Infection control during GI endoscopy

Structural and Electrical Integrity of Transesophageal Echocardiography Probes: Importance and Key Concepts

The clinical utility of transesophageal echocardiography (TEE) is well-established for patients undergoing cardiac surgery. With the increase in percutaneous structural heart disease procedures that rely on TEE for procedural guidance, the use of TEE probes is expanding. Although there are well-established protocols for routine cleaning and decontaminating TEE probes between patient use, there is a lack of awareness and misconceptions about maintaining TEE probes' structural and electrical integrity. The electrical leakage test (ELT) is routinely performed between patient use. From a patient safety standpoint, the ELT is necessary to ensure the longevity of this expensive equipment and prevent disruptions to the workflow in a busy department caused by TEE probes being decommissioned due to probe damage. This technical communication aims to highlight the importance of maintaining TEE probes' structural and electrical integrity. The article also highlights and discusses probe handling techniques between patient use, emphasizing the ELT to ensure patient safety and compliance with national and international standards.

Evaluation of the Application Effect of a New Anti-reflux Water Injection Tube Device in the Prevention of the Contamination of Endoscopy Water Injection Bottles

BACKGROUND

Water delivery tube reflux during gastrointestinal endoscopy examination is widespread and it is the leading cause of water injection bottle pollution.

AIM

To evaluate the application effect of a new anti-reflux water injection tube device in preventing the contamination of endoscopy water injection bottles.

METHODS

A total of 520 cases received gastrointestinal endoscopy examination were included. Patients were randomly divided into the experimental and control group. The experimental group used the anti-reflux injection tube device to assist with water injection, and the control group used the ordinary delivery tube. After every five cases of gastrointestinal endoscopy, water from the injection bottles was collected. Visual inspection, crystalline violet staining, microbial culture, and microbial species analysis were performed to analyze the contamination state of the water samples.

RESULTS

The contamination rate in the experimental group was 5.66%, significantly lower than 76.47% in the control group. Crystalline violet staining confirmed that microorganisms existed in contaminated water samples. Microbiological culture results showed that the experimental group's undetectable rate of bacteria and fungi was 100%, significantly higher than that of the control group (19.61% for bacteria and 25.49% for fungi). The mean values of the total bacterial and fungal colonies of the control samples were 9.80 × 10⁶ cfu/ml and 9.18 × 10⁶ cfu/ml, respectively. The microbial species in the contaminated samples of the control group were Pseudomonas aeruginosa, Escherichia coli, and Proteus mirabilis.

CONCLUSION

The anti-reflux water injection tube device can effectively prevent the contamination of the endoscopy water injection bottles caused by the reflux of the ordinary water supply tube.

The Effect of Covid-19 Pandemic on Current and Future Endoscopic Personal Protective Equipment Practices: A National Survey of 77 Endoscopists

Introduction

The COVID-19 pandemic has raised awareness about the importance of personal protective equipment (PPE). We aimed to study and compare PPE practices among Canadian endoscopists before and after the COVID-19 pandemic.

Methods

A 74-item questionnaire was emailed from June 2020 to September 2020 to practicing endoscopists in Canada. Survey questions collected basic demographics and differences between PPE practices pre- and post-COVID-19. PPE practices were categorized into four endoscopic procedure types including upper or lower endoscopy and diagnostic or interventional. Outcomes for specific procedures were reported as rates, with ranges shown when evaluating all procedure types together.

Results

A total of 77 respondents completed the survey with the majority of respondents aged 40 to 49 (44%) and identifying as Gastroenterologists (70%). Gender was evenly split (49% females versus 51% males). In the pre-pandemic era, the majority of endoscopists wore gowns (91 to 94%) and all endoscopists wore gloves (100%). However, the majority of endoscopists did not wear surgical masks (21 to 31%), face shields (13 to 34%), eye protection (13 to 21%), hair protection (11 to 13%), or N95 respirators (2 to 3%). In the post-pandemic era, more surgeons plan on wearing face shields (33 to 47%, P = 0.001 to 0.045), goggles (38.5 to 58.7%, P < 0.001), hair protection (33 to 36%, P = 0.011 to 0.024), and a trend suggests more surgeons will wear surgical masks (51 to 61%, P = 0.163 to 0.333). More endoscopists also plan on wearing N95 respirators during lower endoscopy (6 to 7%, P < 0.005).

Conclusion

The COVID-19 pandemic has changed the attitudes of many endoscopists regarding future PPE use in routine endoscopy. Ongoing studies are needed to inform new post-pandemic PPE consensus guidelines.

Medical Device Sterilization and Reprocessing in the Era of Multidrug-Resistant (MDR) Bacteria: Issues and Regulatory Concepts

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.

Minimizing endoscopist facial exposure to droplets: Optimal patient-endoscopist distance and use of a barrier device

BACKGROUND AND AIM

Minimizing endoscopist exposure to bodily fluids is important for reducing the risk of infection transmission. This study investigated the patient-endoscopist vertical distance necessary to minimize an endoscopist's facial exposure to a patient's visible droplets during upper gastrointestinal endoscopy and the ability of a new device to prevent droplets from reaching the endoscopist's face.

