps, hindering the 95-95-95 targets. Lebanon, despite progress, falls short. Our study addresses Pre-exposure Prophylaxis (PrEP) gaps for effective HIV prevention. METHODS: Surveying 410 participants via snowball sampling and an online questionnaire, we analyzed data with chi-square and regression over 5 months for insights into PrEP awareness and readiness. RESULTS: Summarizing the pivotal statistical outcomes of the study, 22.2% reported awareness of PrEP, showcasing diverse knowledge levels about its purpose and usage. Out of them, 57.1% expressed a willingness to use it; while a mere 5.5% have utilized it. The study reveals diverse demographic profiles, with age influencing PrEP awareness and willingness to use. Positive correlations exist between PrEP discussions within social circles, increased information availability, and elevated willingness. Financial considerations and accessibility at pharmacies emerge as critical determinants, guiding the development of targeted interventions. CONCLUSIONS: This analysis emphasizes tailored education, community initiatives, and policy enhancements to address PrEP challenges in Lebanon. Guiding public health initiatives, our study considers age, social dynamics, education, and accessibility in HIV prevention.

Susceptibility of urinary Enterobacteriaceae to selected antimicrobials in an out-patient setting in Wallonia-Belgium: retrospective analysis over 5 years period (2018-2022).

OBJECTIVE: Increasing antimicrobial resistance in urinary tract infection is a major healthcare concern. In this study, we evaluate the patterns of resistance exhibited by the most implicated microorganisms in urine infections. This approach is a prerequisite for an appropriate and successful empiric therapy in ambulatory patients. METHODS: A retrospective study was carried out from January 2018 to September 2022 in Synlab-Collard laboratory, Liège, Belgium; a total of 129,939 Enterobacteriaceae isolated from 120,616 positive urine sample were included. RESULTS: Sex ratio is 81.6% female and 18.4% male. E. coli is the most common urinary pathogen (70.4% of cases), followed by Klebsiella spp. (13.5%), Proteus spp. (8.5%), and Citrobacter spp. (2.5%). Ampicillin shows the highest resistance at 56%. Nitrofurantoin, the recommended antimicrobial treatment for cystitis in Belgium, expresses an overall resistance rate of 19% in females and 32% in males peaking at 43% in males over 80 years. Fosfomycin and ciprofloxacin display higher resistance rates in subjects over the age of 80 (18%, 24% in females, and 25%, 35% in males respectively). Trimethoprim shows 24% and 29% resistance rate in females and males over the age of 80 respectively. CONCLUSION: Even if empiric treatment of suspected UTIs may be of benefit in some cases, it is important for healthcare providers to carefully consider its limitations and evaluate its potential failure rate based on the resistance profiles of urinary Enterobacteriaceae. Susceptibility tests should be performed, and treatments adjusted especially in elderly populations.

First reported case of Cladosporium para-aortic abscess.

Cladosporium species are ubiquitous dematiaceous fungi, widely found in the indoor and outdoor environments. They are considered a frequent source of contamination in laboratory settings. In human pathology, Cladosporium is a main agent of phaeohyphomycosis, known to cause subcutaneous and brain abscess, especially in immunocompromised hosts. The route of disseminated infections is mainly hematogenous after inhalation of the spores. However, a direct inoculation could be possible. We report the first case of a para-aortic abscess with thrombus formation, caused by Cladosporium spp., after a valvular replacement surgery, in an immunocompetent patient. This raises the alarm about the rapid identification of the source of contamination in the operating room, in order to prevent the emergence of further fatal infections.

Lack of regulation over antibiotic prescription and dispensation: A prospective cohort in a community setting.

BACKGROUND: The emergence of bacterial resistance caused health authorities to attempt to implement strict regulations for rational antibiotic prescription. However, supervision is often neglected in low- and middle-income countries, leading to inappropriate administration of antibiotics. The objective of our study is to highlight the lack of monitoring in the community setting of a middle-income country. MATERIAL AND METHODS: We asked 68 patients presenting to an infectious diseases consultation office to report the antibiotic courses they had taken in the three months preceding their visit. We assessed for treatment indication, molecule choice, dosing and duration, as well as microbial cultures, demographics and specialty of the prescriber. RESULTS: Among the 68 patients included in our study, we counted a total of 95 outpatient antibiotic courses, mostly composed of quinolones (36%), followed by amoxicillin-clavulanate (21%). The prescriber was most commonly a primary care physician, but we reported several cases of auto-medication and dispensation of antibiotics by pharmacists. Only 30% of cases had true indications for antibiotics. CONCLUSION: In sum, our results indicate an evident lack of regulation over the administration of antibiotics. This easy accessibility needs to be promptly addressed as we run the risk of inevitable bacterial resistance.

