EXCLUSIVE (February 18, 2015; 7:00 pm) — UCLA’s Ronald Reagan Medical Center in Los Angeles (CA) has identified an outbreak of a “nightmarish” bacteria among patients who had undergone endoscopic retrograde cholangiopancreatography, the gastrointestinal (GI) endoscopic procedure better known as “ERCP,” my research has found.
As many as 8 of this hospital’s patients were infected by GI endoscopes contaminated with a deadly antibiotic-resistant strain of Klebsiella, which is a type of carbapenem-resistant Enterobacteriaceae, or CRE.
Two of these patients infected with this deadly “superbug” reportedly died.
When UCLA’s Klebsiella outbreak was first identified is unclear, though it apparently has now been terminated. This outbreak might otherwise not have been detected were it not for the hospital’s active surveillance system.
The hospital’s detection of this superbug outbreak using this sensitive system suggests that the incidence of CRE outbreaks in the U.S., at least those linked to contaminated GI endoscopes, may be significantly higher than realized and reported.
In some instances, CRE outbreaks may not be detected if a hospital uses an insufficiently sensitive surveillance system.
Out of an abundance of caution, UCLA has stopped performing ERCPs, albeit temporarily to prevent additional infections and until the necessary corrective actions validated for effectiveness can be put into place.
Additional details about this hospital’s outbreak appear in The Los Angeles Times — click here (which was posted moments after this blog’s article).
Patient notifications
More than 100 of this California hospital’s patients may have been impacted by this superbug outbreak linked to contaminated GI endoscopes.
“Impacted patients” include those who were potentially exposed to this deadly superbug via a contaminated GI endoscope and necessarily include (of course) those patients who were infected and colonized by this outbreak’s resistant Klebsiella strain.
UCLA officials began notifying these impacted patients and their families earlier this week, offering free infection screening.
These several ‘superbug’ outbreaks in the U.S. recently linked to contaminated reusable medical equipment suggest that ‘checks and balances’ necessary to ensure patient safety are currently lacking. — Lawrence F Muscarella, PhD
5th superbug outbreak
UCLA’s Klebsiella outbreak is the fifth (5th) publicly recognized outbreak of CRE linked in the U.S. since 2012 to contaminated GI endoscopes. (A few other virtually identical CRE outbreaks occurred previously in the U.S. beginning in 2008, in Florida, but they have received limited attention.)
The other four outbreaks — each of which are discussed in Dr. Muscarella’s blog (“Discussions in Infection Control“) — were identified in cities across the U.S., from Seattle (WA) to Philadelphia (PA), with Chicago (IL) in between.
Sidebar 1: The following is a list of these several recent superbug outbreaks since 2012 including this southern California’s recent CRE outbreak – the 5th publicized outbreak of this type. For convenience, the hospital where each outbreak occurred is referred to in this list by the state where it is located.
This list is incomplete because a number of CRE outbreaks in the U.S. with similar etiologies have not been publicly disclosed (in some instances, they were not disclosed to the infected patients, either):
- California (2014-2015) – click here to read more (2 patient deaths have been linked to this CRE outbreak; this outbreak is the focus of this article);
- Philadelphia (2014) – click here to read more (2 patient deaths were linked to this CRE outbreak);
- Pittsburgh (2012-2013) – click here to read more (an unknown number of patient deaths were linked to this CRE outbreak; it is unclear at this time whether the impacted patient were notified of this outbreak);
- Seattle (2012-2014) – click here to read more (as many as 11 patients deaths were linked to this CRE outbreak); and
- Chicago (2013) – click here to read more (2 patient deaths were linked to this CRE outbreak; actually, this outbreak occurred in Park Ridge, Illinois).
To date, the FDA has not issued any communications, advisories or alerts discussing these five recent superbug outbreaks in U.S. hospitals and the recommended measures necessary to prevent their recurrence.
As displayed in this list, above, more than a 100 confirmed patient infections and colonizations, and more than a dozen patient deaths, since 2012 have been attributed at these five hospitals to GI endoscopes contaminated with CRE (or a related superbug).
Notably, the GI endoscopes implicated in each of these five outbreaks feature what’s called a “forceps elevator mechanism,” which may be particularly challenging to clean and disinfect, according to the Centers for Disease Control and Prevention (CDC).
Collectively, these five recent CRE outbreaks could be the most significant example of disease transmission, with associated patient morbidity and mortality, ever linked to a contaminated reusable medical instrument. — Lawrence F Muscarella, PhD
This forceps elevator mechanism is a crucial component of the type of GI endoscope that is used to perform ERCP, however, allowing the physician to manipulate the angle of an accessory, or to improve the performance of a needle used to sample cells (i.e., a biopsy).
Safety 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.
