Between 2012 and 2014, at least 35 patients at Seattle-based Virginia Mason Medical Center fell ill from carbapenem-resistant Enterobacteriaceae infections, according to a Seattle Times report.
The bacteria were likely spread to the patients by duodenoscopes, a specialized endoscope used in a procedure known as endoscopic retrograde cholangiopancreatography. Investigators found CRE on some of those scopes at Virginia Mason even after they had been disinfected, according to the report.
Since the outbreak, Virginia Mason has changed its cleaning protocol for duodenoscopes, even though investigations found "no breach in infection-control practices at the hospital," according to the Seattle Times. Now, the scopes are quarantined for two days and tested to make sure they are completely free of CRE, and the hospital purchased 20 additional scopes.
"This makes us the safest place in the country to have this done," Andrew Ross, MD, the section head of the hospital's gastroenterology department, told the Seattle Times.
Virginia Mason is not the only hospital with this problem — other hospitals in cities like Pittsburgh and Chicago also experienced CRE infections tied to the scopes. The design of the scope itself makes it difficult to clean properly. They have "a lot of intricate mechanisms and pieces that are very difficult to disinfect," Alex Kallen, MD, a medical epidemiologist with the Centers for Disease Control and Prevention, told the USA TODAY.
A spokeswoman from the Food and Drug Administration told the Seattle Times the agency is aware of infection risks tied to duodenoscopes but "feels that the lifesaving nature of ERCP…makes it important for these devices to remain available."