METHODS

A model was developed to simulate a patient experiencing a forceful cough during an upper gastrointestinal endoscopy with a model endoscopist. Fluorescent dye was expelled from the model patient's mouth towards the model endoscopist during simulated coughs; dye adhesion to the model endoscopist's face was evaluated using ultraviolet light. The simulation was repeated with the model patient positioned 70-100 cm above the floor, with and without a barrier to shield the patient's face. The accuracy of the cough simulation model and the relationship between patient-endoscopist vertical distance and endoscopist's facial exposure were evaluated.

RESULTS

The flow dynamics of the cough simulation model were similar to that of an actual human cough. There was a significant inverse correlation between the patient-endoscopist vertical distance and the model endoscopist's facial exposure, with positive exposures decreasing from 87% at 70 cm to 0% at 100 cm (P < 0.001). The barrier device prevented facial exposure to droplets at all distances.

CONCLUSIONS

We found that positioning the patient at least 100 cm below the top of the endoscopist's head or using a barrier device minimized the endoscopist's facial exposure to visible droplets during upper gastrointestinal endoscopy.

The Effectiveness of Drying on Residual Droplets, Microorganisms, and Biofilms in Gastrointestinal Endoscope Reprocessing: A Systematic Review

BACKGROUND

Despite endoscope reprocessing, residual droplets remain in gastrointestinal endoscope working channels. Inadequate drying of gastrointestinal endoscope working channels may promote microbial reproduction and biofilm formation, increasing the risk of infection in patients. This review was designed to provide the current status of gastrointestinal endoscope drying, emphasize the importance of gastrointestinal endoscope drying, and evaluate the effectiveness of different drying methods of gastrointestinal endoscope in reducing residual droplets and microbial growth risk.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting checklist. The PubMed, Web of Science, Medline, EMBASE, EBSCO, CNKI, CQVIP, and Wanfang Data databases were searched from 2010 to 2020 to identify eligible articles focused on methods of gastrointestinal endoscope drying and the status of endoscope drying. The following key points were analyzed: type of intervention, amount of residual droplets, major microbial types, and effectiveness of biofilm intervention. JBI quality assessment tool was used to determine bias risk for inclusion in the article.

RESULTS

This review included twelve articles. Two of the articles reported lack of drying of gastrointestinal endoscopes while the other ten reported residual droplets, microbial growth, and biofilm formation after different methods of drying. Four articles reported 0 to 4.55 residual droplets; four articles reported that the main microbial types were cocci and bacilli, most commonly Staphylococcus, Escherichia coli, Bacillus maltophilia, and Pseudomonas aeruginosa; and two reported that drying could effectively reduce biofilm regeneration. The type of intervention is as follows: automatic endoscopy reprocessor (AER), manual compressed air drying, and the Dri-Scope Aid for automatic drying and drying cabinet.

CONCLUSIONS

While endoscope reprocessing may not always be effective, an automatic endoscope reprocessor plus the Dri-Scope Aid with automatic drying over 10 min or storage in a drying cabinet for 72 h may be preferred.

Duodenoscope-associated infection prevention: A call for evidence-based decision making

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.

Novel Algorithms for Reprocessing, Drying and Storing Endoscopes

After outbreaks of duodenoscope-transmitted infection with multidrug-resistant organisms, it has become clear that institutions must optimize their endoscope reprocessing programs. Standard endoscope reprocessing practices may not represent the ideal approach for preventing transmission of infection related to endoscopy. We discuss multiple approaches to enhance and optimize reprocessing, drying, and storage of standard duodenoscopes. The optimal enhanced duodenoscope reprocessing modality remains to be determined. Acknowledging the challenges and limitations in effectively reprocessing duodenoscopes, the FDA issued a safety communiqué recommending transitioning to either single use disposable duodenoscopes or duodenoscopes with innovative designs that allow more effective reprocessing.

The importance of sampling technique and rinse water for assessing flexible gastrointestinal endoscope reprocessing: A 3-year study covering 59 centers

BACKGROUND

Various guidelines recommend several sampling techniques to verify endoscope reprocessing, but a comparative study of the efficiency for recovering microorganisms was rare. Our goal was to compare different sampling techniques for the postreprocessing endoscope to assess residual bacterial contamination and analysis of the critical factors affecting the endoscope reprocessing failure.

METHODS

From 2016 to 2018, 3 techniques, the conventional flushing sampling method, flush-brush-flush sampling method (FBFSM), and pump-assisted sampling method (PASM), were compared covering all 59 endoscope units in Tianjin, China.

