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Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines

      Background

      Pathogens have been transmitted via flexible endoscopes that were reportedly reprocessed in accordance with guidelines.

      Methods

      Researchers observed reprocessing activities to ensure guideline compliance in a large gastrointestinal endoscopy unit. Contamination was assessed immediately after bedside cleaning, manual cleaning, high-level disinfection, and overnight storage via visual inspection, aerobic cultures, and tests for adenosine triphosphate (ATP), protein, carbohydrate, and hemoglobin.

      Results

      All colonoscopes and gastroscopes were reprocessed in accordance with guidelines during the study. Researchers collected and tested samples during 60 encounters with 15 endoscopes. Viable microbes were recovered from bedside-cleaned (92%), manually cleaned (46%), high-level disinfected (64%), and stored (9%) endoscopes. Rapid indicator tests detected contamination (protein, carbohydrate, hemoglobin, or ATP) above benchmarks on bedside-cleaned (100%), manually cleaned (92%), high-level disinfected (73%), and stored (82%) endoscopes. Visible residue was never observed on endoscopes, but it was often seen on materials used to sample endoscopes. Seven endoscopes underwent additional reprocessing in response to positive rapid indicators. Control endoscope channels were free of biologic residue and viable microbes.

      Conclusion

      Despite reprocessing in accordance with US guidelines, viable microbes and biologic debris persisted on clinically used gastrointestinal endoscopes, suggesting current reprocessing guidelines are not sufficient to ensure successful decontamination.

