The UCLA Health System notified 179 patients on Feb. 18 that they may have been exposed last fall to the carbapenem-resistant enterobacteriaceae (CRE) bacteria during an endoscopic procedure to diagnose and treat diseases of the liver, bile ducts and pancreas at Ronald Reagan UCLA Medical Center. A total of seven patients were infected; the infection was a contributing factor in the death of two patients.
Only patients who underwent these endoscopic procedures from Oct. 3, 2014 to Jan. 28, 2015 are at risk of infection. Those patients are being offered a free home testing kit for analysis at UCLA to determine if they carry the bacteria in their intestines.
UCLA followed both national guidelines and the sterilization standards stipulated by Olympus Medical Systems Group, the instrument’s manufacturer. However, an internal investigation determined in late January that CRE may have been transmitted by two of the seven Olympus scopes used by the hospital during the four-month period.
UCLA immediately began reviewing every patient record to determine which patients underwent the procedure using this type of scope between October and January. In an abundance of caution, the hospital has notified all 179 patients who were examined with one of the seven instruments during that time.
The two infected scopes were immediately removed from use for return to Olympus. UCLA currently performs a more stringent decontamination process that exceeds both the manufacturer’s standards and national guidelines. Hospital staff thoroughly clean the instrument and place it in an automated machine for disinfection. Then the instrument is sent off-site for a second sterilization process using a gas called ethylene oxide.
The Los Angeles County Department of Health and California Department of Public Health were notified as soon as the outbreak was detected. CRE exposures using the same type of scope have been reported in other U.S. hospitals. Concerned patients may contact their primary care physician or UCLA’s clinical epidemiology and infection prevention department at 310-794-0189.
To read a safety alert from the FDA, CLICK HERE.
To access a slide show from ICT on Duodenoscopes and the Dangers of Improper Reprocessing, CLICK HERE.