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This award-winning blog supplements the articles in Hospital Infection Control & Prevention.

CRE endoscope outbreak raises troubling questions about reprocessing, continuing emergence of New Delhi enzyme

An upper endoscopy procedure performed on some half million patients annually in the U.S. may pose risk for transmission of highly drug resistant carbapenem-resistant Enterobacteriaceae (CRE) even if current cleaning and high level disinfection protocols are followed, Hospital Infection Control & Prevention has learned.

That’s one of the sobering considerations in the aftermath of a hospital CRE outbreak in Illinois that did not end until the facility went beyond standard practice recommendations to gas sterilization with ethylene oxide for scopes used in endoscopic retrograde cholangiopancreatography (ERCP).(1)­­

The mystery is that no breaks in cleaning and high level disinfection practices were found at the hospital. While continuing the investigation, the Centers for Disease Control and Prevention recommends that health care facilities specifically follow the device manufacturer’s reprocessing protocols for ERCP scopes.

“Right now the CDC is not recommending to move from high level disinfection to sterilization,” says Alexander Kallen, MD, MPH, a medical epidemiologist and outbreak response coordinator in the CDC Division of Healthcare Quality Promotion. “Our main recommendation is that facilities review their practices to make sure they adhere to exactly what the manufacturer recommends.”

The CRE outbreak at Advocate Lutheran General Hospital in Park Ridge, IL is also notable for the infecting agent: a strain of Escherichia coli that is highly resistant to antibiotics due to the presence of the New Delhi metallo-β-lactamase (NDM) enzyme. The outbreak included nine patients with positive cultures for NDM-producing E. coli (eight clinical cultures and one rectal surveillance culture) who were identified in northeastern Illinois from March to July 2013, the CDC reported. Patient notification efforts have identified many more cases who had undergone ERCP at the hospital, bringing the total to 44 CRE cases of colonized or infected patients.

“Our leading hypothesis is that the scopes became contaminated at some point and the contamination persisted on the endoscopes and was transferred from patient to patient,” says Lauren Epstein, MD, a CDC EIS officer who investigated the outbreak.

Health care facilities with CRE outbreaks should consider the possibility of ERCP-related transmission, the CDC emphasizes.

For more on this important story see the Feb. 2014 issue of HIC.


  1. CDC. Notes from the Field: New Delhi Metallo-β-Lactamase–Producing Escherichia coli Associated with Endoscopic Retrograde Cholangiopancreatography — Illinois, 2013. MMWR 2014; 62(51):1051-1051