UCLA’s Superbug Isn’t a Public Health Issue…Yet

Question: How do you know when people are getting bored with stories about ISIS and Jeb Bush’s economic program?

Answer: “Superbugs strike” stories begin to re-appear. Yes superbugs—those superhero- sounding villains that have been threatening to destroy us every year since the 1980s—they’re back. For real. And this time they really are going to end life as we know it.

At the Ronald Reagan Medical Center of UCLA, seven patients have developed infection with a particularly antibiotic-resistant bacteria referred to as CRE or carbapenem-resistant Enterobacteriaceae. Thus far two of the seven patients have died; overall the infection kills about half of those infected. Of particular concern is that a medical instrument may be involved in transmission.

Beware: this story is about to enter into acronym overdrive. In general, many patients with gall bladder, pancreas, bowel, and other conditions may, for diagnostic or therapeutic reasons, undergo a procedure called ERCP (endoscopic retrograde cholangiopancreatography) where a high-tech tube—called an endoscope—is passed through the mouth and stomach and into the upper part of the small intestine (the duodenum). This procedure has been going on for decades and has saved and improved countless lives.

The problem is that the ERCP endoscope can be difficult to completely sterilize. That means that the next patient may be exposed to bacteria harbored by the previous patient. As a result, in the case at UCLA, more than 100 others who were treated with the same ERCP equipment may have been exposed and may—may—harbor the potentially deadly bacterium.

The issue is that the lead end of the scope has, over the years, been improved to become more flexible with a better camera, a brighter light, and sharper smaller biopsy forceps. As the gizmo has become more complex, however, it has given rise to more micro-nooks and micro-crannies, places that are nearly impossible to sterilize completely. Think of trying to clean a turkey baster (almost hopeless on a good day) then add 101 tiny little knobs and twists within it. This is the challenge.

A related situation caused a substantial stir in the VA hospital system a few years ago. That time, a colonoscope was incompletely sterilized and a virus, hepatitis C, was spread to several veterans. This was on the heels of many similar reports involving an array of infections associated with various endoscopes reported from many other hospitals. As a result, cleaning protocols were revised for colonoscopes and many other types of invasive procedural scopes, and this particular version of the problem subsided.

But not for ERCP equipment. At the LA hospital, the concern is that the ERCP endoscope may have become contaminated with CRE from one patient and was not fully cleaned. This means that the CRE might have been introduced into subsequent patients undergoing a procedure with the same scope. The scopes cost $100,000 or more, depending on the level of sophistication one requires, so the standard American approach to potential contamination—disposal—is not an option.

The problem is quite real and frightening. CRE infection is extremely difficult to cure because so few antibiotics are available with activity against the strain; furthermore, those that are available have issues with side effects. It is a nasty business affecting already ailing people for whom yet another problem may precipitate a tipping point in the wrong direction.

What it is not is a public health hazard to non-hospitalized people who are in good health. It is not Armageddon nor is it ISIS or the extreme cruelty of the eternal presidential election cycle. Rather it is yet another bump on the road to tomorrow, one caused by the continued hurry to better ever-more-modern medical care. The cost of living on the cutting edge of medicine is that the risks and dangers of new medications and new devices often cannot be anticipated. For better and for worse, the cutting edge can be very sharp indeed.