Highlights
- •Endoscopes accumulated contamination, visible damage, and debris over time.
- •Examination of internal components detected damage or fluid inside every endoscope.
- •Routine cleaning verification tests identified endoscopes requiring re-reprocessing.
- •Microbial culture incubation >48 hours fostered growth and pathogen identification.
- •Microbial growth was found in samples from 60% of gastrointestinal endoscopes.
Background
Flexible endoscopes are currently reused following cleaning and high-level disinfection.
Contamination has been found on endoscopes, and infections have been linked to gastrointestinal,
respiratory, and urologic endoscopes.
Methods
This longitudinal study involved visual inspections with a borescope, microbial cultures,
and biochemical tests for protein and adenosine triphosphate to identify endoscopes
in need of further cleaning or maintenance. Three assessments were conducted over
a 7-month period. Control group endoscopes reprocessed using customary practices were
compared with intervention group endoscopes subjected to more rigorous reprocessing.
Results
At final assessment, all endoscopes (N = 20) had visible irregularities. Researchers
observed fluid (95%), discoloration, and debris in channels. Of 12 (60%) endoscopes
with microbial growth, 4 had no growth until after 48 hours. There were no significant
differences in culture results by study group, assessment period, or endoscope type.
Similar proportions of control and intervention endoscopes (~20%) exceeded postcleaning
biochemical test benchmarks. Adenosine triphosphate levels were higher for gastroscopes
than colonoscopes (P = .014). Eighty-five percent of endoscopes required repair due to findings.
Conclusions
More rigorous reprocessing was not consistently effective. Seven-day incubation allowed
identification of slow-growing microbes. These findings bolster the need for routine
visual inspection and cleaning verification tests recommended in new reprocessing
guidelines.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
PDF Download and 24 Hours Online AccessSubscribe:
Subscribe to American Journal of Infection ControlAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- ESGE-ESGENA guideline: cleaning and disinfection in gastrointestinal endoscopy.Endoscopy. 2008; 40: 939-957
- Guideline for processing flexible endoscopes.Sterilization and Disinfection, Denver (CO)2016: 675-758
- ANSI/AAMI ST91: 2015, Flexible and semi-rigid endoscope processing in health care facilities.(Arlington (VA))2015: 1-70
- Standards of infection prevention in reprocessing flexible gastrointestinal endoscopes.(Chicago (IL))2015: 1-31
- Infection control in endoscopy.3rd ed. Digestive Health Foundation, Victoria, Australia2011: 1-68 (Clinical update)
- The adenosine triphosphate test is a rapid and reliable audit tool to assess manual cleaning adequacy of flexible endoscope channels.Am J Infect Control. 2013; 41: 249-253
- 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
- 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
- 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: 794-801
- 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
- Practical toolkit for monitoring endoscope reprocessing effectiveness: identification of viable bacteria on gastroscopes, colonoscopes, and bronchoscopes.Am J Infect Control. 2016; 44: 815-819
- A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli.Gastrointest Endosc. 2015; 82: 477-483
- Surveillance of guideline practices for duodenoscope and linear echoendoscope reprocessing in a large health system.Gastrointest Endosc. 2016; 84: 392-399
- Guideline for disinfection and sterilization in healthcare facilities, 2008.Department of Health & Human Services, 2008: 1-158
- Establishing a clinically relevant bioburden benchmark: a quality indicator for adequate reprocessing and storage of flexible gastrointestinal endoscopes.Am J Infect Control. 2012; 40: 233-236
- Endoscope disinfection and its pitfalls—requirement for retrograde surveillance cultures.Endoscopy. 2008; 40: 327-332
- Measures to improve microbial quality surveillance of gastrointestinal endoscopes.Endoscopy. 2016; 48: 704-710
- Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy.Clin Microbiol Rev. 2013; 26: 231-254
- New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes.JAMA. 2014; 312: 1447-1455
- Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography.Endoscopy. 2010; 42: 895-899
- Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa.Endoscopy. 2015; 47: 493-502
- Gastroscopy-associated transmission of extended-spectrum beta-lactamase-producing Pseudomonas aeruginosa.J Hosp Infect. 2013; 83: 341-343
- MAUDE adverse event report: Olympus Medical Systems Corporation Olympus Evis Exera colonovideoscope colonoscope.2009 (MDR 1579940)
- Infections associated with reprocessed flexible bronchoscopes: FDA safety communication.(September 17)2015
- Outbreak of ertapenem-resistant Enterobacter cloacae urinary tract infections due to a contaminated ureteroscope.J Hosp Infect. 2013; 85: 118-124
- Outbreak of cystoscopy related infections with Pseudomonas aeruginosa: New Mexico, 2007.J Urol. 2008; 180: 588-592
- Persistent residual contamination in endoscope channels; a fluorescence epimicroscopy study.Endoscopy. 2016; 48: 609-616
- Effectiveness of current disinfection procedures against biofilm on contaminated GI endoscopes.Gastrointest Endosc. 2016; 83: 944-953
- Is bacteriologic surveillance in endoscope reprocessing stringent enough?.Endoscopy. 2009; 41: 913-916
- Validation of adenosine triphosphate to audit manual cleaning of flexible endoscope channels.Am J Infect Control. 2013; 41: 245-248
- Interim protocol for healthcare facilities regarding surveillance for bacterial contamination of duodenoscopes after reprocessing.Department of Health & Human Services, Atlanta (GA)2015: 1-5
- Assessing residual contamination and damage inside flexible endoscopes over time.Am J Infect Control. 2016; (Epub 7 Sep 2016)https://doi.org/10.1016/j.ajic.2016.06.029
- Simethicone residue remains inside gastrointestinal endoscopes despite reprocessing.Am J Infect Control. 2016; (Epub 3 Aug 2016)https://doi.org/10.1016/j.ajic.2016.05.016
- A multi-site field study evaluating the effectiveness of manual cleaning of flexible endoscopes with an ATP detection system.Am J Infect Control. 2013; 41: S24
- Current limitations about the cleaning of luminal endoscopes.J Hosp Infect. 2013; 83: 22-29
- Comparison of clinically relevant benchmarks and channel sampling methods used to assess manual cleaning compliance for flexible gastrointestinal endoscopes.Am J Infect Control. 2014; 42: e1-5
- Documented transmission of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae from patient to gastroscope.Infect Control Hosp Epidemiol. 2016; 37: 493-494
- Simethicone. Letter to health care practitioner.Olympus, 2009 (June 9)
- Instructions for use: Pentax video GI scopes 90i series 90K series.(Japan)2014
- The role of the ERCP duodenoscope in the outbreak by VIM positive P. aeruginosa at the Erasmus MC. FDA gastroenterology-urology devices panel.(Washington DC)2015
- Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak.Infect Control Hosp Epidemiol. 2015; 36: 634-642
- MAUDE adverse event report: Olympus Medical Systems Corporation Olympus Evis Exera II duodenovideoscope duodenoscope.2016 (MDR 5456009)
Article Info
Footnotes
Supported in part by research grants from 3M Company , Medivators Inc , and HealthMark Industries , who were not involved in designing the study, collecting data, interpreting results, or preparing the manuscript. In accordance with the study protocol, the research site received a new automated endoscope reprocessor and reprocessing materials from Medivators and supplies for conducting adenosine triphosphate tests from 3M Company.
Conflicts of interest: CLO is employed by Ofstead & Associates, Inc, which has received research funding and speaking honoraria related to infection prevention from 3M Company, Medivators, HealthMark Industries, STERIS Corporation, Boston Scientific, and Invendo Medical. HPW, OLH, EAJ, and JEE, are employed by Ofstead & Associates, Inc.
Identification
Copyright
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
