Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound endoscope reprocessing: Variables impacting contamination risk

Multisociety guidance for sterilization and high-level disinfection

SHEA, in partnership with ASGE, APIC, AAMI, AORN, HSPA, IDSA, SGNA, and The Joint Commission, developed this multisociety infection prevention guidance document for individuals and organizations that engage in sterilization or high-level disinfection (HLD). This document follows the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities. This guidance is based on a synthesis of published scientific evidence, theoretical rationale, current practices, practical considerations, writing group consensus, and consideration of potential harm when applicable. The supplementary material includes a summary of recommendations. The guidance provides an overview of the Spaulding Classification and considerations around manufacturers' instructions for use (MIFUs). Its recommendations address: point-of-use treatment prior to sterilization or HLD, preparation of reusable medical devices at the location of processing, sterilization, and immediate use steam sterilization (IUSS), HLD of lumened and non-lumened devices, processing of reusable medical devices used with lubricating or defoaming agents, monitoring for effectiveness of processing, handling of devices after HLD, augments and alternatives to HLD, processing of investigational devices, tracking of reusable medical devices, and approaches to implementation.

Endoscope processing effectiveness: A reality check and call to action for infection preventionists and clinicians

BACKGROUND

Flexible endoscopes are heavily exposed to blood, mucus, and other secretions during procedures and may harbor billions of microbes before processing. Guidelines recommend thorough cleaning and sterilization or high-level disinfection (HLD) after each use.

METHODS

This review describes evidence on the effectiveness of HLD from a robust review of peer-reviewed journals, adverse events reports posted by the Food and Drug Administration, and other government reports published during 2019-2024.

RESULTS

Although HLD theoretically eliminates viruses, fungi, and bacteria (except a few resilient spores), numerous studies found it did not reliably eliminate microbes in real-world settings, and a large proportion of endoscopes harbored substantial bioburden and potential pathogens. Dozens of endoscopy-associated outbreaks have been reported in the past 5years, including several involving multidrug-resistant organisms. When contaminated endoscopes or endoscopy-associated infections were discovered, investigators commonly found that personnel were skipping essential steps or doing them improperly.

DISCUSSION

To reduce infection risk and enhance patient safety, infection preventionists, clinicians, sterile processing and departmental managers, and other leaders should review the evidence, perform risk assessments, and implement proactive strategies for quality improvement in their facilities.

Comparison of Sampling Methods for Detecting Protein in Gastrointestinal Endoscopes

