“The article that started a national discussion.“
December 5, 2014 — Federal health officials recently attributed a deadly “superbug” outbreak at a hospital near Chicago (IL), in 2013, to the complex design of certain types of gastrointestinal endoscopes.
According to these officials, these physically-complex, reusable instruments remained contaminated with infectious materials despite their being reprocessed according to the endoscope manufacturer’s instructions.
This hospital’s outbreak is one of the most significant instances in U.S. history of the transmission of a “nightmarish” type of antibiotic-resistant bacteria known as carbapenem-resistant Enterobacteriaceae, or “CRE.”
Two of this hospital’s patients who were infected with the outbreak’s strain of CRE died after having undergone GI endoscopy. This finding is discussed in more detail in Dr. Muscarella’s article entitled, “Alert: Association of GI Endoscopy with Two Patient Deaths: Illinois, 2013.”
CRE are so named, because they are resistant to most antibiotics including those of “last resort” called carbapenems. And, whereas other types of bacteria transmitted during GI endoscopy can typically be eradicated with one or more types of antibiotics, some strains of CRE are resistant to all types of antibiotics (i.e., they are pan-resistant).
This outbreak of CRE near Chicago is similar in many regards to other recent outbreaks of CRE, including one confirmed a year earlier, in 2012, at a hospital in Pittsburgh (PA). In both instances, hospital officials linked the superbug outbreak, with associated morbidity, to contaminated GI endoscopes.
Officials of this Pittsburgh hospital have claimed that no patient deaths were directly attributed to this outbreak. Whether any deaths were indirectly attributed to this outbreak in 2012 is unclear at this time.
At least two dozen patients infected with CRE
Now, a third report filed with the FDA during the summer of 2014 documents yet another outbreak of CRE and a related superbug that infected (or colonized) more than two dozen patients.
Like the CRE outbreaks near Chicago and in Pittsburgh, this third outbreak was also linked to contaminated GI endoscopes, but, this time, at least seven patients who underwent GI endoscopy at a hospital located in Washington reportedly were infected and died.
Collectively, that’s at least nine (9) patient deaths (and dozens of patient infections) since 2012 at just these three hospitals that have been attributed to GI endoscopes contaminated with the outbreak’s strain of CRE (or a related superbug).
Note: This article defines “CRE-related superbugs” as gram-negative bacteria that are either resistant to carbapenem antibiotics, although not of the Enterobacteriaceae family (and therefore not CRE); or are a multidrug-resistant member of the Enterobacteriaceae family, although at this time remain susceptible to carbapenem antibiotics.
These three are only a few of the several outbreaks reported since 2008 that have directly linked GI endoscopy to the transmission of CRE or a related superbug; see: Sidebar #1. Prior to 2008, CRE outbreaks linked to GI endoscopy in the U.S. and globally were rarely if ever reported.
Whether these several outbreaks of CRE, even just those since 2012, could be categorized as a type of national infectious epidemic is debatable. To date (1/23/2015), no guidance has been provided by the FDA regarding these superbug outbreaks.
Sidebar #1: Many of these reported outbreaks of CRE since 2008 are codified in a peer-reviewed report by Dr. Muscarella: “Risk of transmission of carbapenem-resistant Enterobacteriaceae and related ‘superbugs’ during gastrointestinal endoscopy,” which was published in the World Journal of Gastrointestinal Endoscopy in October, 2014.
Dr. Muscarella’s report may be the most comprehensive and focused article published to date discussing the risk of transmission of CRE and their related superbugs during GI endoscopy.
A number of other articles that Dr. Muscarella wrote discussing this outbreak are listed on the dedicated webpage entitled “Superbugs and Endoscopy.“
The CRE outbreak in Chicago (IL), 2013
As noted above, a hospital near Chicago (IL) confirmed in 2013 that it had taken immediate action to stop an outbreak of CRE linked to contaminated GI endoscopes.
This outbreak was investigated by the federal Centers for Disease Control and Prevention (CDC), which reported its findings in the October 8, 2014, issue of the Journal of the American Medical Association (or, JAMA).
