Facing the threat of antibiotic-resistance: Israel’s success to prevent and control the spread of carbapenem-resistant bacteria

November 2017

Dr Mitch Schwaber (left), director of the National Center for Infection Control and Dr David Schwartz, director of National Laboratory for Antibiotic Resistance and Investigation of Outbreaks in Medical Institutions in Israel
Dr Mitch Schwaber (left), director of the National Center for Infection Control and Dr David Schwartz, director of National Laboratory for Antibiotic Resistance and Investigation of Outbreaks in Medical Institutions in Israel
WHO

In 2006 a silent health emergency was spreading in Israel, an emergency which was invisible to most, including the Ministry of Health. The threat was Klebsiella, a gut bacterium which was infecting patients in health care facilities and had become resistant to carbapenems, the most potent class of antibiotics used to treat it.

When the deadly drug-resistant Klebsiella was introduced to the health care system in Israel, it began to spread like wildfire. Unfortunately, there was no mechanism in place for the Ministry of Health to detect the threat and intervene, so the bug continued to claim lives. Luckily, when a group of infection prevention and control specialists gathered at one of their regular meetings, they were able to share data and realized that they were facing a national threat.

Dr Mitchell Schwaber was one of the infection control specialists in this meeting. As a full-time staff physician working in hospital epidemiology and infection control at Tel Aviv Sourasky Medical Center, he understood immediately the massive implications of this situation.

“Unchecked, this bug threatened to overrun the in-patient health care system in the acute care hospitals and put the safety of the hospital system in jeopardy,” says Dr Schwaber.

Representatives of infection control leadership in Israel went straight to the Ministry of Health to present them with a picture of what was happening in hospitals around the country. The Ministry of Health swung into action, listening closely to the advice of the infection control group and made a plan to bolster their health system and combat this growing threat.

“Two things were done at that time, one was to issue guidelines that became mandatory for all acute care hospitals for effective isolation of carriers of this resistant bug,” said Dr Schwaber. “The second element was to create a permanent body at the health ministry level and invest it with the statutory authority to collect data from health care institutions and also to oversee implementation of guidelines.”

"The first order of business was to contain the outbreak of this resistant Klebsiella."

Dr Mitchell Schwaber, Director of the National Center for Infection Control and Dr David Schwartz

“The first order of business was to contain the outbreak of this resistant Klebsiella,” he says. “The second broader mandate was to track and contain all infection control threats, all resistant bacterial threats in the health care system.”

With this new mandate and new guidelines in place, the Ministry of Health taskforce evolved into the National Center for Infection Control (NCIC) as a branch of the National Institute for Infection Control and Antibiotic Resistance, which played an important role in bringing this increasing threat under control.

The NCIC team, which includes doctors, nurses, microbiologists, epidemiologists and data managers, has focused efforts on augmenting and strengthening the infection control staff at all health care institutions, so that each facility has its own professionals who know how to implement the guidelines.

“The first and major success of the intervention has been to put into place a mechanism for identifying and effectively isolating the carriers of these resistant bugs, so that the healthcare system can continue to function and operate,” says Dr Schwaber. “Major success number two has been really building up the field of infection control in Israel.”

In 2017 Dr Schwaber lent his expertise to a WHO-founded committee, tasked with creating global guidelines on Carbapenem-resistant gram-negative bacteria, such as Klebsiella pneumoniae, Pseudomonas aeruginosa).The guidelines provide evidence-based recommendations on the early recognition of these infections and the practices and procedures needed to control the spread of these infections in health care facilities.

These guidelines target professionals in charge of planning, developing and implementing infection control programmes. At the national level, they provide guidance to policymakers responsible for the establishment and monitoring of national IPC programmes and the delivery of national action plans against antimicrobial resistance within Ministries of Health.

“The thrust of the guidelines is to show what measures have been effective around the world to prevent the spread in healthcare systems of these bugs, to evaluate them based on the level of evidence that has been generated, and to give recommendations for implementation to the countries that are going to adopt the guidelines,” says Dr Schwaber.

“The adoption of these guidelines should be a key priority for all countries to face the emerging threat of Carbapenem-resistant bacteria before it becomes too late,” says Dr Benedetta Allegranzi, coordinator of WHO’s Global Unit of Infection Prevention and Control. “Other bugs such as Methicillin-resistant Staphylococcus aureus (known as MRSA) are now widespread in most countries because action was not taken soon enough”.

The guidelines should be integrated with the core components of infection prevention and control programmes and National Action Plans for antimicrobial resistance. With effective implementation around the world, we will be one step closer to achieving strategic objective 3 of the AMR Global Action Plan adopted by all Member States at the World Health Assembly in 2015.