A deadly bacteria has been linked to a commonly used medical device. The pattern of illnesses and deaths showed up in Chicago and Pittsburgh, with the biggest outbreak right here in Seattle. Eleven deaths occurred at Virginia Mason alone, but it’s not clear if those deaths were directly related to the superbug infection.
The bigger fear now is that the problem is nationwide and other hospitals aren’t looking for it.
“You have to understand that this issue dates back to 2011, 2012,” said Dr. Andrew Ross, section head of gastroenterology at Virginia Mason.
It wasn’t until spring 2013 that the Centers for Disease Control an Prevention even recognized this new superbug called CRE (carbapenem-resistant Enterobacteriaceae) as a nationwide threat. Later that same year, Dr. Ross said Virginia Mason voluntarily agreed to be part of surveillance efforts overseen by King County.
“This is a little bit like a rock. If you don’t look underneath the rocks, you’re not going to find what you’re looking for,” Dr. Ross said.
King County found CRE infections linked to a special endoscope, a flexible tool used to treat gallbladder stones, pancreatic cancer and other problems in the gut.
Half a million of these procedures are performed across the country every year.
“This is really the perfect storm. You have an instrument that on the whole is difficult to completely disinfect and at the same time you have a bug that’s become more and more resistant to antibiotics,” said Dr. Ross.
At the tip of the duodenoscope is a tiny opening called the sanctuary site, where debris and bacteria can collect.
“(It’s) frankly very, very hard to clean,” said Dr. Ross.
Virginia Mason’s solution was to buy more scopes to put into the rotation, then to create a “penalty box,” where the used scopes are stored, once they are cleaned and disinfected.
This quarantine lasts for 48 hours, then the scope are tested again to make sure they harbor no bacteria.
“Since we’ve implemented this penalty box, we’ve seen no more transmissions so we know that it works,” said Dr. Ross.
He said that makes Virginia Mason the safest place in the country now to have one of these procedures.
Still, that solution cost the hospital nearly $1 million, something that’s impractical to implement nationwide.
The ultimate solution, Dr. Ross says, needs to be a design change.
There are three manufacturers of these scopes. All three have this same design flaw.
Contrary to some reports, Dr. Ross says patients who contracted CRE during the surveillance period were informed they had the infection.
Virginia Mason, however, did not contact patients who may have been exposed to the bacteria prior to the surveillance period.