Note: It is recommended that this JAMA article be read along with the CDC’s accompanying article entitled “Notes from the Field: New Delhi Metallo-β-Lactamase–Producing Escherichia coli Associated with Endoscopic Retrograde Cholangiopancreatography — Illinois, 2013,” which was published 9 months earlier in the January 3, 2014, issue of Morbidity and Mortality Weekly Report.
According to the CDC’s report in JAMA, the primary factor responsible for this outbreak was this superbug’s contamination of one manufacturer’s type of GI endoscope that is used exclusively to perform the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or “ERCP.”
This type of GI endoscope, which is complex in physical design, features an elevator mechanism at its distal tip, and may be difficult to clean, is called a side-viewing duodenoscope or — not surprisingly, because of how it is used — an ERCP endoscope.
Other reports of CRE outbreaks have linked the GI endoscopes of at least two other manufacturers to disease transmission, indicating that no one manufacturer’s models of GI endoscopes is common to all of these outbreaks.
This hospital has been identified in the press as Advocate Lutheran General Hospital (Park Ridge, IL).
Twenty-eight (28) of this hospital’s patients, most of whom had recently undergone ERCP, were colonized, and 10 were infected, with the outbreak’s strain of CRE, which is known more specifically as New Delhi Metallo Beta Lactamase-1-producing (or, NDM-1-producing) Escherichia coli.
Note: Whereas “colonized” patients harbor the bacterium, only those infected display symptoms of transmission and disease.
And two of these 10 patients infected with this NDM-1-producing strain of E. coli died (see: Sidebar #2).
Sidebar #2: Although the CDC (which investigated the CRE outbreak at this hospital near Chicago in 2013 — click here to read its findings) suggests that these two patient deaths were unrelated to their CRE infection, another review of the same clinical data could contrarily conclude that at least one of these patients may have died as a direct consequence of the outbreak’s CRE.
Dr. Muscarella’s above-referenced article entitled, “Alert: Association of GI Endoscopy with Two Patient Deaths: Illinois, 2013” provides more details of this differing conclusion.
This incident in 2013 was the first well-publicized outbreak of CRE linked to ERCP in the U.S., and, as the local and national press reported at the time, it is one of the largest recorded outbreaks of this superbug in U.S. history.
Other reports of CRE transmissions during GI endoscopy in the U.S. have been reported, but, to date, they have received limited, if any, attention from the media (see: Sidebar #1).
The CRE outbreak in Pittsburgh (PA), 2012
The second aforementioned outbreak of CRE that infected several patients following ERCP was confirmed at a hospital in Pittsburgh (PA) one year earlier, in 2012, although details of this superbug outbreak were not publicized by the hospital or the press until 2014.
Note: This outbreak of CRE in Pittsburgh is discussed in Dr. Muscarella’s article entitled, “Superbugs, Contaminated Gastrointestinal Endoscopes, and a Growing Number of Hospital Infections: Is an FDA Action Imminent?“
In addition to ERCP endoscopes, hospital officials concluded that another type of GI endoscope that also features a forceps elevator mechanism at its distal tip (this mechanism is used to control and manipulate accessories used during ERCP) was responsible for transmitting CRE.
But, unlike the ERCP endoscope, this second type of GI endoscope uses ultrasound imagery to perform endoscopic ultrasound, or “EUS.”
Sidebar #3: A news article quoted hospital officials as saying that: “No patients died as a direct result of the CRE infection. … Some had heart failure and other chronic conditions. … It’s impossible to say whether that infection was a contributor.“
This quote implicitly advances the claim that neither did this Pittsburgh hospital’s superbug outbreak indirectly harm any of the infected patients. But, if this were a known fact, it seems certain that it would have been stated, explicitly, to ensure no misunderstanding (e.g., “No patients died as a direct or indirect result of the CRE infection“).