RESULTS

A total of 237 (84.64%) flushing channel samples and 110 (61.11%) final rinse water samples met the Chinese national standard. The univariate analysis showed that the qualified rates of endoscope reprocessing sampled by PASM (65.52%) and FBFSM (75%) were significantly lower than those of the conventional flushing sampling method (91.38%). Five other factors, including the final rinse water, dry, and hospital level, were potential factors besides sample technique. The multivariate logistic analysis indicated only 2 factors (sampling technique and final rinse water) remained in the model. FBFSM, PASM, and the purified water were significantly associated with the odds of endoscope reprocessing failure, with the odds ratio (95% confidence interval) of which were 4.206 (1.757-10.067), 5.326 (2.463-11.645), and 0.309 (0.137-0.695), respectively.

CONCLUSIONS

The problem of residual microorganisms of the postreprocessing endoscope was severe. Sampling technique and final rinse water were critical for endoscope reprocessing verification.

[Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management]

Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.

Guidelines for standardizing cleansing and disinfection of gastrointestinal endoscopes

As part of the activities toward standardizing endoscopy procedures, the Japan Gastroenterological Endoscopy Society has prepared guidelines for cleansing and disinfection of gastrointestinal endoscopes. The environment of gastrointestinal endoscopy differs between Japan and advanced Western countries. In advanced Western countries, gastrointestinal endoscopy is performed almost exclusively at specialized facilities, where strict provisions are observed for cleansing and disinfecting endoscopes. In Japan, however, gastrointestinal endoscopy is performed even in small clinics, and the annual number of gastrointestinal endoscopy cases is enormous. In addition, the method for cleansing and disinfecting endoscopes differs among hospitals. Although there is a distinct lack of evidence for how gastrointestinal endoscopes are cleaned and disinfected, it is necessary to standardize the method for doing so to advance the field of endoscopic medicine.

Prion disease and recommended procedures for flexible endoscope reprocessing - a review of policies worldwide and proposal for a simplified approach

Several guidelines recommend specific treatments for endoscopes, procedures of quarantine for endoscopes, or additional treatments for the endoscope washer disinfector (EWD) in suspected or confirmed cases of Creutzfeldt-Jakob disease (CJD) or variant CJD (vCJD) but vary in many details. This study therefore reviewed guidelines on reprocessing flexible endoscopes after use in patients with suspected or confirmed prion disease. In addition, a literature search was performed in Medline on prion, CJD, vCJD, chemical inactivation, transmission healthcare, epidemiology healthcare, concentration tissue human and endoscope. Thus far, no case of CJD or vCJD transmitted by flexible endoscope has been reported. In animals it has been shown that oral uptake of 0.1-5 g of bovine spongiform encephalopathy (BSE)-infected brain homogenate is necessary for transmission. The maximum prion concentration in other tissues (e.g., terminal ileum) is at least 100-fold lower. Automated cleaning of endoscopes alone results in very low total residual protein ≤5.6 mg per duodenoscopes. Recommendations vary between countries, sometimes with additional cleaning, use of alkaline cleaners, no use of cleaners with fixative properties, use of disinfectants without fixative properties or single-use disinfectants. Sodium hydroxide (1 M) and sodium hypochlorite (10,000 and 25,000 mg/L) are very effective in preventing transmission via contaminated wires implanted into animal brains, but their relevance for endoscopes is questionable. Based on circumstantial evidence, it is proposed to consider validated reprocessing as appropriate in the case of delayed suspected prion disease when immediate bedside cleaning, routine use of alkaline cleaners, no fixative agents anywhere prior to disinfection and single use brushes and cleaning solutions can be assured.

Duodenoscope-Associated Infections: Update on an Emerging Problem

The duodenoscope is among the most complex medical instruments that undergo disinfection between patients. Transmission of infection by contaminated scopes has remained a challenge since its inception. Notable risk factors for pathogen transmission include non-adherence to disinfection guidelines, encouragement of biofilm deposition due to complex design and surface defects and contaminated automated endoscope reprocessors. The most common infections following endoscopy are endogenous infections involving the patient's own gut flora. Exogenous infections, on the other hand, are associated with contaminated scopes and can theoretically be prevented by effective reprocessing. Pseudomonas aeruginosa is currently the most common organism isolated from contaminated endoscopes. Of note, reports of multidrug-resistant duodenoscopy-associated outbreaks have surfaced recently, many of which occurred despite adequate reprocessing. The FDA and CDC currently recommend comprehensive cleaning followed with at least high-level disinfection for reprocessing of flexible GI endoscopes. Reports of duodenoscope-related outbreaks despite compliance with established guidelines have prompted professional and government bodies to revisit existing guidelines and offer supplementary recommendations for duodenoscope processing. For the purposes of this review, we identified reports of duodenoscope-associated infections from 2000 till date. For each outbreak, we noted the organisms isolated, the number of cases reported, any possible explanations of contamination, and the measures undertaken to end each outbreak. We have also attempted to present an overview of recent developments in this rapidly evolving field.

