Los Angeles-based Cedars-Sinai Medical Center has reported four patients contracted "superbug" infections from the same type of endoscope that caused similar problems at Ronald Reagan UCLA Medical Center, also located in Los Angeles.
Below are six things to know about the most recent report of infections tied to duodenoscopes.
1. Cedars-Sinai has identified a total of four patients who contracted carbapenem-resistant Enterobacteriaceae infections after undergoing procedures using duodenoscopes. The same duodenoscope was used on all four patients between August 2014 and January 2015. The scope, made by Olympus, has since been removed from use.
2. Cedars-Sinai has sent letters to 71 other patients who had a procedure with that particular scope between August 2014 and February 2015 out of "an abundance of caution." The hospital offered free home testing kits for CRE that can be sent to Cedars-Sinai for analysis.
3. All this happened despite the fact that Cedars-Sinai "meticulously followed the disinfection procedure recommended in instructions provided by the manufacturer," according to a hospital statement. In response to these infections, the hospital has started using additional measures to disinfect the scopes, including culturing the scopes before and after procedures.
4. Cedars-Sinai halted non-urgent duodenoscope procedures Feb. 19 after learning of reports that manufacturer's disinfection instructions may not be sufficient. However, the hospital has since reinstated such procedures. That decision was made "based on consultation with other academic medical centers around the nation, as well as with government agencies, about the additional monitoring techniques."
5. Cedars-Sinai is just the latest in a string of hospitals reporting infections caused by contaminated duodenoscopes. UCLA recently reported two patients died after contracting CRE from duodenoscopes, and at least 35 patients at Seattle-based Virginia Mason Medical Center fell ill from different antibiotic-resistant bacteria transmitted from contaminated scopes.
6. Experts have said the duodenoscopes are "almost impossible to clean correctly" and several hospitals have taken extra steps that go above and beyond manufacturers' instructions for reprocessing the scopes to reduce the risk of infection. ECRI Institute recently released recommendations for cleaning the scopes, urging hospitals to culture the scopes for up to 48 hours.