A case series of brain abscesses: an eleven-year retrospective single center study.

INTRODUCTION: We lack data on the epidemiology and management of brain abscesses in the Middle East. The aim of this study is to report a case series of brain abscesses admitted at a tertiary care center in Lebanon, between January 2008 and December 2018. METHODOLOGY: This retrospective study aimed at determining the demographic data, treatment, and correlations between different studied variables with prognosis of patients that received treatment. RESULTS: Forty-one patients (30 males) were included with a median age of 37 years (2-85). The analysis showed that the classic triad of fever, headache and neurologic deficit was only present in 12% of patients on admission. The source of infection was contiguous in 36.5%, post surgical in 32%, and distant in 17% of cases. Stereotactic biopsy was performed in 41.5% of patients, and craniotomy in 19.5%. A microorganism was isolated in 63% of patients (26 cases). The most used antibiotics were carbapenems (46%) and glycopeptides (66%). Eighty percent of patient (33) had a good outcome. A worse prognosis was significantly correlated with immunosuppression and multiple cerebral abscesses. CONCLUSIONS: Brain abscess remains a relatively rare condition.

Antibiotics in treatment of COVID-19 complications: a review of frequency, indications, and efficacy.

OBJECTIVES: To report available information in the literature regarding frequency, indications, types of antibiotic usage, duration, and their efficacy in Covid-19 infected patients. METHODS: The search was conducted on April 30 and May 7, 2020, using Ovid database and Google search. Patients' characteristics, clinical outcomes, as well as selected characteristics regarding antibiotic use (indication, class used, rates and types of bacterial secondary and co-infection, and duration of treatment) were analyzed. RESULTS: Nineteen clinical studies reporting data from 2834 patients were included. Mean rate of antibiotic use was 74.0 % of cases. Half the studies reported occurrence of a bacterial co-infection or complication (10 studies). Amongst the latter, at least 17.6 % of patients who received antibiotics had secondary infections. Pooled data of 4 studies show that half of patients receiving antibiotics were not severe nor critical. Detailed data on antibiotic use lack in most articles. CONCLUSIONS: The present review found a major use of antibiotics amongst Covid-19 hospitalized patients, mainly in an empirical setting. There is no proven efficacy of this practice. Further research to determine relevant indications for antibiotic use in Covid-19 patients is critical in view of the significant mortality associated with secondary infections in these patients, and the rising antimicrobial resistance.

Clostridioides difficile infections: Epidemiology, correlations and treatment in a Lebanese cohort with use of ATLAS scoring.

INTRODUCTION: The objectives of the present study were to investigate epidemiology, correlations, severity, and therapeutic response of Clostridioides difficile infections in a Lebanese tertiary care hospital. METHODOLOGY: In this retrospective cohort study, patients having at least one positive Clostridioides difficile test (antigen glutamate dehydrogenase/GDH with toxins, or PCR) were studied. RESULTS: Among 58 patients, 20 (34.5%) and 53 (91.4%) had positive antigen GDH and toxins, respectively. PCR was performed in 25 (43.1%) patients without any positive ribotype 027. Fifteen (25.9%) patients were immunocompromised, 35 (60.3%) patients received antibiotics prior to the infection and 34 (58.6%) on proton pump inhibitors. Fifty-four (93%) patients had a resolution of their symptoms after a mean period of 4.2 days of treatment. Twenty-two (38%) participants were treated with oral vancomycin, 11 (19%) with intravenous metronidazole and 23 (39.6%) with both antibiotics. Resolution of symptoms was significantly more rapid with monotherapy (p = 0.007) with no significant difference between vancomycin and metronidazole (p = 0.413). A positive correlation was found between ATLAS score and delay to symptoms resolution (r = 0.553; p < 0.001; N = 54), as well as between ATLAS score and prevalence of complications (p = 0.003). CONCLUSIONS: History of treatment with antibiotics, proton pump inhibitors, and hospital admission during the previous year were prevalent among our patient cohort. Rates of symptomatic resolution were similar with monotherapy and dual therapy.

COVID-19 in a Patient Treated for Granulomatosis with Polyangiitis: Persistent Viral Shedding with No Cytokine Storm.