Based on reason and that, in this instance, the hospital admits that it was not possible to say whether the outbreak contributed to any of the infected patients’ deaths, it cannot be ruled out that this superbug outbreak was at least indirectly responsible for the deaths of one or more of this hospital’s patients who, while also suffering from other co-morbidities, were infected with the outbreak’s strain of CRE.
It can be reasonably argued that the standard of care necessitates attributing the death of an infected patient, at least in part, to the infection, unless there is convincing clinical evidence to the contrary. — Lawrence F Muscarella, PhD
News reports confirm this hospital to be The University of Pittsburgh Medical Center – Presbyterian, or “UPMC” (Pittsburgh, PA).
(Note: Infections attributed to inadequately reprocessed GI endoscopes are almost always due to one or more missteps or breaches and therefore would in most cases not be covered by the process of informed consent.)
Seven deaths linked to a third CRE outbreak: Washington, 2014
A medical device report (MDR) filed in the FDA’s “MAUDE” database in the summer of 2014 documents an otherwise all-but-overlooked third outbreak of CRE, this time in Washington, that, just like the other two described above, was linked to contaminated GI endoscopes used to perform ERCP (see: Sidebar #4).
Little else is known about this superbug outbreak other than a few documented details provided in this filed MDR, including that this outbreak began in November, 2012, and ended in August 2013.
Like most filed in the FDA’s MAUDE database, this report includes the name of the medical device’s manufacturer who filed the report, but it does not mention the name of the hospital where this outbreak occurred.
In addition to this report, this hospital’s outbreak is documented in an abstract that was presented at an infection control conference in Philadelphia, (PA) in October, 2014. This abstract’s authors include an official from the Department of Public Health Public Health – Seattle and King County, Seattle, WA.
Click here to download and read a copy of this abstract, which is entitled: “Endoscope-Associated Multidrug-Resistant Escherichia coli Outbreak — King County, Washington, 2012–2014.”
Another of this abstract’s authors is affiliated with the Virginia Mason Medical Center, Seattle (WA). Whether this is the hospital where this outbreak occurred is unclear. Also uncertain is whether more than one hospital in Seattle (WA) is involved.
UPDATE: On January 22, 2015, The Seattle Times confirmed the hospital to be Virginia Mason Medical Center (Seattle, WA) i its article “Undisclosed superbug sickened dozens at Virginia Mason.”
To be certain, this E. coli outbreak in Washington (2014) is remarkably similar to the other two outbreaks of CRE confirmed at Advocate Lutheran General Hospital in 2013 and UPMC in 2012.
In total, 30 of Virgina Mason Medical Center’s patients were infected following ERCP with a deadly strain of either CRE or a related superbug (called an AmpC β-lactamase-producing isolate). The isolates of E. coli from ten of these patients displayed carbapenem resistance (i.e., CRE).
Notably, the abstract documenting this CRE outbreak at Virgina Mason Medical Center states that the mortality rate at 30 days was 23% for all cases (i.e., 7 of these 30 patients that were infected with either CRE or a related superbug died) and 50% for the CRE cases (i.e., 5 of the patients infected with CRE died).
Legal Reviews for Patients, Hospitals, Manufacturers: Click here to read about Dr. Muscarella’s expertise and legal assessments of the causes of healthcare-associated infections, including “superbug” outbreaks linked to contaminated GI endoscopes and other reusable medical equipment.
Washington’s CRE outbreak: The largest in history?
Little is know about Virgina Mason Medical Center’s superbug outbreak in 2012 other than what is discussed in the manufacturer’s file medical device report and in the aforementioned abstract authored by, among others, an official from Seattle’s Department of Public Health Public Health.
This outbreak’s lack of publicity would not ordinarily be noteworthy or conspicuous, but in this instance it is particularly weighty, because this outbreak of CRE appears to be the most significant instance of the transmission of any infectious agent, with associated morbidity and mortality, ever linked to a GI endoscope.
According to The Seattle Times, the public learned for the first time that 30 of the hospital’s patients infected with the outbreak strain of CRE were not told of the outbreak in 2012 by either Virginia Mason (the hospital) or the Department of Public Health Public Health (Seattle and King County, Seattle, WA).
