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.

Assessment of Dietary Supplements Use among American University of Beirut Students: Prevalence, Knowledge, and Reasons for Supplementation.

The purpose of this study was to evaluate the prevalence and type of supplements used among university students, level of knowledge in this respect, reasons to supplement their diet, and the sources for information about dietary supplements. A sample of 100 students at the American University of Beirut were surveyed through a questionnaire composed of 22 questions and divided into four sections: socio-demographic, anthropometric, dietary supplement (DS) knowledge, DS intake and reasons. Descriptive statistics were conducted to determine the frequency of respondents for each variable and appropriate statistical tests were used for associations according to variable type and data. A total of 100 participants were included in the study of which 49 (49.0%) were males and 51 (51.0%) were females. Sixty-eight participants were dietary supplement users, of which 27 (39.7%) were males and 41 (60.3%) were females. Supplementation reasons differed: 53 consumed supplements to improve energy and vitality, 22 to enhance cognitive performance, 22 to promote hair, skin and health, and 13 to prevent or treat cold. A significant association was observed between dietary supplements use and female gender (OR = 5.66, 95% CI: 1.60-20.10). No significance was found between consuming dietary supplements and smoking status, BMI, living conditions, medical condition, age, exercise, major, dietary knowledge, and side effects. More than half of the participants are dietary supplements users with females being more likely to use them. The main reason for both genders to resort to dietary supplement use is to improve their energy and vitality.

QTc prolongation during levofloxacin and triazole combination chemoprophylaxis: Prevalence and predisposing risk factors in a cohort of hematopoietic cell transplantation recipients.

BACKGROUND: QTc interval prolongation has been reported when combining fluoroquinolones and triazoles for chemoprophylaxis in cancer patients. Herein, we aimed to identify the prevalence and contributing factors to QTc prolongation in hematopoietic cell transplantation (HCT) recipients who received these agents during the neutropenic phase. METHODS: This is a retrospective medical chart review conducted at a university hospital in Lebanon from 2017 to 2020. It included all adult HCT inpatients on antimicrobial prophylaxis with fluoroquinolones and triazoles and whose baseline ECG monitoring done prior to chemoprophylaxis administration, then on day-3 and day-6 of therapy, were available. RESULTS: Overall, 68 HCT recipients met our inclusion criteria, of which 22% developed QTc prolongation. Based on bivariate analysis, female gender contributed to QTc prolongation (P = 0.001). There was a trend to QTc prolongation in patients with predisposing thyroid disease (P = 0.12), grade 2 vomiting and diarrhea (P = 0.16, P = 0.46, respectively), baseline hypokalemia (P = 0.18) and hypocalcemia (P = 0.3), hypomagnesemia on day-3 (P = 0.21) and day-6 hyponatremia (P = 0.36). Patients receiving two or more drugs with a known or probable risk of QTc prolongation (other than the fluoroquinolone/ triazole combination) were more prone to experience a prolonged QTc interval (P = 0.09). None of the patients that had QTc prolongation died or developed serious arrhythmias. CONCLUSION: The prevalence of QTc prolongation was 22% among HCT recipients on fluoroquinolone and triazole prophylaxis, yet we did not identify any independent risk factors for this issue. None of the patients that had QTc interval prolongation died or developed serious arrhythmias.

Sacrococcygeal Local Anesthesia for Complicated Versus Uncomplicated Pilonidal Sinus Surgery: A Single Center Study.

