Pasadena Hospital Duodenoscope Superbug Outbreak
One hospital in California which had suffered a duodenoscope superbug outbreak released a letter revealing the hospital’s own negligence in reporting the outbreak. Huntington Hospital in Pasadena, California broke state law by not quickly reporting a suspected deadly outbreak last year.
The duodenoscope superbug outbreak sickened 16 patients, 11 of whom died, from the first patient case in January 2013 to August 2015.
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Pasadena Hospital Duodenoscope Superbug Outbreak Goes Unreported to City Health Officials
The newly-released letter shows that City health officials did not investigate the cause of the duodenoscope superbug outbreak patients’ deaths, many of whom were already seriously ill. The city officials indicate that only one of the sixteen patients’ death certificate listed a duodenoscope superbug as the cause of death.
As the LA Times reports, Pasadena officials said in their investigation that Huntington doctors were reviewing suspected duodenoscope superbug infections in 35 patients before the city’s public health department was alerted to the possible outbreak by county officials on Aug. 19.
Hospitals must report an “occurrence of any unusual disease” or “any outbreaks of disease” within 24 hours to local health officials, according to State law.
Originally, there were only three known patient deaths connected to the duodenoscope superbug outbreak. These three deaths lost in the Huntington Hospital duodenoscope outbreak prompted comment and new legislation by Rep. Ted Lieu (CA-D) to mandate improved medial device cleaning regulation.
Duodenoscope Cleaning Problems
Duodenoscopes may be used in procedures to drain fluids from blocked pancreatic and biliary ducts, inject contrast dyes, obtain tissue samples for biopsy, or to treat certain medical conditions. The flexible scope is passed through the mouth, throat, and stomach, into the top of the small intestine ( known as the duodenum).
In a Safety Communication dated February 19, 2015, the U.S. Food and Drug Administration (FDA) cautioned that the design of certain ERCP duodenoscopes may interfere with the ability to sterilize these reusable medical devices, putting patients at risk for infection with potentially deadly multidrug-resistant bacteria. Referred to as Carbapenem-Resistant Enterobacteriaceae (CRE), these drug-resistant bacteria include E. coli and Klebsiella species and have been linked to infections following duodenoscope procedures, even when the manufacturer’s cleaning instructions are followed.
Pasadena Hospital Duodenoscope Superbug Outbreak Connected to Negligent Decontamination Procedure
According to the LA Times, “The city’s investigation blamed the scope’s hard-to-clean design, as well as the hospital’s lapses in infection control, for the outbreak.
Pasadena officials said that when they arrived at the hospital Aug. 20, they found visible residue in the machines where the devices were disinfected. They also said the hospital was not properly following cleaning guidelines, including by using canned compressed air from Office Depot to dry the scopes.”
