anxiety grows after another outbreak linked to popular medical device

Last week, our blog began discussing how both medical professionals and officials with the Food and Drug Administration were growing increasingly fearful over the spread of an especially virulent type of bacteria via a medical scope used in roughly 500,000 procedures here in the U.S. every year.

Unfortunately, it appears that these fears have now been realized, as one of the nation’s preeminent medical facilities announced earlier this week that over 100 patients may have been exposed to the superbug known as carbapenem-resistant enterobacteriaceae — or CRE — thanks to contaminated medical scopes.

To recap, the Centers for Disease Control and Prevention defines CRE infections as having very high levels of resistance to antibiotics and a fatality rate as high as 40 to 50 percent if the infection spreads to the bloodstream.

Since 2012, there have been at least six CRE outbreaks in hospitals across the nation, and in each case, health investigators traced them to contaminated duodenoscopes, which are placed down the throats of patients and used for the treatment of cancer, gallstones and other digestive system disorders.

Here, the problem wasn’t improper sterilization, as all facilities were cleaning them in accordance with instructions by the manufacturer, but rather that the “elevator mechanisms” that extend outward from the bottom of the duodenoscopes could accumulate trace amounts of biological material that remained after cleaning.

Unfortunately, this appears to be exactly what happened at UCLA’s Ronald Reagan Medical Center, as officials there announced earlier this week that at least seven patients have developed CRE infections due to contaminated duodenoscopes with two of them ultimately dying.

Furthermore, the hospitals indicated that has many as 179 other patients treated there sometime between October and January may also have been exposed.

According to reports, while the hospital has long been cleaning its duodenoscopes “according to standards stipulated by the manufacturer,” it has since removed the two affected duodenoscopes from service and introduced a more rigorous decontamination process for its other duodenoscopes.

As for the 179 patients, UCLA has indicated that they have been notified, along with their primary care physicians, by phone and letter. Free testing has also been offered.

This is truly an alarming development. Indeed, one patient safety expert categorized these CRE outbreaks as “the most significant instance of disease transmission ever linked to a contaminated reusable medical instrument.”

Stay tuned for updates …

Source: The Los Angeles Times, “Superbug linked to 2 deaths at UCLA hospital; 179 potentially exposed,” Chad Terhune, Feb. 18, 2015

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