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Institutional Control Measures to Curtail the Epidemic Spread of Carbapenem-Resistant Klebsiella pneumoniae: A 4-Year Perspective

  • Matan J. Cohen (a1), Colin Block (a2), Phillip D. Levin (a3), Carmela Schwartz (a2), Ilana Gross (a2), Yuval Weiss (a4), Allon E. Moses (a2) and Shmuel Benenson (a2)...

To describe the implementation of an institution-wide, multiple-step intervention to curtail the epidemic spread of carbapenem-resistant Klebsiella pneumoniae (CRKP).


Consecutive intervention analyses.

Patients and Setting.

All patients admitted to a 775-bed tertiary care medical center in Jerusalem, Israel, from 2006 through 2010.


The effects of 4 interventions were assessed: (1) a policy of isolation for patients colonized or infected with CRKP in single rooms, which was started in March 2006; (2) cohorting of CRKP patients with dedicated nursing staff and screening of patients neighboring a patient newly identified as a carrier of CRKP, which was started in March 2007; (3) weekly active surveillance of intensive care unit patients, which was started during August 2008; and (4) selective surveillance of patients admitted to the emergency department, which was started in March 2009. Interrupted regression analysis and change-point analysis were used to assess the effect of each intervention on the CRKP epidemic.


Patient isolation alone failed to control the spread of CRKP, with incidence increasing to a peak of 30 new cases per 1,000 hospital beds per month. Institution of patient cohorting led to a steep decline in the incidence of CRKP acquisition (P< .001). Introduction of active surveillance interventions was followed by a decrease in the incidence of CRKP-positive clinical cultures but an increase in the incidence of CRKP-positive screening cultures. The mean prevalence of CRKP positivity for the period after cohorting began showed a statistically significant change from the mean prevalence in the preceding period (P< .001).


The cohorting of patients with dedicated staff, combined with implementation of focused active surveillance, effectively terminated the epidemic spread of CRKP. Cohorting reduced cross-infection within the hospital, and active surveillance allowed for earlier detection of carrier status. Both interventions should be considered in attempts to contain a hospital epidemic.

Corresponding author
Division of Anaesthesia and Critical Care Medicine, Hadassah–Hebrew University Medical Center, POB 12000, Jerusalem, 91120, Israel (
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1.Leavitt, A, Navon-Venezia, S, Chmelnitsky, I, Schwaber, MJ, Carmeli, Y. Emergence of KPC-2 and KPC-3 in carbapenem-resistant Klebsiella pneumoniae strains in an Israeli hospital. Antimicrob Agents Chemother 2007;51:30263029.
2.Schwaber, MJ, Carmeli, Y. Carbapenem-resistant Enterobacteriaceae: a potential threat. JAMA 2008;300:29112913.
3.Murray, PR, Baron, EJ. Manual of Clinical Microbiology. 9th ed. Washington, DC: ASM Press; 2007.
4.Cockerill, FR, Wikler, MA, Bush, K, et al. Performance standards for antimicrobial susceptibility testing; twentieth informational supplement (June 2010 update). Wayne, PA: Clinical and Laboratory Standards Institute; 2010.
5.Wikler, MA, Cockerill, FR, Bush, K, et al. Performance standards for antimicrobial disk susceptibility tests: approved standard, 10th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2009.
6.Anderson, KF, Lonsway, DR, Rasheed, JK, et al. Evaluation of methods to identify the Klebsiella pneumoniae carbapenemase in Enterobacteriaceae. J Clin Microbiol 2007;45:27232725.
7.Samra, Z, Bahar, J, Madar-Shapiro, L, Aziz, N, Israel, S, Bishara, J. Evaluation of CHROMagar KPC for rapid detection of carbapenem-resistant Enterobacteriaceae. J Clin Microbiol 2008;46:31103111.
8.Navon-Venezia, S, Chmelnitsky, I, Leavitt, A, Schwaber, MJ, Schwartz, D, Carmeli, Y. Plasmid-mediated imipenem-hydrolyzing enzyme KPC-2 among multiple carbapenem-resistant Escherichia coli clones in Israel. Antimicrob Agents Chemother 2006;50:30983101.
9.Shardell, M, Harris, A, El-Karamy, S, Furuno, J, Miller, R, Perencevich, E. Statistical analysis and application of quasi experiments to antimicrobial resistance intervention studies. Clin Infectious Dis 2007;45:901907.
10.Harbarth, S, Samore, M. Interventions to control MRSA: high time for time series analysis? J Antimicrob Chemother 2008;62:431433.
11.Wagner, A, Soumrai, A. Segmented regression analysis of interrupted time series studies in medication use research. J Clinical Pharm Therapeutics 2002;27.
12.Chib, S. Estimation and comparison of multiple change-point models. J Econometrics 1998;86:221241.
13.Murray-Leisure, K, Geib, S, Graceley, D, et al. Control of epidemic methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 1990;11:343350.
14.Montecalvo, M, Jarvis, W, Uman, J, et al. Infection-control measures reduce transmission of vancomycin resistant enterococci in an endemic setting. Ann Intern Med 1999;131:269272.
15.Jochimsen, E, Fish, L, Manning, K, et al. Control of vancomycin-resistant enterococci at a community hospital: efficacy of patient and staff cohorting. Infect Control Hosp Epidemiol 1999;20:106109.
16.Sample, M, Gravel, D, Oxley, C, Toye, B, Garber, G, Ramotar, K. An outbreak of vancomycin-resistant enterococci in a hematology-oncology unit: control by patient cohorting and terminal cleaning of the environment. Infect Control Hosp Epidemiol 2002;23:468470.
17.Zawacki, A, O'Rourke, E, Potter-Bynoe, G, Macone, A, Harbarth, S, Goldman, D. An outbreak of Pseudomonas aeruginosa and bloodstream infection associated with intermittent otitis externa in a healthcare worker. Infect Control Hosp Epidemiol 2004;25:10831089.
18.Gregory, C, Llata, E, Stine, N, et al. Outbreak of carbapenem-resistant Klebsiella pneumonia in Puerto Rico associated with a novel carbapenemase variant. Infect Control Hosp Epidemiol 2010;31:476484.
19.Urban, C, Segal-Maurer, S, Rahal, J. Considerations in control and treatment of nosocomial infections due to multidrug-resistant Acinetobacter baumannii. Clin Infect Dis 2003;36:12681274.
20.Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR Morb Mortal Wkly Rep 2009;58:256260.
21.Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L; Healthcare Infection Control Practices Advisory Committee (HICPAC). 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35:S65S164.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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