Clinical outcomes and risk factors associated with bloodstream infections caused by multidrug-resistant Gram-negative bacteria in hospitalized patients: a prospective cohort study in Libya

<b>Introduction.</b> Bloodstream infections (BSIs) caused by multidrug-resistant Gram-negative bacteria (MDR-GNB) are a major cause of mortality, with limited treatment options.<b>Gap/Hypothesis.</b> Despite the global rise of MDR-GNB, prospective data on their clinical impact in North Africa remain scarce, restricting evidence-based guidance for empiric therapy.<b>Aim.</b> To assess the prevalence, resistance patterns and clinical outcomes of MDR-GNB BSIs in Libya, and to identify predictors of 30-day mortality.<b>Methodology.</b> A prospective cohort study was conducted in two Libyan hospitals between November 2022 and November 2024. Adult patients with positive blood cultures were enrolled. Isolates were identified using standard microbiological methods, and antimicrobial susceptibility testing was interpreted according to Clinical and Laboratory Standards Institute (CLSI) 2023 guidelines. Multivariable logistic regression was applied to identify independent predictors of 30-day mortality.<b>Results.</b> Among 673 BSI episodes, 37.4% were multidrug resistance (MDR). <i>Escherichia coli</i> (32.0%) and <i>Klebsiella pneumoniae</i> (25.9%) predominated, while carbapenem resistance was highest in <i>Acinetobacter baumannii</i> (42.4%). Overall, 30-day mortality was 23.8%, and was significantly higher in MDR infections (32.1% vs 18.8%; <i>P</i><0.001). Independent predictors of mortality were MDR infection [adjusted odds ratio (aOR), 1.9], Intensive care Unit (ICU) admission (aOR, 2.6), Charlson Comorbidity Index ≥3 (aOR, 1.7) and inappropriate empiric therapy (aOR, 2.3).<b>Conclusion.</b> MDR-GNB BSIs are highly prevalent in Libya and substantially worsen outcomes. These findings highlight the urgent need for improved empiric therapy, antimicrobial stewardship and infection control programmes.