Staff shortages and lack of space at Prince Mshiyeni Hospital in Umlazi, south of Durban, was blamed for an outbreak of Klebsiella that has claimed the lives of five babies. Contaminated intravenous equipment and poor infection control measures were found to be the source of an outbreak of Klebsiella Pneumoniae, which killed twenty-one babies in another KwaZulu-Natal hospital. "Several flaws were identified" with infection control methods, according to the report that was released and compiled by medical microbiologist Professor Willem Sturm of the Nelson R Mandela School of Medicine in Durban. Initial investigations at the Mahatma Gandhi Memorial Hospital north of Durban, found Klebsiella Pneumoniae on the hands of 10% of staff. Interviews revealed that the nursery was usually overcrowded, under-equipped and under-staffed, which worked against adherence to infection control. Early in the investigation at this hospital, a link was found to the babies' intravenous treatment and after other possibilities were ruled out, medication information for seventeen of the babies showed that they had received regular intravenous injections. The spread was attributed to multiple-use of units of the medication to save costs, inadequate hand washing practices and inappropriate hand wash facilities. Recommendations included sealing off the nursery with strict hygiene controls and abandoning the practice of multiple uses of units of intravenous preparations. "Such preparations should be used only once. Multiple-use for one patient should also not be done" Furthermore, long sleeves on gowns, white coats and uniforms, or personal wear should be forbidden, and rings and watches should not be worn on hands and wrists as these interfere with hand washing. Such recommendations, though pertinent, do not disguise the seriousness of this situation in our hospitals. / A case study submitted in partial fulfillment of the requirements for the degree of Masters in Public Administration.