BACKGROUND: Several anesthetic techniques have been used for pilonidal sinus surgery such as general, spinal, and local anesthesia infiltration. However, the most effective technique remains controversial. The aim of this study was to assess the effectiveness of sacrococcygeal local anesthesia for complicated pilonidal cysts in terms of postoperative analgesic consumption. METHODS: This was a retrospective cohort study conducted by collecting data from medical records for male patients who underwent pilonidal surgery using sacrococcygeal local anesthesia from 2008 to 2018. Patients' demographics, operative data, and postoperative outcomes such as pain, nausea, as well as analgesic consumption at 0 and 3 hours were analyzed. Pain scores at rest and upon pressure were recorded using the Visual Analogue Scale. The length of complicated pilonidal sinus was considered to be greater than or equal to 7 cm with multiple openings. RESULTS: A total of 394 patients were included in the study, 173 patients (43.9%) had complicated cysts while 221 patients (56.1%) had uncomplicated cysts. The majority of patients were males (85.5% vs. 76.9% in the complicated and uncomplicated groups respectively). Patients' weight was significantly higher in the complicated cyst group (87.12 ± 17.07 vs. 82.43 ± 20.30 kg, P value = 0.02). Around 41% of the patients in the complicated group were obese (body mass index ≥ 30 kg/m^2) compared to 32.0% of the patients in the uncomplicated group. Mean arterial pressure and heart rate at baseline, intraoperatively and at the end of the operation were similar between the two groups. Pain scores at rest and upon pressure were low in both groups. Analgesic consumption was similar between the two groups. Eight patients (4.6%) in the complicated group required acetaminophen at 0 hour compared to 6 patients (2.7%) in the uncomplicated group. Three patients (1.7%) received ketoprofen at 0 hour in the complicated group and 3 patients (1.4%) in the other group. Three patients, 2 (1.2%) in the complicated group and 1 (0.5%) in the second group required tramadol hydrochloride. CONCLUSIONS: Sacrococcygeal local anesthetic technique for complex pilonidal sinus surgery provided intra-operative hemodynamic stability as well as low post-operative pain and analgesic consumption.

Comparison of clinical effects of meperidine and sufentanil added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean delivery: a randomized controlled trial.

PURPOSE: The objective of this study was to compare the effect of adding meperidine or sufentanil to hyperbaric bupivacaine in patients undergoing elective cesarean delivery (CD) under spinal anesthesia. The primary outcome was the first analgesic request time, and secondary outcomes included an analgesic requirement in the first 24 h and intraoperative and postoperative side effects. METHODS: This was a randomized, double-blind clinical trial in which patients were allocated into two groups. One group received preservative-free meperidine 12.5 mg (1 mL) in addition to 0.5% 10 mg (2 mL) of hyperbaric bupivacaine for spinal anesthesia. The other group received sufentanil 5 µg (1 mL) added to 0.5% 10 mg (2 mL) of hyperbaric bupivacaine. RESULTS: A total of 60 parturients were included in the study, 30 patients in each group. Time to first analgesic request was significantly longer in the meperidine group (400.0 ± 142.1 min) compared to (274.0 ± 104.1 min) in the sufentanil group (P < 0.0001). Around 73% of the parturients in the sufentanil group required analgesics at 4 h compared to 13% in the meperidine group (P < 0.0001). There were no significant differences in postoperative pruritus, nausea and vomiting, in addition to shivering. As for surgeon satisfaction, 56.7% reported excellent abdominal muscle relaxation during the surgery in the meperidine group compared to 10% in the sufentanil group (P < 0.0001). CONCLUSION: Meperidine was superior to sufentanil in terms of improved analgesia, intraoperative postoperative pruritus, and shivering, as well as increased surgeon satisfaction in women undergoing spinal anesthesia for elective cesarean delivery. CLINICAL TRIAL NUMBER AND REGISTRY: ClinicalTrials.gov (NCT04446715).

The psychological health of patients diagnosed with cancer in Iraq during the COVID-19 pandemic: A single center study.

