1
|
Nicolás-Pérez D, Gimeno-García AZ, Romero-García RJ, Castilla-Rodríguez I, Hernandez-Guerra M. Cost-effectiveness Analysis of Single-Use Duodenoscope Applied to Endoscopic Retrograde Cholangiopancreatography. Pancreas 2024; 53:e357-e367. [PMID: 38518062 DOI: 10.1097/mpa.0000000000002311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
OBJECTIVES Secondary infections due to transmission via the duodenoscope have been reported in up to 3% of endoscopic retrograde cholangiopancreatographies. The use of single-use duodenoscopes has been suggested. We investigate the cost-effectiveness of these duodenoscopes use in cholangiopancreatography. MATERIALS AND METHODS A cost-effectiveness analysis was implemented to compare the performance of cholangiopancreatographies with reusable duodenoscopes versus single-use duodenoscopes. Effectiveness was analyzed by calculating quality-adjusted life years (QALY) from the perspective of the National Health System. Possibility of crossover from single-use to reusable duodenoscopes was considered. A willingness-to-pay of €25,000/QALY was set, the incremental cost-effectiveness ratio (ICER) was calculated, and deterministic and probabilistic sensitivity analyses were performed. RESULTS Considering cholangiopancreatographies with single-use and reusable duodenoscopes at a cost of €2900 and €1333, respectively, and a 10% rate of single-use duodenoscopes, ICER was greater than €3,000,000/QALY. A lower single-use duodenoscope cost of €1211 resulted in an ICER of €23,583/QALY. When the unit cost of the single-use duodenoscope was €1211, a crossover rate of more than 9.5% made the use of the single-use duodenoscope inefficient. CONCLUSIONS Single-use duodenoscopes are cost-effective in a proportion of cholangiopancreatographies if its cost is reduced. Increased crossover rate makes single-use duodenoscope use not cost-effective.
Collapse
Affiliation(s)
| | | | | | - Iván Castilla-Rodríguez
- Departamento de Ingeniería Informática y de Sistemas, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | | |
Collapse
|
2
|
Bereanu AS, Vintilă BI, Bereanu R, Codru IR, Hașegan A, Olteanu C, Săceleanu V, Sava M. TiO 2 Nanocomposite Coatings and Inactivation of Carbapenemase-Producing Klebsiella Pneumoniae Biofilm-Opportunities and Challenges. Microorganisms 2024; 12:684. [PMID: 38674628 PMCID: PMC11051735 DOI: 10.3390/microorganisms12040684] [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: 03/04/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
The worldwide increase of multidrug-resistant Gram-negative bacteria is a global threat. The emergence and global spread of Klebsiella pneumoniae carbapenemase- (KPC-) producing Klebsiella pneumoniae represent a particular concern. This pathogen has increased resistance and abilities to persist in human reservoirs, in hospital environments, on medical devices, and to generate biofilms. Mortality related to this microorganism is high among immunosuppressed oncological patients and those with multiple hospitalizations and an extended stay in intensive care. There is a severe threat posed by the ability of biofilms to grow and resist antibiotics. Various nanotechnology-based strategies have been studied and developed to prevent and combat serious health problems caused by biofilm infections. The aim of this review was to evaluate the implications of nanotechnology in eradicating biofilms with KPC-producing Klebsiella pneumoniae, one of the bacteria most frequently associated with nosocomial infections in intensive care units, including in our department, and to highlight studies presenting the potential applicability of TiO2 nanocomposite materials in hospital practice. We also described the frequency of the presence of bacterial biofilms on medical surfaces, devices, and equipment. TiO2 nanocomposite coatings are one of the best long-term options for antimicrobial efficacy due to their biocompatibility, stability, corrosion resistance, and low cost; they find their applicability in hospital practice due to their critical antimicrobial role for surfaces and orthopedic and dental implants. The International Agency for Research on Cancer has recently classified titanium dioxide nanoparticles (TiO2 NPs) as possibly carcinogenic. Currently, there is an interest in the ecological, non-toxic synthesis of TiO2 nanoparticles via biological methods. Biogenic, non-toxic nanoparticles have remarkable properties due to their biocompatibility, stability, and size. Few studies have mentioned the use of nanoparticle-coated surfaces as antibiofilm agents. A literature review was performed to identify publications related to KPC-producing Klebsiella pneumoniae biofilms and antimicrobial TiO2 photocatalytic nanocomposite coatings. There are few reviews on the antibacterial and antibiofilm applications of TiO2 photocatalytic nanocomposite coatings. TiO2 nanoparticles demonstrated marked antibiofilm activity, but being nano in size, these nanoparticles can penetrate cell membranes and may initiate cellular toxicity and genotoxicity. Biogenic TiO2 nanoparticles obtained via green, ecological technology have less applicability but are actively investigated.
Collapse
Affiliation(s)
- Alina-Simona Bereanu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| | - Bogdan Ioan Vintilă
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| | - Rareș Bereanu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
| | - Ioana Roxana Codru
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| | - Adrian Hașegan
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| | - Ciprian Olteanu
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| | - Vicențiu Săceleanu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| | - Mihai Sava
- Faculty of Medicine, Lucian Blaga University of Sibiu, Lucian Blaga Street 2A, 550169 Sibiu, Romania; (A.-S.B.); (R.B.); (A.H.); (V.S.); (M.S.)
- County Clinical Emergency Hospital, Bld. Corneliu Coposu nr. 2-4, 550245 Sibiu, Romania;
| |
Collapse
|
3
|
Rerknimitr R. Getting the Bugs Out: Disposable Duodenoscopes Have a Shallower Learning Curve but Face a Steep Climb in Usability. Dig Dis Sci 2024:10.1007/s10620-024-08307-x. [PMID: 38466462 DOI: 10.1007/s10620-024-08307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/18/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10310, Thailand.
- Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| |
Collapse
|
4
|
Cimen C, Bathoorn E, Loeve AJ, Fliss M, Berends MS, Nagengast WB, Hamprecht A, Voss A, Lokate M. Uncovering the spread of drug-resistant bacteria through next-generation sequencing based surveillance: transmission of extended-spectrum β-lactamase-producing Enterobacterales by a contaminated duodenoscope. Antimicrob Resist Infect Control 2024; 13:31. [PMID: 38459544 PMCID: PMC10924313 DOI: 10.1186/s13756-024-01386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/03/2024] [Indexed: 03/10/2024] Open
Abstract
Contamination of duodenoscopes is a significant concern due to the transmission of multidrug-resistant organisms (MDROs) among patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), resulting in outbreaks worldwide. In July 2020, it was determined that three different patients, all had undergone ERCP with the same duodenoscope, were infected. Two patients were infected with blaCTX-M-15 encoding Citrobacter freundii, one experiencing a bloodstream infection and the other a urinary tract infection, while another patient had a bloodstream infection caused by blaSHV-12 encoding Klebsiella pneumoniae. Molecular characterization of isolates was available as every ESBL-producing isolate undergoes Next-Generation Sequencing (NGS) for comprehensive genomic analysis in our center. After withdrawing the suspected duodenoscope, we initiated comprehensive epidemiological research, encompassing case investigations, along with a thorough duodenoscope investigation. Screening of patients who had undergone ERCP with the implicated duodenoscope, as well as a selection of hospitalized patients who had ERCP with a different duodenoscope during the outbreak period, led to the discovery of three additional cases of colonization in addition to the three infections initially detected. No microorganisms were detected in eight routine culture samples retrieved from the suspected duodenoscope. Only after destructive dismantling of the duodenoscope, the forceps elevator was found to be positive for blaSHV-12 encoding K. pneumoniae which was identical to the isolates detected in three patients. This study highlights the importance of using NGS to monitor the transmission of MDROs and demonstrates that standard cultures may fail to detect contaminated medical equipment such as duodenoscopes.
Collapse
Affiliation(s)
- Cansu Cimen
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
| | - Erik Bathoorn
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Arjo J Loeve
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Monika Fliss
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Matthijs S Berends
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
- Certe Medical Diagnostics and Advice Foundation, Department of Medical Epidemiology, Groningen, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Axel Hamprecht
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
| | - Andreas Voss
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Mariëtte Lokate
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands.
| |
Collapse
|
5
|
Smith MW, Hernandez LV, Lee P, Martinello RA, Singh H, Sherman JD. Single-Use vs Reusable Duodenoscopes: How Infection Knowledge Gaps Are Driving Environmental Harm and What Can Be Done. Gastroenterology 2024:S0016-5085(24)00247-6. [PMID: 38442783 DOI: 10.1053/j.gastro.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Matthew W Smith
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa; Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Lyndon V Hernandez
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin; GI Associates, Milwaukee, Wisconsin
| | - Pamela Lee
- Division of Infectious Diseases, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Richard A Martinello
- Departments of Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut; CT Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey, Veterans Affairs Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Jodi D Sherman
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
| |
Collapse
|
6
|
Craney A, Miller S. Present and Future Non-Culture-Based Diagnostics: Stewardship Potentials and Considerations. Clin Lab Med 2024; 44:109-122. [PMID: 38280793 DOI: 10.1016/j.cll.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
The medical microbiologist plays a key role in the transition from culture-based to molecular test methods for diagnosis of infectious diseases. They must understand the scientific and technical bases underlying these tests along with their associated benefits and limitations and be able to educate administrators and patient providers on their proper use. Coordination of testing practices between clinical departments and the spectrum of public health and research laboratories is essential to optimize health care delivery.