Background: Persistent microbial contamination of flexible endoscopes has been linked to infections and outbreaks. Valid and reliable sampling methods are critical for monitoring processing effectiveness in flexible endoscopes. In this study, the effectiveness of protein extraction via turbulent fluid flow (TFF) sampling was compared with flush-only sampling in manually cleaned gastrointestinal endoscopes. Methods: A crossover study design, in which both sampling methods were used in alternating order during each endoscope encounter, was utilized to assess protein levels after colonoscopes and gastroscopes underwent manual cleaning. Endoscope channels were sampled with 20 mL sterile water using TFF and flush-only methods. Protein levels were quantified using a spectrophotometer. Results: Protein samples were collected during a total of 40 encounters with 20 unique endoscopes (19 colonoscopes and 21 gastroscopes) following procedural use. More effluent was captured following TFF (20-30 mL) compared with flush-only (19-21 mL) sampling. Zero samples had detectable protein after flush-only sampling, and nine samples (22.5%; two gastroscopes and seven colonoscopes) had detectable protein following TFF sampling (range 1-4 μg/mL). Of those, four exceeded the 2 μg/mL study threshold for recleaning after the first cleaning and three of four dropped to 2 μg/mL or less after recleaning. Conclusion: TFF sampling of the entire suction-biopsy channel allowed the detection of residual protein in nine gastrointestinal endoscopes, whereas no protein was detected in samples obtained by manually flushing the instrument channel. More research is needed to characterize the real-world utility of using the TFF system to verify whether soil and bioburden have been effectively removed during processing. Numerous studies have documented that a majority of fully processed, patient-ready endoscopes harbor microbes.1-8 Microbes found in endoscopes include high-concern organisms (e.g., multidrug-resistant microbes and pathogens) that have been linked to endoscopy-associated outbreaks.9-12 In these outbreaks, visible residual soil was discovered during the outbreak investigation. Current guidelines and standards note that effectively cleaning endoscopes is critical to the success of high-level disinfection (HLD) and sterilization.13,14 Several studies by Ofstead and colleagues6,15,16 have documented high protein levels on endoscopes. A study involving colonoscopes and gastroscopes detected protein on 100% of manually cleaned endoscopes (range 3-11 μg/mL).6 Other studies also found protein in 100% of manually cleaned bronchoscopes (range 2-30 μg/mL) and sterilized ureteroscopes (range 9-32 μg/mL).15,16 These contamination levels were higher than positive controls, which were dirty gastroscopes that had not been manually cleaned. Microbes were found on 12.5% to 60% of fully processed endoscopes, including potential pathogens such as Pseudomonas aeruginosa, Escherichia coli, and Micrococcus luteus.6,15,16 This reinforces the need to verify that endoscopes are clean prior to undergoing HLD or sterilization. Evidence shows that protein can persist through multiple rounds of cleaning.17,18 Despite efforts to clean the endoscope, harvesting samples from surfaces that remain contaminated with soil can be challenging because sampling commonly uses the same tools as cleaning (e.g., brushes or swabs and flushing). Residual soil or bioburden may also be encased in a biofilm matrix that has been hardened through exposure to harsh chemicals used during HLD and/or sterilization and repeated cycles of drying,19,20 thereby increasing the difficulty of capturing a sample. Hervé et al.21 noted that protein deposits in endoscopes were able to resist brushing and flushing, especially in the presence of wear and damage. Historically, flush-only ("flush") sampling was used,22,23 but this method often was limited to the instrument channel and captured lower yields compared with more robust methods.4,24,25 As the effectiveness of sampling affects the validity of results of tests for organic soil and microbial cultures, more robust sampling methods may be required.26 Guidance on sampling for microbial cultures provided by the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) involves incorporating a brushing step and an additional flushing step ("flush-brush-flush") to dislodge and flush out microbes.27 This method has been found to be more effective than flush sampling,3,24 but brushes cannot access every endoscope channel and may leave behind bristles. Researchers have reported that the FDA/CDC sampling method is cumbersome, time consuming,28 and prone to contamination.7 Even when using recommended sampling methods, investigators have reported needing to rely on external experts and destructive sampling to effectively harvest samples that ultimately revealed the outbreak pathogen.10,11 This underscores the importance of robust sampling methods, both to avoid false negatives from failing to capture soil or bioburden that is present and to avoid false positives from environmental contamination.7,29 Given the challenges associated with current sampling techniques for organic soil testing and microbial cultures, this study was conducted to evaluate a method that could potentially improve sample validity and reduce the influence of human factors on sampling. The automated turbulent fluid flow (TFF) system pumps a mixture of air and water through the suction and instrument channels from the suction connector to the distal end and into a sterile collection cup that is sealed during sampling to maintain a closed system. The turbulent flow provides friction to endoscope interior surfaces without needing to use a brush.30 In this study, protein extraction via TFF sampling was compared with flush sampling in manually cleaned gastrointestinal endoscopes.

Establishment of predictive models and determinants of preoperative gastric retention in endoscopic retrograde cholangiopancreatography

BACKGROUND

Study on influencing factors of gastric retention before endoscopic retrograde cholangiopancreatography (ERCP) background: With the wide application of ERCP, the risk of preoperative gastric retention affects the smooth progress of the operation. The study found that female, biliary and pancreatic malignant tumor, digestive tract obstruction and other factors are closely related to gastric retention, so the establishment of predictive model is very important to reduce the risk of operation.

AIM

To analyze the factors influencing preoperative gastric retention in ERCP and establish a predictive model.

METHODS

A retrospective analysis was conducted on 190 patients admitted to our hospital for ERCP preparation between January 2020 and February 2024. Patient baseline clinical data were collected using an electronic medical record system. Patients were randomly matched in a 1:4 ratio with data from 190 patients during the same period to establish a validation group (n = 38) and a modeling group (n = 152). Patients in the modeling group were divided into the gastric retention group (n = 52) and non-gastric retention group (n = 100) based on whether gastric retention occurred preoperatively. General data of patients in the validation group and modeling group were compared. Univariate and multivariate logistic regression analyses were performed to identify factors influencing preoperative gastric retention in ERCP patients. A predictive model for preoperative gastric retention in ERCP patients was constructed, and calibration curves were used for validation. The receiver operating characteristic (ROC) curve was analyzed to evaluate the predictive value of the model.

