2.20.15 | Forbes
By Steve Brozak and Anne Marie Noronha
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A deadly strain of antibiotic-resistant bacteria, dubbed “nightmare bacteria” by the head of the Centers for Disease Control and Prevention (CDC), has struck again. This time two people died and 179 were exposed to life-threatening carbapenem resistant enterbacteriaceae (CRE), a deadly and often untreatable bacterial infection. Yet this is not a story about deadly bacteria and the need for new antibiotics; this is a story about bad medicine. The cause of the outbreak, like so many others, was improperly cleaned endoscopes used for diagnostic and medical procedures. In this case, patients were undergoing routine endoscopic examinations for their bile ducts, gall bladder and pancreas.
This most recent outbreak of CRE occurred at the Ronald Reagan UCLA Medical Center. But contamination of endoscopes with CRE can happen anywhere and is being detected ever more frequently. Last month at least 35 people who had endoscopic procedures contracted CRE infections at the Virginia Mason Medical Center in Seattle, Washington. Eleven of them died following the deadly infection. The same thing happened in 2013 to at least 38 patients at the Advocate Lutheran General Hospital, as reported by the CDC.
We wrote about this very issue in The British Medical Journal about a year ago. While writing our report we came across a 2013 study that found that 15% of endoscopes for the stomach, colon and duodenum were still contaminated after many complex cleaning processes. Every time you undergo an endoscopic procedure, you share an endoscope with someone else, and unfortunately, a germ-free instrument is not guaranteed although it may be assumed. Over 19 million people undergo an endoscopic procedure every year. Though physicians may be casual about performing these procedures, any time a doctor uses an endoscope to look for digestive problems, a cystoscope to identify the cause of urinary tract problems, or a bronchoscope to examine airways, there is a significant risk of serious infection passed from someone else who came into contact with the same equipment earlier in the day. The problem is that it is extremely difficult to remove 100% of microbes due to the intricate design of endoscopes. Regardless of how strong any sterilant or disinfectant is, the narrow channels and ports are hard to reach and the debris trapped in those places can harbor germs as dangerous as CRE through multiple uses and cleaning cycles. The complex and tedious process used to “clean” scopes consumes over half an hour of labor and requires up to 43 steps to merely reduce – but not eliminate – the risk of one person infecting another. As seen in the in the Los Angeles and Seattle CRE outbreaks, the consequences are deadly. What troubles us most about those outbreaks and the one in Illinois is that investigators have not identified any lapses in the procedure used to clean the scopes at each hospital, which means the fault is with the procedure and not necessarily with the people who performed it. Infections from endoscopes are largely underreported. Because of low awareness of the issue, healthcare providers do not often make the connection between an infection and scopes. Since most endoscopies are performed at outpatient surgery centers while the resulting infections are treated at hospitals, it is especially difficult to trace the source of infections. The risk of acquiring a deadly infection in your doctor’s office or a surgery center can be reduced to practically zero with simple and less expensive technology that is already available. Scopes used for the urinary tract, lungs, esophagus and throat are now on the market that are designed to fit into specially-made protective sheaths. The key is that each disposable sheath is used once over the scope and then thrown away after the procedure. Because of the sheath, the scope itself never makes contact with the patient. An infection has never been traced back to a sheathed endoscope. Not only do sheathed scopes avoid spreading disease, but they can also reduce procedure and equipment maintenance costs. Preparing the scope for the next patient requires two steps instead of 43. What makes it even easier is that a doctor wouldn’t need to own dozens of scopes to be able to quickly go from one patient to another or several assistants to perform the cleaning procedure. The equipment also lasts longer because it doesn’t have to be exposed to harsh chemicals. So, if the risk is significant and the fix is so intuitive and simple, why aren’t doctors adopting the newer system? We believe there are two connected reasons. The first reason is reluctance to change the way they are accustomed to performing the procedures. Doctors are creatures of habit, and they conduct the same procedure the same way for years. The second reason is that doctors and hospitals may worry that buying new sheath-compatible equipment and a new maintenance contract will be very expensive, even though the system is a lot more cost-effective than what they currently have. Using sheaths means less time cleaning the endoscopes and more patients that can be serviced. Finally, patients just don’t know the infection risk of these so-called “routine” procedures. Patients assume that the equipment their doctors use is sterile and that their procedures are too commonplace to worry about. But there is no such thing as a routine medical procedure that has a routine risk of life threatening infection. Even though using a sheathed scope during any procedure is the best protection you can get, you’re probably not going to get it. More stringent policies are required to get doctors to adopt newer scopes with sheaths. The next best thing is for patients to step up and ask what kind of scope their doctor is using before their procedure, and insist on sheathed scopes. If you don’t, the next time you’re in a doctor’s waiting room for a colonoscopy or any other scope procedure, take a look to your left and to your right. Chances are you may be sharing more than just a scope with all the people in the room with you.