Hostname: page-component-5c6d5d7d68-thh2z Total loading time: 0 Render date: 2024-08-15T18:44:29.193Z Has data issue: false hasContentIssue false

Contaminated flexible endoscopes: Review of impact of channel sampling methods on culture results and recommendations for root-cause analysis

Published online by Cambridge University Press:  07 May 2021

Michelle J. Alfa*
Affiliation:
Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
Harminder Singh
Affiliation:
Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
*
Author for correspondence: Michelle J. Alfa, E-mail: michellealfa001@gmail.com

Abstract

Recently, infection transmission risk associated with contaminated, patient-ready flexible endoscopes has attracted attention. Outbreaks of multidrug-resistant organisms resulting in infection and/or colonization have been particularly concerning. Recent CDC and FDA recommendations focus on reducing “exogenous” infection transmission and specifically recommend that endoscopy sites have quality systems in place for endoscope reprocessing. Another key recommendation is the culture of patient-ready endoscopes to detect contamination with organisms of concern. Remaining gaps in the guidelines include ensuring that optimal endoscope-channel sample methods are used and ensuring effective root-cause analysis and remediation when contamination is detected. In this review, we summarize the critical aspects of endoscope sample collection and present a practical approach to root-cause analysis and remedial action plans.

Type
Review
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ofstead, C, Langlay, AMD, Mueller, NJ, Tosh, PK, Wetzler, HP. Re-evaluating endoscopy-associated infection risk estimates and their implications. Am J Infect Control 2013;41:734736.CrossRefGoogle ScholarPubMed
Spach, DH, Silverstein, FE, Stamm, WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993;118:117128.CrossRefGoogle ScholarPubMed
Cowen, A. The clinical risks of infection associated with endoscopy. Can J Gastroenterol 2001;15:321331.CrossRefGoogle ScholarPubMed
Epstein, L, Hunter, JC, Arwady, MA, et al. New Delhi metallo-beta-lactamase–producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014;312:14471455.CrossRefGoogle Scholar
McCafferty, CE, Aghajani, MJ, Abi-Hanna, D, Gosbell, IB, Jensen, SO. An update on gastrointestinal endoscopy-associated infections and their contributing factors. Ann Clin Microbiol Antimicrob 2018;17:36.CrossRefGoogle ScholarPubMed
Wang, P, Xu, T, Ngamruengphong, S, et al. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut 2018;67:16261636.CrossRefGoogle ScholarPubMed
Alfa, MJ, Singh, H. Impact of wet storage and other factors on biofilm formation and contamination of patient-ready endoscopes: a narrative review. Gastrointest Endosc 2020;91:236247.CrossRefGoogle ScholarPubMed
Ofstead, CL, Wetzler, HP, Heymann, OL, Johnson, EA, Eiland, JE, Shaw, MJ. Longitudinal assessment of reprocessing effectiveness for colonoscopes and gastroscopes: results of visual inspections, biochemical markers, and microbial cultures. Am J Infect Control 2017;45:e26e33.CrossRefGoogle ScholarPubMed
Ofstead, CL, Hopkins, KM, Buro, BL, Eiland, JE, Wetzler, HP. Challenges in achieving effective high-level disinfection in endoscope reprocessing. Am J Infect Control 2020;48:309315.CrossRefGoogle ScholarPubMed
Barakat, MT, Huang, RJ, Banerjee, S. Simethicone is retained in endoscopes despite reprocessing: impact of its use on working channel fluid retention and adenosine triphosphate bioluminescence values (with video). Gastrointest Endosc 2019;89:115123.CrossRefGoogle Scholar
Barakat, MT, Huang, RJ, Banerjee, S. Comparison of automated and manual drying in the eliminating residual endoscope working channel fluid after reprocessing (with video). Gastrointest Endosc 2019;89:124132.CrossRefGoogle Scholar