Collapse
Affiliation(s)
- Arryn Craney
- Center for Infectious Disease Diagnostics and Research, Diagnostic Medicine Institute, Geisinger Health System, 100 North Academy Avenue, Danville, PA 17822, USA
| | - Steve Miller
- Delve Bio, Inc. and Department of Laboratory Medicine, University of California San Francisco, 953 Indiana Street, San Francisco, CA 94107, USA.
| |
Collapse
|
7
|
Masciangelo G, Cecinato P, Bacchilega I, Masetti M, Ferrari R, Zagari RM, Napoleon B, Sassatelli R, Fusaroli P, Lisotti A. Urgent ERCP performed with single-use duodenoscope (SUD) in patients with moderate-to-severe cholangitis: Single-center prospective study. Endosc Int Open 2024; 12:E116-E122. [PMID: 38250162 PMCID: PMC10798844 DOI: 10.1055/a-2219-0826] [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: 08/25/2023] [Accepted: 11/10/2023] [Indexed: 01/23/2024] Open
Abstract
Background and study aims To assess the outcomes of urgent endoscopic retrograde cholangiopancreatography (ERCP) performed with a single-use duodenoscope (SUD) in patients with moderate-to-severe cholangitis. Patients and methods Between 2021 and 2022 consecutive patients with moderate-to-severe cholangitis were prospectively enrolled to undergo urgent ERCP with SUD. Technical success was defined as the completion of the planned procedure with SUD. Multivariate analysis was used to identify factors related to incidence of adverse events (AEs) and mortality. Results Thirty-five consecutive patients (15 female, age 81.4±6.7 years) were enrolled. Twelve (34.3%) had severe cholangitis; 26 (74.3%) had an American Society of Anesthesiologists (ASA) score ≥3. Twenty-eight patients (80.0%) had a naïve papilla. Biliary sphincterotomy and complete stone clearance were performed in 29 (82.9%) and 30 patients (85.7%), respectively; in three cases (8.6%), concomitant endoscopic ultrasound-gallbladder drainage was performed. Technical and clinical success rates were 100%. Thirty-day and 3-month mortality were 2.9% and 14.3%, respectively. One patient had mild post-ERCP pancreatitis and two had delayed bleeding. No patient or procedural variables were related to AEs. ASA score 4 and leucopenia were related to 3-month mortality; on multivariate analysis, leukopenia was the only variable independently related to 3-month mortality (odds ratio 12.8; 95% confidence interval 1.03-157.2; P =0.03). Conclusions The results of this "proof of concept" study suggest that SUD use could be considered safe and effective for urgent ERCP for acute cholangitis. This approach abolishes duodenoscope contamination from infected patients without impairing clinical outcomes.
Collapse
Affiliation(s)
| | - Paolo Cecinato
- Gastroenterology and Endoscopy Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia, Italy
| | - Igor Bacchilega
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Michele Masetti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Rodolfo Ferrari
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | | | | | - Romano Sassatelli
- Gastroenterology and Endoscopy Unit, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| |
Collapse
|
8
|
Dabaja-Younis HK, Schechner V, Firan I, Khamaysi I, Levi GD, Lurie-Weinberger MN, Weissman A, Guriel Y, Geffen Y, Hussein K. Identification and control of two outbreaks of unrelated New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli traced to the same endoscope defect. Infect Control Hosp Epidemiol 2023; 44:1673-1675. [PMID: 36815278 DOI: 10.1017/ice.2023.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
We report 2 outbreaks of genetically unrelated carbapenem-resistant New Delhi metallo-β-lactamase-producing Escherichia coli caused by contaminated duodenoscopes. Using endoscopes with disposable end caps, adherence to the manufacturer's reprocessing instructions, routine audits, and manufacturer evaluation are critical in preventing such outbreaks.
Collapse
Affiliation(s)
- Halima K Dabaja-Younis
- Infection Control and Prevention Unit, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Vered Schechner
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ibrahim Firan
- Infection Control and Prevention Unit, Rambam Health Care Campus, Haifa, Israel
| | - Iyad Khamaysi
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Gastroenterology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Gabrielle D Levi
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Mor N Lurie-Weinberger
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Avi Weissman
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Hospital Management, Rambam Health Care Campus, Haifa, Israel
| | - Yuri Guriel
- Gastroenterology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Khetam Hussein
- Infection Control and Prevention Unit, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
9
|
Liu E, Prinzi AM, Borjan J, Aitken SL, Bradford PA, Wright WF. #AMRrounds: a systematic educational approach for navigating bench to bedside antimicrobial resistance. JAC Antimicrob Resist 2023; 5:dlad097. [PMID: 37583473 PMCID: PMC10424884 DOI: 10.1093/jacamr/dlad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
Antimicrobial resistance (AMR) continues to serve as a major global health crisis. Clinicians practising in this modern era are faced with ongoing challenges in the therapeutic management of patients suffering from antimicrobial-resistant infections. A strong educational understanding and synergistic application of clinical microbiology, infectious disease and pharmacological concepts can assist the adventuring clinician in the navigation of such cases. Important items include mobilizing laboratory testing for pathogen identification and susceptibility data, harnessing an understanding of intrinsic pathogen resistance, acknowledging epidemiological resistance trends, recognizing acquired AMR mechanisms, and consolidating these considerations when constructing an ideal pharmacological plan. In this article, we outline a novel framework by which to systematically approach clinical AMR, encourage AMR-related education and optimize therapeutic decision-making in AMR-related illnesses.
Collapse
Affiliation(s)
- Elaine Liu
- Division of Pharmacy and Division of Infectious Diseases, The Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Baltimore, MD, USA
| | - Andrea M Prinzi
- US Medical Affairs, bioMérieux, Salt Lake City, UT 84104, USA
| | - Jovan Borjan
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samuel L Aitken
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | | | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD, USA
| |
Collapse
|
10
|
Yassin M, Clifford A, Dixon H, Donskey CJ. How effective are the alcohol flush and drying cycles of automated endoscope reprocessors? Stripped endoscope model. Am J Infect Control 2023; 51:527-532. [PMID: 36842713 DOI: 10.1016/j.ajic.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Effective drying of the internal channels of endoscopes is essential to prevent the growth of water-borne pathogens and to assure adequate sterilization with vaporized hydrogen peroxide or ethylene oxide. The aim of this study was to evaluate the dryness of endoscopes after a routine disinfection process in an automated endoscope reprocessor. METHODS Stripped endoscopes (SE) that allow for visual inspection of the inside channels were reprocessed per protocol in a large urban medical center, with a 3-minute or 10-minute air flush following reprocessing. SE was hung and observed for any water within the channels after reprocessing and after a week of ambient storage. Ready-for-use endoscopes were also randomly spot-checked for moisture visually and with moisture detection paper. RESULTS All SE were grossly wet after HLD with a 3-minute air flush, despite alcohol flush and drying cycle. The 10-minute air flush was effective at drying the biopsy/suction channel, but not the air/water channels. Hanging had limited effect, being most effective in the biopsy/suction channels. Of the 77 ready-for-use respiratory and gastrointestinal endoscopes assessed, 37 (48.1%) showed evidence of retained moisture. CONCLUSIONS Air flush cycles commonly used in the final steps of automated endoscope reprocessing may not adequately dry endoscope channels, particularly the narrower diameter air/water channels. An extended 10-minute air flush appears effective at drying the larger biopsy/suction channel, but has limited effect on the air/water channels.
Collapse
Affiliation(s)
- Mohamed Yassin
- University of Pittsburgh School of Medicine & Public Health, Pittsburgh, PA; Infection Prevention Department University of Pittsburgh Medical Center Mercy, Pittsburgh, PA.
| | - Adrian Clifford
- University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Heather Dixon
- Infection Prevention Department University of Pittsburgh Medical Center Mercy, Pittsburgh, PA; University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Curtis J Donskey
- Infectious Diseases Section, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| |
Collapse
|
11
|
Kwakman JA, Vos MC, Bruno MJ. Higher yield in duodenoscope cultures collected with addition of neutralizing agent. J Hosp Infect 2023; 132:28-35. [PMID: 36414167 DOI: 10.1016/j.jhin.2022.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022]
Abstract
AIM Microbiological cultures are the gold standard in the monitoring of duodenoscope reprocessing. However, many different sampling and culturing techniques are used, making it difficult to compare results. The latest Centers for Disease Control and Prevention protocol advises the use of a neutralizer to deactivate any remaining disinfectants in the samples. This study compared culturing results of duodenoscope samples collected with and without addition of a neutralizer. METHODS Six duodenoscopes were soiled with gut bacteria in a non-clinical experimental setting and reprocessed afterwards. Samples of the tip and working channel were collected immediately after decontamination or after drying. Dey-Engley (DE) broth was added as a neutralizer to the samples of four duodenoscopes; samples for the other two duodenoscopes were collected without the addition of DE broth. RESULTS Post-decontamination cultures were significantly more likely to be positive for growth of the applied micro-organisms in the group of samples with DE broth (88.1% vs 20.2%; P<0.0001). Post-drying samples were significantly more likely to be positive in the group of samples without DE broth (75.7% vs 33.4%; P<0.001). CONCLUSION The addition of DE broth to samples collected from wet duodenoscopes increases the yield of those cultures. Remaining disinfectants in wet duodenoscopes can lead to false-negative results. This can be overcome by adding a neutralizer, such as DE broth, to the samples. The higher yield after drying in the group without neutralizer could be due to biofilm formation in these two duodenoscopes, but this was not investigated. Standardization of the sampling method can help to compare both clinical and study results regarding duodenoscope contamination.
Collapse
Affiliation(s)
- J A Kwakman
- 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.
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| |
Collapse
|
12
|
Madureira RADS, de Oliveira AC. Cleaning of in-hospital flexible endoscopes: Limitations and challenges. Rev Lat Am Enfermagem 2022; 30:e3684. [PMID: 36287399 PMCID: PMC9580990 DOI: 10.1590/1518-8345.5969.3684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE to analyze the cleaning process of gastroscopes, colonoscopes and duodenoscopes in eight in-hospital health services. METHOD a cross-sectional study conducted with 22 endoscopes (eight gastroscopes, eight colonoscopes and six duodenoscopes), and microbiological analysis of 60 samples of air/water channels (all endoscopes) and elevator (duodenoscopes), in addition to protein testing. Descriptive statistics with calculation of frequencies and central tendency measures was used in data analysis. RESULTS the processing of 22 endoscopes was monitored with microbiological analysis for 60 channels. In the pre-cleaning procedure, in 82.3% (14/17) of the devices, gauze was used in cleaning the insertion tube. Incomplete immersion of the endoscope in detergent solution occurred in 72.3% (17/22) of the cases, and in 63.6% (14/22) there was no standardization of filling-in of the channels. Friction of the biopsy channel was not performed in 13.6% (3/22) of the devices. In the microbiological analysis, 25% (7/32) of the samples from the stored endoscopes were positive for microbial growth (from 2x101 to 9.5x104 CFU/mL), while after processing, contamination was 32% (9/28). Protein residues in the elevator channel were detected in 33% of duodenoscopes. CONCLUSION the results indicate important gaps in the stages of pre-cleaning and cleaning of endoscopes that, associated with presence of protein residues and growth of microorganisms of epidemiological importance, indicate limitations in safety of the processing procedures, which can compromise the disinfection processes and, consequently, their safe use among patients subjected to such tests.
