Outbreak of urinary tract infections by Salmonella spp. after cystoscopic manipulation

Market Readiness for Single-Use Cystoscopes According to Urologists and Procurement Managers Worldwide

PURPOSE

Single-use endoscopes have been subjected to increase awareness in recent years, and several new single-use cystoscopes (eg Ambu® aScope 4 Cysto) have entered the market. However, the market readiness for such single-use cystoscopes remains unknown. This study investigates the worldwide market readiness for single-use cystoscopes among urologists and procurement managers (PMs) from Europe, Japan, and the US.

MATERIALS AND METHOD

An online survey using QuestionPro® was distributed to urologists and PMs in France, Germany, Italy, Japan, Spain, the UK, and the US between March 10, 2020 and July 14, 2020. All surveys were translated into the respective local language. Statistical analyses were performed using the software package Stata/SE version 16.1, StataCorp. Fisher's exact test was used to analyze categorical variables and simple linear regression was applied to continuous variables.

RESULTS

A total of 415 urologists and PMs completed the survey (343 [82.7%] urologists and 72 [17.3%] PMs). Seventy (16.9%) were from Japan, 100 (24.1%) were from the US, and 245 (59.0%) were evenly distributed across the following European countries: France, Germany, Italy, Spain, and the UK. On average, respondents indicated that they would consider converting to single-use in 44.5% of their cystoscopy procedures. Respondents anticipated significantly higher conversion (p<0.05) when they (1) used single-use ureteroscopes in their department, (2) were concerned about cystoscopy-related infection as a result of contaminated cystoscopes, (3) were members of their institution's value committee, or (4) considered cost-transparency to be important when purchasing cystoscopes.

CONCLUSION

This study investigated the marked readiness for single-use cystoscopes according to urologists and PMs worldwide. Respondents indicated a willingness to convert to single-use cystoscopes in nearly half (44.5%) of their cystoscopy procedures. Respondents that were concerned about cystoscopy-related infections as a result of contaminated cystoscopes indicated a significantly higher anticipated conversion rate (p<0.05).

A Case-Control Study on the Association between Salmonella Bacteriuria and Cystoscopy

To date, there is only one published report of an outbreak of urinary tract infections by Salmonella species after cystoscopy. Disinfection procedures for cystoscope have come into question. The current study aimed to determine the odds of developing Salmonella bacteriuria after cystoscopy. A retrospective case-control study was conducted on all patients with Salmonella species in urine (case) and blood (control) from 2017 to 2019 in 16 hospitals in Eastern Ontario, Canada. Eight of the 11 patients had cystoscopy prior to Salmonella bacteriuria; three of the 74 patients had urological procedures prior to Salmonella bacteremia, but none of their procedures were cystoscopy. The odds ratio of urological procedures with Salmonella bacteriuria was 63.1 (95% CI 10.9 to 366.6; p < 0.0001). In the bacteriuria group, the most frequently identified isolates were Salmonella enteritidis (n = 8), followed by Salmonella oranienburg, and Salmonella heidelberg. Seven of the S. enteritidis isolates had identical susceptibilities (ampicillin-sensitive; sulfamethoxazole/trimethoprim-sensitive; ciprofloxacin intermediate). In the bacteremia group, the most frequently identified isolates were S. enteritidis (n = 22), followed by Salmonella typhi, S. heidelberg, S. oranienburg, and Salmonella typhimurium. The result suggested cystoscopy is a risk factor for Salmonella bacteriuria. Identification of Salmonella bacteriuria should prompt public health investigations of linkage between cystoscopy and Salmonella bacteriuria.

Establishment of a quality control circle to reduce biofilm formation in flexible endoscopes by improvement of qualified cleaning rate

Objective

In recent years, the Emergency Care Research Institute has advised that endoscope cleaning is of considerable importance. In the present study, a quality control circle (QCC) was used to reduce the formation of biofilms in flexible endoscopes within one hospital in Guangdong Province, China.

Methods

During reprocessing of 235 flexible endoscopes in the urology surgical suite, adenosine triphosphate (ATP) detection was used to monitor the efficacy of biofilm removal. The internal and external parts of flexible endoscopes were used as sampling sites by means of the flushing and smudge methods, respectively. When the two results reached the standard of less than 500 relative light units/piece at the same time, endoscopic biofilm clearance was considered to be qualified. A QCC was established to implement a 10-step plan-do-check-act model.

Results

The baseline qualified rate (i.e., ATP monitoring pass rate) during reprocessing of 235 flexible endoscopes was 50%. During the study, the qualified rate increased to 85.29% after establishment of the QCC. During reprocessing of 150 flexible endoscopes in the following 6 months, the qualified rate remained at 90%.

Conclusion

Establishment of the QCC improved the removal of biofilm from flexible endoscopes in the urology surgical suite.

Challenges in achieving effective high-level disinfection in endoscope reprocessing

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.

Reprocessing semicritical items: Outbreaks and current issues

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (eg, gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection. As many of these items are temperature sensitive, low-temperature chemical methods must be used rather than steam sterilization. Strict adherence to current guidelines is required as more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items than any other reusable medical devices.

A Systematic Review of Disposable Sheath Use During Flexible Endoscopy

Flexible endoscopes are exposed to blood, mucus, and other secretions during procedures. Single-use sheaths are designed to prevent contact between contaminants and reusable endoscope components. This systematic review examined findings from 22 studies that assessed endoscopic sheath use during urologic, gastrointestinal, or respiratory procedures. The evidence showed that sheaths were durable and yielded faster endoscope turnover times because their reusable components did not require high-level disinfection or sterilization. After a brief learning period, health care providers successfully assembled and maneuvered sheathed endoscopes. Patients generally did not experience greater discomfort during procedures in which sheaths were used. Microbial cultures of sheathed endoscopes were negative or similar to unsheathed endoscopes. More research is needed to evaluate the potential effect of disposable sheaths on infection risks. The evidence suggests that sheaths are a viable option for reliably providing a barrier between endoscopes and patients without affecting the quality of endoscopic procedures.

Residual moisture and waterborne pathogens inside flexible endoscopes: Evidence from a multisite study of endoscope drying effectiveness

BACKGROUND

Endoscopy-associated infection transmission is frequently linked to inadequate reprocessing. Residual organic material and moisture may foster biofilm development inside endoscopes. This study evaluated the effectiveness of endoscope drying and storage methods and assessed associations between retained moisture and contamination.

METHODS

Endoscope reprocessing, drying, and storage practices were assessed at 3 hospitals. Researchers performed visual examinations and tests to detect fluid and contamination on patient-ready endoscopes.

RESULTS

Fluid was detected in 22 of 45 (49%) endoscopes. Prevalence of moisture varied significantly by site (5%; 83%; 85%; P < .001). High adenosine triphosphate levels were found in 22% of endoscopes, and microbial growth was detected in 71% of endoscopes. Stenotrophomonas maltophilia, Citrobacter freundii, and Lecanicillium lecanii/Verticillium dahliae were found. Retained fluid was associated with significantly higher adenosine triphosphate levels (P < .01). Reprocessing and drying practices conformed with guidelines at 1 site and were substandard at 2 sites. Damaged endoscopes were in use at all sites.

CONCLUSIONS

Inadequate reprocessing and insufficient drying contributed to retained fluid and contamination found during this multisite study. More effective methods of endoscope reprocessing, drying, and maintenance are needed to prevent the retention of fluid, organic material, and bioburden that could cause patient illness or injury.