Blog | Wednesday, March 4, 2015

Drug resistant bacteria versus advanced medical technology: No contest

The duodenoscope implicated now in several deadly outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) is an otherwise terrific device for management of biliary or pancreatic duct disorders. Unfortunately, the same features that allow the scope to guide fine instruments into miniscule spaces also provide sanctuary for bacterial pathogens, protecting them from all standard approaches to disinfection.

To quote yesterday's FDA safety communication: ”… reports associate multidrug-resistant bacterial infections in patients who have undergone ERCP (endoscopic retrograde cholangiopancreatography) with reprocessed duodenoscopes, even when manufacturer reprocessing instructions are followed correctly. Meticulously cleaning duodenoscopes prior to high-level disinfection should reduce the risk of transmitting infection, but may not entirely eliminate it.”

Translation: You pays your money and you takes your chances.

There aren't any great options for further reducing the (albeit small) risk for infection transmission from these devices. Some hospitals that have experienced outbreaks have switched to ethylene oxide gas, which is time-consuming and may still fail if organic debris remains in the tiny spaces that are so difficult to clean mechanically. Microbiological surveillance (culturing scopes after disinfection) is time-consuming, costly, and has unknown sensitivity for detection of transmission risk.

This problem is just one example of the limitations that antimicrobial resistance and infection control practice place on advanced health care delivery. Each year we see advances in our ability to provide life-saving care, but each of these advances can be easily circumvented by a simple lapse in infection control practice, or an untreatable bacterial pathogen.

As for this particular device, there must be a safer approach that doesn't sacrifice utility. In a world where you can buy a robot hat-backpack that feeds you tomatoes while you jog, there must be a way to design a duodenoscope that can be effectively cleaned.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.