Collapse
|
13
|
van der Ploeg K, Bruno MJ. Gastrointestinal Endoscopy‑Associated Infections: We Need to Be Specific. Dig Dis Sci 2022; 67:4261-4262. [PMID: 35704256 DOI: 10.1007/s10620-022-07584-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/25/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Koen van der Ploeg
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands. .,Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
14
|
Wang J, Lv Y, Yang W, Zhao P, Yin C. Epidemiology and clinical characteristics of infection/colonization due to carbapenemase-producing Enterobacterales in neonatal patients. BMC Microbiol 2022; 22:177. [PMID: 35820815 PMCID: PMC9277881 DOI: 10.1186/s12866-022-02585-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background The aim of this study was to elucidate the epidemiological features of carbapenemase-producing Enterobacterales (CPE) in the pediatric and neonatal patients, to describe clinical characteristics of neonatal patients with CPE infections, and to assess risk factors for neonatal rectal colonization with CPE. Results A total of 439 carbapenem-resistant Enterobacterales (CRE) isolates recovered from 367 infant patients were characterised, including 397 isolates of Klebsiella pneumoniae (KP) and 42 isolates of Escherichia coli (EC). Carbapenemase gene blaNDM-1 was the most commonly detected, accounting for 86.56% (n = 380), followed by blaKPC-2 (9.11%, 40) and blaIMP-4 (4.33%, 19). MLST analysis showed 17 different STs detected within CPKP isolates, with ST20, ST2068, ST36 and ST17 being the most frequently isolated types. Eleven STs were identified within CPEC isolates, with ST325 being the dominant types. Eight isolates of NDM-1 producing KP, belonging to ST23, were identified as having hypervirulent traits. The main infections caused by CPE were pneumonia (n = 90) and sepsis (n = 16). All infected patients received monotherapy, with meropenem and ciprofloxacin being the most commonly used antibiotics. All pneumonia patients were cured or improved after treatment. Of the 16 patients with sepsis, 9 were cured or improved, 3 died, and 4 abandoned treatment without any clinical improvement. The rectal prevalences of CPE in the 0–3 days old (DO), the 4–28 DO, and the 29 DO-1 year old groups were decreased from 15.31%, 27.37% and 14.29% in the first stool screening period to 11.78%, 19.59% and 4.07% in the second stool screening period, respectively. Multivariate analysis showed that cesarean section, acidosis, respiration failure, gastric lavage and enema were independent risk factors for rectal colonization in the 0–3 DO group, whereas cesarean section, cephalosporins, gastric lavage and residence in rural area were independently associated with rectal colonization in the 4–28 DO group. The implementation of a series of evidence-based control measures eventually contained the CPE transmission. Conclusions Continued vigilance, epidemiological studies, and multimodal infection prevention strategies are urgently needed due to frequent importations.
Collapse
Affiliation(s)
- Jiansheng Wang
- Clinical Laboratory, Hebei General Hospital, 348 Hepingxi Road, Shijiazhuang, 050051, Hebei, China.
| | - Yuanpeng Lv
- Clinical Laboratory, Hebei General Hospital, 348 Hepingxi Road, Shijiazhuang, 050051, Hebei, China
| | - Weiwei Yang
- Clinical Laboratory, Hebei General Hospital, 348 Hepingxi Road, Shijiazhuang, 050051, Hebei, China
| | - Peng Zhao
- Clinical Laboratory, Hebei General Hospital, 348 Hepingxi Road, Shijiazhuang, 050051, Hebei, China
| | - Changfu Yin
- The Experimental Center, Clinic College of Hebei Medical University, 309 South Jianhua Street, Shijiazhuang, 050031, Hebei, China
| |
Collapse
|
15
|
Goyal H, Larsen S, Perisetti A, Larsen NB, Ockert LK, Adamsen S, Tharian B, Thosani N. Gastrointestinal endoscope contamination rates - elevators are not only to blame: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E840-E853. [PMID: 35692921 PMCID: PMC9187382 DOI: 10.1055/a-1795-8883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 01/31/2022] [Indexed: 10/27/2022] Open
Abstract
Background and study aims Duodenoscopes that are contaminated due to inadequate reprocessing are well-documented. However, studies have demonstrated poor reprocessing of other kinds of endoscopes as well, including echoendoscopes, gastroscopes, and colonoscopes. We estimated the contamination rate beyond the elevator of gastrointestinal endoscopes based on available data. Methods We searched PubMed and Embase from January 1, 2010 to October 10, 2020, for studies investigating contamination rates of reprocessed gastrointestinal endoscopes. A random-effects model was used to calculate the contamination rate of patient-ready gastrointestinal endoscopes. Subgroup analyses were conducted to investigate differences among endoscope types, countries, and colony-forming unit (CFU) thresholds. Results Twenty studies fulfilled the inclusion criteria, including 1,059 positive cultures from 7,903 samples. The total contamination rate was 19.98 % ± 0.024 (95 % confidence interval [Cl]: 15.29 %-24.68 %; I 2 = 98.6 %). The contamination rates of colonoscope and gastroscope channels were 31.95 % ± 0.084 and 28.22 % ± 0.076, respectively. Duodenoscope channels showed a contamination rate of 14.41 % ± 0.029. The contamination rates among studies conducted in North America and Europe were 6.01 % ± 0.011 and 18.16% ± 0.053 %, respectively. The contamination rate among studies using a CFU threshold > 20 showed contamination of 30.36 % ± 0.094, whereas studies using a CFU threshold < 20 showed a contamination rate of 11 % ± 0.026. Conclusions On average, 19.98 % of reprocessed gastrointestinal endoscopes may be contaminated when used in patients and varies between different geographies. These findings highlight that the elevator mechanism is not the only obstacle when reprocessing reusable endoscopes; therefore, guidelines should recommend more surveillance of the endoscope channels as well.
Collapse
Affiliation(s)
- Hemant Goyal
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, Texas, United States,Clinical Assistant Professor, Mercer University School of Medicine, Macon, Georgia, United States
| | | | - Abhilash Perisetti
- Division of Interventional Oncology & Surgical Endoscopy (IOSE). Parkview Cancer Institute, Wayne, Indiana, United States
| | | | - Lotte Klinten Ockert
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, Texas, United States
| | - Sven Adamsen
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, Texas, United States,Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Benjamin Tharian
- General and Advanced Endoscopy, Assoc. Prof of Medicine, University of Arkansas for Medical Sciences Little Rock, Arkansas, United States
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, Texas, United States
| |
Collapse
|
16
|
Lisotti A, Fusaroli P, Napoleon B, Cominardi A, Zagari RM. Single-use duodenoscopes for the prevention of endoscopic retrograde cholangiopancreatography -related cross-infection – from bench studies to clinical evidence. World J Methodol 2022; 12:122-131. [PMID: 35721249 PMCID: PMC9157629 DOI: 10.5662/wjm.v12.i3.122] [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: 11/28/2021] [Revised: 01/16/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several strategies have been implemented to reduce or abolish the life-threatening risk of endoscopic retrograde cholangiopancreatography (ERCP)-related multidrug-resistant infections due to duodenoscopes contaminations; among those strategies, serial microbiologic tests, thorough reprocessing schedules, and use of removable scope cap have been adopted, but the potential cross-infection risk was not eliminated.
AIM To review available evidence in the field of single-use duodenoscopes (SUD) use for ERCP.
METHODS An overview on ongoing clinical studies was also performed to delineate which data will become available in the next future.
RESULTS One bench comparative study and four clinical trials performed with EXALT model-D (Boston Scientific Corp., United States) have been identified. Of them, one is a randomized controlled trial, while the other three studies are prospective single-arm, cross-over studies. Pooled technical success rate (4 studies, 368 patients) was 92.9% [95% confidence interval (CI): 89.9-95.5; I2: 11.8%]. Pooled serious adverse event (4 studies, 381 patients) rate was 5.9% [3.7%-8.5%; I2: 0.0%].
CONCLUSION Although few clinical trials are available, evidence is concordant in identifying an absolute feasibility and safety and feasibility for SUD use for ERCP. The expertise and quality of evidence in this field are going to be improved by further large clinical trials; data on cost-effectiveness and environmental impact will be needed for a worldwide spread of SUD use for ERCP.
Collapse
Affiliation(s)
- Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Bertrand Napoleon
- Gastroenterology Unit, Hôpital privé Jean Mermoz - Ramsay Générale de Santé, Lyon 69008, FR, France
| | - Anna Cominardi
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Rocco Maurizio Zagari
- Dipertimento Di Scienze Mediche e Chirurgiche, Università di Bologna, Policlinico San Orsola Malpighi, Bologna 40138, Italy
| |
Collapse
|
17
|
Deb A, Perisetti A, Goyal H, Aloysius MM, Sachdeva S, Dahiya D, Sharma N, Thosani N. Gastrointestinal Endoscopy-Associated Infections: Update on an Emerging Issue. Dig Dis Sci 2022; 67:1718-1732. [PMID: 35262904 DOI: 10.1007/s10620-022-07441-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/07/2022] [Indexed: 02/06/2023]
Abstract
Over 17.7 million gastrointestinal (GI) endoscopic procedures are performed annually, contributing to 68% of all endoscopic procedures in the United States. Usually, endoscopic procedures are low risk, but adverse events may occur, including cardiopulmonary complications, bleeding, perforation, pancreatitis, cholangitis, and infection. Infections after the GI endoscopies most commonly result from the patient's endogenous gut flora. Although many studies have reported infection after GI endoscopic procedures, a true estimate of the incidence rate of post-endoscopy infection is lacking. In addition, the infection profile and causative organisms have evolved over time. In recent times, multi-drug-resistant microorganisms have emerged as a cause of outbreaks of endoscope-associated infections (EAI). In addition, lapses in endoscope reprocessing have been reported, with some but not all outbreaks in recent times. This systematic review summarizes the demographical, clinical, and management data of EAI events reported in the literature. A total of 117 articles were included in the systematic review, with the majority reported from North America and Western Europe. The composite infection rate was calculated to be 0.2% following GI endoscopic procedures, 0.8% following ERCP, 0.123% following non-ERCP upper GI endoscopic procedures, and 0.073% following lower GI endoscopic procedures. Pseudomonas aeruginosa was the most common culprit organism, followed by other Enterobacteriaceae groups of organisms and Gram-positive cocci. We have also elaborated different prevention methods such as antimicrobial prophylaxis, adequate sterilization methods for reprocessing endoscopes, periodic surveillance, and current evidence supporting their utilization. Finally, we discuss disposable endoscopes, which could be an alternative to reprocessing to minimize the chances of EAIs with their effects on the environmental and financial situation.
