Early last year, the Ronald Reagan UCLA Medical Center saw an outbreak of the “superbug”, carbapenem-resistant Enterobacteriaceae (CRE) bacteria. A noxious killing bug resulting in seven confirmed infections and two Californian deaths due to basic medical errors.
The source of the superbug outbreak has been found to be two of UCLA’s seven Olympus Corp. duodenoscopes, exposing a total of 179 patients to CRE. Those individuals have since been provided with free, at-home screening tests to determine whether they were infected due to that exposure.
CRE bacteria are a part of a family of bacteria commonly found in a person’s gut. Some Americans will carry such bacteria for decades with no ill effects, but due to antibiotic overuse some of these gut-dwelling bacteria, notably CRE, have evolved into virulent strains capable of killing host bodies. By some medical estimates, CRE kills as many as half of all infected patients.
The source patient of the UCLA outbreak underwent an ERCP (endoscopic retrograde cholangiopancreatography) procedure in late 2014. This is generally considered a relatively innocuous procedure with nearly 700,000 performed each year nationwide and 800 performed each year at UCLA alone. The procedure utilizes the duodenoscope to diagnose and treat problems located in the digestive tract, such as blockages of the bile duct and cancers.
Unfortunately, this medical scope also picked up CRE bacteria residing along the source patient’s intestinal tract. This might still have been a non-issue had medical errors in the cleaning process been avoided and the scope thoroughly cleaned.
While the UCLA Medical Center continues to assert that the duodenoscopes had been cleaned according to both FDA and manufacturer guidelines, those procedures are the medical errors at the heart of the CRE outbreak as they are not sufficient to completely remove all of the bacteria due to sensitive structure and mechanics of the devices.
This inadequate cleaning procedure being the heart of the medical errors gains further support as the UCLA outbreak is not unprecedented. In the last four years, there have been deadly CRE outbreaks in Illinois, Pennsylvania, and Washington. In all of these cases, the source medical errors relate to duodenoscopes being the conduit for disease transmission.
Healthcare leaders are now encouraging all hospitals to re-evaluate their sterilization procedures while consumer advocates are demanding for fuller disclosures to patients undergoing this and any other medical procedure that might put them at risk for the deadly CRE superbug infection.