The Seattle Times: “Undisclosed superbug sickened dozens at Virginia Mason” (January 22, 2015)
An outbreak of multidrug-resistant superbugs spread by contaminated endoscopes infected at least 35 patients at Virginia Mason Medical Center between 2012 and 2014. Neither the hospital nor health officials notified patients or the public.
Dr. Andrew Ross: “This makes us the safest place in the country to have this done,” said Dr. Andrew Ross, section head for the gastroenterology department.
Dr. Chris Baliga: “Are you going to create unnecessary fear in the public about something we can’t do anything about?” said Dr. Chris Baliga, Virginia Mason’s medical director of infection prevention. [Note: According to hospital officials, “there’s little the very sick people could have done in response to (knowing) this information (abut the outbreak’s cause and source).”]
Dr. Lawrence F Muscarella: “My concern now is that when we talk about there being a risk, there is no longer just a risk. It’s a reality. People are dying from it,” Muscarella said.
“There’s more ways than one to skin a cat. Possibly, the designs of these specific types of GI endoscopes — namely, ERCP endoscopes and EUS endoscopes — that have been recently linked to CRE outbreaks in U.S. hospitals could be enhanced to facilitate their more effective cleaning and disinfection.”
Dr. Jeffrey Duchin: “Patients are at the same or higher risk all across the country,” said Dr. Jeffrey Duchin, King County interim health officer, who helped investigate the outbreak. “We didn’t feel like it was a new issue that warranted emergency notification.”
“If you need the procedure because you have an obstructed biliary duct and are going to die without it, it’s worth the risk,” Duchin said.
“It’s way beyond what anybody else in the country is doing,” Duchin said. “We think that the steps they’ve put in place to culture and quarantine the scopes have been effective.”
CDC: CDC officials said the complex design of these duodenoscopes used to perform ERCP “makes them difficult to clean with the potential for contamination persisting following reprocessing and subsequent transmission of pathogenic bacteria to patients.”
FDA: “The FDA feels that the lifesaving nature of ERCP, performed on more than 500,000 patients annually in the U.S., makes it important for these devices to remain available.”
Art Caplan: “People have a right to know that’s intrinsic or inherent,” Caplan said. “If my spouse died because of an infected piece of medical equipment or dental equipment, I would like to know. I would even like to examine a lawsuit.” (Dr. Kaplan is a bioethicist at New York University’s Langone Medical Center.)
Dr. Michael Gluck: “What we would like to see is a better design of the elevator,” said Dr. Gluck, Virginia Mason’s chief of medicine.
Olympus: According to Mark A. Miller, a spokesman for Olympus, the firm is aware of reports of CRE infections after ERCP procedures and is “monitoring the issue closely.”
“All types of endoscopes require thorough reprocessing after patient use, and customers who purchase Olympus duodenoscopes, as with all of our products, receive instruction and documentation to pay careful attention to cleaning and reprocessing steps to ensure effective reprocessing,” (Mr. Miller) said in an email.