INTRODUCTION: The coronavirus disease COVID-19 is considered a pandemic disease that has developed rapidly all over the world. As of today, it is unclear whether immunosuppression confers an increased risk for pulmonary complications, or conversely, whether it can be a protective factor with respect to a cytokine storm. CASE DESCRIPTION: We report the case of a 55-year-old male patient with granulomatosis with polyangiitis treated with rituximab who was infected with COVID-19 pneumonia. To the best of our knowledge, only 1 case has been reported in the literature with similar characteristics. The patient had a non-classic evolution of clinical symptoms with persistent fever and viral shedding, in addition to a negative serology. CONCLUSION: This case emphasizes the management and immunity response to COVID-19 pneumonia in such patients. Data are still needed regarding patients who have prolonged B-cell depletion, which may put the patient at a higher risk for reinfection. LEARNING POINTS: Demonstration of the immunity response to COVID-19 pneumonia in an immunosuppressed patient.To highlight the management and evolution of such rare cases during this pandemic.

Extended spectrum beta lactamase producing Escherichia coli tricuspid valve endocarditis.

Escherichia coli is a rare cause of endocarditis. This article reports an 82-year-old male with a mechanical aortic valve replacement who was admitted for fever and fatigue. He was diagnosed with a tricuspid valve endocarditis caused by an extended spectrum beta lactamase producing Escherichia coli following positive blood cultures and echocardiography. He received six weeks of imipenem / cilastatin and subsequently improved and was discharged with ambulatory follow ups with his infectious disease specialist.

Chronic Mercury Intoxication Masquerading as Systemic Disease: A Case Report and Review of the Literature.

BACKGROUND: Mercury is a highly toxic environmental metal that exists in three different forms: elemental, inorganic and organic. Intoxication occurs in either occupational or non-occupational settings, mainly after the inhalation of vapour and fumes in work places, laboratories or homes. Chronic mercury toxicity ranges from mild and insignificant to severe and life-threatening. We describe the case of a young male patient who presented with multiple organ dysfunction after chronic mercury exposure. CASE PRESENTATION: We report the case of 28-year-old male artisanal gold miner who was admitted to hospital for severe neurological impairment associated with inflammatory bowel disease-like symptoms and a skin rash after mercury exposure. Symptomatic treatment and corticosteroid administration assured rapid clinical improvement. Chronic mercury poisoning can masquerade as an autoimmune or systemic inflammatory disease. CONCLUSION: Physicians should be aware that low exposure to mercury, even from artisanal gold mining, may be harmful to health. Management can be simple without the need for aggressive or invasive therapeutic measures. Larger case series are required in order to establish a clear management plan. LEARNING POINTS: Mercury intoxication has a wide the variety of clinical manifestations that may involve the neurological, gastrointestinal and dermatological systems.Therefore, it can mimic degenerative neurological conditions, autoimmune diseases, as well as metabolic and mitochondrial disorders.Once diagnosed, mercury intoxication is easily treated.

Ciprofloxacin and imipenem resistance and cross-resistance in Pseudomonas aeruginosa: A single institution experience.

We conducted a pilot study to evaluate the resistance and cross-resistance of Pseudomonas aeruginosa to imipenem and ciprofloxacin. Our results highlight the importance of the judicious use of antibiotics, particularly fluoroquinolones, amidst the limited arsenal of effective antibiotics against Pseudomonas aeruginosa and the risk of cross-resistance induction.

Extensive infectious myelitis post bariatric surgery.

BACKGROUND: Inflammatory myelopathy is an inflammatory neurological disorder of the spinal cord (myelopathy). It occurs in 1 (severe) to 8 (mild) cases/million per year. It is often referred to in the literature as "transverse myelitis" or "acute transverse myelitis". Myelopathy and by extension myelitis, can present as pyramidal (motor), sensory, and/or autonomic dysfunction to varying degrees. Symptoms typically develop over hours to days and worsen over days to weeks. Sensory symptoms usually present as paresthesia ascending from the feet with or without back pain at or near the level of the myelitis. A cervical level focal myelitis can present as sensory symptoms restricted to the feet without ascending extension. Motor symptoms often include weakness that preferentially affects the flexors of the legs and the extensors of the arms (pyramidal distribution of weakness) and can include sphincter dysfunction. CASE PRESENTATION: This is the case of a 55 years old female patient who develops sudden onset abdominal abscess one year after bariatric surgery that was complicated by an extensive infectious myelitis and cerebral abscesses without any cerebral symptoms. She received adequate antibiotherapy treatment with good evolution. CONCLUSIONS: This case is among the first in the medical literature that has occurred one year after bariatric surgery complicated by an abdominal and cerebral abscesses, and extensive infectious myelitis. We discussed all types of myelitis including, the autoimmune and the infectious origin. We showed the progressive evolution by showing MRI sequences. We emphasized about the importance of rapid initiation of the antibiotherapy as well as adding glucocorticoids.