Pajkos, A, Vickery, K, Cossart, YE. Is biofilm accumulation on endoscope tubing a contributor to failure of cleaning and decontamination? J Hosp Infect 2004;58:224229.CrossRefGoogle ScholarPubMed
Alfa, MJ, Sitter, DL. In-hospital evaluation of contamination of duodenoscopes: a quantitative assessment of the effect of drying. J Hosp Infect 1991;19:8998.CrossRefGoogle ScholarPubMed
Bridier, A, del Pilar Sanchez-Vizuete, M, Le Coq, D, et al. Biofilms of a Bacillus subtilis hospital isolate protect Staphylococcus aureus from biocide action. PLoS One 2012;7(9):e44506.CrossRefGoogle ScholarPubMed
Naryzhny, I, Silas, D, Chi, K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc 2016;84:259262.CrossRefGoogle ScholarPubMed
ANSI/AAMI ST91:2015 Flexible and semi-rigid endoscope processing in health care facilities. American National Standards Institute/Association for the Advancement of Medical Instrumentation (publisher). https://webstore.ansi.org%20Published%202015. Accessed April 8, 2021.Google Scholar
Standards of infection prevention in reprocessing of flexible gastrointestinal endoscopes. Society of Gastroenterology Nurses and Associates website. https://www.sgna.org/Portals/0/SGNA%20Standards%20of%20infection%20prevention%20in%20reprocessing_FINAL.pdf?ver=2018-11-16-084835-387. Updated 2018. Accessed March 29, 2019.Google Scholar
Ofstead, CL, Wetzler, HP, Eiland, JE, Heymann, OL, Held, SB, Shaw, MJ. Assessing residual contamination and damage inside flexible endoscopes over time. Am J Infect Control 2016;44:16751677.CrossRefGoogle ScholarPubMed
Ofstead, CL, Heymann, OL, Quick, MR, Eiland, JE, Wetzler, HP. Residual moisture and waterborne pathogens inside flexible endoscopes: evidence from a multisite study of endoscope drying effectiveness. Am J Infect Control 2018;46:689696.CrossRefGoogle ScholarPubMed
Food and Drug Administration, Centers for Disease Control, American Society for Microbiology. Duodenoscope surveillance sampling and culturing; reducing the risks of infection. US Food and Drug Administration website. https://www.fda.gov/media/111081/download. Published 2018. Accessed April 2020.Google Scholar
Statement from Jeff Shuren, MD, Director of the Center for Devices and Radiological Health, on continued efforts to assess duodenoscope contamination risk. US Food and Drug Administration website. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pss.cfm. Published April 12, 2019. Accessed March 30, 2021Google Scholar
Thornhill, G, David, Maren. Endoscope-associated infections: a microbiologist’s perspective on current technologies. Techniques Gastrointest Endosc 2019;21:150625.CrossRefGoogle Scholar
ESGE-ESGENA guideline for quality assurance in reprocessing: microbiological surveillance testing in endoscopy. Endoscopy 2007;39:175–181.CrossRefGoogle Scholar
Elements d’assurance qualite en hygiene ralitifs au controle microbiologique des endoscopes et a la tracabilite en endoscopie. Ministère de la santé et des solidarités website. http://www.sante.gouv.fr. Published March 2007. Accessed April 2020.Google Scholar
Infection prevention and control guideline for flexible gastrointestinal endoscopy and flexible bronchoscopy. Public Health Agency of Canada website. http://www.phac-aspc.gc.ca. Published 2010. Accessed April 2020.Google Scholar
GESA-GENCA Infection control in endoscopy. Gastroenterological Nurses College of Australia, Gastroenterological Society of Australia website. https://www.gesa.org.au/public/13/files/Clinical%20Updates%20and%20Guidelines/Infection_Control_in_Endoscopy_Guidelines_2010.pdf. Published 2010. Accessed April 2020.Google Scholar
Health technical memorandum (HTM) 01-06: Decontamination of flexible endoscopes part E: testing methods. UK Department of Health website. www.gov.uk/government/collections/health-building-notes-core-elements. Published March 2016. Accessed April 27, 2020.Google Scholar