Collapse
Affiliation(s)
- Anasua Deb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - Abhilash Perisetti
- Advance Endoscopy, Interventional Oncology & Surgical Endoscopy (IOSE), Parkview Cancer Institute, 11050 Parkview Circle, Fort Wayne, IN, 46845, USA
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, 501 S. Washington Avenue, Scranton, PA, 18503, USA.
| | - Mark M Aloysius
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, 501 S. Washington Avenue, Scranton, PA, 18505, USA
- Geisinger Commonwealth School of Medicine, 525, Pine Street, Scranton, PA, 18510, USA
| | - Sonali Sachdeva
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Dushyant Dahiya
- Central Michigan University College of Medicine, 1000 Houghton Ave, Saginaw, MI, 48603, USA
| | - Neil Sharma
- Division of Interventional Oncology & Surgical Endoscopy (IOSE), Parkview Cancer Institute, 11050 Parkview Circle, Fort Wayne, IN, 46845, USA
- Indiana University School of Medicine, Fort Wayne, IN, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology & Nutrition, Center for Interventional Gastroenterology at UTHealth (iGUT), Atilla Ertan MD Chair in Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, USA
| |
Collapse
|
18
|
Influential Papers that Shaped Paradigms and Changed Practice in Infection Prevention in the Last 60 Years: Then, Now, and Future Directions. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00775-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
19
|
Walker JT, Bak A, Marsden G, Spencer W, Griffiths H, Stanton GA, Williams C, White LJ, Ross E, Sjogren G, Bradley CW, Garvey M. Final rinse water quality for flexible endoscopy to minimise the risk of post-endoscopic infection. Report from Healthcare Infection Society Working Party. J Hosp Infect 2022; 124:79-96. [PMID: 35276281 DOI: 10.1016/j.jhin.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/02/2022] [Indexed: 01/10/2023]
Affiliation(s)
- James T Walker
- Central Sterilising Club, UK; Healthcare Infection Society, London, UK
| | - Aggie Bak
- Healthcare Infection Society, London, UK.
| | | | - Wayne Spencer
- Authorising Engineer, Spencer Nickson Ltd, Frodsham, UK
| | - Helen Griffiths
- Decontamination and TSE advisor, British Society of Gastroenterology, London, UK
| | | | - Craig Williams
- Healthcare Infection Society, London, UK; Consultant Microbiologist, University Hospitals of Morecambe Bay, UK
| | - Leila J White
- Healthcare Infection Society, London, UK; Lancashire Teaching Hospitals NHS Foundation Trusts, UK
| | - Elaine Ross
- Healthcare Infection Society, London, UK; Infection Prevention Society, Seafield, UK
| | - Geoff Sjogren
- Western Sussex Hospitals NHS Foundation Trust (retired), UK
| | - Christina W Bradley
- Healthcare Infection Society, London, UK; University Hospitals Birmingham NHS Foundation Trust, UK
| | - Mark Garvey
- Healthcare Infection Society, London, UK; University Hospitals Birmingham NHS Foundation Trust, UK
| |
Collapse
|
20
|
Cao Z, Yue C, Kong Q, Liu Y, Li J. Risk Factors for a Hospital-Acquired Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infection: A Five-Year Retrospective Study. Infect Drug Resist 2022; 15:641-654. [PMID: 35241916 PMCID: PMC8887613 DOI: 10.2147/idr.s342103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/03/2021] [Indexed: 12/26/2022] Open
Abstract
Purpose This study aimed to describe trends in Klebsiella pneumoniae (KP) resistance in bloodstream infections (BSI) and to identify risk factors for a hospital-acquired carbapenem-resistant Klebsiella pneumoniae (CRKP) BSI and 28-day mortality from a hospital-acquired KP BSI. Patients and Methods We recorded the results of antimicrobial susceptibility testing of 396 KP-positive blood cultures from January 2016 to December 2020. A total of 277 patients with a KP BSI were included in this study, of which 171 had a hospital-acquired infection and 84 had a hospital-acquired CRKP BSI. Multivariate logistic regression analysis was used to identify risk factors for a hospital-acquired CRKP BSI and 28-day mortality from a hospital-acquired KP BSI. Results The proportion of hospital-acquired infections among KP BSI patients increased from 53.1% in 2016 to 72.8% in 2020. The detection rate of CRKP among KP BSI patients increased from 18.8% in 2016 to 37.7% in 2020. Multivariate logistic regression showed that β-lactam/β-lactamase inhibitor combinations (BLBLIs) exposure (P = 0.022, OR 2.863), carbapenems exposure (P = 0.007, OR 3.831) and solid organ transplantation (P <0.001, OR 19.454) were independent risk factors for a hospital-acquired CRKP BSI. Risk factors for a 28-day mortality from hospital-acquired KP BSI were CRKP BSI (P =0.009, OR 5.562), septic shock (P =0.002, OR 4.862), mechanical ventilation>96 hours (P =0.020, OR 8.765), and platelet counts <100×109/L (P =0.003, OR 4.464). Conclusion The incidence of hospital-acquired KP BSI continues to rise and the proportion of CRKP BSI is also increasing. We believe that the use of the BLBLIs needs to be carefully evaluated in hospital-acquired infection. Hospital-acquired KP BSI Patients with CRKP BSI, septic shock, mechanical ventilation and deficiency of platelets are more likely to have a poor prognosis.
Collapse
Affiliation(s)
- Zubai Cao
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Chengcheng Yue
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Qinxiang Kong
- Department of Infectious Diseases, The Chaohu Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Yanyan Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
- Anhui Center for Surveillance of Bacterial Resistance, Anhui Medical University, Hefei, Anhui, People’s Republic of China
- Institute of Bacterial Resistance, Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Jiabin Li
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People’s Republic of China
- Anhui Center for Surveillance of Bacterial Resistance, Anhui Medical University, Hefei, Anhui, People’s Republic of China
- Institute of Bacterial Resistance, Anhui Medical University, Hefei, Anhui, People’s Republic of China
- Correspondence: Jiabin Li Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Jixi road 218, Hefei, Anhui, 230022, People’s Republic of ChinaTel +86-551-62922713Fax +86-551-62922281 Email
| |
Collapse
|
21
|
Josephs-Spaulding J, Singh OV. Medical Device Sterilization and Reprocessing in the Era of Multidrug-Resistant (MDR) Bacteria: Issues and Regulatory Concepts. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 2:587352. [PMID: 35047882 PMCID: PMC8757868 DOI: 10.3389/fmedt.2020.587352] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022] Open
Abstract
The emergence of multidrug-resistant (MDR) bacteria threatens humans in various health sectors, including medical devices. Since formal classifications for medical device sterilization and disinfection were established in the 1970's, microbial adaptation under adverse environmental conditions has evolved rapidly. MDR microbial biofilms that adhere to medical devices and recurrently infect patients pose a significant threat in hospitals. Therefore, it is essential to mitigate the risk associated with MDR outbreaks by establishing novel recommendations for medical device sterilization, in a world of MDR. MDR pathogens typically thrive on devices with flexible accessories, which are easily contaminated with biofilms due to previous patient use and faulty sterilization or reprocessing procedures. To prevent danger to immunocompromised individuals, there is a need to regulate the classification of reprocessed medical device sterilization. This article aims to assess the risks of improper sterilization of medical devices in the era of MDR when sterilization procedures for critical medical devices are not followed to standard. Further, we discuss key regulatory recommendations for consistent sterilization of critical medical devices in contrast to the risks of disinfection reusable medical devices.
Collapse
Affiliation(s)
- Jonathan Josephs-Spaulding
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Om V Singh
- Advance Academic Program, The Johns Hopkins University, Washington, DC, United States.,Technology Science Group (TSG) Consulting Inc., A Science Group Company, Washington, DC, United States
| |
Collapse
|
22
|
Gromski MA, Sherman S. Technological review: developments in innovative duodenoscopes. Gastrointest Endosc 2022; 95:42-50. [PMID: 34487777 DOI: 10.1016/j.gie.2021.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/23/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Mark A Gromski
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
23
|
Madureira RADS, Oliveira ACD. Limpieza de endoscopios flexibles intrahospitalarios: limitaciones y desafíos. Rev Lat Am Enfermagem 2022. [DOI: 10.1590/1518-8345.5969.3683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Resumen Objetivo: analizar el proceso de limpieza de gastroscopios, colonoscopios y duodenoscopios en ocho servicios de salud intrahospitalarios. Método: estudio transversal con 22 endoscopios, de los cuales ocho eran gastroscopios, ocho colonoscopios y seis duodenoscopios, y análisis microbiológico de 60 muestras de los canales de aire/agua (todos los endoscopios) y elevador (duodenoscopios), además de prueba de proteínas. En el análisis de los datos se utilizó estadística descriptiva, con cálculo de frecuencias y medidas de tendencia central. Resultados: el procesamiento de los 22 endoscopios fue monitoreado con el análisis microbiológico de 60 canales. En la prelimpieza, en el 82,3% (14/17) de los equipos se utilizó gasa para limpiar el tubo de inserción. En el 72,3% (17/22) de los casos la inmersión del endoscopio en solución detergente fue incompleta y en el 63,6% (14/22) no hubo estandarización del llenado de los canales. La fricción del canal de biopsia no se realizó en el 13,6% (3/22) de los equipos. En el análisis microbiológico, el 25% (7/32) de las muestras endoscópicas almacenadas dio positivo para crecimiento microbiano (2x101 a 9,5x104 UFC/ml), mientras que después del procesamiento, la contaminación fue del 32% (9/28). Se detectaron residuos de proteína en el canal elevador en el 33% de los duodenoscopios. Conclusión: los resultados indican que hay importantes lagunas en las etapas de prelimpieza y limpieza de los endoscopios que, junto con la presencia de residuos de proteínas y del crecimiento de microorganismos de importancia epidemiológica, indican limitaciones en la seguridad del procesamiento, que pueden comprometer los procesos de desinfección y, por ende, el uso seguro en los pacientes que se someten a esos procedimientos.