Recurrent Lower Urinary Tract Infections Have a Detrimental Effect on Patient Quality of Life: a Prospective, Observational Study.

INTRODUCTION: This study investigated the effects of recurrent urinary tract infections (rUTI) and the impact of prophylaxis on rUTI and patients' quality of life (QoL). METHODS: Altogether, 575 patients affected by rUTI were included in a 6-month observational study. QoL was assessed using the Hospital Anxiety and Depression (HAD) and the Leicester scales. Statistical analyses were performed using SAS® Version 8.2 software (SAS Institute Inc., Cary, NC, USA). The significance level was set at 5%. Spearman correlation was used to assess the degree of correlation between infectious episodes and HAD and Leicester scores. For each parameter, the comparison between Day 0 and Day 180 was performed using Wilcoxon signed-rank test for quantitative data. RESULTS: In total, 61.9% of patients suffering from rUTI exhibited some degree of depression at baseline (Day 0). Alternative oral non-antimicrobial prophylactic treatment for rUTI [Escherichia coli lyophilized bacterial lysate (OM-89)] was administered to 94.4% of patients (1 capsule a day for 90 days), followed by a 3-month treatment-free period. At the end of the study (Day 180), the mean number of UTI decreased by 59.3% (P ≤ 0.0001), the total HAD score decreased by 32.1% (P ≤ 0.0001), and the mean Leicester score decreased by 44.0% (P ≤ 0.0001) from baseline. There was a correlation trend between the reduction in the numbers of UTI at the end of the study compared to the 6 months prior to study entry and the reduction in the anxiety, depression, total HAD scores, activity, feeling, and total Leicester scores registered from Day 0 to Day 180, suggesting a lessening of emotional problems, and social and functional handicaps with decreasing UTI incidence. CONCLUSIONS: This study showed that rUTI had a negative impact on patients' QoL and that effective alternative prophylaxis significantly improved their QoL.

Recurrent lower limb abscesses as the primary manifestation of aorto-femoral graft paraprosthetic fistula.

A 62-year-old man was presented to our facility with recurrent right lower limb abscesses. He had an aortobifemoral graft for an aortoiliac occlusive disease. The diagnosis of paraprosthetic fistula was confirmed by performing a high-resolution contrast-enhanced computed tomography, whereas labeled leukocyte imaging provided a negative result. The graft present in the right limb was removed and extra-anatomical femoro-femoral bypass was performed along with segmental ileal resection of the affected loop and a side-to-side anastomosis. Recovery was unremarkable, with no recurrence of abscess 18 months after surgery. To our knowledge, this is the first report in published data on a paraprosthetic fistula presenting as recurrent lower limb abscesses. In this article, we have discussed the clinical features, principal diagnostic findings, and therapeutic options.

Post-graduation migration intentions of students of Lebanese medical schools: a survey study.

BACKGROUND: The international migration of physicians is a global public health problem. Lebanon is a source country with the highest emigration factor in the Middle East and North Africa and the 7th highest in the World. Given that residency training abroad is a critical step in the migration of physicians, the objective of this study was to survey students of Lebanese medical schools about their intentions to train abroad and their post training plans. METHODS: Our target population consisted of all students of Lebanese medical schools in the pre-final and final years of medical school. We developed the survey questionnaire based on the results of a qualitative study assessing the intentions and motives for students of Lebanese medical schools to train abroad. The questionnaire inquired about student's demographic and educational characteristics, intention to train abroad, the chosen country of abroad training, and post-training intention of returning to Lebanon. RESULTS: Of 576 eligible students, 425 participated (73.8% response rate). 406 (95.5%) respondents intended to travel abroad either for specialty training (330 (77.6%)) or subspecialty training (76 (17.9%)). Intention to train abroad was associated with being single compared with being married. The top 4 destination countries were the US (301(74.1%)), France (49 (12.1%)), the United Kingdom (31 (7.6%)) and Canada (17 (4.2%)). One hundred and two (25.1%) respondents intended to return to Lebanon directly after finishing training abroad; 259 (63.8%) intended to return to Lebanon after working abroad temporarily for a varying number or years; 43 (10.6%) intended to never return to Lebanon. The intention to stay indefinitely abroad was associated male sex and having a 2nd citizenship. It was inversely associated with being a student of one of the French affiliated medical schools and a plan to train in a surgical specialty. CONCLUSION: An alarming percentage of students of Lebanese medical schools intend to migrate for post graduate training, mainly to the US. A minority intends to return directly to Lebanon after finishing training abroad.