On-site comparison of an enzymatic detergent and a non-enzymatic detergent-disinfectant for routine manual cleaning of flexible endoscopes

Background and study aims  Flexible endoscopes are potential vectors of pathogen transmission to patients that are subjected to cleaning and high-level disinfection after each procedure. Efficient manual cleaning is a prerequisite for effective high-level disinfection. The goal of this study was to demonstrate the impact of the cleaning chemistry in the outcome of the manual cleaning of endoscopes. Materials and methods  Twelve endoscopes were included in this study: four colonoscopes, four gastroscopes, two duodenoscopes and two bronchoscopes. This study was designed with two phases; in each of them, the manual cleaning procedure remained identical, but a different detergent was used: a non-enzymatic detergent-disinfectant (NEDD) and an enzymatic detergent (ED). Biopsy and suction channels of endoscopes were sampled using 10 mL of physiological saline at two points: before and after manual cleaning, and adenosine triphosphate (ATP) was measured on each sample. In total, 208 procedures were analyzed for the NEDD phase and 253 for the ED phase. Results  For each endoscope type, cleaning endoscopes with ED resulted in larger median decrease in ATP than with NEDD: respectively 99.43 % and 95.95 % for bronchoscopes ( P  = 0.0007), 99.28 % and 96.93 % for colonoscopes ( P  < 0.0001) and 98.36 % and 95.36 % for gastroscopes ( P  < 0.0001). In addition, acceptability rates of endoscopes based on defined post-manual cleaning ATP thresholds (200, 150, 100 or 50 relative light units) for all endoscope types were significantly higher with ED compared to NEDD. Conclusions  With all other parameters of manual cleaning remaining unchanged, the enzymatic chemistry of ED provided more consistent and improved cleaning of endoscopes compared to NEDD. Therefore, choice of the detergent for endoscope cleaning has an impact on the outcome of this process.

Comparison of automated and manual drying in the elimination of residual endoscope working channel fluid after reprocessing (with video)

BACKGROUND AND AIMS

Residual fluid within endoscope working channels after reprocessing may promote growth of pathogens. Current reprocessing guidelines therefore recommend endoscope drying with administration of forced filtered air; however, the duration and modality of administered air are not specified. The new DriScope Aid device enables automated administration of filtered air at controlled pressure through all internal endoscope channels. We systematically compared, for the first time, the impact of manual drying and automated drying on retained working channel fluid and bioburden after reprocessing.

METHODS

We assessed for residual working channel fluid after reprocessing and/or drying by using the SteriCam borescope. Drying was performed either manually (forced filtered air) or was automated (DriScope Aid) for either 5 or 10 minutes. Adenosine triphosphate (ATP) bioluminescence testing was performed on working channel rinsates after drying, to evaluate for residual bioburden.

RESULTS

Significantly more fluid droplets were evident after manual drying (4.55 ± 6.14) than with automated device-facilitated drying for either 5 minutes (0.83 ± 1.29; P = .007) or 10 minutes (0 ± 0; P = .001). ATP bioluminescence values were higher for manual drying compared with automated drying at 48 hours (P = .001) and 72 hours (P = .014) after reprocessing.

CONCLUSIONS

We demonstrate significantly fewer water droplets and delayed ATP bioluminescence values within endoscope working channels after automated drying compared with manual drying. In particular, virtually no retained fluid was evident within endoscope working channels after automated drying for 10 minutes. These findings support recommendations for automation of as many reprocessing steps as possible. Automated drying may decrease the risk of transmission of infection related to endoscopy.

An update on gastrointestinal endoscopy-associated infections and their contributing factors

INTRODUCTION

During clinical use, gastrointestinal endoscopes are grossly contaminated with patient's native flora. These endoscopes undergo reprocessing to prevent infectious transmission upon future use. Endoscopy-associated infections and outbreaks have been reported, with a recent focus on the transmission of multi-drug resistant organisms. This review aims to provide an update on endoscopy-associated infections, and the factors contributing to their occurrence.

METHODS

PubMed, ScienceDirect, and CINAHL were searched for articles describing gastrointestinal endoscopy-associated infections and outbreaks published from 2008 to 2018. Factors contributing to their occurrence, and the outcomes of each outbreak were also examined.

RESULTS

This review found 18 articles, 16 of which described duodenoscope-associated infections, and the remaining two described colonoscope- and gastroscope-associated infection respectively. Outbreaks were reported from the United States, France, China, Germany, the Netherlands and the United Kingdom. The causative organisms reported were Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli and Salmonella enteritidis.

CONCLUSIONS

A number of factors, including lapses in reprocessing, biofilm formation, endoscope design issues and endoscope damage, contribute to gastrointestinal endoscopy associated infection. Methods of improving endoscope reprocessing, screening for contamination and evaluating endoscope damage may be vital to preventing future infections and outbreaks.