      Key Words

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      References

        • Rutala W.A.
        • Weber D.J.
        Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008.
        Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta [GA]2008
        • Petersen B.T.
        • Chennat J.
        • Cohen J.
        • Cotton P.B.
        • Greenwald D.A.
        • Kowalski T.E.
        • et al.
        Multisociety guideline on reprocessing flexible GI endoscopes: 2011.
        Infect Control Hosp Epidemiol. 2011; 32: 527-537
        • Society of Gastroenterology Nurses and Associates (SGNA)
        Standards of infection control in reprocessing of flexible gastrointestinal endoscopes.
        Society of Gastroenterology Nurses and Associates, Chicago [IL]2012: 1-23
        • Alfa M.J.
        • Degagne P.
        • Olson N.
        Worst-case soiling levels for patient-used flexible endoscopes before and after cleaning.
        Am J Infect Control. 1999; 27: 392-401
        • Association for the Advancement of Medical Instrumentation (AAMI)
        Standard 58: Chemical sterilization and high-level disinfection in health care facilities.
        Association for the Advancement of Medical Instrumentation, Arlington [VA]2013 (1-154)
        • Ofstead C.L.
        • Dirlam Langlay A.M.
        • Mueller N.J.
        • Tosh P.K.
        • Wetzler H.P.
        Re-evaluating endoscopy-associated infection risk estimates and their implications.
        Am J Infect Control. 2013; 41: 734-736
        • Nelson D.B.
        • Muscarella L.F.
        Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy.
        World J Gastroenterol. 2006; 12: 3953-3964
        • Spach D.H.
        • Silverstein F.E.
        • Stamm W.E.
        Transmission of infection by gastrointestinal endoscopy and bronchoscopy.
        Ann Intern Med. 1993; 118: 117-128
        • Kovaleva J.
        • Peters F.T.
        • van der Mei H.C.
        • Degener J.E.
        Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy.
        Clin Microbiol Rev. 2013; 26: 231-254
        • Epstein L.
        • Hunter J.C.
        • Arwady M.A.
        • Tsai V.
        • Stein L.
        • Gribogiannis M.
        • et al.
        New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes.
        JAMA. 2014; 312: 1447-1455
        • McCool S.
        • Muto C.A.
        • Querry A.
        • McGrath K.
        • Slivka A.
        • Zonker J.
        • et al.
        High level disinfection failure (HLD) in gastrointestinal scopes with elevator channels - is it time to switch to ethylene oxide (ETO) sterilization?.
        (Abstract presented at: ID Week 2014)October 8-12, 2014 (Arlington [VA]. Available at: https://idsa.confex.com/idsa/2014/webprogram/Paper47957.html. Accessed April 17, 2015)
        • Wendorf K.
        • Kay M.
        • Baliga C.
        • Verma P.
        • Weissman S.
        • Gluck M.
        • et al.
        Endoscope-associated multidrug-resistant Escherichia coli outbreak - King County, Washington, 2012-2014.
        (Abstract presented at: ID Week 2014)October 8-12, 2014 (Arlington [VA]. Available at: https://idsa.confex.com/idsa/2014/webprogram/Paper48240.html. Accessed April 17, 2015)
        • Kovaleva J.
        • Meessen N.E.
        • Peters F.T.
        • Been M.H.
        • Arends J.P.
        • Borgers R.P.
        • et al.
        Is bacteriologic surveillance in endoscope reprocessing stringent enough?.
        Endoscopy. 2009; 41: 913-916
        • Obee P.C.
        • Griffith C.J.
        • Cooper R.A.
        • Cooke R.P.
        • Bennion N.E.
        • Lewis M.
        Real-time monitoring in managing the decontamination of flexible gastrointestinal endoscopes.
        Am J Infect Control. 2005; 33: 202-206
        • Hansen D.
        • Benner D.
        • Hilgenhoner M.
        • Leisebein T.
        • Brauksiepe A.
        • Popp W.
        ATP measurement as method to monitor the quality of reprocessing flexible endoscopes.
        Ger Med Sci. 2004; 2: Doc04
        • Alfa M.J.
        • Olson N.
        • Degagne P.
        • Simner P.J.
        Development and validation of rapid use scope test strips to determine the efficacy of manual cleaning for flexible endoscope channels.
        Am J Infect Control. 2012; 40: 860-865
        • Fushimi R.
        • Takashina M.
        • Yoshikawa H.
        • Kobayashi H.
        • Okubo T.
        • Nakata S.
        • et al.
        Comparison of adenosine triphosphate, microbiological load, and residual protein as indicators for assessing the cleanliness of flexible gastrointestinal endoscopes.
        Am J Infect Control. 2013; 41: 161-164
        • Alfa M.J.
        • Fatima I.
        • Olson N.
        Validation of adenosine triphosphate to audit manual cleaning of flexible endoscope channels.
        Am J Infect Control. 2013; 41: 245-248
        • Mazurek J.N.
        • Hudesman D.
        • Korman A.S.
        • Glennon F.
        • Bernstein B.B.
        218 dramatic improvement in endoscope cleanliness using a commercial bioburden detection system and implementation of a modified cleaning algorithm.
        Gastrointest Endosc. 2014; 79: AB121
        • Turner D.E.
        • Daugherity E.K.
        • Altier C.
        • Maurer K.J.
        Efficacy and limitations of an ATP-based monitoring system.
        J Am Assoc Lab Anim Sci. 2010; 49: 190-195
        • Visrodia K.H.
        • Ofstead C.L.
        • Yellin H.L.
        • Wetzler H.P.
        • Tosh P.K.
        • Baron T.H.
        The use of rapid indicators for the detection of organic residues on clinically-used gastrointestinal endoscopes with and without visually-apparent debris.
        Infect Control Hosp Epidemiol. 2014; 35: 987-994
        • Alfa M.J.