[A case of PAN with positive Hbs Ag cured by immunosuppressive and antiviral therapies: a case report]. / Guérison d'un cas de pan avec Ag Hbs positif sous immunosuppresseurs et antiviraux: a propos d'un cas.

Polyarteritis nodosa (PAN) first described by Kussmaul and Maier in 1866, is a multisystem necrotizing vasculitis of small and middle-sized muscular arteries. The presence of hepatitis B antigenemia (Hbs Ag) in approximately 30% of patients with PAN as well as immune complexes of Hbs Ag-Immunoglobulins and complement in the blood vessel walls strongly suggest the role of immunologic phenomena. The extremely poor prognosis of classic PAN has been modified by corticosteroid treatment with boluses of cyclophosphamide, and plasmapheresis. We report a case of PAN with renal, cardiac, central and peripheral nervous system involvement associated with active hepatitis B that got a total remission with corticosteroids, lamivudine and boluses of cyclophosphamide without plasmapheresis.

Why are you draining your brain? Factors underlying decisions of graduating Lebanese medical students to migrate.

In the context of a worldwide physician brain drain phenomenon, Lebanon has the highest emigration factor in the Middle East and North Africa. In this manuscript we aim to identify and develop a conceptual framework for the factors underlying the decisions of graduating Lebanese medical students to train abroad. We conducted two focus groups and seven semi-structured individual interviews with 23 students. In the deductive analysis (based on the push-pull theory), students reported push factors in Lebanon and pull factors abroad related to five dimensions. They focused predominantly on how training abroad provides them with a competitive advantage in an oversaturated Lebanese job market. An inductive analysis revealed the following emerging concepts: repel factors abroad and retain factors locally; societal expectations that students should train abroad; marketing of abroad training; and an established culture of migration. The marketing of abroad training and the culture of migration are prevalent in the academic institutions.

Pseudomonas aeruginosa bacteremia at a tertiary care center: a cohort study.

BACKGROUND: Pseudomonas aeruginosa bacteremia (PAB) is associated with high mortality and morbidity rates, but the outcome for patients with PAB has not been recently well evaluated. METHODS: Between 1997 and 1999, all episodes of PAB at the Hôtel-Dieu de France University Hospital, Lebanon, were analyzed to evaluate the outcome for patients with PAB. RESULTS: Fifty-five episodes of PAB in 53 patients (26 episodes in men and 29 in women) were analyzed. The mean age of the patients in the cohort was 60.7 years (range: 18-89 years). The mean time between the onset of hospitalization and the first episode of PAB was 21 days (range: 0-77 days). Most of the tested isolates showed favorable in vitro susceptibility to ceftazidime (85%), amikacin (77%) and imipenem (67%). The overall in-hospital cumulative survival was 89% at one week and 49% at 2 months. Among the variables analyzed, four were statistically associated with a higher mortality rate: prior use of antimicrobials (85% vs 54%), use of systemic steroids (49% vs 36%), intubation (67% vs 32%), and admission to the intensive care unit (74% vs 39%) (P < .05). CONCLUSION: Hospitalized patients with PAB have low survival rates. Newer strategies for prevention and treatment are crucial.

[Thrombotic thrombocytopenic purpura occurring simultaneously with systemic lupus erythematosus. A case report]. / Association simultanée de purpura thrombotique thrombocytopénique et de lupus chez un même patient: fait inhabituel et implications thérapeutiques.

INTRODUCTION: The association between thrombotic thrombocytopenic purpura and systemic lupus erythematosus has been rarely described, especially when the occurrence of both situations is simultaneous. OBSERVATION: We report the case of a 21-year-old young woman who presented with this association. DISCUSSION AND CONCLUSION: The simultaneous diagnosis of these two diseases is difficult because both share similar features. Treatment must be given early. It relies on therapeutic plasma exchange, systemic glucocorticoids or other immunosuppressive agents. The prognosis is very much related to the rapidity of the diagnosis and subsequent treatment.