Ma, GK, Pegues, DA, Kochman, ML, et al. Implementation of a systematic culturing program to monitor the efficacy of endoscope reprocessing: outcomes and costs. Gastrointest Endosc 2018;87:104109.CrossRefGoogle ScholarPubMed
Chui, K-W, Tsai, M-C, Wu, K-L, Chun, Y-C, Lin, M-T, Hu, T-H. Surveillance cultures of samples obtained from biopsy channels and automated endoscope reprocessors after high-level disinfection of gastrointestinal endoscopes. BMC Gastroent 2012;12:120.CrossRefGoogle Scholar
Ross, AS, Bruno, MJ, Kozarek, RA, et al. Novel single-use duodenoscope compared with 3 models of reusable duodenoscopes for ERCP: a randomized bench-model comparison. Gastrointest Endosc 2020;91:396403.CrossRefGoogle ScholarPubMed
Becq, A, Snyder, GM, Heroux, R, et al. Prospective assessment of the effectiveness of standard high-level disinfection for echoendoscopes. Gastrointest Endosc 2019;89:984989.CrossRefGoogle ScholarPubMed
Cotterelli, A, DeGiusti, M, Solimini, AG, et al. Microbiological surveillance of endoscopes and implications for current reprocessing procedures adopted by an Italian teaching hospital. Ann Ig 2020;32:166177.Google Scholar
Ribeiro, MM, de Oliveira, AC. Analysis of the air/water channels of gastrointestinal endoscopies as a risk factor for the transmission of microorganisms among patients. Am J Infect Control 2012;40:913916.CrossRefGoogle ScholarPubMed
Gillespie, EE, Kotsanas, D, Stuart RL Microbiological monitoring of endoscopes: 5-year review. J Gastroenterol Hepatol 2008;23:10691074.CrossRefGoogle ScholarPubMed
Alfa, MJ, DeGagne, P, Olson, N, Fatima, I. EVOTECH endoscope cleaner and reprocessor (ECR) simulated-use and clinical-use evaluation of cleaning efficacy. Infect BMC Dis 2010;10:200.CrossRefGoogle ScholarPubMed
Alfa, MJ, Sepehri, S, Olson, N, Wald, A. Establishing a clinically relevant bioburden benchmark: a quality indicator for adequate reprocessing and storage of flexible gastrointestinal endoscopes. Am J Infect Control 2012;40:233236.CrossRefGoogle ScholarPubMed
Pineau L De Philippe E. Evaluation of endoscope cleanliness after reprocessing: a clinical-use study. Central Service 2013;1:22–27.Google Scholar
Ofstead, CL, Wetzler, HP, Doyle, EM, Rocco, CK, Visrodia, KH, Baron, TH, Tosh, PK. Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines. Am J Infect Control 2015;43:794801.CrossRefGoogle ScholarPubMed
Buss, AJ, Been, MH, Borgers, RP, et al. Endoscope disinfection and its pitfalls— requirement for retrograde surveillance cultures. Endoscopy 2008;40:327332.CrossRefGoogle ScholarPubMed
Kovaleva, JU, Buss, A. Usefulness of bacteriological monitoring of endoscope reprocessing. In: Therapeutic Gastrointestinal Endoscopy. London: IntechOpen.com; 2011:141–162.CrossRefGoogle Scholar
Moses, FM, Lee, J. Surveillance cultures to monitor quality of gastrointestinal endoscope reprocessing. J Gastroenterol 2003;98:7781.Google ScholarPubMed
Machado, AP, Pimenta, ATM, Contijo, PP, Geocze, S, Fischman, O. Microbiologic profile of flexible endoscope disinfection in two Brazilian hospitals. Arq Gastroenterol 2006;43:255258.CrossRefGoogle ScholarPubMed
Bajolet, O. Ciocan, D, Vallet, C, et al. Gastroscopy-associated transmission of extended-spectrum beta-lactamase-producing Pseudomonas aeruginosa . J Hosp Infect 2013;83:341343.CrossRefGoogle ScholarPubMed
Ubhayawardana, DLN, Kottahachchi, J, Weerasekerja, MM, Wanigasooriya, WWP, Fernando, SSN, de Silva, M. Residual bioburden in reprocessed side-view endoscopes used for endoscopic retrograde cholangiopancreatography (ERCP). Endoscy Int Open 2013;1:E12E16.Google Scholar
Gavalda, L, Olmo, AR, Hernandez, R, et al. Microbiological monitoring of flexible bronchoscopes after high-level disinfection and flushing channels with alcohol: results and costs. Respir Med 2015;10:10791085.CrossRefGoogle Scholar
