Gastroenterology Societies Address CRE, ERCP-Related Infections

Patient safety is a primary concern for gastrointestinal endoscopists. You may have recently heard or read about the spread of infection by Carbapenem-Resistant Enterobacteriaceae (CRE) through a procedure called ERCP. The following information provides background information and explains important concepts.

What is ERCP?
ERCP stands for endoscopic retrograde cholangiopancreatography. It is an advanced highly technical endoscopic procedure. The vast majority of people will never have an ERCP. For patients who do need it, ERCP is a critical and potentially life-saving procedure. ERCP is performed using a special device called a duodenoscope. The duodenoscope is different from what is used in routine upper endoscopy or colonoscopy.  ERCP allows gastrointestinal endoscopists to diagnose and treat problems in the bile ducts and pancreatic ducts such as stones, narrowing (called strictures) and even complete blockages of a duct. The bile ducts and pancreatic ducts are the channels that carry fluids from the liver and pancreas to the intestine.
Before an ERCP, the gastrointestinal endoscopist will discuss the benefits and risks of this procedure with the patient and/or family members.

What is CRE?
CRE stands for Carbapenem-Resistant Enterobacteriaceae (CRE). Some have referred to this germ as a "superbug" because it has become resistant to most available antibiotics. CRE is a challenge for all specialties of medicine, including gastroenterology.

How common is infection by CRE bacteria through ERCP?
It is estimated that more than 500,000 ERCPs are performed each year in the US. From what we know, over the past few years, there have been fewer than 100 known cases of transmission of these problematic bacteria through ERCP.  In general, the infectious complication rate for ERCP overall is in total only about 1 percent, but that includes all types of bacteria and these few CRE cases do not change the overall risk. 

How did CRE bacteria spread in these few cases?
As mentioned, ERCP is a highly advanced procedure that requires a specialized device called a duodenoscope. At this point, it is believed that the complex design of the duodenoscope may present a challenge for high-level disinfection of the device. What we do know is that, when manufacturers' guidelines for cleaning duodenoscopes are followed, the risk of transmission is extremely low. Of course, all procedures carry infection risks. It is important to note that there have been no known cases of transmission of CRE bacteria with endoscopes used in routine endoscopy, such as colonoscopy.

What is being done to improve patient safety?
Patient safety is always the No. 1 concern. This is an important issue for gastrointestinal experts. We share the public's concerns. First, we have made gastroenterologists and surgeons who perform ERCP aware of the potential for infection by CRE bacteria through ERCP. Second, we have urged increased vigilance around cleaning these highly specialized instruments and strict adherence to manufacturers' guidelines and infection control guidelines. Associations have also encouraged hospitals and other facilities to conduct periodic assessments of their disinfection procedures and practices. Additionally, we have urged these facilities to ensure the competency of all staff involved in disinfecting these devices. Unfortunately, simple answers are not readily available. The gastroenterology societies continue to work with the Centers for Disease Controland Prevention (CDC), the Food and Drug Administration (FDA), manufacturers and other groups to evaluate and address this complex issue.

Source: American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American College of Gastroenterology, American Association for the Study of Liver Diseases, Society of American Gastrointestinal and Endoscopic Surgeons