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Pelzer RJ, van der Zwet WC, Eggen MMEG, Beard A, Savelkoul PHM, Dirks JAMC. Evaluation of microbial occurrence in reusable robotic instruments for minimally invasive surgery: A pilot study. PLoS One 2024; 19:e0300355. [PMID: 38573892 PMCID: PMC10994333 DOI: 10.1371/journal.pone.0300355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024] Open
Abstract
In recent decades, minimally invasive surgery has become the favoured surgical technique, with increasing utilisation of robotic surgery to enhance patient outcomes. However, the design complexity of surgical robotic instruments can pose challenges in maintaining adequate cleaning, disinfection and sterilisation-particularly of the device's interior. In our hospital, robotic instruments are reused for a maximum of ten successive patients, following the manufacturer's guidelines. To the best of our knowledge, neither the manufacturer nor ISO standards have specified any methods to determine the sterility of robotic instruments after cleaning, disinfection and sterilisation procedures. In a small pilot study, we used a locally developed protocol to evaluate the sterility of 20 da Vinci SI robotic instruments, with the aim of determining whether the recommended cleaning, disinfection and sterilisation process is adequate to achieve safe usage in subsequent patients. None of the 20 instruments showed viable micro-organisms, therefore the robotic instruments were considered sterile, and suitable for re-use. We recommend our protocol to other hospitals, to be used as an essential control element in the assessment of their unique reprocessing technique for robotic instruments.
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Affiliation(s)
- Roy J. Pelzer
- Department of Medical Microbiology, Maastricht University Medical Center, and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Wil C. van der Zwet
- Department of Medical Microbiology, Maastricht University Medical Center, and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Mike M. E. G. Eggen
- Department of Medical Microbiology, Maastricht University Medical Center, and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Ashley Beard
- Department of Medical Microbiology, Maastricht University Medical Center, and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Paul H. M. Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Center, and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jeanne A. M. C. Dirks
- Department of Medical Microbiology, Maastricht University Medical Center, and Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Wang YF, Wu Y, Liu XW, Li JG, Zhan YQ, Liu B, Fan WL, Peng ZH, Xiao JT, Li BB, He J, Yi J, Lu ZX. Effect of a disposable endoscope precleaning kit in the cleaning procedure of gastrointestinal endoscope: A multi-center observational study. World J Gastrointest Endosc 2023; 15:705-714. [PMID: 38187912 PMCID: PMC10768042 DOI: 10.4253/wjge.v15.i12.705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/20/2023] [Accepted: 11/08/2023] [Indexed: 12/15/2023] Open
Abstract
BACKGROUND Precleaning is a key step in endoscopic reprocessing.
AIM To develop an effective and economic endoscope cleaning method by using a disposable endoscope bedside precleaning kit.
METHODS Altogether, 228 used gastrointestinal endoscopes were selected from five high-volume endoscopy units and precleaned by a traditional precleaning bucket (group T) or a disposable endoscope bedside precleaning kit (group D). Each group was further subdivided based on the replacement frequency of the cleaning solution, which was replaced every time in subgroups T1 and D1 and every several times in subgroups Ts and Ds. The adenosine triphosphate (ATP) level and residual proteins were measured three times: Before and after precleaning and after manual cleaning.
RESULTS After precleaning, the precleaning kit significantly reduced the ATP levels (P = 0.034) and has a more stable ATP clearance rate than the traditional precleaning bucket. The precleaning kit also saved a quarter of the cost of enzymatic detergent used during the precleaning process. After manual cleaning, the ATP levels were also significantly lower in the precleaning kit group than in the traditional precleaning bucket group (P < 0.05). Meanwhile, the number of uses of the cleaning solution (up to four times) has no significant impact on the cleaning effect (P > 0.05).
CONCLUSION Considering its economic cost and cleaning effect, the use of a disposable endoscope bedside precleaning kit can be an optimal option in the precleaning stage with the cleaning solution being replaced several times in the manual cleaning stage.