OBJECTIVE: The objective of this study was to assess the psychological health status of patients diagnosed with cancer in Iraq during the COVID-19 pandemic. The study aim was to measure the prevalence of depression, anxiety, and stress among patients diagnosed with cancer. Secondary aims were to assess the association between depression, anxiety, and stress with sociodemographic characteristics, cancer-specific characteristics, patients' experience in healthcare visit, risk perception towards COVID-19, and health concern during the outbreak. METHODS: A cross-sectional study was conducted between September 1, 2020 and December 1, 2020 at an Oncology clinic in Baghdad. Included in the study were two hundred patients diagnosed with cancer. Data collected included: demographic variables (age, gender, residential location, marital status, education, employment status), clinical characteristics and cancer-specific parameters (duration since cancer diagnosis, cancer type, treatment duration, clinic visits frequency), experience during the pandemic (skipping or postponing treatment or periodical tests, suffering from new body pain, fear of acquiring the infection, fear of health deterioration), as well as psychological health status (depression, anxiety, stress). Pain, risk perception towards COVID-19, and health concern were measured using categorical Likert scale with responses being no, sometimes, and often. The psychological health status was measured by the "Depression, Anxiety, and Stress Scale" (DASS-21). Cut-off scores of the DASS-21 greater than 9, 7, and 14 represent a positive screen of depression, anxiety, and stress, respectively. RESULTS: The prevalence of patients who screened positive for depression was 22.0%, anxiety 22.0%, and stress 13.5%. The prevalence of depression, anxiety and stress were significantly more in those who had university or higher education (34.3%, p-value <0.0001; 32.3%, p-value <0.0001; 19.2%, p-value = 0.02 respectively). Those were four times more likely to have depression and two times more likely to have anxiety than participants who had school education (OR = 4.40 CI [1.98-9.77], p-value <0.0001; OR = 2.55 CI [1.15-5.65], p-value = 0.02, respectively). The prevalence of anxiety was significantly the highest in the age group 16-39 years (40.9%) compared to 22.3% in the age group 40-64 years and 10.3% in the group ≥65 years (p-value = 0.02). Patients ≥65 years of age were less likely to develop anxiety compared to younger patients (OR = 0.44 CI [0.22-0.89], p-value = 0.02). As for the patients' experience in healthcare visit, 66 patients (33.0%) skipped or postponed their treatment or tests due to the outbreak. Around (8%) sometimes suffered from new body pain. Those who sometimes suffered from new body pain had significantly more depression than patients who did not suffer new pain or often had new pain (50.0% vs. 15.0% vs. 28.1% respectively, p-value = 0.002). Those were two times more likely to be depressed (OR = 2.18 CI [1.29-3.68], p-value = 0.003). Around (50%) of the patients were often afraid that their health would deteriorate during the outbreak. Those were significantly more depressed (31.7%, p-value = 0.002), anxious (30.7%, p-value <0.0001) and stressed (21.8%, p-value = 0.002) than those who did not have fear of losing their health and were two times more likely to have anxiety and stress. CONCLUSION: These findings, especially the association between developing new pain and depression, raised concerns regarding the psychological health in patients diagnosed with cancer during COVID-19 pandemic. It is crucial to implement psychological health screening for patients diagnosed with cancer during the pandemic to help prevent any psychological health problems. The DASS-21 could be used as a screening tool for distress in these patients.

Epidemiology, risk factors, and prediction score of carbapenem resistance among inpatients colonized or infected with 3rd generation cephalosporin resistant Enterobacterales.

