Multidrug resistance and clinical outcomes among patients with confirmed Enterococcus infections in a tertiary hospital in a low- and middle-income setting

Enterococcus species are increasingly recognized as important causes of healthcare-associated infections, particularly in resource-limited settings. The growing burden of multidrug resistance (MDR) further complicates clinical management and outcomes. This study aimed to characterize the distribution of Enterococcus species, describe antimicrobial resistance patterns, and identify factors associated with hospital-acquired infection and all-cause in-hospital mortality. We conducted a retrospective study including 563 patients with clinician-confirmed Enterococcus infections at a tertiary hospital in Palestine between January 2023 and December 2024. Antimicrobial susceptibility testing was performed using the VITEK 2 system in accordance with CLSI standards. Multivariable logistic regression was used to identify independent predictors of hospital-acquired infection and all-cause in-hospital mortality. The mean patient age was 54.4 ± 20.0 years; 51.7% were male. Enterococcus faecalis (57.4%, n = 323) predominated over Enterococcus faecium (36.8%, n = 207). Acquired MDR was observed in 64.7% ( n = 364) of isolates, with the highest prevalence among E. faecium isolates (92.3%). Hospital-acquired infections (41.7%) were independently associated with male sex (aOR 1.55, 95% CI 1.05–2.28), hematologic malignancy (aOR 2.54, 95% CI 1.46–4.41), recent surgery (aOR 3.73, 95% CI 2.49–5.59), and prior antibiotic exposure (aOR 3.15, 95% CI 2.10–4.73). All-cause in-hospital mortality (13.7%, n = 77) was independently associated with age (aOR 1.02/year, 95% CI 1.00–1.03), prior antibiotic exposure (aOR 3.51, 95% CI 1.92–6.44), and acquired MDR (aOR 1.97, 95% CI 1.05–3.72). However, the association between acquired MDR and mortality was attenuated after additional adjustment for ICU location and bloodstream infection. A high burden of acquired MDR among patients with confirmed Enterococcus infections supports enhanced local surveillance and antimicrobial stewardship in Palestinian hospitals. Not applicable.