Further, Virginia Mason Medical Center’s outbreak of CRE and related superbugs is one of the largest ever recorded, with seven (7) of the infected patients dying. More than a dozen of these types of superbug outbreaks linked to contaminated GI endoscopes have been documented in the U.S. since 2008.
That means, collectively, that as many as 13 patient deaths may be attributed to these three hospitals’ superbug outbreaks following GI endoscopy since 2012.
UPDATE: According to The Seattle Times (January 22, 2015) and reiterated by CBS NEWS on the same day, 11 (not seven) infected patients died, with both reports adding that “it’s not clear what role, if any, the infections played, doctors said.”
And it is surprising that, despite their association with a mortality rate of as high as 50%, to date no state or federal agency has publicly discussed these CRE outbreaks or given guidance or their prevention during GI endoscopy.
This Washington hospital’s CRE outbreak appears to be the most significant instance of disease transmission, with associated morbidity and mortality, ever linked to a GI endoscope. — Lawrence F Muscarella, PhD
CRE outbreaks in the U.S.: A nati0nal concern
As discussed in a number of Dr. Muscarella’s articles (click here), including his “Overlooked Outbreaks of “CRE” Following GI Endoscopy: A “Superbug” Epidemic in Our Midst?” (click here), several outbreaks of CRE and their related superbugs have been reported in the U.S. since 2012, and even more since 2008.
Whether these many outbreaks of CRE in the U.S. just since 2012 could be categorized as a type of national infectious epidemic could be argued. — Lawrence F Muscarella, PhD
In each case the superbug was reportedly transmitted by improperly reprocessed GI endoscopes used during ERCP. Indeed, these several outbreaks of CRE in the U.S., even just since 2012, could be categorized as a type of national infectious epidemic.
What’s unclear is why no state or federal health advisories, alerts, or bulletins have been issued, to date, either informing the public of the increased risk of patient injury associated with contaminated instrumentation used during ERCP, or providing guidance to hospitals aiming to prevent the transmission of these superbugs during GI endoscopy.
It could be easily argued, too, that these several outbreaks of CRE in the U.S. have not received adequate oversight, discussion or publicity. Improvements in the checks and balances inherent to the prevention of these types of medical errors seem warranted. — Lawrence F Muscarella, PhD
News reports of CRE outbreaks
In general, the recent outbreaks of CRE or their related superbugs linked to patient morbidity and mortality following GI endoscopy — as well as other recent types of bacterial outbreaks linked to more invasive types of surgical procedures — are routinely reported by the press as a public service.
Sometimes these CRE outbreaks are also reported by the CDC, the hospital where the outbreak was identified, the manufacturer of the implicated GI endoscope (or associated medical equipment), and/or the state’s department of health.
In the case of Virginia Mason Medical Center’s outbreak, a manufacturer of GI endoscopes and the state’s department of health, along with the CDC (both by way of the aforementioned abstract), provide details of this CRE outbreak, although these details are scant.
To date, the local press in Seattle (WA) has not reported the details of this CRE outbreak.
UPDATE: On January 22, 2105, the “The Seattle Times” disclosed many more details of this outbreak, including that neither Virginia Mason (the hospital) nor the Department of Public Health Public Health (Seattle and King County, Seattle, WA) informed the infected patients of the outbreak.
Presumably, the families of the as many as 11 infected patients who expired were also not told what was responsible for their deaths, which federal officials have linked to contaminated GI endoscopes that are difficult to clean – read more in the article in “USA TODAY,” dated January 21, 2015.
