106. Los Angeles County Public Health Response to Outbreaks of Carbapenem-Resistant Enterobacteriaceae (CRE) Associated with Endoscopic Retrograde Cholangiopancreatography (ERCP)
Session: Oral Abstract Session: Duodenoscope-Related CRE Infections
Thursday, October 8, 2015: 10:45 AM
Room: 5--AB
Background: Outbreaks of CRE associated with endoscopic retrograde cholangiopancreatography (ERCP) have been documented. Duodenoscopes used during ERCP have a complex design with challenges for cleaning and high-level disinfection (HLD), issues already known to both the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). In January and February 2015, LAC Department of Public Health (DPH) investigated two hospital outbreaks of CRE associated with ERCP. The widespread presence of CRE in LAC and the ~ 7000 ERCP procedures performed annually in LAC hospitals create the potential for similar infections or clusters at other facilities.

Methods: In each outbreak, a case was defined as a patient who was CRE positive from any site after ERCP. We reviewed facility records to identify risk factors and conducted site visits at hospital A and B. Laboratory testing was performed by hospital A and B and/or DPH Public Health Laboratory (PHL). LACDPH sent a letter to all LAC hospitals (n=93) requesting those who perform ERCP conduct retrospective and prospective surveillance to determine whether infections following ERCP have occurred, notify LAC DPH of identified CRE cases following ERCP, and submit the isolate to PHL for molecular testing.

Results: Hospital A had 11 cases from 9/2014-1/2015; all case isolates were CRE OXA 232, an uncommon strain in LAC, and identical via repPCR. Hospital B had 4 cases from 9/2014-1/2015. All available case isolates for hospital B (3) were CRE KPC; repPCR and PFGE showed 2 isolates were identical; 1 isolate matched at >95%. This KPC was unique when compared to other KPC strains in LAC. In both hospitals, epidemiologically implicated duodenoscopes had negative CRE cultures, and observed cleaning and HLD did not identify breaches. LACDPH advised hospital A and B to notify all exposed patients. Through surveillance, one other cluster of two cases was identified in LAC; isolates were unavailable.

Conclusion: In response to two outbreaks of CRE associated with ERCP, LACDPH established enhanced voluntary surveillance for suspect CRE following ERCP. Through identification of potential new cases, contaminated duodenoscopes could be removed preventing further CRE infections and fostering ongoing communication with CDC, FDA, and healthcare facilities.

Dawn Terashita, MD, MPH1, Moon Kim, MD, MPH2, Patricia Marquez, MPH1, L'tanya English, RN, MPH3, Benjamin Schwartz, MD1, Nicole Green, Ph.D., D(ABMM)4, Hector Rivas, MPH4, Juan Lopez, MPH4 and Laurene Mascola, MD, MPH5, (1)Los Angeles County Department of Public Health, Los Angeles, CA, (2)Acute Communicable Disease Control Program, Dept. of Public Health, Los Angeles, CA, (3)Los Angeles County Department of Public Health, Los Angels, CA, (4)Los Angeles County Department of Public Health, Downey, CA, (5)Los Angeles County Public Health Department, Los Angeles, CA

Disclosures:

D. Terashita, None

M. Kim, None

P. Marquez, None

L. English, None

B. Schwartz, None

N. Green, None

H. Rivas, None

J. Lopez, None

L. Mascola, None

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