In this study, we determined the incidence and risk factors of Carbapenem-resistant Enterobacterales (CRE) acquisition in inpatients with 3rd generation cephalosporin-resistant (3GCR) Enterobacterales at a tertiary-care hospital in Lebanon, and suggested a risk prediction score for it. This is a retrospective matched case-control study of inpatients with 3GCR Enterobacterales that are carbapenem resistant (cases) versus those with carbapenem-sensitive isolates (controls). Data analysis was performed on IBM SPSS program, version 23.0 (Armonk, NY, USA: IBM Corp.). Categorical variables were compared between cases and controls through bivariate analysis and those with statistical significance (P < 0.05) were included in the forward stepwise multiple logistic regression analysis. To develop the CRE acquisition risk score, variables that maintained statistical significance in the multivariate model were assigned a point value corresponding to the odds ratio (OR) divided by the smallest OR identified in the regression model, and the resulting quotient was multiplied by two and rounded to the nearest whole number. Summation of the points generated by the calculated risk factors resulted in a quantitative score that was assigned to each patient in the database. Predictive performance was determined by assessing discrimination and calibration. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for different cutoffs of the score. The incidence of CRE acquisition significantly increased with time from 0.21 cases/1000 patient-days (PD) in 2015 to 1.89 cases/1000PD in 2019 (r2 = 0.789, P = 0.041). Multivariate analysis of matched data revealed that the history of cerebrovascular disease (OR 1.96; 95% CI 1.04-3.70; P = 0.039), hematopoietic cells transplantation (OR 7.75; 95% CI 1.52-39.36; P = 0.014), presence of a chronic wound (OR 3.38; 95% CI 1.73-6.50; P < 0.001), endoscopy done during the 3 months preceding the index hospitalization (OR 2.96; 95% CI 1.51-4.73; P = 0.01), nosocomial site of acquisition of the organism in question (OR 2.68; 95% CI 1.51-4.73; P = 0.001), and the prior use of meropenem within 3 months of CRE acquisition (OR 5.70; 95% CI 2.61-12.43; P < 0.001) were independent risk factors for CRE acquisition. A risk score ranging from 0 to 25 was developed based on these independent variables. At a cut-off of ≥ 5 points, the model exhibited a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 64.5%, 85.8%, 82%, 70.7% and 75%, respectively. We also showed that only meropenem consumption intensity and CRE acquisition incidence density showed a strong positive correlation(r = 0.798, P = 0.106), unlike imipenem (r = - 0.868, P = 0.056) and ertapenem (r = 0.385, P = 0.522). Patients with a score of ≥ 5 points in our model were likely to acquire CRE. Only meropenem was associated with CRE carriage. Our proposed risk prediction score would help target surveillance screening for CRE amongst inpatients at the time of hospital admission and properly guide clinicians on using anti-CRE therapy.

Isolated Tubal Torsion: A Rare Cause of Acute Pelvic/Abdominal Pain among Adolescent Females.

Tubal torsion usually occurs as a part of adnexal torsion that affects an ovary and the adjacent tube; however, isolated tubal torsion is an extremely rare condition. Usually, it presents as acute pelvic/abdominal pain but could also exhibit milder intermittent pain alternating with periods of relief (subacute). This condition has seldom been diagnosed preoperative and commonly results in tubal damage due to delayed management. We hereby, report the findings of two cases managed recently at our center. In both cases, the diagnosis was delayed 2-3 days and was only made intraoperative when the tubes could not be salvaged due to extensive necrosis. The extent of tubal damage is predominantly dependent on the duration of vascular insult; hence, the urgency for affecting early diagnosis and intervention to restore blood supply and preserve tubal integrity and function. We advocate the liberal and early use of laparoscopy in patients presenting with subacute unexplained pelvic/abdominal pain.

The effect of an antibiotic stewardship program on tigecycline use in a Tertiary Care Hospital, an intervention study.

BACKGROUND: A drug-oriented antibiotic stewardship intervention targeting tigecycline utilization was launched at Makassed General Hospital, Beirut, Lebanon, in 2016 as a part of a comprehensive Antibiotic Stewardship Program (ASP). In this study, we evaluated the effect of this intervention on changing tigecycline prescription behavior in different types of infections, patient outcome and mortality, along with tigecycline drug use density, when compared to an earlier period before the initiation of ASP. METHODS: This is a retrospective chart review of all adult inpatients who received tigecycline for more than 72 h between Jan-2012 and Dec-2013 [period (P) 1 before ASP] and between Oct-2016 and Dec-2018 [period (P) 2 during ASP]. RESULTS: Tigecycline was administered to 153 patients during P1 and 116 patients during P2. The proportion of patients suffering from cancer, those requiring mechanical ventilation, and those with hemodynamic failure was significantly reduced between P1 and P2. The proportion of patients who received tigecycline for FDA-approved indications increased from 19% during P1 to 78% during P2 (P < 0.001). On the other hand, its use in off-label indications was restricted, including ventilator-associated pneumonia (26.1% in P1, 3.4% in P2, P < 0.001), hospital-acquired pneumonia (19.6% in P1, 5.2% in P2, P = 0.001), sepsis (9.2% in P1, 3% in P2, P = 0.028), and febrile neutropenia (15.7% in P1, 0.9% in P2, P < 0.001). The clinical success rate of tigecycline therapy showed an overall significant increase from 48.4% during P1 to 65.5% during P2 (P = 0.005) in the entire patient population. All-cause mortality in the tigecycline-treated patients decreased from 45.1% during P1 to 20.7% during P2 (P < 0.0001). In general, mean tigecycline consumption decreased by 55% between P1 and P2 (P < 0.0001). CONCLUSION: The drug-oriented ASP intervention targeting tigecycline prescriptions improved its use and patient outcomes, where it helped curb the over-optimistic use of this drug in off-label indications where it is not a suitable treatment option.