Collapse
|
24
|
Madureira RADS, Oliveira ACD. Limpeza de endoscópios flexíveis intra-hospitalares: limitações e desafios. Rev Lat Am Enfermagem 2022. [DOI: 10.1590/1518-8345.5969.3685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Resumo Objetivo: analisar o processo de limpeza de gastroscópios, colonoscópios e duodenoscópios em oito serviços de saúde intra-hospitalar. Método: estudo transversal com 22 endoscópios, sendo oito gastroscópios, oito colonoscópios e seis duodenoscópios, e análise microbiológica de 60 amostras dos canais de ar/água (todos os endoscópios) e elevador (duodenoscópios), além de teste de proteína. Na análise dos dados, utilizou-se estatística descritiva, com cálculo de frequências e medidas de tendência central. Resultados: o processamento de 22 endoscópios foi acompanhado com análise microbiológica de 60 canais. Na pré-limpeza, em 82,3% (14/17) dos equipamentos, foi utilizada gaze na limpeza do tubo de inserção. A imersão incompleta do endoscópio em solução detergente ocorreu em 72,3% (17/22) dos casos, e em 63,6% (14/22) não havia padronização do preenchimento dos canais. A fricção do canal de biópsia não foi realizada em 13,6% (3/22) dos equipamentos. Na análise microbiológica, 25% (7/32) das amostras dos endoscópios armazenados foram positivas para crescimento microbiano (2x101 a 9,5x104 UFC/mL), enquanto após o processamento, a contaminação foi de 32% (9/28). Resíduos de proteína no canal do elevador foram detectados em 33% dos duodenoscópios. Conclusão: os resultados apontam lacunas importantes nas etapas de pré-limpeza e limpeza dos endoscópios que, associadas à presença de resíduos de proteína e ao crescimento de microrganismo de importância epidemiológica, sinalizam limitações na segurança do processamento, que podem comprometer os processos de desinfecção e consequentemente seu uso seguro entre pacientes submetidos a tais exames.
Collapse
|
25
|
Garcia NB, Oliveira ACD. Storage of gastrointestinal endoscopes: when is the safe time for re-use? Rev Bras Enferm 2022; 75:e20210216. [DOI: 10.1590/0034-7167-2021-0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/13/2021] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objectives: to identify the safe storage time for the use of flexible gastrointestinal endoscopes after high-level disinfection, as well as the defining criteria for this time. Methods: an integrative literature review was carried out in the Virtual Health Library, PubMed, Scopus, and Web of Science, considering original articles published since 2000. Results: eleven articles were selected, whose storage times ranged from 1 to 56 days, with a predominance of one to seven days (73%). Several criteria were used to define this time, predominantly the premise of efficient processing (100%), use of alcohol flush (64%), use of drying cabinets (18%), among others. Conclusions: the criteria for determining the storage time did not show a consensus for clinical practice. Expanding the discussion of this theme with the definition of the minimum necessary conditions is of fundamental importance for the reduction of risks and safety of the procedure and the patient.
Collapse
|
26
|
Thornhill G, Dunkin B. Duodenoscope-Acquired Infections: Risk Factors to Consider. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1739562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractIn the wake of highly publicized duodenoscope-associated outbreaks caused by multidrug-resistant organisms (MDRO), a herculean effort was made to understand the conditions that led to these transmission events. Although there is now a clearer picture on how these outbreaks happened, there are still significant data gaps when it comes to understanding the rate of duodenoscope-acquired infections (DAIs), especially in nonoutbreak situations. Recent publications indicate that DAIs are still occurring and suggest that infection rates are higher than currently believed. Given this data gap, it is important to identify those patient populations that are most at risk of postprocedure infection, so that appropriate infection control measures may be implemented. Although those patients receiving antibiotic prophylaxis are most at risk for infection, there are additional risk factors that should be considered. For the purposes of this review, risk factors for infection were divided into three broad categories as follows: (1) those that increase patient susceptibility to infection, (2) those related to the endoscopic procedure, and (3) those factors that put reusable duodenoscope inventories at risk of contamination. Infection risk is a complex interaction between the immune status of the patient, the characteristics of the infectious agent (antibiotic sensitivity, virulence factors, and epidemiology), and the environment of care. Because of this complexity, any assessment of the risk of infection should be performed on a case-by-case basis. There is a dearth of information on infection risk for those patients undergoing endoscopic retrograde cholangiopancreatograpy (ERCP), especially in the context of the development and implementation of new device technology, and new endoscopic procedures that are increasing in complexity. This narrative review was developed using the Medical Subject Heading (MeSH) terms to perform an electronic search in PubMed with the goal of generating a summary of the patient, procedural, and duodenoscope-associated factors that increase the risk of infection in patients undergoing ERCP. This review provides practical information regarding the segmentation of ERCP patients by infection risk, so that endoscopists can make informed decisions about the risk benefits of using enhanced duodenoscope technologies in the care of their patients.
Collapse
Affiliation(s)
- Grace Thornhill
- Infection Prevention Fellow, Boston Scientific—Endoscopy, Marlborough, Massachusetts, United States
| | - Brian Dunkin
- Chief Medical Officer, Boston Scientific—Endoscopy, Marlborough, Massachusetts, United States
| |
Collapse
|
27
|
Kwakman JA, Rauwers AW, Klaassen CHW, Bruno MJ, Vos MC. Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report. Antimicrob Resist Infect Control 2021; 10:127. [PMID: 34454611 PMCID: PMC8403455 DOI: 10.1186/s13756-021-00996-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/20/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias. CASE PRESENTATION We describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients' blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences. CONCLUSION This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored.
Collapse
Affiliation(s)
- Judith A Kwakman
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, Mailbox 2040, 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, Dr. Molewaterplein 40, Mailbox 2040, Rotterdam, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Corné H W Klaassen
- 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, Dr. Molewaterplein 40, Mailbox 2040, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
28
|
Biofilm accumulation in new flexible gastroscope channels in clinical use. Infect Control Hosp Epidemiol 2021; 43:174-180. [PMID: 34128460 DOI: 10.1017/ice.2021.99] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Assess the accumulation of protein and biofilm on the inner surfaces of new flexible gastroscope (FG) channels after 30 and 60 days of patient use and full reprocessing. DESIGN Clinical use study of biofilm accumulation in FG channels. SETTING Endoscopy service of a public hospital. METHODS First, we tested an FG in clinical use before the implementation of a revised reprocessing protocol (phase 1 baseline; n = 1). After replacement of the channels by new ones and the implementation of the protocol, 3 FGs were tested after 30 days of clinical use (phase 2; n = 3) and 3 FGs were tested after 60 days of clinical use (phase 3; n = 3), and the same FGs were tested in phase 2 and 3. Their biopsy, air, water, and air/water junction channels were removed and subjected to protein testing (n = 21), bacteriological culture (n = 21), and scanning electron microscopy (SEM) (n = 28). Air-water junction channels fragments were subjected to SEM only. RESULTS For the FGs, the average number of uses and reprocessing cycles was 60 times. Extensive biofilm was detected in air, water, and air-water junction channels (n = 18 of 28). All channels (28 of 28) showed residual matter, and structural damage was identified in most of them (20 of 28). Residual protein was detected in the air and water channels of all FG evaluated (phases 1-3), except for 1 air channel from phase 2. Bacteria were recovered from 8 of 21 channels, most air or water channels. CONCLUSIONS The short time before damage and biofilm accumulation in the channels was evident and suggests that improving the endoscope design is necessary. Better reprocessing methods and channel maintenance are needed.
Collapse
|
29
|
Day LW, Muthusamy VR, Collins J, Kushnir VM, Sawhney MS, Thosani NC, Wani S. Multisociety guideline on reprocessing flexible GI endoscopes and accessories. Gastrointest Endosc 2021; 93:11-33.e6. [PMID: 33353611 DOI: 10.1016/j.gie.2020.09.048] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Lukejohn W Day
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | | | - James Collins
- Department of Digestive Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University, St Louis, Missouri, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav C Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
30
|
Ofstead CL, Buro BL, Hopkins KM, Eiland JE, Wetzler HP, Lichtenstein DR. Duodenoscope-associated infection prevention: A call for evidence-based decision making. Endosc Int Open 2020; 8:E1769-E1781. [PMID: 33269310 PMCID: PMC7671768 DOI: 10.1055/a-1264-7173] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023] Open
Abstract
Background Recent outbreaks of duodenoscope-associated multidrug-resistant organisms (MDROs) have brought attention to the infection risk from procedures performed with duodenoscopes. Prior to these MDRO outbreaks, procedures with duodenoscopes were considered safe and low risk for exogenous infection transmission, provided they were performed in strict accordance with manufacturer instructions for use and multisociety reprocessing guidelines. The attention and efforts of the scientific community, regulatory agencies, and the device industry have deepened our understanding of factors responsible for suboptimal outcomes. These include instrument design, reprocessing practices, and surveillance strategies for detecting patient and instrument colonization. Various investigations have made it clear that current reprocessing methods fail to consistently deliver a pathogen-free instrument. The magnitude of infection transmission has been underreported due to several factors. These include the types of organisms responsible for infection, clinical signs presenting in sites distant from ERCP inoculation, and long latency from the time of acquisition to infection. Healthcare providers remain hampered by the ill-defined infectious risk innate to the current instrument design, contradictory information and guidance, and limited evidence-based interventions or reprocessing modifications that reduce risk. Therefore, the objectives of this narrative review included identifying outbreaks described in the peer-reviewed literature and comparing the findings with infections reported elsewhere. Search strategies included accessing peer-reviewed articles, governmental databases, abstracts for scientific conferences, and media reports describing outbreaks. This review summarizes current knowledge, highlights gaps in traditional sources of evidence, and explores opportunities to improve our understanding of actual risk and evidence-based approaches to mitigate risk.