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Affiliation(s)
- Yi-Fan Wang
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Yu Wu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
- Department of Gastroenterology, Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha 410008, Hunan Province, China
| | - Xiao-Wei Liu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
- Department of Gastroenterology, Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha 410008, Hunan Province, China
- Department of Gastroenterology, National Research Center of Geriatric Diseases, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Jian-Guo Li
- Department of Gastroenterology, The Fourth Hospital of Changsha, Changsha 410006, Hunan Province, China
| | - Yan-Qiong Zhan
- Department of Gastroenterology, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou 412007, Hunan Province, China
| | - Bin Liu
- Department of Gastroenterology, Xiangtan Central Hospital, Xiangtan 411100, Hunan Province, China
| | - Wen-Ling Fan
- Department of Gastroenterology, The First Hospital of Changsha, Changsha 410005, Hunan Province, China
| | - Zi-Heng Peng
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Jin-Tao Xiao
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Bing-Bing Li
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Jian He
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Jun Yi
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
| | - Zhao-Xia Lu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
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Ley-Ngardigal S, Bertolin G. Approaches to monitor ATP levels in living cells: where do we stand? FEBS J 2022; 289:7940-7969. [PMID: 34437768 DOI: 10.1111/febs.16169] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/30/2021] [Accepted: 08/25/2021] [Indexed: 01/14/2023]
Abstract
ATP is the most universal and essential energy molecule in cells. This is due to its ability to store cellular energy in form of high-energy phosphate bonds, which are extremely stable and readily usable by the cell. This energy is key for a variety of biological functions such as cell growth and division, metabolism, and signaling, and for the turnover of biomolecules. Understanding how ATP is produced and hydrolyzed with a spatiotemporal resolution is necessary to understand its functions both in physiological and in pathological contexts. In this review, first we will describe the organization of the electron transport chain and ATP synthase, the main molecular motor for ATP production in mitochondria. Second, we will review the biochemical assays currently available to estimate ATP quantities in cells, and we will compare their readouts, strengths, and weaknesses. Finally, we will explore the palette of genetically encoded biosensors designed for microscopy-based approaches, and show how their spatiotemporal resolution opened up the possibility to follow ATP levels in living cells.
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Affiliation(s)
- Seyta Ley-Ngardigal
- CNRS, Univ Rennes, IGDR (Genetics and Development Institute of Rennes), Rennes, France.,LVMH Research Perfumes and Cosmetics, Saint-Jean-de-Braye, France
| | - Giulia Bertolin
- CNRS, Univ Rennes, IGDR (Genetics and Development Institute of Rennes), Rennes, France
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Kwakman JA, Rauwers AW, Buijs JG, de Groot W, Vos MC, Bruno MJ. No relation between adenosine triphosphate after manual cleaning and presence of microorganisms on endoscopes after automated high-level disinfection. Endosc Int Open 2022; 10:E1275-E1281. [PMID: 36118629 PMCID: PMC9473803 DOI: 10.1055/a-1897-5000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background and study aims Adenosine triphosphate (ATP) tests are increasingly used to detect biological material; however, their reliability to detect bacterial contamination in endoscopes is not proven. We investigated the predictive value of ATP tests after manual cleaning for presence or absence of microorganisms as shown by culture after automated high-level disinfection (HLD) in duodenoscopes and linear echoendoscopes (DLEs). Patients and methods After manual cleaning, ATP tests were performed on swab samples taken from the detachable cap and forceps elevator, and on flush samples of the DLE working channels. These results were compared to the growth of any microorganisms in cultures acquired after automated HLD. ATP tests with > 200 relative light units (RLU) were considered positive. Receiver operator characteristic (ROC) curves were used to compare the RLU levels with microbial presence in cultures. Results In total, 903 procedures were performed involving 26 distinct DLEs. Depending on sample site, 20.8 % (cap) to 63.8 % (channel brush) of the ATP negative samples were accompanied by positive post-HLD cultures. 54.4 % of the cap samples with a positive culture (growth of any kind of microorganism) and 91.8 % of the channel samples with a positive culture had a negative ATP test after manual cleaning. ROC curves per sample site, DLE type and microorganism type all had area under the curves below 0.6. Conclusions In our study, ATP tests performed after manual cleaning could not predict presence or absence of microorganisms after automated HLD as shown by culture. More than half of the positive cultures were preceded by a negative ATP test.