In contrast, examples of CRE outbreaks that have received attention by the local press include:
- the aforementioned outbreak of CRE at Advocate Lutheran General Hospital (in 2013) that was linked to contaminated GI endoscopes — this outbreak was reported or publicly addressed by: (1) the CDC (p. 1051): (2) the local Chicago press; (3) the hospital; (4) the Illinois Department of Public Health; (5) a manufacturer; and (6) by Dr. Muscarella (in the peer-review literature);
- the other aforementioned outbreak of CRE at UPMC (in 2012) that was linked, too, to contaminated GI endoscopes — this outbreak was reported or publicly addressed by the: (1) the Pittsburgh local press; (2) the hospital; (3) by Dr. Muscarella; and
- an outbreak of atypical mycobacteria that was linked to surgical procedures performed at Greenville Memorial Hospital (Greenville, SC) — this outbreak, which was linked to multiple patient infections and 4 patient deaths in 2014, was reported or publicly addressed by the: (1) the local Greenville press; (2) the hospital; (3) South Carolina’s Department of Health and Environmental Control; and (4) Dr. Muscarella.
Recommendations for the prevention of these types of CRE outbreaks are provided in Dr. Muscarella’s related article “Investigation and Prevention of Bacterial Outbreaks following Endoscopic Retrograde Cholangiopancreatography, or ERCP” — click here.
Sidebar #4: Briefly, the FDA’s MAUDE database lists medical device reports, or MDRs, which federal regulations mandate that hospitals and manufacturers file with the FDA within 10 or 30 days, respectively, of learning that a regulated medical device, including a GI endoscope or an automated endoscope reprocessor (AER), might have potentially contributed to, or could have indirectly or directly caused, an adverse medical event — click here to read the FDA’s rules regarding filing a MAUDE report.
Notably, while the reader’s search of the FDA’s MAUDE database certainly retrieves a report filed by the manufacturer of the GI endoscopes that were used by the aforementioned hospital near Chicago that identified its outbreak of CRE in 2013, a similar search of this same database, in contrast, would not retrieve any filed reports describing the aforementioned Pittsburgh hospital’s CRE outbreak in 2012 (see: main article).
This omission is noteworthy, because officials of this Pittsburgh hospital implicated at least four regulated medical devices as having possibly contributed to or caused its CRE outbreak, which resulted in multiple patient injuries (click here to read a poster prepared by this hospital in 2014 discussing these implicated devices).
And, according to the FDA’s regulations, the hospital and the manufacturers of these four implicated devices are required to file such a report in the FDA’s MAUDE database documenting this, like any, adverse event.
The importance of filing a MAUDE report to the principles of quality assurance and “continual improvement,” in general, and to a manufacturer’s prompt implementation of one or more corrective actions demonstrated to reduce the risk of the adverse event’s recurrence is well established.
CA-CRE (community-acquired carbapenem-resistant Enterobacteriaceae)
As with most types of bacterial outbreaks, especially those caused by a superbug like CRE that is resistant to “last-resort” antibiotics, their public disclosure by the hospital, the state’s department of health, or the local press serves, among other purposes, to increase public awareness and minimize the risk of this specific concern:
- that discharged and otherwise-seemingly healthy patients, who unknowingly are colonized with the outbreak’s bacterial strain, might innocently transmit the strain to other people in the community (due to, for example, poor hand hygiene), resulting in additional superbug infections.
In fact, this specific concern was a primary reason why health officials and the Chicago press notified the public in 2013 of the CRE outbreak linked to GI endoscopy performed at Advocate Lutheran General Hospital.
According to one presentation, officials investigating this hospital’s outbreak in 2013 found several patients in the community to be infected or colonized with the outbreak’s strain of CRE — click here. Whether any of these cases demonstrate a community-acquired infection (or colonization) of CRE, or “CA-CRE,” is unclear.
This outbreak of CRE in Washington state may be the largest outbreak of this superbug ever recorded, worldwide. — Lawrence F Muscarella, PhD
A common reservoir for CRE is the human GI tract, and this superbug can be transmitted from person-to-person in the community (like in the healthcare setting) as a result of poor hand hygiene.
According to the CDC, CRE “can become a community bug.”