        • Olson N.
        • DeGagne P.
        • Jackson M.
        A survey of reprocessing methods, residual viable bioburden, and soil levels in patient-ready endoscopic retrograde choliangiopancreatography duodenoscopes used in Canadian centers.
        Infect Control Hosp Epidemiol. 2002; 23: 198-206
        • 3M
        Clean-Trace ATP Surface Test.
        October 2010 ed. 3M Health Care, Saint Paul [MN]2010: 1-4
        • 3M
        Clean-Trace ATP Water Test.
        3M Health Care, Saint Paul [MN]2011: 1-4
        • 3M
        Clean-Trace Surface Protein-High Sensitivity.
        3M Microbiology, Saint Paul [MN]2007: 1-4
        • Healthmark Industries
        Instructions for Use: ChannelCheck.
        Healthmark Industries, Fraser [MI]2013 (1-3)
        • 3M
        Petrifilm aerobic count plate interpretation guide.
        3M Microbiology, Saint Paul [MN]2005: 1-6
        • Petersen B.T.
        • Chennat J.
        • Cohen J.
        • Cotton P.B.
        • Greenwald D.A.
        • et al.
        • ASGE Quality Assurance In Endoscopy Committee
        Multisociety guideline on reprocessing flexible gastrointestinal endoscopes.
        Gastrointest Endosc. 2011; 73: 1075-1084
        • Ofstead C.L.
        • Wetzler H.P.
        • Snyder A.K.
        • Horton R.A.
        Endoscope reprocessing methods: a prospective study on the impact of human factors and automation.
        Gastroenterol Nurs. 2010; 33: 304-311
        • Alfa M.J.
        • Olson N.
        • DeGagne P.
        Automated washing with the Reliance Endoscope Processing System and its equivalence to optimal manual cleaning.
        Am J Infect Control. 2006; 34: 561-570
        • Bajolet O.
        • Ciocan D.
        • Vallet C.
        • de Champs C.
        • Vernet-Garnier V.
        • Guillard T.
        • et al.
        Gastroscopy-associated transmission of extended-spectrum beta-lactamase-producing Pseudomonas aeruginosa.
        J Hosp Infect. 2013; 83: 341-343
        • DiazGranados C.A.
        • Jones M.Y.
        • Kongphet-Tran T.
        • White N.
        • Shapiro M.
        • Wang Y.F.
        • et al.
        Outbreak of Pseudomonas aeruginosa infection associated with contamination of a flexible bronchoscope.
        Infect Control Hosp Epidemiol. 2009; 30: 550-555
        • Zweigner J.
        • Gastmeier P.
        • Kola A.
        • Klefisch F.R.
        • Schweizer C.
        • Hummel M.
        A carbapenem-resistant Klebsiella pneumoniae outbreak following bronchoscopy.
        Am J Infect Control. 2014; 42: 936-937
        • Wendelboe A.M.
        • Baumbach J.
        • Blossom D.B.
        • Frank P.
        • Srinivasan A.
        • Sewell C.M.
        Outbreak of cystoscopy related infections with Pseudomonas aeruginosa: New Mexico, 2007.
        J Urol. 2008; 180 (discussion 592): 588-592
        • Alrabaa S.F.
        • Nguyen P.
        • Sanderson R.
        • Baluch A.
        • Sandin R.L.
        • Kelker D.
        • et al.
        Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment.
        Am J Infect Control. 2013; 41: 562-564
        • Hunter J.
        • Epstein L.
        Epi-Aid trip report: cluster of plasmid-mediated AmpC-producing carbapenem-resistant Enterobacteriaceae (CRE)-Washington, 2014.
        Department of Health and Human Services, Atlanta [GA]2014
        • Aumeran C.
        • Poincloux L.
        • Souweine B.
        • Robin F.
        • Laurichesse H.
        • Baud O.
        • et al.
        Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography.
        Endoscopy. 2010; 42: 895-899
        • Carbonne A.
        • Thiolet J.M.
        • Fournier S.
        • Fortineau N.
        • Kassis-Chikhani N.
        • Boytchev I.
        • 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
        • Alfa M.J.
        • Howie R.
        Modeling microbial survival in buildup biofilm for complex medical devices.
        BMC Infect Dis. 2009; 9: 56
        • Food and Drug Administration
        Mitigating the risk of cross-contamination from valves and accessories used for irrigation through flexible gastrointestinal endoscopes.
        United States Department of Health and Human Services, Rockville [MD]2014: 1-9
        • Gastoenterological Society of Australia (GESA)
        • Gastroenterological Nurses College of Australia (GENCA)
        • Australian Gastrointestinal Endoscopy Association (AGEA)
        Infection control in endoscopy.
        (Clinical update)3rd ed. Diagnostic Health Foundation, Vienna, Austria2010
        • Standards New Zealand
        Microbiological surveillance of flexible hollow endoscopes.
        New Zealand Ministry of Health: Standards Council, Wellington, New Zealand2001
        • Beilenhoff U.
        • Neumann C.S.
        • Rey J.F.
        • Biering H.
        • Blum R.
        • Schmidt V.
        • et al.
        ESG-ESGENA guideline for quality assurance in reprocessing: microbiological surveillance testing in endoscopy.
        Endoscopy. 2007; 39: 175-181
        • Public Health Agency of Canada
        Infection prevention and control guideline for flexible gastrointestinal endoscopy and flexible bronchoscopy.
        Infection Prevention and Control Guideline Development Process, Winnipeg, Manitoba, Canada2010
        • Aiken Z.A.
        • Wilson M.
        • Pratten J.
        Evaluation of ATP bioluminescence assays for potential use in a hospital setting.
        Infect Control Hosp Epidemiol. 2011; 32: 507-509
        • Dirlam Langlay A.M.
        • Ofstead C.L.
        • Mueller N.J.
        • Tosh P.K.
        • Baron T.H.
        • Wetzler H.P.
        Reported gastrointestinal endoscope reprocessing lapses: the tip of the iceberg.
        Am J Infect Control. 2013; 41: 1188-1194