VA investigation finds superbug infections related to endoscopy highly unlikely at VA hospitals

Prompt and Thorough Investigation


shadow

This is about superbugs, medical equipment and the great job VA is doing to provide safe, modern health care for our Veterans.

CRE are a family of superbugs. You might have seen media stories about infections due to these bacteria at some private sector hospitals. CRE are carbapenem-resistant Enterobacteriaceae. That link will take you to the CDC with a lot more information about these bacteria, which are resistant to treatment by the antibiotics usually used to fight them. Superbug infections have occurred more often in the last several years. A Google search of superbugs today will provide more than 600,000 links. People are right to be concerned.

In some instances, it is believed that people got CRE from a piece of medical equipment called a duodenoscope. The doctor uses it to view a patient’s pancreatic and bile ducts using a flexible, lighted tube.

Out of concern for Veterans, and to be sure that no CRE transmission through contaminated duodenoscopes was occurring at VA hospitals, VA conducted a review to determine if there was evidence of CRE infections in Veterans who underwent the procedure with a duodenoscope.

There were over 55,000 duodenoscopy and related procedures performed on 40,329 Veteran patients between 2010 and 2015. Of these more than 40,000 patients, a total of 97 patients from 39 different VA facilities who underwent these procedures were found to have CRE.

Duodenoscope

Duodenoscope

For many patients there was no connection because CRE infection occurred before the patient had the procedure. But we needed to know if other patients with a superbug had picked it up from another patient who might have infected the duodenoscope. So we looked at their records and matched the duodenoscope make, model and serial number.

We identified 59 Veterans who had a procedure within 6 months of another Veteran at the same facility. For 49 of them, a different duodenoscope was used for the two procedures, so the bacteria could not have been transmitted between the two Veterans.

For the remaining 10 Veterans, the possibility of transmission could not be completely excluded. For some, the duodenoscope model and serial number were unavailable. For others, the duodenoscope with the same model and serial number was used for both procedures, but they were performed 3-4 months apart, and there was no evidence of superbug infection in any of the patients who had a procedure using the same equipment between the procedures of the patients under investigation.

I believe these findings demonstrate the effectiveness of VA medical center policies and processes. Our medical centers employ high quality sterile processing of reusable medical equipment to prevent such infections.

We have the tools to systematically investigate potential problems of the kind reported in other health care facilities. Our prompt and thorough investigation of possible transmission of CRE infections by duodenoscopes demonstrated that transmission of these infections in our system was highly unlikely.

Veterans, other stakeholders, and the public can be assured that VA will continue applying the highest possible standards for cleaning all reusable medical equipment, monitoring for any infections that might develop, rapidly investigating potential breaches, and applying robust preventive measures when infections do occur within its facilities.

by Mark Holodniy
Director, Public Health Surveillance and Research

Author

VAntagePoint Contributor

— VAntage Point Contributors provide insight and perspective on a wide range of Veterans issues. If you’d like to contribute a story to VAntage Point, learn how you can submit a guest blog at http://www.blogs.va.gov/VAntage/how-to-submit-a-guest-post/

Comments

  1. james l bowman    

    I had this done at the San Diego VA,,I’ve been sick for over a year now..I am now a Los Angeles Pt. and L.A. is putting me through all the same MEDS that i had in San Diego,,,I’ ve had surgury to remove testie’s because infection spread throughout entire urine tract,,, VA will not replace my knee until this infection is cleared up….Pat Adv. no help,Congresswoman (Ventura Ca.) lip service, Newspaper ,,don’t want to hear it anymore,,Got return call from staff of Bob Mac Donald,,NO ACTION,,I am so sick of all the pain,drugs,depression, and the same old B.S. from the VA…. I complained to everyone who would listen about this test URLOG,INFECT DISEASE’s, CLINIC, PRIMARY CARE PERSONS, SURGURY STAFF,PAT ADVOC. VFW, I Was Admitted 15+- times at VA, 4 times to CIVIL ER with infection,,have been advised by more than 1 Nurseing Staff, Pat Advoc. both S.D. and L.A…that i should file a TORT to get their attention..

  2. Howard E. Gordon    

    It is ironic that so many vets are concerned that they could have contracted CRE infection after orthoscopy procedure.
    How many of these patient reported be for 2010? I had a orthoscopy in may of 2005. Two weeks later, i had a infection that spread all over my rear. I did not have this infection prior to the procedure. There was 30 of us the received it
    that day and i was next to last. You cannot tell me that 30 people could have this procedure in less than 2 hours.
    This happened at the V.A clinic in Columbia Missouri. I moved to Omaha Nebraska in September of 2005. I went yo the V.A hospital. I have had 14 surgeries to remove large areas of infection. The infection just move from one spot to another.
    The hospital is now giving me ramacade infusions (Humira) every 6 weeks. this slows it down for three weeks and in the fifth week it comes back with a vengance. There is heavy drainage that stinks real bad and the infection spreads.
    I life is ruined. I have to live in the basement because the stench fills a room. You say you’ve ran test for 2010 to 2012
    and found no issues. What about prior to 2010 ? Something must have happened because you have vet complaints.
    How many of the vet complaints were reported prior to 2010 ? How many vets have died from this CRE ? I nearly died twice,If given time the equipment cleaning procedures could have been improved. I am not stupid! but it is clear that you are.
    You are playing with peoples lives while you try to cover your ass!

  3. John Walker    

    I had endoscopy exams twice at Palo Alto VA. it’s been three years with no unusual developments. That’s all I can contribute at this point.

  4. Mary Thornton    

    In light of the fact that I might need to have this procedure done soon, this information does NOT make me feel more comfortable. There was a story yesterday in the news about patients at a hospital in the cardiac unit, not VA that died from being exposed to MOLD in the intensive care unit. 2 people died. I have seen how some of the people who clean rooms in a regular hospital miss visible things. Missing mold is even more dangerous. All hospitals need to screen the people they hire, to clean them. And maybe pay them a little more, and give them a little more respect, because they really are the ones who can stop this type of thing from occurring from the start. And making sure that the job is done right, does make me feel more comfortable.

  5. Robert Jorgensen    

    How about other internal instrument examination procedures? I had a TEE and about a month and a half later, a raging infection appeared in my foot. There was no cuts, abrasions, punctures, bites/stings, or bruieses leading up to this.I have read a case where a patient had a duodenoscope and a month later the infection appeared in his foot.

Comments are closed.