Moreover, as reported by a Pittsburgh newspaper that investigated UPMC’s outbreak of CRE in 2012 – click here:
“Molecular testing matched cultures from 18 patients to the same bug found in a reusable scope that is typically inserted in the mouth and moved down the throat into the body. Only half of the patients carrying the superbug had undergone a gastrointestinal procedure, but it was enough for infection control specialists to suspect disinfection of the scope had failed, said Dr. Carlene Muto, director of infection prevention at UPMC Presbyterian.”
Whether the other nine patients who did not undergo GI endoscopy became infected as a result of patient-to-patient transmission as a result of, for example, soiled hands is unclear.
Sidebar #5: It is unclear whether the GI endoscopes at this hospital in Washington were being reprocessed manually, or more likely, was being reprocessed using an AER (i.e., an automated endoscope reprocessor).
And, if the latter, whether the hospital was relying on the AER to clean the GI endoscope completely — rather than having a trained healthcare practitioner clean the GI endoscope’s complex surfaces, including the ERCP’s endoscopes elevator mechanism, using a brush and detergent — is unclear.
Lessons being taught
Like the two superbug outbreaks confirmed by the hospitals located near Chicago (IL) and in Pittsburgh (PA), the outbreak of CRE in Washington teaches a number of lessons:
— First, that ERCP and endoscopic ultrasound, or EUS, both of which are performed using a GI endoscope that features a complex and difficult-to-clean forceps elevator mechanism at its distal tip, pose a significant risk of transmission of CRE and other infectious agents, having been linked to multiple patient infections and deaths;
— Second, that, despite the significant number of patient deaths associated with recent outbreaks of CRE in the U.S., the risk of infection posed by contaminated ERCP (and EUS) endoscopes appears not to have received the publicity or national attention it necessarily warrants. Checks and balances inherent to the prevention of these types of medical errors are seemingly inadequate; and
— Third, that CRE outbreaks linked to contaminated GI endoscopes may not be promptly reported to the FDA via its “MAUDE” database but may be reported as many as 18 months later, or longer. And, some outbreaks are not reported publicly or to the FDA at all (unpublished data), despite not only federal regulations requiring prompt filing (see: Sidebar #4), but also the importance of documenting these reports to data trending, surveillance optimization, and other quality and safety activities;
Sidebar #6: With the filing of a MAUDE report can come increased regulatory scrutiny, the risk of litigation, and unwanted publicity for the hospital and the device’s manufacturer.
Yet, on the flip side, the lack of transparency associated with a manufacturer or hospital not filing a MAUDE report can also beget complacency, a lack of accountability, the delay of important corrective actions necessary to prevent the outbreak’s recurrence, and, therefore, an increased risk of patient harm.
That better oversight designed to improve the prompt and complete filing of MAUDE reports might demonstrably reduce the risk of healthcare-associated infections and their associated costs can certainly be argued.
Several additional lessons that these several recent CRE outbreaks are teaching are provided in Dr. Muscarella’s related article: “Important Lessons Taught by Recent “Superbug” Outbreaks Linked to GI Endoscopes.”
Indeed, during the past few years more than a dozen outbreaks of CRE have occurred in the U.S. following GI endoscopy, some linked to patient death. Other than the CDC’s published investigation of one of these outbreaks in 2014 (click here), however, few (if any) federal health reports have been published giving healthcare professionals detailed guidance about what specific precautionary measures to take to prevent outbreaks of CRE following GI endoscopy, particularly ERCP.
This outbreak of CRE in Washington teaches several lessons, including that outbreaks of CRE, even when associated with patient deaths, are not always publicly addressed, which could adversely impact both the quality and safety of health care. — Lawrence F Muscarella, PhD
Is an FDA action forthcoming?
That said, the FDA is reputed to be issuing a public health advisory in early 2015 discussing the risk of superbug infections following GI endoscopy.
This possibility that such an advisory might be published soon is discussed in more detail in Dr. Muscarella’s article, “Superbugs, Contaminated Gastrointestinal Endoscopes, and a Growing Number of Hospital Infections: Is an FDA Action Imminent?”
