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Since 2006, Israel has been confronting an outbreak of carbapenem-resistant Enterobacteriaceae (CRE), and in 2007 Israel implemented a national strategy to contain spread. The intervention was initially directed toward acute-care hospitals and later expanded to include an established reservoir of carriage in long-term-care hospitals. It included regular reporting of CRE cases to a central registry and daily oversight of management of the outbreak at the institutional level. Microbiological methodologies were standardized in clinical laboratories nationwide. Uniform requirements for carrier screening and isolation were established, and a protocol for discontinuation of carrier status was formulated. In response to the evolving epidemiology of CRE in Israel and the continued need for uniform guidelines for carrier detection and isolation, the Ministry of Health in 2016 issued a regulatory circular updating the requirements for CRE screening, laboratory diagnosis, molecular characterization, and carrier isolation, as well as reporting and discontinuation of isolation in healthcare institutions nationwide. The principal elements of the circular are contained herein.
To assess the prevalence of and risk factors for carbapenem-resistant Klebsiella pneumoniae (CRKP) carriage among patients in post-acute-care facilities (PACFs) in Israel.
Design, Setting, and Patients.
A cross-sectional prevalence survey was conducted in 12 PACFs. Rectal swab samples were obtained from 1,144 patients in 33 wards. Risk factors for CRKP carriage were assessed among the cohort. Next, a nested, matched case-control study was conducted to define individual risk factors for colonization. Finally, the cohort of patients with a history of CRKP carriage was characterized to determine risk factors for continuous carriage.
The prevalence of rectal carriage of CRKP among 1,004 patients without a history of CRKP carriage was 12.0%. Independent risk factors for CRKP carriage were prolonged length of stay (odds ratio [OR], 1.001; P < .001), sharing a room with a known carrier (OR, 3.09; P = .02), and increased prevalence of known carriers on the ward (OR, 1.02; P = .013). A policy of screening for carriage on admission was protective (OR, 0.41; P = .03). Risk factors identified in the nested case-control study were antibiotic exposure during the prior 3 months (OR, 1.66; P = .03) and colonization with other resistant pathogens (OR, 1.64; P = .03). Among 140 patients with a history of CRKP carriage, 47% were colonized. Independent risk factors for continued CRKP carriage were antibiotic exposure during the prior 3 months (OR, 3.05; P = .04), receipt of amoxicillin-clavulanate (OR, 4.18; P = .007), and screening within 90 days of the first culture growing CRKP (OR, 2.9; P = .012).
We found a large reservoir of CRKP in PACFs. Infection-control polices and antibiotic exposure were associated with patient colonization.
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