Multi-society guideline for reprocessing flexible gastrointestinal endoscopes

Investigating the failure of repeated standard cleaning and disinfection of a Pseudomonas aeruginosa-infected pancreatic and biliary endoscope

Digestive endoscopy is an important technique for the diagnosis and treatment of digestive system disease. To assure medical safety, a digestive endoscope must be cleaned and disinfected before its use in an operation on the next patient. The most common treatment procedure on a digestive endoscope is high-level disinfection. The potential risk associated with digestive endoscopes is always the focus of endoscopic management in clinical practice. In this study, a polluted pancreatic and biliary endoscope after surgery was cleaned and disinfected multiple times with the standard procedure but still tested positive for Pseudomonas aeruginosa culture, which is very rare and has not been reported in China or abroad.

Endowashers: an overlooked risk for possible post-endoscopic infections

BACKGROUND

Prevention of post-endoscopy infections is an important objective to assure patient safety. Endowashers, or high throughput irrigation water pumps, are a frequently used device on endoscopes. Recommendations published by professional bodies and regulatory health agencies cover not only adequate reprocessing of fiber-endoscopes but also state accepted methods of regular microbial sampling. Although major instruments like endoscopes are covered by these recommendations, other devices used as optional add-ons for endoscopes are not included.

OBJECTIVE

The aim of this prospective study was to investigate the potential for endowashers to act as a possible source of infection.

METHOD

24 endowashers were sampled. Sterile rinse-water was pumped through the endowasher and tested microbiologically according to standardised tests. Sampling was performed in 18 hospitals, including 2 university teaching hospitals, in northern Germany. If endowashers were contaminated, devices were reprocessed and re-tested.

RESULTS

Of 44 samples, 6 (14%) were contaminated with pathogens of up to >20,000 cfu/ml. Pseudomonas aeruginosa and other Gram-negative non-fermenters such as Stenotrophomonas spp. (18x) and Acinetobacter spp. (2x), followed by Staphylococcus aureus (1x), Enterobacter cloacae (1x), Candida albicans (1x), Serratia spp. (1x), Streptococcus spp. (1x) and others (2x).

CONCLUSION

Endowashers can be a potential source of infection. Despite their common use, they are not routinely sampled microbiologically. Endowashers should be clearly mentioned in respective guidelines and routine quality control sampling of endowashers should be part of such recommendations. If endowashers are not monitored regularly, devices with single-use hoses should be used.

Current status of cleaning and disinfection for gastrointestinal endoscopy in China: a survey of 122 endoscopy units

BACKGROUND

Adequate compliance with the existing guidelines for cleaning and disinfection of gastrointestinal endoscopes and accessories is necessary to obtain high-level disinfection and prevent pathogen transmission.

AIM

To investigate cleaning and disinfection practice in China.

METHODS

A questionnaire with 21 questions concerning gastrointestinal endoscopy reprocessing was sent by e-mail to 189 endoscopy units in China.

RESULTS

One hundred and twenty-two (80.39%) of the 189 units responded. Compared with the low-workload units (<5000 procedures/year), the high-workload units (≥5000 procedures/year) had a significantly higher number of gastrointestinal endoscopes (25.8 ± 3.6 vs. 4.7 ± 1.8, p < 0.01) and the higher possessing rate of automated endoscope reprocessors (43.9% vs. 3.1%, p<0.01). Glutaraldehyde was the most commonly employed disinfectant (88.5%) in all the units. In 23/122 (18.8%) units, the exposure time to glutaraldehyde was <45 min in the case of infectious disease patients. Eighty-six of 122 (70.5%) units reused disposable materials, of which 21/86 (24.4%) reused disposable forceps and disposable polypectomy hooks, and 2/86 (1.6%) reused disposable injection needles intermittently.

CONCLUSION

Although gastrointestinal endoscopy has developed rapidly in China in the past decade, there is still room for improvement in the practice of endoscopy reprocessing, especially in middle-sized and small cities.

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.

Use of flexible endoscopes for NOTES: sterilization or high-level disinfection?

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) involves the use of flexible endoscopes to perform intra-abdominal or intra-thoracic surgeries. Surgery in the operating room usually involves sterile instrumentation, whereas in the endoscopy suite high-level disinfection seems to be sufficient. Our objective was to assess the necessity for endoscope sterilization for clinical NOTES and to develop an endoscope processing protocol based on a score for the available processing options.

METHODS

Score and processing protocol development for clinical NOTES endoscopes was based on a comprehensive review of the available relevant literature. Options for sterilization for flexible endoscopes in the Good Samaritan Hospital, Legacy Health in Portland, Oregon, were analyzed for patient safety, potential for recontamination, cost, and validation.