In addition to teaching lessons, these outbreaks of CRE at hospitals near Chicago and in both Pittsburgh (PA) and Washington, among other documented outbreaks confirmed during the past few years, raise a number of questions, most of which the FDA, ideally, will address in its forthcoming advisory about the risk of CRE transmissions during GI endoscopy.
These questions include:
- Is there one single factor, or many, that is primarily responsible for these recent outbreaks of CRE following ERCP and EUS?
- Is there something about the design of GI endoscopes featuring an elevator mechanism that might hinder their thorough cleaning and high-level disinfection?
- Could more enhanced, better manual cleaning of the GI endoscope be the key to the prevention of CRE outbreaks?
- Have GI endoscopes been transmitting antibiotic-susceptible Enterobacteriaceae and other types of bacteria to patients for years, but these transmissions were being masked by antibiotics are only now becoming detectable because the bacteria, as with CRE, have become resistant even to carbapenem antibiotics?
Legal Reviews for Patients, Hospitals, Manufacturers: Click here to read about Dr. Muscarella’s expertise and legal assessments of the causes of healthcare-associated infections, including “superbug” outbreaks linked to contaminated GI endoscopes and other reusable medical equipment.
Several additional questions that the FDA’s forthcoming advisory in early 2015 may address are provided in Dr. Muscarella’s related article: “Questions the FDA May Soon Address in Response to Recent ‘Superbug’ Outbreaks Linked to GI Endoscopes.”
It would also seem that the FDA’s forthcoming advisory will give important guidance to healthcare practitioners and, ideally, provide specific recommendations for the prevention of CRE outbreaks following GI endoscopy (rather, possibly, than just expressing a general concern about this risk).
A review of the FDA’s advisory, once it is published, is urged.
Additional recommendations for the prevention of the transmission of CRE and their related superbugs during GI endoscopy are provided in a number of Dr. Muscarella’s articles, including in “Risk of transmission of carbapenem-resistant Enterobacteriaceae and related ‘superbugs’ during gastrointestinal endoscopy” (October, 2014).
Additional recommended reading
- Muscarella LF. Alert: Association of GI Endoscopy with Two Patient Deaths: Illinois, 2013 — click here.
- Muscarella LF. A ‘Superbug’ Outbreak Linked to Two Types of Gastrointestinal Endoscopes: Pennsylvania, 2012 — click here.
- Muscarella LF. Important Lessons Taught by Recent “Superbug” Outbreaks Linked to GI Endoscopes — click here.
- Muscarella LF. Overlooked Outbreaks of “CRE” Following GI Endoscopy: A “Superbug” Epidemic in Our Midst? — click here.
- Muscarella LF. Investigation and Prevention of Bacterial Outbreaks following Endoscopic Retrograde Cholangiopancreatography, or ERCP — click here.
- Muscarella LF. Superbugs, Contaminated Gastrointestinal Endoscopes, and a Growing Number of Hospital Infections: Is an FDA Action Imminent? — click here.
- Muscarella LF. Risk of Transmission of Carbapenem-Resistant Enterobacteriaceae and Related “Superbugs” during Gastrointestinal Endoscopy. World J Gastrointest Endosc 2014 October 16; 6(10): 457-474 — click here.
- Webpage: Superbugs and Endoscopy — click here.
- Centers for Disease Control and Prevention (CDC). New Delhi Metallo-β-Lactamase–Producing Carbapenem-Resistant Escherichia coli Associated With Exposure to Duodenoscopes. Journal of the American Medical Association. October 8, 2014 — click here.
- Centers for Disease Control and Prevention (CDC). Notes from the Field: New Delhi Metallo-β-Lactamase–Producing Escherichia coli Associated with Endoscopic Retrograde Cholangiopancreatography — Illinois, 2013. Morbidity and Mortality Weekly Report January 3, 2014;62(51); 1051-1051 — click here.
- Medscape. CDC Confirms Superbug Transmission via Endoscopy. January 3, 2014.
By: Lawrence F Muscarella, PhD. Originally posted: 12/24/2014. Updated: 3/28/2016, Rev A.