title: Prolonged delay for controlling KPC-2-producing Klebsiella pneumoniae outbreak: the role of clinical management.
abstract: BACKGROUND
  Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak.
  
  
  METHODS
  An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method.
  
  
  RESULTS
  The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members.
  
  
  CONCLUSIONS
  Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.
authors.affiliation: Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France.
authors.forename: T
authors.initials: T
authors.lastname: Delory
authors.affiliation: Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France. Electronic address: elise.seringe@aphp.fr.
authors.forename: E
authors.initials: E
authors.lastname: Seringe
authors.affiliation: Groupe Générale de Santé, Paris, France.
authors.forename: G
authors.initials: G
authors.lastname: Antoniotti
authors.affiliation: Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France.
authors.forename: I
authors.initials: I
authors.lastname: Novakova
authors.affiliation: Groupe Générale de Santé, Paris, France.
authors.forename: C
authors.initials: C
authors.lastname: Goulenok
authors.affiliation: Groupe Générale de Santé, Paris, France.
authors.forename: I
authors.initials: I
authors.lastname: Paysant
authors.affiliation: Groupe Générale de Santé, Paris, France; Laboratoire Bactériologie Novescia, Paris, France.
authors.forename: S
authors.initials: S
authors.lastname: Boyer
authors.affiliation: Office of Quality and Safety in Care, Direction Générale de l'Offre de Soins-Bureau PF2-Ministère de la Santé, des affaires sociales et du droit des femmes, Paris, France.
authors.forename: A
authors.initials: A
authors.lastname: Carbonne
authors.affiliation: Department of Bacteriology, APHP, Laboratoire de Bactériologie-Virologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France; Centre National de Référence de la résistance aux antibiotiques, Le Kremlin Bicêtre, France; EA7361, Faculté de Médecine, Université Paris Sud, France.
authors.forename: T
authors.initials: T
authors.lastname: Naas
authors.affiliation: Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France; Department of Epidemiology, Ecole des Hautes Etudes en Santé Publique/Universités Sorbonne Paris Cité, Paris, France.
authors.forename: P
authors.initials: P
authors.lastname: Astagneau
mesh_terms: D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control / Q000635:transmission; D004196:Disease Outbreaks; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D006801:Humans; D017053:Infection Control / Q000379:methods* / Q000458:organization & administration; D007710:Klebsiella Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control / Q000635:transmission; D007711:Klebsiella pneumoniae / Q000201:enzymology* / Q000302:isolation & purification; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D001618:beta-Lactamases / Q000378:metabolism*
chemical_list: C491478:beta-lactamase KPC-2; D001618:beta-Lactamases
keywords: Carbapenem-producing enterobacteriaceae; Infection control; Outbreak; Root causes analysis