RESULTS

Literature survey indicated that there is controversy surrounding the necessity for sterilization of surgical endoscopes. However, standard of practice seems to call for sterile instrumentation for surgery and it is possible to terminally sterilize flexible endoscopes. Within our institution, a score was created to rank the available sterilization options. We successfully introduced a protocol for sterilization of endoscopes for use in clinical NOTES procedures. The protocol involved mechanical cleaning and high-level disinfection per Multi-Society Guidelines, with subsequent terminal sterilization using a validated peracetic acid protocol.

CONCLUSIONS

It remains controversial whether sterile instrumentation is truly needed for surgery. It is difficult but possible to terminally sterilize flexible endoscopes. We recommend sterile instrumentation for clinical NOTES until well-designed, randomized, clinical trials are available and guidelines are published.

Reprocessing in digestive endoscopy units in Lombardy: results of a regional survey

BACKGROUND AND AIM

Inadequate disinfection of endoscopes and associated instrumentation can result in transmission of infections to patients. The aim of this study is to assess cleaning and disinfection practice in gastrointestinal endoscopy units in public and private institutions in the Lombardy region.

METHODS

We drafted a questionnaire which we e-mailed to all gastrointestinal centers in Lombardy.

RESULTS

A total of 79 centers responded (77%). All endoscopy units perform manual cleaning before disinfection. Automated endoscope reprocessors are available in 84.4% of the centers. Glutaraldehyde-based disinfectants are the most common employed (67% of centers). The time of exposure to the disinfectant is of 10 min in only 9.8% of the centers. The majority of endoscopy units modify their disinfection procedures in the case of infectious disease patients. In 59% of centers disposable material is only used once. In 37% of the endoscopy units instruments are dried with propanol.

CONCLUSIONS

The data collected suggest that cleaning and disinfection practices have improved in recent years, and that there is a good compliance with standard guidelines. There is still room for improvement in equipment, disinfection protocols, and traceability of instruments in order to improve safety for patients and staff.

Experimental evaluation of an automated endoscope reprocessor with in situ generation of peracetic acid for disinfection of semicritical devices

OBJECTIVE

To evaluate the effectiveness of a high-level disinfection solution generated inside an endoscope processing system for decontaminating external and internal surfaces of experimentally contaminated heat-sensitive medical devices.

METHODS

The American Society for Testing and Materials Simulated-Use Test protocol (E1837-02), which incorporates a soil load in each inoculum, was used to evaluate the efficacy of the system when processing 4 common types of endoscopes contaminated separately with 5 types of nosocomial pathogens: Pseudomonas aeruginosa (ATCC 15442), spores of Clostridium difficile (ATCC 9689), a glutaraldehyde-resistant strain of Mycobacterium chelonae, a vancomycin-resistant strain of Enterococcus faecalis, and a methicillin-resistant strain of Staphylococcus aureus. Rinse solution samples from channels and from surfaces of the processed endoscopes were tested for any microbicidal residues.

RESULTS

For all organisms tested, the baseline level of contamination of the endoscopes ranged from 5 log(10) to greater than 7 log(10) at each external surface site and internal channel. All tests showed reductions in viability of the test organisms to undetectable levels. All rinse solution samples from external and internal sites of the endoscopes proved to be free of any residual microbicidal activity.

CONCLUSIONS

The endoscope reprocessor, with its processor-generated high-level disinfection solution, successfully reduced the numbers of selected, clinically relevant pathogens to undetectable levels both in the channels and on the outside surfaces of the 4 representative endoscopes tested in this study.

Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy

The purpose of this article is to review the evidence regarding transmission of infection during gastrointestinal endoscopy, factors important in endoscope reprocessing and infection control, areas to focus on to improve compliance, and recent developments and advances in the field.

Validation of low-temperature steam with formaldehyde sterilization for endoscopes, using validation device

BACKGROUND

Validation of sterilization is an important step before clinical use of medical equipment. Adequate validation of sterilization of the endoscope has not been reported. One reason for this is the lack of suitable devices for validation.

METHODS

The VDES (validation device for endoscope sterilization; Olympus prototype model, Olympus, Tokyo, Japan) was designed in two types (type A and type B) and resembles gastroscopes and duodenoscopes, respectively. Each type consists of inner and outer tubing and a central capsule containing a biological indicator. The device was designed to examine the effectiveness of low-temperature sterilizers, such as ethylene oxide gas, hydrogen peroxide gas plasma, and low-temperature steam with formaldehyde (LTSF) sterilizer. The aim of this study was to validate the sterilization of GI endoscopes by the LTSF sterilizer. Sterilization was assessed using both types of VDES after a 60-min application of LTSF.

RESULTS

Culture of the biological indicator confirmed the complete eradication of the bacteria in a total of 10 experiments with each type of VDES after LTSF sterilization.

CONCLUSIONS

Our results confirm that the LTSF sterilizer may sterilize endoscopes currently distributed by Olympus. Commercialization of VDES will make it possible to evaluate the reliability of sterilization when it is set in the sterilization device with endoscopes.