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Affiliation(s)
- Judith A. Kwakman
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Arjan W. Rauwers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jolanda G. Buijs
- Qualtity Assurance and Regulatory Affairs Office Medical Devices, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Woutrinus de Groot
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Margreet C. Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Rauwers AW, Voor In 't Holt AF, Buijs JG, Groot WD, Erler NS, Vos MC, Bruno MJ. Assessment of postmanual cleaning adenosine triphosphate tests to prevent the use of contaminated duodenoscopes and linear echoendoscopes: the DETECT study. Gastrointest Endosc 2022; 96:282-290.e5. [PMID: 35341715 DOI: 10.1016/j.gie.2022.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/17/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We investigated whether the use of postmanual cleaning adenosine triphosphate (ATP) tests lowers the number of duodenoscopes and linear echoendoscopes (DLEs) contaminated with gut flora. METHODS In this single-center before-and-after study, DLEs were ATP tested after cleaning. During the control period, participants were blinded to ATP results: ATP-positive DLEs were not recleaned. During the intervention period, ATP-positive DLEs were recleaned. DLEs underwent microbiologic sampling after high-level disinfection (HLD) with participants blinded to culture results. RESULTS Using 15 endoscopes of 5 different DLE types, we included 909 procedures (52% duodenoscopes, 48% linear echoendoscopes). During the intervention period, the absolute rate of contamination with gut flora was higher (16% vs 21%). The main analysis showed that contamination was less likely to occur in the intervention period (odds ratio, .32; 95% credible interval [CI], .12-.85). A secondary analysis showed that this effect was based on 1 particular duodenoscope type (estimated probability, 39% [95% CI, 18%-64%] vs 9% [95% CI, 2%-21%]), whereas no effect was seen in the other 4 DLE types. In detail, of the 4 duodenoscopes of this type, 2 had lower contamination rates (69% vs 39% and 36% vs 10%). During the control period, both these duodenoscopes had multiple episodes with ongoing contamination with the same microorganism that ended weeks before the start of the intervention period (ie, they were not terminated by ATP testing). CONCLUSIONS Postmanual cleaning ATP tests do not reduce post-HLD gut flora contamination rates of DLEs. Hence, postcleaning ATP tests are not suited as a means for quality control of endoscope reprocessing.
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Affiliation(s)
- Arjan W Rauwers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Jolanda G Buijs
- Staff Office Medical Devices, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Woutrinus de Groot
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Li Y, Lu Y, Cai R, Hu G, Lu L. Monitoring the cleanliness of reusable surgical instruments in central sterile supply department by adenosine triphosphate method. J AOAC Int 2021; 105:844-847. [PMID: 34338782 DOI: 10.1093/jaoacint/qsab102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cleaning is very important in reusable surgical instruments (RSI) reprocessing. Adenosine triphosphate (ATP) method is widely used for cleanliness assessing while few studies focused on using this method on RSIs. OBJECTIVE To assess the effectiveness of ATP Bioluminescence Assay for monitoring the cleanliness of RSIs. METHODS The study conducted in three central sterile supply departments (CSSD) from 2015 to 2020, surgical scissors, haemostatic forceps, and other non-lumen instruments after cleaning were sampled. Each instrument was swabbed in a uniform manner on the surface including hinged joints and teeth, the amount of ATP (amol) was calculated. RESULTS A total of 871 RSIs after cleaning were tested, the mean ATP lg (amol) was 2.829 ± 0.539 and the qualified rate was 80.57%. Washer-disinfector cleaning was more efficiency than manual cleaning, the mean ATP lg (amol) were 2.776 ± 0.513 and 2.948 ± 0.575, respectively; the qualified rates were 84.97% and 70.59%, respectively. The qualified rate was decreased with the time of instruments after cleaning exploring to environment increased (P trend = 0.044). CONCLUSION ATP level are stable and repeatable for continuous monitoring the cleanliness of RSIs, it is a rapid and viable method for assessing the cleanliness of RSIs. Washer-disinfector cleaning is recommended and cleaned instruments should go on packing for sterilization in time. HIGHLIGHTS - ATP method is viable for assessing the cleanliness of reusable surgical instruments in CSSDs.- Reusable surgical instruments suggested washer-disinfector cleaning and should go on packing for sterilization in time.