Cattoir, L, Vanzieleghem, T, Florin, L, et al. Surveillance of endoscopes: comparison of different sampling techniques. Infect Control Hosp Epidemiol 2017;38:10621069.CrossRefGoogle ScholarPubMed
Visrodia, K, Hanada, Y, Pennington, KM, Tosh, PK, Topazian, MD, Petersen, BT. Duodenoscope reprocessing surveillance with adenosine triphosphate testing and terminal cultures: a clinical pilot study. Gastrointest Endosc 2017;86:180186.CrossRefGoogle ScholarPubMed
Decristoforo, P, Kaltseie, J, Fritz, A, et al. High-quality endoscope reprocessing decreases endoscope contamination. Clin Microbiol Infect 2018;24:1101e11101e6.CrossRefGoogle ScholarPubMed
Cristina, ML, Sartini, M, Schinca, E, et al. Is postreprocessing microbiological surveillance of duodenoscopes effective in reducing the potential risk in transmitting pathogens? Int J Environ Res Public Health 2020;17:140.CrossRefGoogle Scholar
Kola, A, Piening, B, Pape, U-F, et al. An outbreak of carbapenem-resistant OXA-48–producing Klebsiella pneumonia associated to duodenoscopy. Antimicrob Resist Infect Control 2015;4:8.CrossRefGoogle ScholarPubMed
Rauwers, AW, Voor’in’t holt, AF, Buijs, JG, et al. High prevalence rate of digestive tract bacteria in duodenoscopes: a nationwide study. Gut 2018;67:16371645.CrossRefGoogle ScholarPubMed
Carbonne, A, Thiolet, JM, Fournier, S, et al. Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009. Euro Surveill 2010;15:19734.CrossRefGoogle ScholarPubMed
Aumeran, C, Thibert, E, Chapelle, FA, Hennequin, C, Lesens, O, Traore, O. Assessment on experimental bacterial biofilms and in clinical practice of the efficacy of sampling solutions for microbiological testing of endoscopes. J Clin Microbiol 2011;50:938942.CrossRefGoogle ScholarPubMed
Aumeran, C. Assessment on experimental bacterial biofilms and in clinical practice of the efficacy of sampling solutions for microbiological testing of endoscopes. J Clin Microbiol 2012;50:938942.CrossRefGoogle ScholarPubMed
Classen, DC, Jacobson, JA, Burke, JP, Jacobson, JT, Serious, Evans RS. Pseudomonas infections associated with endoscopic retrograde cholangiopancreatography. Am J Med 1988;84:590596.CrossRefGoogle ScholarPubMed
Paula, H, Presterl, E, Tribl, B, Diab-Elschahawi, M. Microbiologic surveillance of duodenoscope reprocessing at the Vienna University Hospital from November 2004 through March 2015. Infect Control Hosp Epidemiol 2015;36:12331235.CrossRefGoogle ScholarPubMed
Saviuc, P, Picot-Guéraud, R, Cheong Sing, JS, et al. Evaluation of the quality of reprocessing of gastrointestinal endoscopes. Infect Control Hosp Epidemiol 2015;36:10171023.CrossRefGoogle ScholarPubMed
Saliou, P, Cholet, F, Jézéquel, J, Robaszkiewicz, M, Le Bars, H, Baron, R. The use of channel-purge storage for gastrointestinal endoscopes reduces microbial contamination. Infect Control Hosp Epidemiol 2015;36:11001102.CrossRefGoogle ScholarPubMed
Ciccozzi, M, Cella, E, Lai, A, et al. Phylogenetic analysis of multi-drug resistant Klebsiella pneumoniae strains from duodenoscope biofilm: microbiological surveillance and reprocessing improvements for infection prevention. Front Public Health 2019;7:219.CrossRefGoogle ScholarPubMed
Duc, DL, Ribiolett, A, Dode, X, Ducel, G, Marchetti, B, Calop, J. Evaluation of the microbicidal efficacy of Steris System I for digestive endoscopes using GERMANDE and ASTM validation protocols. J Hosp Infect 2001;48:135141.CrossRefGoogle ScholarPubMed
Li, L, Mendis, N, Trigui, H, Oliver, JD, Faucher, SP. The importance of the viable but nonculturable state in human bacterial pathogens. Front Microbiol 2014;5:258.CrossRefGoogle Scholar
