INTRODUCTION
Hospital length of stay (LOS) serves as a key indicator of healthcare efficiency, cost, and quality outcomes. The growing burden of urinary tract infections (UTIs), especially when complicated by multidrug-resistant (MDR) pathogens and inappropriate antibiotic regimens, poses serious challenges to healthcare systems. In Lebanon, where antimicrobial resistance (AMR) is escalating, identifying the determinants of prolonged LOS becomes critical. This retrospective cohort study, conducted across five university hospitals from March 2022 to December 2023, investigated factors influencing LOS among 401 adult patients hospitalized with UTIs. Key objectives included exploring the influence of clinical and microbiological variables on hospitalization duration and assessing microbial susceptibility profiles. By employing advanced statistical models such as multiple linear regression, the study not only captured the scope of patient and treatment factors but also underscored the implications of empirical antibiotic use. With Escherichia coli emerging as the most common pathogen and antibiotic susceptibility rates declining, the study underscores the necessity for improved antimicrobial stewardship programs. Ultimately, the findings guide future interventions aimed at optimizing treatment protocols and enhancing healthcare delivery in Lebanon.
FACTORS INFLUENCING LENGTH OF STAY
The study identified several patient-related and treatment-related factors significantly associated with prolonged hospital stay in UTI patients. Older age, presence of comorbidities, type of UTI (complicated vs. uncomplicated), specific symptoms, and infection with multidrug-resistant organisms were positively correlated with extended hospitalization. The use of broad-spectrum empirical antibiotics, especially carbapenems and fluoroquinolones, also led to a longer LOS. On the other hand, de-escalation of antibiotics based on culture sensitivity results was associated with shorter hospital stays. These findings suggest that both clinical judgment and microbiological evidence must guide UTI management. Tailoring treatment plans based on individual risk profiles and real-time data may reduce unnecessary hospital occupancy and optimize outcomes. The multifactorial nature of LOS highlights the importance of interdisciplinary collaboration between infectious disease specialists, pharmacists, and clinical microbiologists in minimizing treatment delays and promoting timely discharges.
ANTIBIOTIC UTILIZATION AND ITS IMPACT
The empirical use of antibiotics such as carbapenems and fluoroquinolones showed a statistically significant relationship with increased LOS among UTI patients. These antibiotics, although potent, may be overutilized in empirical settings without confirmed resistance, leading to treatment delays when inappropriate. The regression analysis revealed strong beta coefficients (β = 0.783 for carbapenems; β = 1.360 for fluoroquinolones), reinforcing that empiricism without de-escalation may be detrimental. Inappropriate initial antibiotic prescriptions further contributed to extended hospitalizations (β = 0.609, p = 0.022). This underscores the pressing need for diagnostic stewardship alongside antimicrobial stewardship. Avoiding the knee-jerk prescription of broad-spectrum agents and implementing protocol-driven antibiotic policies can improve patient outcomes and shorten hospital stays. It also promotes better allocation of healthcare resources, especially in low- and middle-income countries grappling with AMR challenges.
ROLE OF DE-ESCALATION STRATEGIES
A pivotal finding of the study was that antibiotic de-escalation, when guided by culture results, significantly reduced hospital stay (β = −0.567, p = 0.029). De-escalation refers to the targeted narrowing of antibiotic therapy based on pathogen identification and susceptibility patterns. This strategy not only ensures optimal therapy but also limits drug toxicity and slows resistance emergence. In the Lebanese hospital setting, incorporating such data-driven strategies into routine care can enhance clinical outcomes and reduce unnecessary antibiotic exposure. Culture-guided therapy empowers clinicians to move from a broad-spectrum “cover-all” mindset to a precision-based approach. As antibiotic resistance grows, especially among uropathogens like E. coli and K. pneumoniae, timely de-escalation becomes more than a stewardship recommendation—it becomes a clinical necessity. Encouraging culture testing and implementing electronic alerts for de-escalation may serve as practical steps forward.
MICROBIAL PROFILE AND RESISTANCE TRENDS
The study confirmed Escherichia coli as the most prevalent UTI pathogen (61.8%), followed by Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. However, the more alarming revelation was the declining antibiotic susceptibility among these isolates. This trend signals a rise in resistant strains, complicating empirical treatment and contributing to prolonged hospitalization. MDR infections not only prolong treatment courses but also elevate costs and risks of complications. The findings reflect a broader, global concern of dwindling effective antibiotics, with Lebanon representing a critical hotspot. Understanding local epidemiology of uropathogens and regularly updating antibiograms are essential. Surveillance efforts need to be bolstered with real-time data sharing between hospitals to track resistance shifts. Furthermore, integrating microbial profiling into hospital dashboards may help clinicians make faster, evidence-based therapeutic decisions and control outbreaks more effectively.
POLICY IMPLICATIONS AND FUTURE DIRECTIONS
This research underscores an urgent call for national policy interventions, particularly the establishment of a unified microbial resistance database and robust antimicrobial stewardship programs (ASPs). Inappropriate antibiotic use and lack of surveillance infrastructure remain central challenges in Lebanon’s healthcare landscape. Data from this study can inform policymakers to implement standardized protocols for antibiotic prescribing, culture testing, and resistance monitoring. Future studies should also explore cost-effectiveness analyses of stewardship interventions. Strengthening medical education, reinforcing hospital guidelines, and funding laboratory diagnostics are essential pillars in combating AMR. The integration of stewardship teams in hospitals, supported by real-time data platforms, can transform reactive treatment into proactive care. By institutionalizing culture-based therapy and continuously monitoring LOS metrics, Lebanon can mitigate AMR threats while improving hospital efficiency and patient safety.
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