RESULTS

We found no statistically significant difference in general data between the validation group and modeling group (P > 0.05). The comparison of age, body mass index, hypertension, and diabetes between the two groups showed no statistically significant difference (P > 0.05). However, we noted statistically significant differences in gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction between the two groups (P < 0.05). Multivariate logistic regression analysis showed that gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction were independent factors influencing preoperative gastric retention in ERCP patients (P < 0.05). The results of logistic regression analysis revealed that gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction were included in the predictive model for preoperative gastric retention in ERCP patients. The calibration curves in the training set and validation set showed a slope close to 1, indicating good consistency between the predicted risk and actual risk. The ROC analysis results showed that the area under the curve (AUC) of the predictive model for preoperative gastric retention in ERCP patients in the training set was 0.901 with a standard error of 0.023 (95%CI: 0.8264-0.9567), and the optimal cutoff value was 0.71, with a sensitivity of 87.5 and specificity of 84.2. In the validation set, the AUC of the predictive model was 0.842 with a standard error of 0.013 (95%CI: 0.8061-0.9216), and the optimal cutoff value was 0.56, with a sensitivity of 56.2 and specificity of 100.0.

CONCLUSION

Gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction are factors influencing preoperative gastric retention in ERCP patients. A predictive model established based on these factors has high predictive value.

Fluid retention in endoscopes: A real-world study on drying effectiveness

BACKGROUND

Outbreaks linked to inadequate endoscope drying have infected numerous patients, and current standards and guidelines recommend at least 10 minutes of forced air for drying channels. This study evaluated a new forced-air drying system (FADS) for endoscopes.

METHODS

Drying was assessed using droplet detection cards; visual inspection of air/water connectors, suction connectors, and distal ends; and borescope examinations of endoscope interiors. Assessments were performed after automated endoscope reprocessor (AER) alcohol flush and air purge cycles and after 10-minute FADS cycles.

RESULTS

Researchers evaluated drying during encounters with 22 gastroscopes and 20 colonoscopes. After default AER alcohol and air purge cycles, 100% (42/42) of endoscopes were still wet. Substantial fluid emerged from distal ends during the first 15 seconds of the FADS cycle, and droplets also emerged from air/water and suction connectors. Following FADS cycle completion, 100% (42/42) were dry, with no retained fluid detected by any of the assessment methods.

CONCLUSIONS

Multiple endoscope ports and channels remained wet after AER cycles intended to aid in drying but were dry after the FADS cycle. This study reinforced the need to evaluate the effectiveness of current drying practices and illustrated the use of practical tools in a real-world setting.

The economic burden of post-endoscopic retrograde cholangiopancreatography (ERCP) procedure infections in Italy

Introduction

The infections of multidrug-resistant organisms (MDROs) associated with duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedure have become a significant cause for concern, especially in fragile patients. While the clinical impacts of these infections are well-documented, their economic implications remain underexplored. This study assesses the incidence and economic burden of post-ERCP infections in Italy using an administrative database.

Methods

We conducted a retrospective observational study using administrative databases from A.O.U. Città della Salute e della Scienza di Torino. The study included all patients who underwent their first inpatient ERCP between 2018 and 2021. Infections were identified using ICD-9-CM codes for Pseudomonas aeruginosa, Clostridium difficile, Escherichia coli, Klebsiella spp., and Staphylococcus aureus. A 1-year follow-up was defined in order to estimate healthcare resource utilization and related costs, including readmissions, drug prescriptions, and outpatient specialist and laboratory services.

Results

The study included 686 inpatient ERCP cases, an overall infection rate of 4.2% was observed. Higher infection rates were observed in women (4.6%), patients over 70 years old (4.6%), emergency admissions (5.1%), and transplant patients (19.1%). The average hospital stay doubled for infected patients (24.3 vs. 11.3 days; p=0.001). Post-ERCP infections led to a 28% increase in average costs (€12,256 vs. €9,561; p=0.048). With an annual volume of 25,000 ERCP procedures, post-ERCP infections in Italy contribute approximately €2.9 million in additional direct costs per year.

Conclusion

Post-ERCP infections impose substantial financial burdens on the healthcare system, underscoring the critical importance of implementing cost-effective prevention strategies to mitigate this public health threat in Italy.