Just a few short weeks after the reports of carbapenem-resistant Enterobacteriaceae (CRE) bacteria infections linked to endoscopic procedures performed at Ronald Reagan UCLA Medical Center were reported, another Los Angeles area hospital is reporting CRE transmission at their facility due to duodenoscopes.

This 2014 image depicts Centers for Disease Control (CDC) microbiologist Kitty Anderson holding up two Petri dish culture plates growing bacteria in the presence of discs containing various antibiotics. The isolate, i.e., bacterial specie, on the left plate is susceptible to the antibiotics on the discs, and is therefore, unable to grow adjacent to the discs. The plate on the right was inoculated with a Carbapenem-Resistant Enterobacteriaceae (CRE) bacterium that proved to be resistant to all of the antibiotics tested, and is therefore, able to grow near the discs/CDC
This 2014 image depicts Centers for Disease Control (CDC) microbiologist Kitty Anderson holding up two Petri dish culture plates growing bacteria in the presence of discs containing various antibiotics. The isolate, i.e., bacterial specie, on the left plate is susceptible to the antibiotics on the discs, and is therefore, unable to grow adjacent to the discs. The plate on the right was inoculated with a Carbapenem-Resistant Enterobacteriaceae (CRE) bacterium that proved to be resistant to all of the antibiotics tested, and is therefore, able to grow near the discs/CDC

Cedars-Sinai Medical Center in Los Angeles announced yesterday that an investigation revealed a total of four patients who had a CRE transmission linked to an ERCP procedure. The same duodenoscope was used in all four patients, whose ERCPs occurred between August 2014 and January 2015.

Cedars-Sinai is the latest hospital around the nation to have identified CRE transmission linked to duodenoscopes. Last week, the FDA asked duodenoscope manufacturers to provide evidence that their recommended disinfection methods work.

Related: FDA issues safety alert about ERCP endoscopes cleaning after UCLA outbreak

Cedars-Sinai removed the particular duodenoscope from use and is continuing to use enhanced disinfection procedures for duodenoscopes — above and beyond the manufacturer’s (Olympus Corporation) recommendations — as it has since first hearing reports from other hospitals on Feb. 19 that the manufacturer’s disinfection recommendations may not be sufficient to protect patients.

The Cedars-Sinai analysis has been reviewed in collaboration with the Los Angeles County Acute Communicable Diseases Division, the California Department of Public Health and the U.S. Centers for Disease Control. One of the four patients died from their underlying disease and not from CRE, as their CRE infection had cleared. No other duodenoscopes at Cedars-Sinai have been linked to CRE, and there is no evidence at this point that any additional patients had a CRE transmission linked to a duodenoscope at Cedars-Sinai.

However, out of an abundance of caution, and to keep patients informed, Cedars-Sinai is mailing letters this week to all 71 patients who had a duodenoscope procedure with that particular scope between August 2014 and February 2015. Although most people who are exposed to CRE do not develop an infection and will clear CRE from their bodies, and there is no evidence at this point that anyone other than the four patients acquired CRE from a duodenoscope, Cedars-Sinai is offering the 71 patients a free home testing kit for CRE that can be sent to Cedars-Sinai for analysis.

Cedars-Sinai is using additional measures to protect patients who need to undergo a procedure involving a duodenoscope. These include enhanced monitoring techniques involving microscopic laboratory analysis (including cultures) of the duodenoscopes, both before and after procedures. These are in addition to the cleaning and high-level disinfection recommended by the manufacturer.

Carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria, that can become carbapenem-resistant.

Healthy people usually do not get CRE infections – they usually happen to patients in hospitals, nursinghomes, and other healthcare settings. Patients whose care requires devices like ventilators (breathing machines), urinary (bladder) catheters, or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics are most at risk for CRE infections.

Some CRE bacteria have become resistant to most available antibiotics. Infections with these germs are very difficult to treat, and can be deadly—one report cites they can contribute to death in up to 50% of patients who become infected.