Cholley, AC, Raore, O, Hennequin, C, Aumeran, C. Klebsiella pneumoniae survival and regrowth in endoscope channel biofilm exposed to glutaraldehyde and desiccation. Eur J Clin Microbiol Infect Dis 2020;39:11291136.CrossRefGoogle ScholarPubMed
Espigares, E, Bueno, A, Fernandez/Crehuet M, Espigares M. Efficacy of some neutralizers in suspension tests determining the activity of disinfectants. J Hosp Infect 2003;55:137140.CrossRefGoogle Scholar
Alfa, MJ, Harminder, Singh, Zoann, Nugent, et al. Sterile reverse osmosis water combined with friction are optimal for channel and lever cavity sample collection of flexible duodenoscopes. Front Med Gastroenterol 2017;4:191.CrossRefGoogle ScholarPubMed
Dey, BP, Engley, FB Jr Methodology for recovery of chemically treated Staphylococcus aureus with neutralizing medium. Appl Environ Microbiol 1983;45:15331537.CrossRefGoogle ScholarPubMed
da la Costa Luciano, C, Olson, N, Tipple, A, Alfa, MJ. Evaluation of the ability of different detergents and disinfectants to remove and kill organisms in traditional biofilm. Am J Infect Control 2016;44:e243e249.CrossRefGoogle Scholar
Sohn, SY, Alfa, MJ, Lai, R, Tabani, Y, Labib, ME. Turbulent fluid flow is a novel closed-system sample extraction method for flexible endoscope channels of various inner diameters. J Microbiol Methods 2020;168:105782.CrossRefGoogle ScholarPubMed
Ma, S, Feng, L, Jiang, Z, et al. Comparative study of microbiological monitoring results from three types of sampling methods after gastrointestinal endoscope reprocessing. Biomed Res Int 2019. doi: 10.1155/2019/7940468.CrossRefGoogle Scholar
Ji, X-Y, Ning, P-Y, Fei, C-N, Liu, J, Liu, H, Song, J. The importance of sampling technique and rinse water for assessing flexible gastrointestinal endoscope reprocessing: a 3-year study covering 59 centers. Am J Infect Control 2020;48:1925.CrossRefGoogle ScholarPubMed
Gazdik, MA, Coombs, J, Burke, JP, Lopansri BK Comparison of two culture methods for use in assessing microbial contamination of duodenoscopes. J Clin Microbiol 2015;54:312316.CrossRefGoogle ScholarPubMed
Centers for Disease Control Advisory. Immediate need to review procedures for cleaning, disinfecting and sterilizing reusable devices. Infection Control Today website. https://www.infectioncontroltoday.com/sterile-processing/immediate-need-reviewprocedures-cleaning-disinfecting-and-sterilizing-reusable. Published 2015. Accessed April 20, 2020.Google Scholar
Program for flexible endoscopes—recommendations of the HICPAC. Centers for Disease Control website. https://www.cdc.gov/hicpac/recommendations/flexibleendoscope-reprocessing.html. Published 2017. Accessed April 12, 2020.Google Scholar
Gillespie, E, Sievert, W, Swan, M, Kay, C, Edridge, I, Stuart, RL. Using adenosine triphosphate bioluminescence to validate decontamination for duodenoscopes. Aust Nurs Midwifery J 2016;24:2628.Google ScholarPubMed
Olafsdottir, LB, Wright, SB, Smithey, A, et al. Adenosine triphosphate quantification correlates poorly with microbial contamination of duodenoscopes. Infect Control Hosp Epidemiol 2017;38:678684.CrossRefGoogle ScholarPubMed
Singh, H, Duerksen, DR, Schultz, G, et al. Evaluation of an overnight non-culture test for detection of viable gram-negative bacteria in endoscope channels. Endosc Int Open 2019;07:E268E273.Google Scholar
Valeriani, F, Agodi, A, Casini, B, et al. Potential testing of reprocessing procedures by real-time polymerase chain reaction: a multicenter study of colonoscopy devices. Am J Infect Control 2018;46:159164.CrossRefGoogle ScholarPubMed
Thaker, AM, Muthusamy, VR, Sedarat, A, et al. Duodenoscope reprocessing practice patterns in US endoscopy centers: a survey study. Gastrointest Endosc 2018;88:316322.CrossRefGoogle Scholar
Supplementary material: File

Alfa and Singh supplementary material

Alfa and Singh supplementary material

Download Alfa and Singh supplementary material(File)
File 21.1 KB