Occupation-associated health hazards for the gastroenterologist/endoscopist

Advances in the field of endoscopy have allowed gastroenterologists to obtain detailed imaging of anatomical structures and to treat gastrointestinal diseases with endoscopic therapies. However, these technological developments have exposed endoscopists and staff to hazards such as musculoskeletal injuries, exposure to infectious agents, and ionizing radiation. We aimed to review the occupational hazards for the gastroenterologist and endoscopist. Using PubMed, Medline, Medscape, and Google Scholar, we identified peer-reviewed articles with the keywords “occupational hazards,” “health hazards,” “occupational health hazards,” “endoscopy,” “gastroenterologist,” “infectious agents,” “musculoskeletal injuries,” and “radiation.” Strategies for reducing exposure to infectious agents, radiation, and the risk of musculoskeletal injuries related to gastroenterology include compliance with established standard measures, the use of thyroid shields and radioprotective eyewear, and ergonomic practices. We conclude that educating endoscopic personnel and trainees in these practices, in addition to further research in these areas, will likely lead to the development of more efficient and user-friendly workspaces that are safer for patients and personnel.

Bacterial presence on flexible endoscopes vs time since disinfection

AIM

To correlate the length of endoscope hang time and number of bacteria cultured prior to use.

METHODS

Prospectively, we cultured specimens from 19 gastroscopes, 24 colonoscopes and 5 side viewing duodenoscopes during the period of 2011 to 2015. A total of 164 results had complete data denoting date of cleansing, number of days stored and culture results. All scopes underwent initial cleaning in the endoscopy suite utilizing tap water, and then manually cleaned and flushed. High level disinfection was achieved with a Medivator^© DSD (Medivator Inc., United States) automated endoscope reprocessor following manufacturer instructions, with Glutacide^® (Pharmax Limited, Canada), a 2% glutaraldehyde solution. After disinfection, all scopes were stored in dust free, unfiltered commercial cabinets for up to 7 d. Prior to use, all scopes were sampled and plated on sheep blood agar for 48 h; the colony count was obtained from each plate. The length of endoscope hang time and bacterial load was analyzed utilizing unpaired t-tests. The overall percentage of positive and negative cultures for each type of endoscope was also calculated.

RESULTS

All culture results were within the acceptable range (less than 200 cfu/mL). One colonoscope cultured 80 cfu/mL after hanging for 1 d, which was the highest count. ERCP scopes cultured at most 10 cfu, this occurred after 2 and 7 d, and gastroscopes cultured 50 cfu/mL at most, at 1 d. Most cultures were negative for growth, irrespective of the length of hang time. Furthermore, all scopes, with the exception of one colonoscope which had two positive cultures (each of 10 cfu/mL), had at most one positive culture. There was no significant difference in the number of bacteria cultured after 1 d compared to 7 d when all scopes were combined (day 2: P = 0.515; day 3: P = identical; day 4: P = 0.071; day 5: P = 0.470; day 6: P = 0.584; day 7: P = 0.575). There was also no significant difference in the number of bacteria cultured after 1 day compared to 7 d for gastroscopes (day 2: P = 0.895; day 3: P = identical; day 4: P = identical; day 5: P = 0.893; day 6: P = identical; day 7: P = 0.756), colonoscopes (day 2: P = 0.489; day 4: P = 0.493; day 5: P = 0.324; day 6: P = 0.526; day 7: P = identical), or ERCP scopes (day 2: P = identical; day 7: P = 0.685).

CONCLUSION

There is no correlation between hang time and bacterial load. Endoscopes do not need to be reprocessed if reused within a period of 7 d.

Endoscope drying and its pitfalls

Inadequate drying of endoscope channels is a possible cause of replication and survival of remaining pathogens during storage. The presence during storage of potentially contaminated water in endoscope channels may promote bacterial proliferation and biofilm formation. An incomplete drying procedure or lack of drying and not storing in a vertical position are the most usual problems identified during drying and endoscope storage. Inadequate drying and storage procedures, together with inadequate cleaning and disinfection, are the most important sources of endoscope contamination and post-endoscopic infection. Flexible endoscopes may be dried in automated endoscope reprocessors (AERs), manually, or in drying/storage cabinets. Flushing of the endoscope channels with 70-90% ethyl or isopropyl alcohol followed by forced air drying is recommended by several guidelines. Current guidelines recommend that flexible endoscopes are stored in a vertical position in a closed, ventilated cupboard. Drying and storage cabinets have a drying system that circulates and forces the dry filtered air through the endoscope channels. Endoscope reprocessing guidelines are inconsistent with one another or give no exact recommendations about drying and storage of flexible endoscopes. There is no conclusive evidence on the length of time endoscopes can be safely stored before requiring re-disinfection and before they pose a contamination risk. To minimize the risk of disease transmission and nosocomial infection, modification and revision of guidelines are recommended as required to be consistent with one another.

Adenosine triphosphate bioluminescence for bacteriologic surveillance and reprocessing strategies for minimizing risk of infection transmission by duodenoscopes

BACKGROUND AND AIMS

Recent outbreaks of duodenoscope-transmitted infections underscore the importance of adequate endoscope reprocessing. Adenosine triphosphate (ATP) bioluminescence testing allows rapid evaluation of endoscopes for bacteriologic/biologic residue. In this prospective study we evaluate the utility of ATP in bacteriologic surveillance and the effects of endoscopy staff education and dual cycles of cleaning and high-level disinfection (HLD) on endoscope reprocessing.

