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Longitudinal assessment of reprocessing effectiveness for colonoscopes and gastroscopes: Results of visual inspections, biochemical markers, and microbial cultures

      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

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      References

        • Beilenhoff U.
        • Neumann C.S.
        • Rey J.F.
        • Biering H.
        • Blum R.
        • Cimbro M.
        • et al.
        ESGE-ESGENA guideline: cleaning and disinfection in gastrointestinal endoscopy.
        Endoscopy. 2008; 40: 939-957
        • Associate of periOperative Registered Nurses
        Guideline for processing flexible endoscopes.
        Sterilization and Disinfection, Denver (CO)2016: 675-758
        • Association for the Advancement of Medical Instrumentation
        • American National Standards Institute
        ANSI/AAMI ST91: 2015, Flexible and semi-rigid endoscope processing in health care facilities.
        (Arlington (VA))2015: 1-70
        • Society of Gastroenterology Nurses and Associates
        Standards of infection prevention in reprocessing flexible gastrointestinal endoscopes.
        (Chicago (IL))2015: 1-31
        • Gastroenterological Society of Australia
        • Gastroenterological Nurses College of Australia
        Infection control in endoscopy.
        3rd ed. Digestive Health Foundation, Victoria, Australia2011: 1-68 (Clinical update)
        • Alfa M.J.
        • Fatima I.
        • Olson N.
        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
        • 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
        • Ofstead C.L.
        • Wetzler H.P.
        • Doyle E.M.
        • Rocco C.K.
        • Visrodia K.H.
        • Baron T.H.
        • et al.
        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
        • 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
        • Ofstead C.L.
        • Doyle E.M.
        • Eiland J.E.
        • Amelang M.R.
        • Wetzler H.P.
        • England D.M.
        • et al.
        Practical toolkit for monitoring endoscope reprocessing effectiveness: identification of viable bacteria on gastroscopes, colonoscopes, and bronchoscopes.
        Am J Infect Control. 2016; 44: 815-819
        • Ross A.S.
        • Baliga C.
        • Verma P.
        • Duchin J.
        • Gluck M.
        A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli.
        Gastrointest Endosc. 2015; 82: 477-483
        • Brandabur J.J.
        • Leggett J.E.
        • Wang L.
        • Bartles R.L.
        • Baxter L.
        • Diaz G.A.
        • et al.
        Surveillance of guideline practices for duodenoscope and linear echoendoscope reprocessing in a large health system.
        Gastrointest Endosc. 2016; 84: 392-399
        • Rutala W.A.
        • Weber D.J.
        • Healthcare Infection Control Practices Advisory Committee
        Guideline for disinfection and sterilization in healthcare facilities, 2008.
        Department of Health & Human Services, 2008: 1-158
        • Alfa M.J.
        • 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: 233-236
        • Buss A.J.
        • Been M.H.
        • Borgers R.P.
        • Stokroos I.
        • Melchers W.J.
        • Peters F.T.
        • et al.
        Endoscope disinfection and its pitfalls—requirement for retrograde surveillance cultures.
        Endoscopy. 2008; 40: 327-332
        • Saliou P.
        • Le Bars H.
        • Payan C.
        • Narbonne V.
        • Cholet F.
        • Jézéquel J.
        • et al.
        Measures to improve microbial quality surveillance of gastrointestinal endoscopes.
        Endoscopy. 2016; 48: 704-710
        • 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
        • 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
        • Verfaillie C.J.
        • Bruno M.J.
        • Voor in ‘t Holt A.F.
        • Buijs J.G.
        • Poley J.W.
        • Loeve A.J.
        • et al.
        Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa.
        Endoscopy. 2015; 47: 493-502
        • 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
        • Food and Drug Administration
        MAUDE adverse event report: Olympus Medical Systems Corporation Olympus Evis Exera colonovideoscope colonoscope.
        2009 (MDR 1579940)
        • Food and Drug Administration
        Infections associated with reprocessed flexible bronchoscopes: FDA safety communication.
        (September 17)2015
        • Chang C.L.
        • Su L.H.
        • Lu C.M.
        • Tai F.T.
        • Huang Y.C.
        • Chang K.K.
        Outbreak of ertapenem-resistant Enterobacter cloacae urinary tract infections due to a contaminated ureteroscope.
        J Hosp Infect. 2013; 85: 118-124
        • 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: 588-592
        • Herve R.C.
        • Keevil C.W.
        Persistent residual contamination in endoscope channels; a fluorescence epimicroscopy study.
        Endoscopy. 2016; 48: 609-616
        • Neves M.S.
        • Gomes da Silva M.
        • Ventura G.M.
        • Cortes P.B.
        • Duarte R.S.
        • de Souza H.S.
        Effectiveness of current disinfection procedures against biofilm on contaminated GI endoscopes.
        Gastrointest Endosc. 2016; 83: 944-953
        • 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
        • 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
        • Centers for Disease Control and Prevention
        Interim protocol for healthcare facilities regarding surveillance for bacterial contamination of duodenoscopes after reprocessing.
        Department of Health & Human Services, Atlanta (GA)2015: 1-5
        • Ofstead C.L.
        • Wetzler H.P.
        • Eiland J.E.
        • Heymann O.L.
        • Held S.B.
        • Shaw M.J.
        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
        • Ofstead C.L.
        • Wetzler H.P.
        • Johnson E.A.
        • Heymann O.L.
        • Maust T.J.
        • Shaw M.J.
        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
        • Bommarito M.
        • Thornhill G.
        • Morse D.
        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
        • Herve R.
        • Keevil C.W.
        Current limitations about the cleaning of luminal endoscopes.
        J Hosp Infect. 2013; 83: 22-29
        • Alfa M.J.
        • Olson N.
        • Murray B.L.
        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
        • England D.
        • Houseman J.
        • Horn L.
        • Mascotti K.
        • Kline S.
        Documented transmission of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae from patient to gastroscope.
        Infect Control Hosp Epidemiol. 2016; 37: 493-494
        • Catalone B.J.
        Simethicone. Letter to health care practitioner.
        Olympus, 2009 (June 9)
        • PENTAX Medical Company
        Instructions for use: Pentax video GI scopes 90i series 90K series.
        (Japan)2014
        • Vos M.C.
        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
        • Wendorf K.A.
        • Kay M.
        • Baliga C.
        • Weissman S.J.
        • Gluck M.
        • Verma P.
        • et al.
        Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak.
        Infect Control Hosp Epidemiol. 2015; 36: 634-642
        • Food and Drug Administration
        MAUDE adverse event report: Olympus Medical Systems Corporation Olympus Evis Exera II duodenovideoscope duodenoscope.
        2016 (MDR 5456009)