Collapse
Affiliation(s)
- Cori L. Ofstead
- Ofstead & Associates, Inc., St. Paul, Minnesota, United States
| | - Brandy L. Buro
- Ofstead & Associates, Inc., St. Paul, Minnesota, United States
| | | | - John E. Eiland
- Ofstead & Associates, Inc., St. Paul, Minnesota, United States
| | | | | |
Collapse
|
31
|
Snyder GM. Introduction to Transmission of Infection: Potential Agents Transmitted by Endoscopy. Gastrointest Endosc Clin N Am 2020; 30:611-618. [PMID: 32891220 DOI: 10.1016/j.giec.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pathogen contamination of endoscopes depends on pathogen factors, surface factors, and environmental conditions. The most common pathogens associated with transmission and infections associated with gastrointestinal endoscope contamination are Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa. Biofilm production together with disruption to device surfaces play an outsized role in the risk of contamination. Sampling schemes are limited by these factors, and further developments are needed to improve the accuracy of sampling.
Collapse
Affiliation(s)
- Graham M Snyder
- Department of Infection Control and Hospital Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| |
Collapse
|
32
|
de St Maurice A, Rubin ZA. Outbreak Investigations: A Brief Primer for Gastroenterologists. Gastrointest Endosc Clin N Am 2020; 30:735-743. [PMID: 32891229 DOI: 10.1016/j.giec.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Transmission of pathogens during endoscopy and subsequent outbreak investigations generated by potential nosocomial transmissions have become a major concern for gastroenterologists. These investigations have resulted in significant media coverage for individual institutions and can cause massive disruption to the institution if not handled well. Gastroenterologists should have a central role in investigation of these outbreaks and management of the communications and patient notification that is required. This article summarizes important aspects of outbreak investigations for physicians who do not frequently manage these investigations and gives practical advice for how gastroenterologists can help identify outbreaks and manage these investigations successfully.
Collapse
Affiliation(s)
- Annabelle de St Maurice
- UCLA Division of Infectious Diseases, Department of Pediatrics, 22-442 MDCC, 10833 Le Conte Avenue, Los Angeles, CA 90095-1752, USA; Department of Pediatrics, David Geffen School of Medicine at UCLA, 924 Westwood Boulevard, Suite 900, Los Angeles, CA 90095, USA
| | - Zachary A Rubin
- Acute Communicable Disease Control, Los Angeles County Department of Public Health, 313 North Figueroa Street, Room 212, Los Angeles, CA 90012, USA.
| |
Collapse
|
33
|
Liu JY, Dickter JK. Nosocomial Infections: A History of Hospital-Acquired Infections. Gastrointest Endosc Clin N Am 2020; 30:637-652. [PMID: 32891222 DOI: 10.1016/j.giec.2020.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the United States, healthcare acquired infections (HAIs) or nosocomial infections are the sixth leading cause of death. This article reviews the history, prevalence, economic costs, morbidity and mortality, and risk factors associated with HAIs. Types of infections described include bacterial, fungal, viral, and multidrug resistant infections that contribute to the most common causes of HAIs, which include catheter- associated urinary tract infections, hospital-acquired pneumonias, bloodstream infections, and surgical site infections. Most nosocomial infections are preventable and monitoring and prevention strategies are described.
Collapse
Affiliation(s)
- Jia-Yia Liu
- American Medical Physicians and Surgeons Advancement Alliance; Department of Medicine, Loma Linda University, Loma Linda, CA, USA; Division of Infectious Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jana K Dickter
- Division of Infectious Diseases, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| |
Collapse
|
34
|
Larsen S, Russell RV, Ockert LK, Spanos S, Travis HS, Ehlers LH, Mærkedahl A. Rate and impact of duodenoscope contamination: A systematic review and meta-analysis. EClinicalMedicine 2020; 25:100451. [PMID: 32954234 PMCID: PMC7486302 DOI: 10.1016/j.eclinm.2020.100451] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Multiple infection outbreaks have been linked to contaminated duodenoscopes worldwide. However, the contamination rate of patient-ready duodenoscopes varies highly amongst published studies testing this subject. We aimed to estimate the contamination rate of reprocessed patient-ready duodenoscopes for endoscopic retrograde cholangio-pancreatography (ERCP) based on currently available data. METHODS We searched the PubMed and Embase databases from January 1, 2010 until March 10, 2020, for citations investigating contamination rates of reprocessed patient-ready duodenoscopes. Studies not assessing other types of endoscopes than duodenoscopes were excluded from the analysis. Study eligibility and data extraction was evaluated by three reviewers independently. A random-effects model (REM) based on the proportion distribution was used to calculate the pooled total contamination rate of reprocessed patient-ready duodenoscopes. Subgroup analyses were carried out to assess contamination rates when using different reprocessing methods by comparing single high-level disinfection (HLD) with double HLD and ethylene oxide (EtO) gas sterilization. Additionally, we investigated the contamination rate between studies conducted following an outbreak compared to non-outbreak-initiated studies. FINDINGS We identified 15 studies that fulfilled the inclusion, which included 925 contaminated duodenoscopes from 13,112 samples. The calculated total weighted contamination rate was 15.25% ± 0.018 (95% confidence interval [Cl]: 11.74% - 18.75%). The contamination rate after only using HLD was 16.14% ± 0.019 (95% Cl: 12.43% - 19.85%) and after using either dHLD or EtO the contamination rate decreased to 9.20% ± 0.025 (95% Cl: 4.30% - 14.10%). Studies conducted following an outbreak (n=4) showed a 5.72% ± 0.034 (95% Cl: 0.00% - 12.43%) contamination rate, and non-outbreak-initiated studies (n=11) revealed a contamination rate of 21.50% ± 0.031 (95% Cl: 15.35% - 27.64%). INTERPRETATION This is the first meta-analysis to estimate the contamination rate of patient-ready duodenoscopes used for ERCP. Based on the available literature, our analysis demonstrates that there is a 15.25% contamination rate of reprocessed patient-ready duodenoscopes. Additionally, the analysis indicates that dHLD and EtO reprocessing methods are superior to single HLD but still not efficient in regards to cleaning the duodenoscopes properly. Furthermore, studies conducted following an outbreak did not entail a higher contamination rate compared to non-outbreak-initiated studies. FUNDING The authors received no financial support for the research, authorship, and/or publication of this article.
Collapse
Key Words
- AGA, American Gastroenterological Association
- AORN, The Joint Commission and The Association of Perioperative Registered Nurses
- Bacterial*
- CDC, Center for Disease Control and Prevention
- CFU, colony-forming units
- CRE, carbapenem-resistant Enterobacteriaceae
- Cl, confidence interval
- Cross infection
- Drug Resistance
- Duodenoscopes
- ERCI, Environmental Risk Communications, Inc.
- ERCP, endoscopic retrograde cholangio-pancreatography
- Equipment contamination
- EtO, ethylene oxide
- FDA, Food & Drug Administration
- HLD, high-level disinfection
- Infection Control
- MDR, multi-drug-resistant
- MeSH, medical subject headings
- Multiple
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- REM, random-effects model
- dHLD, double high-level disinfection
Collapse
Affiliation(s)
- Sara Larsen
- Ambu A/S, Ambu A/S, Baltorpbakken 13, 2750 Ballerup, Denmark
| | | | | | - Stephen Spanos
- Anesthesia and Acute Pain Department of Anesthesia University of Utah Primary Children's Hospital, United States
| | | | - Lars Holger Ehlers
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
| | | |
Collapse
|
35
|
Bajaj JS, Brenner DM, Cai Q, Cash BD, Crowell M, DiBaise J, Gallegos-Orozco JF, Gardner TB, Gyawali CP, Ha C, Holtmann G, Jamil LH, Kaplan GG, Karsan HA, Kinoshita Y, Lebwohl B, Leontiadis GI, Lichtenstein GR, Longstreth GF, Muthusamy VR, Oxentenko AS, Pimentel M, Pisegna JR, Rubenstein JH, Russo MW, Saini SD, Samadder NJ, Shaukat A, Simren M, Stevens T, Valdovinos M, Vargas H, Spiegel B, Lacy BE. Major Trends in Gastroenterology and Hepatology Between 2010 and 2019: An Overview of Advances From the Past Decade Selected by the Editorial Board of The American Journal of Gastroenterology. Am J Gastroenterol 2020; 115:1007-1018. [PMID: 32618649 DOI: 10.14309/ajg.0000000000000709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - D M Brenner
- Northwestern University, Chicago Illinois, USA
| | - Q Cai
- Emory University, Atlanta, Georgia, USA
| | - B D Cash
- McGovern Medical School, Houston, Texas, USA
| | - M Crowell
- Mayo Clinic, Scottsdale, Arizona, USA
| | - J DiBaise
- Mayo Clinic, Scottsdale, Arizona, USA
| | | | - T B Gardner
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C Ha
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - G Holtmann
- University of Queensland, Brisbane, Australia, USA
| | - L H Jamil
- Beaumont Health-Royal Oak, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - G G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - H A Karsan
- Atlanta Gastroenterology Associates and Emory University, Atlanta, Georgia, USA
| | - Y Kinoshita
- Steel Memorial Hirohata Hospital and Himeji Brain and Heart Center, Himeji, Japan
| | - B Lebwohl
- Columbia University Irving Medical Center, New York, New York, USA
| | | | | | - G F Longstreth
- Kaiser Permanente Southern California, San Diego, California, USA
| | - V R Muthusamy
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - M Pimentel
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - J R Pisegna
- Department of Veterans Affairs, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA Los Angeles, California, USA
| | - J H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - M W Russo
- Carolinas Medical Center-Atrium Health, Charlotte, North Carolina, USA
| | - S D Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - A Shaukat
- Minneapolis Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - M Simren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - T Stevens
- Cleveland Clinic, Cleveland, Ohio, USA
| | - M Valdovinos
- Instituto Nacional de Ciencias Médicas y Nutricion S.Z., Mexico City, Mexico
| | - H Vargas
- Mayo Clinic, Scottsdale, Arizona, USA
| | - B Spiegel
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - B E Lacy
- Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
36
|
Reply. Clin Gastroenterol Hepatol 2020; 18:1900-1901. [PMID: 32173482 DOI: 10.1016/j.cgh.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 02/07/2023]
|
37
|
Bove V, Schepis T, Boškoski I, Landi R, Orlandini B, Pontecorvi V, Familiari P, Tringali A, Perri V, Costamagna G. Bilio-pancreatic endoscopy during COVID-19 pandemic. Therap Adv Gastroenterol 2020; 13:1756284820935187. [PMID: 32636930 PMCID: PMC7315654 DOI: 10.1177/1756284820935187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/21/2020] [Indexed: 02/04/2023] Open
Abstract
On 31 December 2019, the WHO China Country Office was informed of cases of pneumonia of unknown etiology detected in Wuhan (Hubei Province of China). In January 2020, a new coronavirus named SARS-CoV2 was isolated and, since that time, SARS-CoV2 related disease (COVID-19) rapidly spread all over the world becoming pandemic in March 2020. The COVID-19 outbreak dramatically affected the public-health and the health-care facilities organization. Bilio-pancreatic endoscopy is considered a high-risk procedure for cross-contamination and, even though it is not directly involved in COVID-19 diagnosis and management, its reorganization is crucial to guarantee high standards of care minimizing the risk of SARS-CoV2 transmission among patients and health-care providers. Bilio-pancreatic endoscopic procedures often require a short physical distance between the endoscopist and the patient for a long period of time, a frequent exchange of devices, the involvement of a large number of personnel, the use of complex endoscopes difficult to reprocess. On this basis, endoscopic units should take precautions with adjusted management of bilio-pancreatic endoscopy. The aim of this article is to discuss the approach to bilio-pancreatic endoscopy in the COVID-19 era with focus on diagnostic algorithms, indications, management of the endoscopic room, proper use of Personal Protective Equipment and correct reprocessing of instrumentation.