METHODS

ATP bioluminescence was measured after precleaning, manual cleaning, and HLD on rinsates from suction-biopsy channels of all endoscopes and elevator channels of duodenoscopes/linear echoendoscopes after use. ATP bioluminescence was remeasured in duodenoscopes (1) after re-education and competency testing of endoscopy staff and subsequently (2) after 2 cycles of precleaning and manual cleaning and single cycle of HLD or (3) after 2 cycles of precleaning, manual cleaning, and HLD.

RESULTS

The ideal ATP bioluminescence benchmark of <200 relative light units (RLUs) after manual cleaning was achieved from suction-biopsy channel rinsates of all endoscopes, but 9 of 10 duodenoscope elevator channel rinsates failed to meet this benchmark. Re-education reduced RLUs in duodenoscope elevator channel rinsates after precleaning (23,218.0 vs 1340.5 RLUs, P < .01) and HLD (177.0 vs 12.0 RLUs, P < .01). After 2 cycles of manual cleaning/HLD, duodenoscope elevator channel RLUs achieved levels similar to sterile water, with corresponding negative cultures.

CONCLUSIONS

ATP testing offers a rapid, inexpensive alternative for detection of endoscope microbial residue. Re-education of endoscopy staff and 2 cycles of cleaning and HLD decreased elevator channel RLUs to levels similar to sterile water and may therefore minimize the risk of transmission of infections by duodenoscopes.

Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators

The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification.

Evolutionary clade affects resistance of Clostridium difficile spores to Cold Atmospheric Plasma

Clostridium difficile is a spore forming bacterium and the leading cause of colitis and antibiotic associated diarrhoea in the developed world. Spores produced by C. difficile are robust and can remain viable for months, leading to prolonged healthcare-associated outbreaks with high mortality. Exposure of C. difficile spores to a novel, non-thermal atmospheric pressure gas plasma was assessed. Factors affecting sporicidal efficacy, including percentage of oxygen in the helium carrier gas admixture, and the effect on spores from different strains representing the five evolutionary C. difficile clades was investigated. Strains from different clades displayed varying resistance to cold plasma. Strain R20291, representing the globally epidemic ribotype 027 type, was the most resistant. However all tested strains displayed a ~3 log reduction in viable spore counts after plasma treatment for 5 minutes. Inactivation of a ribotype 078 strain, the most prevalent clinical type seen in Northern Ireland, was further assessed with respect to surface decontamination, pH, and hydrogen peroxide concentration. Environmental factors affected plasma activity, with dry spores without the presence of organic matter being most susceptible. This study demonstrates that cold atmospheric plasma can effectively inactivate C. difficile spores, and highlights factors that can affect sporicidal activity.

Risk of infection transmission in curvilinear array echoendoscopes: results of a prospective reprocessing and culture registry

BACKGROUND AND AIMS

The complex design of the elevator mechanism in duodenoscopes has been recognized as a challenge for disinfection and recently implicated as a potential source of persistent bacterial contamination. Curvilinear array (CLA) echoendoscopes also have an elevator mechanism; however, there are no recommendations or data regarding the risk of persistent bacterial contamination of echoendoscopes. Here we hoped to determine the yield of microbial growth with routine bacterial surveillance cultures of reprocessed CLA echoendoscopes.

METHODS

Beginning in February 2015 to February 2016, CLA echoendoscopes at a single tertiary care center underwent prospective bacterial surveillance cultures after reprocessing. Any growth of gram-negative bacilli was considered to be critical. Echoendoscopes with a positive result underwent quarantine followed by repeat disinfection and culture.

RESULTS

During the study period, 540 cultures were obtained; 521 (96.5%) were primary cultures obtained from 18 CLA echoendoscopes. Twenty-two primary cultures (4.2%) were positive for gram-negative bacilli after high-level disinfection reprocessing. Eleven different bacteria were isolated: Klebsiella pneumoniae, Citrobacter freundii, Escherichia coli, Pseudomonas aeruginosa, Klebsiella oxytoca, Sphingomonas paucimobilis, Acinetobacter baumanii, Enterobacter cloacae, Hafnia alvei, Pseudomonas putida, and Stenotrophomonas maltophilia. Antibiotic sensitivity data on 19 of 24 bacteria (79.2%) isolated from positive primary cultures revealed no documented cases of carbapenem-resistant enterobacteriaceae, cephalosporin-resistant-Klebsiella, or multidrug-resistant Acinetobacter. There have been no documented cases of patient-to-patient transmission.

CONCLUSIONS

After following standard high-level disinfection and reprocessing, CLA echoendoscopes can remain culture positive for high-concern organisms. Recommendations regarding infection risk should take into consideration elevator-containing echoendoscopes in addition to duodenoscopes to ensure patient safety and endoscope reprocessing efficacy.

Prophylaxis of post-ERC infectious complications in patients with biliary obstruction by adding antimicrobial agents into ERC contrast media- a single center retrospective study

Background

Patients with biliary obstruction are at high risk to develop septic complications after endoscopic retrograde cholangiography (ERC). We evaluated the benefits of local application of antimicrobial agents into ERC contrast media in preventing post-ERC infectious complications in a high-risk study population.