It is emphasized that the types of GI endoscopes featuring this “difficult-to-clean-and-disinfect” forceps elevator mechanism include not only “ERCP endoscopes” (also known as side-viewing duodenoscopes), but also those used to perform “EUS,” or endoscopic ultrasonography.
A video demonstrating how to reprocess one manufacturer’s EUS endoscope may be viewed by clicking here.
The rare type of CRE
CRE are so named, because they are resistant to most antibiotics including “last resort” carbapenems. In fact, some strains of CRE are resistant to all types of antibiotics — that is, they are pan-resistant.
The strain of antibiotic-resistant Klebsiella (likely, K. pneumoniae) responsible for UCLA’s recent superbug outbreak reportedly produces the OXA-232 carbapenemase enzyme via the blaOXA-232 gene. This enzyme chemically dismantles carbapenems, thereby rendering these antibiotics ineffective.
Sidebar 2: To learn more about carbapenem antibiotics, carbapenemase enzymes, and ‘bla’ genes, the reader is referred to Dr. Muscarella’s peer-reviewed article published last October (2014) in The World Journal of Gastrointestinal Endoscopy:
Newspaper articles discussing CRE outbreaks
Noted previously, UCLA’s CRE outbreak is the 5th of its kind since 2012 to be linked in the U.S. to contaminated GI endoscopes (used to perform either ERCP or EUS).
In addition to his blog, Dr. Muscarella discusses these five recent CRE outbreaks in articles published in each of the following U.S. newspapers:
- The Los Angeles Times (February 18, 2015)
- The Iowa City Gazette (February 9, 2015)
- The Philadelphia Inquirer (February 7, 2015)
- The Seattle Times (February 3, 2015)
- USA TODAY (January 27, 2015)
- The Seattle Times (January 21, 2015)
- Medscape (January 3, 3014)
Is an FDA action forthcoming?
The FDA is reputed to be issuing a public health advisory sometime in 2015 discussing the increased risk of superbug infections following certain types of GI endoscopic procedures.
This possibility that such an advisory might be published is discussed in more detail in Dr. Muscarella’s related article, “Superbugs, Contaminated Gastrointestinal Endoscopes, and a Growing Number of Hospital Infections: Is an FDA Action Imminent?”
Recommendations for hospitals
Several recommendations for the prevention of superbug outbreaks linked to contaminated GI endoscopes are provided in a number of Dr. Muscarella’s articles, including in his aforementioned peer-reviewed article:
“Risk of transmission of carbapenem-resistant Enterobacteriaceae and related ‘superbugs’ during gastrointestinal endoscopy” (October, 2014) — click here.
The reader’s review of the FDA’s advisory once it is published is urged.
Recommendations for patients
Education and knowing what specific questions to ask physicians are important for patients to prevent infections and improve their safety.
Soon, Dr. Muscarella will provide some educational suggestions and advice for patients to reduce their risk of becoming infected with a superbug during GI endoscopy. Check back soon to read an updated version of this article.
In the meantime, patients who have either already undergone ERCP (or EUS) or are scheduled to soon undergo one of these two types of GI endoscopic procedures may consider reading the following articles or contacting Dr. Muscarella via email – click here.
Recommended articles
Visit this blog’s webpage “Superbugs and Endoscopy” for a list of more than a dozen related articles discussing the risk of ‘superbug’ infections following GI endoscopy.
Also read these articles by the CDC and Medscape:
- 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.
- 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.
- Medscape. CDC Confirms Superbug Transmission via Endoscopy. January 3, 2014.
By: Lawrence F Muscarella, PhD. Posted: 2/18/2015, Rev B; updated 1/11/2016, Rev A.
Lawrence F Muscarella, PhD, is the author of this report. He is the president of LFM Healthcare Solutions, LLC, an independent quality improvement company. Click here for a list of the quality and research services he provides hospitals and manufacturers.
My brother died in March, 2013 after a 3 month in-hospital stay from a bowel obstruction and surgery. He contracted a virus and was ventilated not long after his surgery and was never able to breathe on his own before he died in a treatment facility about 2 weeks after transfer. It was the nearest facility that would care for ventilated patients. I feel he succumbed to the virus spoken of here in the article and I heard about it on T. V.
His name was Newton Grady Bible, D.O.B.-4/2/1952, born in Knoxville, Tn. He had surgery in St. Mary’s Hospital, Knoxville, Tn. and was in ICU for 3 months.
I want justice for him and hopefully no one else will have to go though what he did.
Glenna B. Mullenix
4000 Deerfield Rd.
Knoxville, Tn. 37921
))))))DO NOT POST!!!!!!!FORWARD TO CDC, PLEASE. THANK YOU. (I JUST REALIZED THIS WAS FOR COMMENTS, I thought it was for info.)