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Affiliation(s)
- Ye Li
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Ye Lu
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Ran Cai
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Guoqing Hu
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Longxi Lu
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
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Alfa MJ. Quality Systems Approach for Endoscope Reprocessing: You Don't Know What You Don't Know! Gastrointest Endosc Clin N Am 2020; 30:693-709. [PMID: 32891226 DOI: 10.1016/j.giec.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Several factors affect the efficacy of endoscope reprocessing, including human factors, inadequate cleaning, simethicone residuals, moisture in channels during storage, and biofilm or buildup biofilm formation. These factors all contribute to contamination of patient-ready endoscopes that may contribute to transmission of microorganisms resulting in infection and/or colonization. This article reviews monitoring as part of a quality management system that includes manual cleaning, dry storage, and culture to detect endoscope contamination. The published data for rapid tests that detect organic residuals and adenosine triphosphate to monitor manual cleaning are reviewed.
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Affiliation(s)
- Michelle J Alfa
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada.
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Ji XY, Ning PY, Fei CN, 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; 48:19-25. [PMID: 31400884 DOI: 10.1016/j.ajic.2019.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Various guidelines recommend several sampling techniques to verify endoscope reprocessing, but a comparative study of the efficiency for recovering microorganisms was rare. Our goal was to compare different sampling techniques for the postreprocessing endoscope to assess residual bacterial contamination and analysis of the critical factors affecting the endoscope reprocessing failure. METHODS From 2016 to 2018, 3 techniques, the conventional flushing sampling method, flush-brush-flush sampling method (FBFSM), and pump-assisted sampling method (PASM), were compared covering all 59 endoscope units in Tianjin, China. RESULTS A total of 237 (84.64%) flushing channel samples and 110 (61.11%) final rinse water samples met the Chinese national standard. The univariate analysis showed that the qualified rates of endoscope reprocessing sampled by PASM (65.52%) and FBFSM (75%) were significantly lower than those of the conventional flushing sampling method (91.38%). Five other factors, including the final rinse water, dry, and hospital level, were potential factors besides sample technique. The multivariate logistic analysis indicated only 2 factors (sampling technique and final rinse water) remained in the model. FBFSM, PASM, and the purified water were significantly associated with the odds of endoscope reprocessing failure, with the odds ratio (95% confidence interval) of which were 4.206 (1.757-10.067), 5.326 (2.463-11.645), and 0.309 (0.137-0.695), respectively. CONCLUSIONS The problem of residual microorganisms of the postreprocessing endoscope was severe. Sampling technique and final rinse water were critical for endoscope reprocessing verification.
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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. [PMID: 30314500 PMCID: PMC6182826 DOI: 10.1186/s12941-018-0289-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/06/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION During clinical use, gastrointestinal endoscopes are grossly contaminated with patient's native flora. These endoscopes undergo reprocessing to prevent infectious transmission upon future use. Endoscopy-associated infections and outbreaks have been reported, with a recent focus on the transmission of multi-drug resistant organisms. This review aims to provide an update on endoscopy-associated infections, and the factors contributing to their occurrence. METHODS PubMed, ScienceDirect, and CINAHL were searched for articles describing gastrointestinal endoscopy-associated infections and outbreaks published from 2008 to 2018. Factors contributing to their occurrence, and the outcomes of each outbreak were also examined. RESULTS This review found 18 articles, 16 of which described duodenoscope-associated infections, and the remaining two described colonoscope- and gastroscope-associated infection respectively. Outbreaks were reported from the United States, France, China, Germany, the Netherlands and the United Kingdom. The causative organisms reported were Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli and Salmonella enteritidis. CONCLUSIONS A number of factors, including lapses in reprocessing, biofilm formation, endoscope design issues and endoscope damage, contribute to gastrointestinal endoscopy associated infection. Methods of improving endoscope reprocessing, screening for contamination and evaluating endoscope damage may be vital to preventing future infections and outbreaks.
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Affiliation(s)
- Charles Eugenio McCafferty
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Sydney, NSW, 2560, Australia. .,Western Sydney University, School of Medicine, Sydney, 2560, Australia.
| | - Marra Jai Aghajani
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Sydney, NSW, 2560, Australia.,Western Sydney University, School of Medicine, Sydney, 2560, Australia
| | - David Abi-Hanna
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, 2170, Australia.,School of Medicine, University of New South Wales, Sydney, 2033, Australia
| | | | - Slade Owen Jensen
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Sydney, NSW, 2560, Australia.,Western Sydney University, School of Medicine, Sydney, 2560, Australia
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