Effect of a "handshake" stewardship program versus a formulary restriction policy on High-End antibiotic use, expenditure, antibiotic resistance, and patient outcome.

This study reports the effect of implementing an antibiotic stewardship program (ASP) based on the "handshake" strategy for 2 years on multiple endpoints compared with that in a preceding period when an antimicrobial restriction policy was only applied in the absence of a complete program in a tertiary-care Lebanese hospital. The studied endpoints were broad-spectrum antibiotic consumption, antibiotic expenditure, nosocomial bacteremia incidence rate, and patient outcome.An interrupted time series analysis was undertaken to assess the changes in the trend (ΔT) and level (ΔL) of the aforementioned endpoints among adult inpatients before (October 2013 to September 2015) and after the introduction of the ASP (October 2016 to September 2018).After the implementation of the "handshake" ASP, marked changes were observed in the consumption of broad-spectrum antibiotics. The mean use density levels for imipenem and meropenem decreased by 13.72% (P = 0.017), coupled with a decreasing rate of prescription (ΔT = -24.83 defined daily dose [DDD]/1,000 patient days [PD]/month; P = 0.02). Tigecycline use significantly decreased in level by 69.19% (P < 0.0001) and in trend (ΔT = -25.63 DDD/1,000 PD/month; P < 0.0001). A reduction in the use of colistin was also documented but did not reach statistical significance (ΔL = -8.71%, P = 0.56; ΔT = -5.51 DDD/1,000 PD/month = -5.5; P = 0.67). Antibiotic costs decreased by 24.6% after ASP implementation (P < 0.0001), and there was a distinct change from an increasing rate to a decreasing rate of expenditure (ΔT = -12.19 US dollars/PD/month; P = 0.002). The incidence rate of nosocomial bacteremia caused by carbapenem-resistant gram-negative bacteria (CRGNB) decreased by 34.84% (P = 0.13) coupled with a decreasing trend (ΔT = -0.23 cases/1,000 PD/month, P = 0.08). Specifically, a noticeable reduction in the incidence rate of bacteremia due to carbapenem-resistant Acinetobacter baumannii was documented (ΔL = -54.34%, P = 0.01; ΔT = -0.24 cases/1000 PD/month, P = 0.01). Regarding patient outcome, all-cause mortality rates did not increase in level or in rate (ΔL = -3.55%, P = 0.59; ΔT = -0.29 deaths/1000 PD/month, P = 0.6). The length of stay and 7-day readmission rate remained stable between the two periods.In conclusion, the "handshake" ASP succeeded in controlling the prescription rates of antibiotics and in decreasing the nosocomial bacteremia rates caused by CRGNB without compromising patient outcome in our facility. It also had an economic effect in reducing antibiotic costs compared with the previous restriction policy on antimicrobial dispensing.

Prescription Patterns for Tigecycline in Severely Ill Patients for Non-FDA Approved Indications in a Developing Country: A Compromised Outcome.