Methods

Patients undergoing ERC at our tertiary referral center were retrospectively included. Addition of vancomycin, gentamicin and fluconazol into ERC contrast media was evaluated in a case-control design. Outcomes comprised infectious complications within 3 days after ERC.

Results

In total, 84 ERC cases were analyzed. Primarily indications for ERC were sclerosing cholangitis (75%) and malignant stenosis (9.5%). Microbial testing of collected bile fluid in the treatment group was positive in 91.4%. Detected organisms were sensitive to the administered antimicrobials in 93%. The use of antimicrobials in contrast media was associated with a significant decrease in post-ERC infectious complications compared to non-use (14.3% vs. 33.3%; odds ratio [OR]: 0.33, 95% confidence interval [CI]: 0.114–0.978). After adjusting for the variables acute cholangitis prior to ERC and incomplete biliary drainage, the beneficial effect of intraductal antibiotic prophylaxis was even more evident (OR = 0.153; 95% CI: 0.039–0.598, p = 0.007). Patients profiting most obviously from intraductal antimicrobials were those with secondary sclerosing cholangitis.

Conclusion

Local application of a combination of antibiotic and antimycotic agents to ERC contrast media efficiently reduced post-ERC infectious events in patients with biliary obstruction. This is the first study that evaluates ERC-related infectious complications in patients with secondary sclerosing cholangitis. Our first clinical results should now be prospectively evaluated in a larger patient cohort to improve the safety of ERC, especially in patients with secondary sclerosing cholangitis.

Disposable Bronchoscope Model for Simulating Endoscopic Reprocessing and Surveillance Cultures

BACKGROUND Endoscope-associated infections are reported despite following proper reprocessing methods. Microbiological testing can confirm the adequacy of endoscope reprocessing. Multiple controversies related to the method and interpretation of microbiological testing cultures have arisen that make their routine performance a complex target. OBJECTIVE We conducted a pilot study using disposable bronchoscopes (DBs) to simulate different reprocessing times and soaking times and to compare high-level disinfection versus ethylene oxide sterilization. We also reviewed the time to reprocessing and duration of the procedures. METHODS Bronchoscopes were chosen because an alternative disposable scope is commercially available and because bronchoscopes are more prone to delays in processing. Disposable bronchoscopes were contaminated using a liquid bacterial suspension and were then incubated for 1-4 hours. Standard processing and high-level disinfection were performed on 36 endoscopes. Ethylene oxide sterilization was performed on 21 endoscopes. Endoscope cultures were performed using the standard "brush, flush, brush" technique. RESULTS After brushing was performed, a final water-flush culture procedure was the most effective method of detecting bacterial persistence on the disposable scopes. Klebsiella pneumoniae was the most commonly recovered organism after reprocessing. Ethylene oxide sterilization did not result in total elimination of viable bacteria. CONCLUSION Routine endoscopy cultures may be required to assess the adequacy of endoscopic processing. Infect Control Hosp Epidemiol 2017;38:136-142.

Screening for Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus, and Treponema pallidum by Blood Testing Using a Bio-Flash Technology-Based Algorithm before Gastrointestinal Endoscopy

Currently, conventional enzyme immunoassays which use manual gold immunoassays and colloidal tests (GICTs) are used as screening tools to detect Treponema pallidum (syphilis), hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus type 1 (HIV-1), and HIV-2 in patients undergoing surgery. The present observational, cross-sectional study compared the sensitivity, specificity, and work flow characteristics of the conventional algorithm with manual GICTs with those of a newly proposed algorithm that uses the automated Bio-Flash technology as a screening tool in patients undergoing gastrointestinal (GI) endoscopy. A total of 956 patients were examined for the presence of serological markers of infection with HIV-1/2, HCV, HBV, and T. pallidum The proposed algorithm with the Bio-Flash technology was superior for the detection of all markers (100.0% sensitivity and specificity for detection of anti-HIV and anti-HCV antibodies, HBV surface antigen [HBsAg], and T. pallidum) compared with the conventional algorithm based on the manual method (80.0% sensitivity and 98.6% specificity for the detection of anti-HIV, 75.0% sensitivity for the detection of anti-HCV, 94.7% sensitivity for the detection of HBsAg, and 100% specificity for the detection of anti-HCV and HBsAg) in these patients. The automated Bio-Flash technology-based screening algorithm also reduced the operation time by 85.0% (205 min) per day, saving up to 24 h/week. In conclusion, the use of the newly proposed screening algorithm based on the automated Bio-Flash technology can provide an advantage over the use of conventional algorithms based on manual methods for screening for HIV, HBV, HCV, and syphilis before GI endoscopy.

Carbapenem-resistant Enterobacteriaceae and endoscopy: An evolving threat

BACKGROUND

Several clusters of Carbapenem-resistant Enterobacteriaceae (CRE) infections associated with contaminated endoscopes have recently been reported. Interim guidelines for mitigating endoscope-associated transmission have been proposed, but there has not been a systematic appraisal of CRE prevention practices.

