Duodenoscope Related CRE Outbreaks

Events

Outbreak at 2 Hospitals in Highland County Florida

January 2008 - December 2008

As many as 70 exposed, 15 dead, legitimate issues with reprocessing

Outbreak at Erasmus Medical Center, Rotterdam Netherlands

January 2012 - April 2012

30 infected, 22 due to a TJF-Q180V scope

Outbreak in Charlotte County Florida

January 2012 - December 2012

22 infected, 7 dead, likely reprocessing issues

Outbreak at University of Pittsburgh Medical Center, Pittsburgh, PA

January 2012 - December 2012

18 infected, unreleased numbers dead, questionable link to duodenoscope, not exposed until 2014

Outbreak at Charite University, Berlin, Germany

October 2012 - February 2013

12 infected, ended when scopes sent to Olympus for maintenance

Outbreak at Virginia Mason, Seattle Washington

November 2012 - August 2013

32 infected, 16 dead

Outbreak at University of Massachusetts Medical Center, Worchester MA

January 2013 - December 2013

10 infected

Outbreak at Advocate Lutheran General Hospital, Park Ridge IL

January 2013 - December 2013

39 patients infected, at least 4 dead, First proven instance of infected, properly reprocessed scopes

Outbreak at Medical College of Wisconsin, Milwaukee WI

May 19 2013 - November 2013

4 patients infected

Outbreak at Thomas Jefferson University Hospital, Philadelphia PA

January 2014 - December 2014

8 infected, 2 dead

Outbreak at Cedars Sinai Hospital, Los Angeles CA

August 2014 - January 2015

4 infected, 1 dead, but from other complcations

Outbreak at UCLA Ronald Reagan Memorial Hospital, Los Angeles CA

October 2014 - January 2015

8 infected, 3 dead, 179 patients exposed

Outbreak at Huntington Memorial Hospital Pasadena CA

June 2015 - August 2015

3 infected

General Trends in Duodenoscope related CRE infections

142 Disclosed Incident Reports from the FDA

2010 - 2015

TJF-Q180V Goes on the Market

2010

Less than 10 reported incident reports- spike in incidences noticed here

2012

Olympus Warns European users of safety concerns around TJF-Q180V

January 2013

70 incidence Reports

2014

Dutch Doctors report how they stopped their outbreak in 2012 at a conference in DC

September 2014

40 incident reports in the first 6 weeks of 2015

January 2015 - February 14 2015

LA Times runs expose uncovering CRE outbreak at UCLA

February 18 2015

FDA releases safety warnings around use of duodenoscopes

February 19 2015

Olympus releases new reprocessing manual

March 2015

FDA convenes panel of experts to consult on whether or not current reprocessing is adequate

May 2015

Come to the conclusion that it is not

Olympus currently faces 14 lawsuits

May 2015

Dutch doctors publish report on 2012 outbreak in "Endoscopy"

June 1 2015

FDA gives ultimatum to manufacturers- 30 days to determine better safety procedures

October 2015