A nightmare superbug may have led to 11 deaths at a Seattle hospital. What they're doing to stop it.

Deadly bacteria is 'no longer just a risk. It's a reality,' experts say

At least 32 patients at a Seattle hospital were sickened and 11 died after contracting a superbug that spread through contaminated specialized endoscopes. Now, the hospital is promoting a new cleaning protocol to keep patients safe.

Officials say it is unclear yet if the infection contributed at all to the patients' deaths.

In just four years, hospitals report fivefold spike in 'nightmare' superbug

Details of the cases

The patients who contracted carbapenem-resistant Enterobacteriaceae (CRE) were treated at Virginia Mason Medical Center between 2012 and 2014, according to new investigative reports. The reports found that, although the special endoscopes—known as duodenoscopes—had been cleaned following the manufacturers' directions, they still harbored some of the deadly bacteria when they were used on patients.

Dozens of already critically ill patients who had undergone procedures with the endoscopes were found to have identical bacteria in their systems. And some of the bacteria were CRE, which has a mortality rate as high as 50%, according to the CDC.

In a statement, the hospital said, "We discovered a problem more than a year ago, we responded quickly to investigate potential causes, and we worked to fix the problem," adding, "The few patients who were affected by this bacteria received appropriate and timely medical treatment."

The hospital has said it has revamped its cleaning protocols for the tools, even though the reports did not reveal any breach in infection control procedures at the facility. For instance, the hospital has taken steps to "culture and quarantine" for 48 hours all of the devices used in nearly 1,800 procedures annually. In addition, it has invested in 20 new Olympus Medical System duodenoscopes so that some can be "out of service" for periods of time.

Jeffrey Duchin, a physician who leads disease control at the Seattle and King County Public Health Department, says the process is "way beyond what anybody else in the country is doing." Andrew Ross, a section head for the hospital's gastroenterology department, adds, "This makes us the safest place in the country to have this done."

Why superbugs are thriving in hospitals

'There is no longer just a risk. It's a reality.'

Some experts say the most recent outbreak of the nightmare bacteria represents a new era of antibiotic-resistant superbugs.  Infection control expert Lawrence Muscarella says, "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 says the design of the duodenoscope is to blame for the spreading bacteria, because the device contains small flaps that hold stents and other accessories. As a result, bacteria can become trapped in the flaps, making it difficult to purge even when following manufacturer or FDA guidelines.

In just four years, hospitals report fivefold spike in 'nightmare' superbug

CDC officials agree. In the report on the Seattle outbreak, the agency wrote that the design "makes them difficult to clean with the potential for contamination persisting following reprocessing and subsequent transmission of pathogenic bacteria to patients."

In addition, Muscarella notes an increase in the number of patients opting to undergo a procedure known as endoscopic retrograde cholangiopancreatography (ERCP), which treats disease of the bile or pancreatic ducts, could increase the number of patients who contract the disease because the procedure is done with a duodenoscope.

FDA has not issued a warning or recall of the devices, but a spokesperson says the agency is aware of the possible connection and will monitor the device very closely. FDA is currently in talks with the three major manufacturers of duodenoscopes—Olympus, FUJIFILM, and Pentax—to evaluate a potential new design for the device that would make them easier to clean, and the agency is also looking into a new disinfecting process (Aleccia, Seattle Times, 1/26; Eisler, USA Today, 1/22; CBS News, 1/22).

The takeaway: Although the hospital followed appropriate infection control practices, it has developed a new way to clean the devices to reduce the risk of further infection. Meanwhile, health officials are working with manufacturers to improve the devices' design to improve safety.

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