METHODS

We conducted a systematic review of endoscope-associated CRE infection episodes, abstracting information on outbreak detection, mitigation, outcomes, and corrective steps taken to prevent recurrence.

RESULTS

Seven distinct outbreaks were identified in the published literature, and 5 of these were associated with duodenal endoscopy, with the remaining 2 associated with cystoscopy and ureteroscopy. Several investigators noted difficulties in cleaning protocols surrounding difficult to access components, such as the elevator on duodenoscopes. The published investigations did not report any failures of sterilization. It is unclear if routine reprocessing was ineffective, or difficult to execute properly.

CONCLUSIONS

Meticulous cleaning protocols and increased surveillance are necessary to prevent and detect future outbreaks of CRE and to determine whether more stringent measures, such as sterilization, are needed for duodenoscopes.

Methodological proposal for validation of the disinfecting efficacy of an automated flexible endoscope reprocessor

OBJECTIVE

to elaborate and apply a method to assess the efficacy of automated flexible endoscope reprocessors at a time when there is not an official method or trained laboratories to comply with the requirements described in specific standards for this type of health product in Brazil.

METHOD

the present methodological study was developed based on the following theoretical references: International Organization for Standardization (ISO) standard ISO 15883-4/2008 and Brazilian Health Surveillance Agency (Agência Nacional de Vigilância Sanitária - ANVISA) Collegiate Board Resolution (Resolução de Diretoria Colegiada - RDC) no. 35/2010 and 15/2012. The proposed method was applied to a commercially available device using a high-level 0.2% peracetic acid-based disinfectant.

RESULTS

the proposed method of assessment was found to be robust when the recommendations made in the relevant legislation were incorporated with some adjustments to ensure their feasibility. Application of the proposed method provided evidence of the efficacy of the tested equipment for the high-level disinfection of endoscopes.

CONCLUSION

the proposed method may serve as a reference for the assessment of flexible endoscope reprocessors, thereby providing solid ground for the purchase of this category of health products.

OBJETIVO

propor e aplicar um método para a avaliação da eficácia de processadoras automáticas de endoscópios flexíveis, em um momento em que ainda não existe no Brasil um método oficial, nem tampouco laboratórios capacitados que contemplem os requisitos das normas específicas aplicáveis a esse tipo de produto para a saúde.

MÉTODO

caracterizou-se como pesquisa metodológica e foi desenvolvido com base em três referenciais teóricos: norma técnica International Organization for Standardization (ISO) - ISO 15883-4/2008, Resolução de Diretoria Colegiada (RDC) nº35/2010 e RDC nº15/2012 da Agência Nacional de Vigilância Sanitária (ANVISA). Aplicou-se o método proposto em um equipamento específico, comercialmente disponível, utilizando desinfetante de alto nível à base de ácido peracético 0,2%.

RESULTADOS

o método de avaliação proposto mostrou-se robusto, à medida que as recomendações das legislações pertinentes ao equipamento avaliado foram incorporadas, com algumas adaptações para sua exequibilidade. A aplicação do método proposto permitiu atestar a eficácia do equipamento utilizado na desinfecção de alto nível de endoscópios.

CONCLUSÃO

o método pode servir de referência para a avaliação de reprocessadoras de endoscópios flexíveis, subsidiando a aquisição dessa categoria de produtos para a saúde.

OBJETIVO

elaborar y aplicar un método para evaluar la eficacia de reprocesadores automatizados de endoscopios flexibles en un momento en el que no hay un método oficial o laboratorios capacitados para cumplir con los requisitos descritos en las normas específicas para este tipo de producto para la salud en Brasil.

MÉTODO

el presente estudio metodológico fue desarrollado en base a las siguientes referencias teóricas: Organización Internacional de Normalización (International Organization for Standardization - ISO) norma ISO 15883-4/2008 y Agencia Nacional de Vigilancia de la Salud de Brasil (Agência Nacional de Vigilância Sanitária - ANVISA) Resolución del Directorio Colegiado (Resolução de Diretoria Colegiada - RDC) № 35/2010 y 15/2012. El método propuesto se aplicó a un dispositivo comercialmente disponible usando un desinfectante al 0,2% a base de ácido peracético de alto nivel.

RESULTADOS

el método de evaluación propuesto se evaluó como fuerte después de que las recomendaciones formuladas en la legislación pertinente se incorporaron con algunos ajustes para garantizar su factibilidad. La aplicación del método propuesto proporciona evidencia de la eficacia de los equipos de prueba para la desinfección de alto nivel de endoscopios.

CONCLUSIÓN

el método propuesto puede servir de referencia para la evaluación de reprocesadores de endoscopios flexibles, proporcionando de este modo bases sólidas para la compra de esta categoría de productos de salud.

Evaluating Quality and Adequacy of Gastrointestinal Samples Collected using Reusable or Disposable Forceps

Background

Sample quality of gastrointestinal endoscopic biopsies is of paramount importance for accurate histological diagnosis. