EP 63 - Management of a New Delhi Metallo-β-lactamase (NDM)-producing Escherichia coli Outbreak and Large-scale Exposure Event Associated with Endoscopes

Background: Between July 2021-March 2023, 9 cases of genetically similar New Delhi metallo-β-lactamase (NDM)-producing Escherichia coli (E. coli) were identified in our healthcare facility. Upon investigation, it was discovered that these patients had procedures in the same procedural area using the same five endoscopes. These endoscopes were also used in thousands of other procedures.

Methods: A multi-prong approach was taken to evaluate the situation and determine if other patients may have been exposed and prevent further transmission. This approach included establishing a case definition to determine exposure period, offering screening to 1097 exposed patients, auditing the affected procedural and reprocessing areas, evaluating the maintenance of the implicated endoscopes, and having these endoscopes evaluated by an external third-party vendor.

Results: An incredible amount of resources and time were required to manage this event. Seventy-seven individuals participated in the planning, implementation, and management of this outbreak. A total of 205 patients sought testing and 115 called with questions. During live observations, it was discovered that the cleaning process of rooms between cases was inconsistent and varied by staff member due to lack of formal education or competency on room cleaning and turn-over. This area also lacked the necessary housekeeping support due to staffing. Investigation into the endoscopes revealed a lengthy history of repair and minimal preventative maintenance (e.g., borescope inspections). The external assessment of the endoscopes revealed significant internal damage within the channels, and all grew multiple organisms.

Conclusions: Through proper planning, communication, and having a clearly outlined process for patient screening, we were able to manage this exposure event relatively smoothly. This also helped minimize fear and backlash on social media and in the news media. This presentation will outline the steps taken to manage an exposure event involving nearly 1100 patients and provide lessons learned to help other Infection Preventionists prepare for future outbreaks.