Introduction: With the rise in antibiotic resistance, tigecycline has been used frequently in off-label indications, based on its in-vitro activity against multidrug-resistant organisms. In this study, our aim was to assess its use in approved and unapproved indications. Materials and Methods: This is a retrospective chart review evaluating a 2-year experience of tigecycline use for > 72 h in 153 adult patients inside and outside critical care unit from January 2012 to December 2013 in a Lebanese tertiary-care hospital. Results: Tigecycline was mostly used in off-label indications (81%) and prescribed inside the critical care area, where the number of tigecycline cycles was 16/1,000 patient days. Clinical success was achieved in 43.4% of the patients. In the critically ill group, it was significantly higher in patients with a SOFA score <7 using multivariate analysis (Odds Ratio (OR) = 12.51 [4.29-36.51], P < 0.0001). Microbiological success was achieved in 43.3% of patients. Yet, the univariate and adjusted multivariate models failed to show a significant difference in this outcome between patients inside vs. outside critical care area, those with SOFA score <7 vs. ≥ 7, and in FDA-approved vs. off-label indications. Total mortality reached ~45%. It was significantly higher in critically ill patients with SOFA score ≥7 (OR = 5.17 [2.43-11.01], P < 0.0001) and in off-label indications (OR = 4.00 [1.30-12.31], P = 0.01) using an adjusted multivariate model. Gram-negative bacteria represented the majority of the clinical isolates (81%) and Acinetobacter baumannii predominated (28%). Carbapenem resistance was present in 85% of the recovered Acinetobacter, yet, more than two third of the carbapenem-resistant Acinetobacter species were still susceptible to tigecycline. Conclusion: In our series, tigecycline has been mostly used in off-label indications, specifically in severely ill patients. The outcome of such infections was not inferior to that of FDA-approved indications, especially inside critical care area. The use of this last resort antibiotic in complicated clinical scenarios with baseline microbiological epidemiology predominated by extensively-drug resistant pathogens ought to be organized.

Third generation cephalosporin resistant Enterobacteriaceae and multidrug resistant gram-negative bacteria causing bacteremia in febrile neutropenia adult cancer patients in Lebanon, broad spectrum antibiotics use as a major risk factor, and correlation with poor prognosis.

INTRODUCTION: Bacteremia remains a major cause of life-threatening complications in patients receiving anticancer chemotherapy. The spectrum and susceptibility profiles of causative microorganisms differ with time and place. Data from Lebanon are scarce. We aim at evaluating the epidemiology of bacteremia in cancer patients in a university hospital in Lebanon, emphasizing antibiotic resistance and risk factors of multi-drug resistant organism (MDRO)-associated bacteremia. MATERIALS AND METHODS: This is a retrospective study of 75 episodes of bacteremia occurring in febrile neutropenic patients admitted to the hematology-oncology unit at Makassed General Hospital, Lebanon, from October 2009-January 2012. It corresponds to epidemiological data on bacteremia episodes in febrile neutropenic cancer patients including antimicrobial resistance and identification of risk factors associated with third generation cephalosporin resistance (3GCR) and MDRO-associated bacteremia. RESULTS: Out of 75 bacteremias, 42.7% were gram-positive (GP), and 57.3% were gram-negative (GN). GP bacteremias were mostly due to methicillin-resistant coagulase negative staphylococci (28% of total bacteremias and 66% of GP bacteremias). Among the GN bacteremias, Escherichia coli (22.7% of total, 39.5% of GN organisms) and Klebsiella pneumoniae(13.3% of total, 23.3% of GN organisms) were the most important causative agents. GN bacteremia due to 3GC sensitive (3GCS) bacteria represented 28% of total bacteremias, while 29% were due to 3GCR bacteria and 9% were due to carbapenem-resistant organisms. There was a significant correlation between bacteremia with MDRO and subsequent intubation, sepsis and mortality. Among potential risk factors, only broad spectrum antibiotic intake >4 days before bacteremia was found to be statistically significant for acquisition of 3GCR bacteria. Using carbapenems or piperacillin/tazobactam>4 days before bacteremia was significantly associated with the emergence of MDRO (p < 0.05). CONCLUSION: Our findings have major implications for the management of febrile neutropenia, especially in breakthrough bacteremia and fever when patients are already on broadspectrum antibiotics. Emergence of resistance to 3GCs and, to a lesser extent, to carbapenems in GN isolates has to be considered seriously in our local guidelines for empiric treatment of febrile neutropenia, especially given that their occurrence was proven to be associated with poorer outcomes.