title: Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention.
abstract: BACKGROUND
  During 2006, Israeli hospitals faced a clonal outbreak of carbapenem-resistant Klebsiella pneumoniae that was not controlled by local measures. A nationwide intervention was launched to contain the outbreak and to introduce a strategy to control future dissemination of antibiotic-resistant bacteria in hospitals.
  
  
  METHODS
  In March 2007, the Ministry of Health issued guidelines mandating physical separation of hospitalized carriers of carbapenem-resistant Enterobacteriaceae (CRE) and dedicated staffing and appointed a professional task force charged with containment. The task force paid site visits at acute-care hospitals, evaluated infection-control policies and laboratory methods, supervised adherence to the guidelines via daily census reports on carriers and their conditions of isolation, provided daily feedback on performance to hospital directors, and intervened additionally when necessary. The initial intervention period was 1 April 2007-31 May 2008. The primary outcome measure was incidence of clinically diagnosed nosocomial CRE cases.
  
  
  RESULTS
  By 31 March 2007, 1275 patients were affected in 27 hospitals (175 cases per 1 million population). Prior to the intervention, the monthly incidence of nosocomial CRE was 55.5 cases per 100,000 patient-days. With the intervention, the continuous increase in the incidence of CRE acquisition was halted, and by May 2008, the number of new monthly cases was reduced to 11.7 cases per 100,000 patient-days (P<.001). There was a direct correlation between compliance with isolation guidelines and success in containment of transmission (P=.02). Compliance neutralized the effect of carrier prevalence on new incidence (P=.03).
  
  
  CONCLUSIONS
  A centrally coordinated intervention succeeded in containing a nationwide CRE outbreak after local measures failed. The intervention demonstrates the importance of strategic planning and national oversight in combating antimicrobial resistance.
authors.affiliation: National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel. mitchells@tasmc.health.gov.il
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Schwaber
authors.forename: Boaz
authors.initials: B
authors.lastname: Lev
authors.forename: Avi
authors.initials: A
authors.lastname: Israeli
authors.forename: Ester
authors.initials: E
authors.lastname: Solter
authors.forename: Gill
authors.initials: G
authors.lastname: Smollan
authors.forename: Bina
authors.initials: B
authors.lastname: Rubinovitch
authors.forename: Itamar
authors.initials: I
authors.lastname: Shalit
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Carmeli
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D015780:Carbapenems / Q000494:pharmacology*; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D004196:Disease Outbreaks; D006291:Health Policy; D006761:Hospitals; D006801:Humans; D015994:Incidence; D017053:Infection Control / Q000379:methods*; D007557:Israel / Q000453:epidemiology; D007710:Klebsiella Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D007711:Klebsiella pneumoniae / Q000187:drug effects* / Q000302:isolation & purification; D018440:beta-Lactam Resistance
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems