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Even worse than having to have a doctor run a down your throat to drain fluid from your pancreas or bile duct is finding out later that you were infected with a superbug during the procedure. The scope for this procedure is being redesigned.

By the time 18-year-old Aaron Young wound up at Ronald Reagan UCLA Medical Center in Los Angeles in October of 2014, he had made multiple trips to the emergency room for treatment of excruciating abdominal pain. Doctors diagnosed him with pancreatitis, and ordered what is ordinarily a low-risk procedure involving the placement of a scope down the throat to remove an obstruction of the duct that allows the pancreas to release its digestive juices into the small intestine.

Instead of getting better, unfortunately, Young quickly developed a persistent 104-degree (40 degrees Celsius) fever. He only recovered from the infection after another three months in the hospital, but not long after he got out he had to have another procedure for pancreatitis. His infection flared up again, and he had to spend another day in the hospital for his underlying problem and another month in the hospital for the infection he picked up during the second procedure.

Young was just one of seven patients at UCLA to come down with a superbug infection after being treated with the same instrument. Two of the other patients died. Dozens more patients at UCLA had to be monitored for months to make sure they did not also come down with these antibiotic-resistant infections.

Superbug Infections Across the United States

All the patients like Aaron Young, it turned out, were not at UCLA. Shortly after Young was released from the hospital for the second time, another hospital Cedars-Sinai, also in Los Angeles, announced that four patients there who had undergone the same procedure had been diagnosed with the same germ that the seven UCLA patients had, a drug-resistant form of carbapenem-resistant Enterobacteriaceae, or CRE.

Then Hartford Hospital in Connecticut, on the other side of the country, announced that 282 patients undergoing the same procedure with same kind of instrument had been exposed to an antibiotic-resistant form of E. coli.

A Scandal Leads to a Congressional Investigation

The three outbreaks of superbugs in three hospitals known for high standards of care triggered a Congressional investigation. When the FDA was ordered to take a closer look at the outbreaks, an even more disturbing pattern emerged. 

These three incidents involving nearly 300 people were hardly the only superbug outbreaks. A similar problem appeared after use of the device at the Virginia Mason Medical Center in Seattle, where 32 patients became ill and 11 died in 2012. Also since 2012, a total of 44 patients have caught superbug infections after use of the device at Advocate Lutheran General Hospital near Chicago. The Veterans Administration had been aware of the problem in its hospitals since at least 2011.

Altogether, more than two dozen hospitals in the United States and Europe had the same kinds of problems with the same kind of instrument, but nobody noticed a trend until the cases in Los Angeles and Connecticut were reported by the news services. The medical profession has been aware of problems with the device since 1987, when 10 patients in a Minnesota hospital treated with the same device came down with an infection with a kind of bacteria known as Pseudomonas. A Congressional hearing resulted in a finding that hospitals had been negligent in letting other institutions know of the problem and in a demand that the FDA take forceful action. However, the FDA concluded that taking the medical scope used to do the procedure off the market immediately would result in even more deaths than are caused by superbugs.

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