Collapse
Affiliation(s)
- Vincenzo Bove
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Largo A. Gemelli, 8, Rome, 00168, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Beatrice Orlandini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Valerio Pontecorvi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| |
Collapse
|
38
|
Mark JA, Underberg K, Kramer RE. Results of duodenoscope culture and quarantine after manufacturer-recommended cleaning process. Gastrointest Endosc 2020; 91:1328-1333. [PMID: 31945325 DOI: 10.1016/j.gie.2019.12.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Outbreaks of infections transmitted by duodenoscopes have prompted changes to duodenoscope cleaning protocols. However, little is known about effectiveness of clinical cleaning practices. We present culture data after duodenoscope manufacturer-recommended high-level disinfection (HLD) and quarantine. METHODS Our institution adopted a combination of manufacturer-recommended cleaning with the Centers for Disease Control and Prevention-recommended culture and quarantine in 2015. Duodenoscopes (models TJF-Q180V, TJF-160, and PJF-160; Olympus, Center Valley, Penn, USA) underwent HLD according to the manufacturer's reprocessing manual protocols after use. Two culture specimens were then obtained using a sterile brush from the distal tip, including elevator mechanism, and by flushing sterile water through the working channel. Duodenoscopes were quarantined until cultures resulted. Positive cultures were defined as >10 colony-forming units (CFUs) of low-concern organisms or any CFUs of high-concern organisms according to Centers for Disease Control and Prevention recommendations. If either culture specimen was positive, the process was repeated until cultures were negative. Data were collected from December 2015 to July 2018. RESULTS There were 140 instances of duodenoscope cleaning with 280 specimens. Twenty-eight of 234 (12%) initial culture specimens (18% of cultured duodenoscopes) were positive. Five of 36 (14%) second cultures were positive. Two of 8 (25%) third cultures were positive. Ninety-eight percent of organisms cultured were gram positive. In 8 instances both culture methods (brushing and flush) were positive; otherwise, only 1 method was positive. In 11 instances (8%) duodenoscopes were removed from quarantine before final culture results. No patient had infections related to ERCP. CONCLUSIONS Eighteen percent of duodenoscopes had a positive culture after initial HLD. Only 3% were gram-negative bacteria. Repeated HLD was 86% and 75% effective at eliminating initial and repeat positive cultures, respectively. Initial HLD per manufacturer recommendations is not always effective at eliminating bacterial contamination. Additional steps are necessary to decrease risks of duodenoscope-transmitted infections.
Collapse
Affiliation(s)
- Jacob A Mark
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Karin Underberg
- Perioperative Services, Children's Hospital Colorado, Aurora Colorado, USA
| | - Robert E Kramer
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
39
|
Ofstead CL, Hopkins KM, Buro BL, Eiland JE, Wetzler HP. Challenges in achieving effective high-level disinfection in endoscope reprocessing. Am J Infect Control 2020; 48:309-315. [PMID: 31677925 DOI: 10.1016/j.ajic.2019.09.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 01/15/2023]
Abstract
Endoscope reprocessing is often ineffective, and microbes frequently remain on endoscopes after the use of high-level disinfectants (HLDs). Several factors impact reprocessing effectiveness, including non-adherence to guidelines, use of damaged endoscopes, use of insoluble products during endoscopy, insufficient cleaning, contaminated rinse water, and inadequate drying before storage. Our team suspected that issues with HLD chemistries and monitoring could also contribute to reprocessing failures. We conducted a mixed-methods analysis of published literature, our interviews with frontline personnel, and evidence from our previous studies. The evidence showed that reusable HLDs commonly failed tests for minimum effective concentration (MEC) before their maximum usage periods. MEC tests also detected failures associated with single-use HLDs that did not fully deploy. These failures were due to product issues, process complexities, and personnel non-adherence with guidelines and manufacturer instructions. HLDs will likely continue to be used for the foreseeable future. More research is needed to assess real-world practice patterns related to the high-level disinfection step and MEC testing and to establish more realistic usage periods for reusable HLD chemistries. Manufacturers and researchers should evaluate the ability of technological solutions and engineered safeguards to overcome human error. Recognition of the need for quality improvement is growing, and infection preventionists should take action to build on this momentum and collaborate with manufacturers, endoscopists, and reprocessing personnel to improve the effectiveness of high-level disinfection.
Collapse
|
40
|
Alfa MJ, Singh H. Impact of wet storage and other factors on biofilm formation and contamination of patient-ready endoscopes: a narrative review. Gastrointest Endosc 2020; 91:236-247. [PMID: 31521779 DOI: 10.1016/j.gie.2019.08.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/31/2019] [Indexed: 02/07/2023]
Abstract
The 2019 U.S. Food and Drug Administration report indicates that the clinical studies undertaken by the 3 main GI endoscope manufacturers demonstrate 5.4% of patient-ready duodenoscopes remain culture positive for high-concern organisms. The root causes of this persistent contamination are poorly understood. The objectives of this review include summarizing (1) the impact of inadequate manual cleaning and inadequate drying during storage on the formation of build-up biofilm in endoscope channels, (2) the impact of defoaming agents used during patient procedures on drying efficacy, (3) the data showing the importance of build-up biofilm on persistent microbial survival, and (4) the potential impact of implementation of a quality systems approach in GI endoscopy reprocessing.
Collapse
Affiliation(s)
- Michelle J Alfa
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
41
|
Food and Drug Administration and disposable duodenoscopes: A bolt from the blue for the rich or a godsend for the poor? Gastrointest Endosc 2020; 91:459-461. [PMID: 31634475 DOI: 10.1016/j.gie.2019.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022]
|
42
|
Mehta AC, Muscarella LF. Bronchoscope-Related “Superbug” Infections. Chest 2020; 157:454-469. [DOI: 10.1016/j.chest.2019.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 12/18/2022] Open
|
43
|
Overestimated discriminatory power of MALDI-TOF mass spectrometry for typing of carbapenem-resistant Klebsiella pneumoniae clones. Epidemiol Infect 2019; 147:e324. [PMID: 31845635 PMCID: PMC7006016 DOI: 10.1017/s0950268819002097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Homology surveillance of carbapenem-resistant Klebsiella pneumoniae (CRKP) is critical to monitor and prevent outbreaks of nosocomial infections. In the present study, a matrix-assisted laser desorption/ionisation-time of flight (MALDI-TOF MS)-based method was evaluated as a rapid tool for typing CRKP in comparison with pulsed-field gel electrophoresis (PFGE) and multi locus sequence typing (MLST). Drug-resistant phenotypes and genotypes of 44 CRKP isolates were detected by microdilution broth method and polymerase chain reaction, and typed by PFGE, MLST and MALDI-TOF MS. Simpson's Index of Diversity was used to evaluate taxonomic diversity, Adjusted Rand Index (ARI) for congruence between the typing methods and Wallace coefficients (W) for the ability of either method to predict each other. Forty-four CRKP isolates of 15 sequence types (STs) produced either NDM-1 (n = 16), NDM-5 (n = 9) or KPC-2 (n = 19) carbapenemases. PFGE differentiated these isolates into 16 distinct types, and two deoxyribonucleic acid profiles were assigned to ST337 and ST11, respectively. MALDI-TOF MS failed to clearly delineate between clusters on dendrograms based on principal components analysis and main spectrum profile. The chosen parameters resulted in a maximum ARI of 0.310 (95% CI 0.088-0.531) between MALDI-TOF MS typing and the PFGE reference, indicating a low ability of the former to correctly identify related isolates. Likewise, the maximum W coefficient of 0.367 (95% CI 0.203-0.532) showed that MALDI-TOF MS had a lower predictive power than PFGE. We conclude that MALDI-TOF MS lacks the discriminatory power necessary for clone assignment of CRKP isolates and consequently cannot be considered as a rapid and creditable method for this purpose.
Collapse
|
44
|
Balan GG, Sfarti CV, Chiriac SA, Stanciu C, Trifan A. Duodenoscope-associated infections: a review. Eur J Clin Microbiol Infect Dis 2019; 38:2205-2213. [PMID: 31482418 DOI: 10.1007/s10096-019-03671-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Abstract
Flexible digestive endoscopes are used for the management of various conditions with hundreds of thousands of therapeutic procedures performed worldwide each year. Duodenoscopes are indispensable tools for the delivery of minimally invasive vital care of numerous pancreaticobiliary disorders. Despite the fact that nosocomial infections after endoscopic retrograde cholangiopancreatography (ERCP) have always been among the most frequently cited postprocedural complications, recent emergence of duodenoscope-transmitted multiple drug-resistant bacterial infections has led to intense research and debate yet with no clearly delineated solution. Duodenoscope-transmitted nosocomial infections have become one of the most visible topics in the recent literature. Hundreds of high-impact articles have therefore been published in the last decade. This review article discusses how such infections were seen in the past and what is the current situation in both research and practice and thus tries to solve some of the unanswered questions for the future. With the persistence of nosocomial infections despite strict adherence to both manufacturer-issued reprocessing protocols and international guidelines and regulations, an urgent and proper microbiologically driven common action is needed for controlling such nosocomial worldwide threat.
