The “nightmare bacteria” known as carbapenem-resistant Enterobacteriaceae, or CRE, is making headlines again after at least seven patients at UCLA’s Ronald Reagan Medical Center seemingly contracted the superbug from contaminated duodenoscopes. Two subsequently died. As many as 179 people were potentially exposed during endoscopic retrograde cholangiopancreatography procedures performed there between October and January.
Similar duodenoscope-linked CRE outbreaks in recent years were also reported at Advocate Lutheran General Hospital in Park Ridge, IL, and Virginia Mason Medical Center in Seattle. Some 44 people were infected in the former; 35 in the latter, including 11 who died.
Two culprits were involved in the outbreaks: allegedly unsterile duodenoscopes, and a family of superbugs known collectively as CRE. As a result, hospital and government officials, as well as the public, are taking a hard look at both in trying to comprehend what happened, and ultimately prevent future recurrences.
At issue, it seems, is the design of the duodenoscope—particularly, how its moveable “elevator” channel can be difficult to reprocess.. In a recent alert, the FDA noted that “effective cleaning of all areas of the duodenoscope may not be possible.” Subsequently, residual body fluids and other debris can remain, resulting in the possible transmission of bacteria from one patient to another.
UCLA maintains workers had cleaned the two duodenoscopes involved in the outbreak per product manufacturer recommendations, but the hospital has since removed them from circulation and ramped up its decontamination process for the duodenoscopes that remain, to go “above and beyond the manufacturer and national standards” for such equipment, according to the Los Angeles Times.
The newspaper also reported on an upgraded decontamination process at Virginia Mason Medical Center that involves quarantining duodenoscopes for 2 days after their use to look for evidence of bacterial growth. If none is found, the cleaned scopes are then cleared for use in the next patient.
“Experts say it would be difficult to stop using the scopes entirely because many patients benefit from their use and there is currently no alternative,” the New York Times noted in a recent editorial. “But there are surely ways to improve sterilization and to keep them out of use until there is proof that they are completely clean.”
CRE isn’t new, but the deadly superbug is multiplying. The percentage of CRE bacteria quadrupled from 2002 to 2012, according to the Centers for Disease Control and Prevention. Consequently, the CDC issued a call to action nearly 2 years ago for the entire healthcare community to work together to protect patients from CRE, which is believed to kill as many as half the patients who get the bacteria in their bloodstream.
CRE is resistant to carbapenems, a class of antibiotics often considered as a last-result because of its unusually strong usual potency.
“So if carbapenem fails,” the New York Times explained, “the patient is in serious trouble.”
CRE usually infects patients in hospitals and other healthcare facilities as opposed to healthy people. About 4% of U.S. hospitals and 18% of long-term acute care facilities treated a patient with a CRE infection during the first half of 2012, according to the CDC. Patients who take long courses of antibiotics or whose care requires medical devices such as ventilators, urinary catheters, intravenous catheters—and, apparently, duodenoscopes—are at higher risk.
To prevent the spread of CRE, the CDC has made available a prevention toolkit for hospitals and other healthcare facilities. Recommendations include enforcing the use of infection control precautions as well as wise use of antibiotics.
“We have seen in outbreak after outbreak that when facilities and regions follow CDC’s prevention guidelines, CRE can be controlled and even stopped,” said the CDC’s Michael Bell, MD, in 2012. “As trusted healthcare providers, it is our responsibility to prevent further spread of these deadly bacteria.”