Collapse
Affiliation(s)
- Gheorghe G Balan
- Grigore T. Popa, University of Medicine and Pharmacy of Iași, Iași, Romania
| | | | | | - Carol Stanciu
- Institute of Gastroenterology and Hepatology, St. Spiridon Emergency Hospital of Iași, Iași, Romania
| | - Anca Trifan
- Grigore T. Popa, University of Medicine and Pharmacy of Iași, Iași, Romania
| |
Collapse
|
45
|
Rauwers AW, Kwakman JA, Vos MC, Bruno MJ. Endoscope-associated infections: A brief summary of the current state and views toward the future. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
46
|
Thornhill G, David M. Endoscope-associated infections: A microbiologist's perspective on current technologies. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.150625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
47
|
Muscarella LF. Use of ethylene-oxide gas sterilisation to terminate multidrug-resistant bacterial outbreaks linked to duodenoscopes. BMJ Open Gastroenterol 2019; 6:e000282. [PMID: 31423318 PMCID: PMC6688681 DOI: 10.1136/bmjgast-2019-000282] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 01/17/2023] Open
Abstract
Background Cleaning and high-level disinfection have been the standard in the USA and other countries for reprocessing flexible endoscopes, including duodenoscopes and other types of gastrointestinal endoscopes. For decades, this practice has been a cornerstone for infection prevention in the endoscopic setting. However, amid recent reports associating the use of duodenoscopes with infections and outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) and related multidrug-resistant organisms (MDROs), reasonable questions about the adequacy of current practices for reprocessing duodenoscopes have emerged. Objectives To review and evaluate the adequacy of current reprocessing practices for preventing duodenoscopes from transmitting CRE and related MDROs. Methods The MEDLINE/PubMed database was searched to identify published cases associating confirmed (or suspected) infections of CRE or a related MDRO with exposure to a duodenoscope since 2012, when duodenoscopes became a recognised risk factor for the transmission of CRE. The Internet was also searched to identify news articles and other reports documenting eligible cases occurring during this same timeframe but not identified during the MEDLINE database’s search. The Food and Drug Administration’s (FDA) medical device database was queried to identify regulatory reports describing these same types of cases, also recorded since 2012. The clinical and reprocessing details of each eligible case were reviewed to identify (when possible): (a) the reprocessing method (eg, high-level disinfection) performed at the time of the infections, (b) whether the facility’s compliance with the manufacturer’s reprocessing instructions was confirmed, and (c) the measure(s) or corrective action(s) the facility implemented to prevent additional multidrug-resistant infections. Results Seventeen cases in the USA and six in other countries (primarily Europe) associating infections (and colonizations) of CRE or a related MDRO with exposure to a duodenoscope were reviewed. Fourteen of these 23 outbreaks were caused by CRE, and six by a related MDRO. Two of these six latter cases identified Klebsiella pneumoniae carrying the mcr-1 gene as the pathogen. For 12 of these 23 cases, it was reported or implied that the duodenoscope was being high-level disinfected at the time of the infections, consistent with published guidelines. For the remaining 11 cases, the associated report(s) did not clearly identify how the duodenoscope was being reprocessed at the time of the infections (although it may be reasonably concluded that at least some, if not all, of these 11 cases involved high-level disinfection). Further, eight of the 23 cases reported the duodenoscope was being reprocessed in accordance with the manufacturer’s instructions for use (and professional guidelines) at the time of the infections. Seven of the cases discussed the design of the duodenoscope (eg, the forceps elevator mechanism) in the context of reprocessing and the infections. Three of the cases identified one or more reprocessing lapses, including inadequate cleaning, delayed reprocessing and improper drying and/or storage of the duodenoscope. Most of these 23 cases were associated with exposure to a duodenoscope model featuring a sealed elevator-wire channel. Six of the cases reported adopting (or in one case supplementing high-level disinfection with) ethylene oxide (EO) gas sterilisation of the duodenoscope, with at least three reporting this measure terminated the outbreak. Other measures adopted to prevent additional infections included removing the implicated duodenoscope from use, re-training staff about proper cleaning, microbiological culturing of the duodenoscope and returning the duodenoscope to the manufacturer for evaluation, maintenance and/or repair. Conclusions This study's findings suggest current reprocessing practices may not always be sufficiently effective to prevent a duodenoscope from transmitting CRE and related MDROs, at least in some circumstances including an outbreak setting. Factors this review identified that may contribute to the device remaining contaminated after reprocessing include the device’s design; breaches of recommended reprocessing guidelines (eg, inadequate manual cleaning, delayed reprocessing or improper device storage); damage to the device; lacking servicing, maintenance or repair; and/or the presence of biofilms. Measures that can mitigate the impact of these and other reprocessing challenges and reduce, if not eliminate, the risk of transmission of CRE or a related MDRO by a duodenoscope include the use of EO gas sterilization (or another comparably effective process or method). In 2015, the FDA suggested healthcare facilities consider performing at least one of four supplemental measures, which include EO gas sterilisation, to improve the effectiveness of duodenoscope reprocessing. Whether the FDA and Centers for Disease Control and Prevention might reclassify duodenoscopes as critical devices requiring sterilisation is currently unresolved.
Collapse
|
48
|
|
49
|
Devereaux BM, Athan E, Brown RR, Greig SM, Jones DM, Bailey FK, Wallis DJ, Singh R. Australian infection control in endoscopy consensus statements on carbapenemase-producing Enterobacteriaceae. J Gastroenterol Hepatol 2019; 34:650-658. [PMID: 30345549 DOI: 10.1111/jgh.14511] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/14/2018] [Indexed: 01/27/2023]
Abstract
Outbreaks of carbapenemase-producing Enterobacteriaceae clinical infections related to endoscopic transmission are well documented. The high morbidity and mortality associated with these infections emphasizes the need to reassess endoscopic reprocessing protocols. The Gastroenterological Society of Australia established a multi-society committee to formulate evidence-based consensus statements on the prevention and management of endoscopic transmission of carbapenemase-producing Enterobacteriaceae. A literature search was undertaken utilizing the MEDLINE database. Further references were sourced from published paper bibliographies. Nine statements were formulated. Using the Delphi methodology, the statements were initially reviewed electronically by the committee members and subsequently at a face-to-face meeting in Melbourne, Australia. After further discussion, four additional sub-statements were added resulting in a total of 13 statements. Each statement was assessed for level of evidence, recommendation grade and the voting on recommendation was recorded. For a statement to be accepted, five out of six committee members had to "accept completely" or "accept with some reservation." All 13 statements achieved consensus agreement. Eleven statements achieved 100% "accepted completely." Two statements were 83% "accepted completely" and 17% "accepted with some reservation." Of particular significance, automated flexible endoscope reprocessors were mandated for high-level disinfection, and the use of forced-air drying cabinets was mandated for endoscope storage. These evidence-based statements encourage preventative strategies with the aim of ensuring the highest possible standards in flexible endoscope reprocessing thereby optimizing patient safety. They must be considered in addition to the broader published guidelines on infection control in endoscopy.
Collapse
Affiliation(s)
- Benedict M Devereaux
- University of Queensland, Herston, Queensland, Australia.,Gastroenterological Society of Australia (GESA), Melbourne, Victoria, Australia
| | - Eugene Athan
- Deakin University, Geelong, Victoria, Australia.,Australasian Society for Infectious Diseases (ASID), Surrey Hills, NSW, Australia
| | - Robyn R Brown
- Gastroenterological Nurses College of Australia (GENCA), Beaumaris, Victoria, Australia
| | - Sue M Greig
- Australasian College for Infection Prevention and Control (ACIPC), Brisbane, Tasmania, Australia
| | - Dianne M Jones
- Gastroenterological Nurses College of Australia (GENCA), Beaumaris, Victoria, Australia
| | - Fiona K Bailey
- Gastroenterological Society of Australia (GESA), Melbourne, Victoria, Australia
| | - David J Wallis
- Gastroenterological Society of Australia (GESA), Melbourne, Victoria, Australia
| | - Rajvinder Singh
- Gastroenterological Society of Australia (GESA), Melbourne, Victoria, Australia.,University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
50
|
Molloy-Simard V, Lemyre JL, Martel K, Catalone BJ. Elevating the standard of endoscope processing: Terminal sterilization of duodenoscopes using a hydrogen peroxide-ozone sterilizer. Am J Infect Control 2019; 47:243-250. [PMID: 30442443 DOI: 10.1016/j.ajic.2018.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/07/2018] [Accepted: 09/08/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND The health care community is increasingly aware of the processing challenges and infection risks associated with duodenoscopes owing to published reports of outbreaks and regulatory recalls. Studies have demonstrated that the current practices are inadequate for consistently producing patient-ready endoscopes. Alternatively, terminal sterilization would offer a greater margin of safety and potentially reduce the risk of patient infection. The purpose of this study was to evaluate the efficacy of a hydrogen peroxide-ozone sterilizer with regulatory clearance for terminal sterilization of duodenoscopes. METHODS AND RESULTS Validation studies were performed under laboratory simulated-use and clinical in-use conditions. The overkill method study demonstrated a reduction of at least 6-log of Geobacillus stearothermophilus spores at half-cycle, providing a sterility assurance level of 10-6. In addition, the sterilizer achieved a 6-log reduction of G stearothermophilus in the presence of inorganic and organic soils in a simulated-use study. The clinical in-use study confirmed that the sterilizer achieved sterilization of patient-soiled duodenoscopes under actual use conditions. CONCLUSIONS Simulated-use and clinical in-use studies demonstrated the efficacy of a hydrogen peroxide-ozone sterilizer for terminal sterilization of duodenoscopes. This offers health care facilities a viable alternative for duodenoscope processing to enhance patient safety as part of a comprehensive infection control strategy.
Collapse
|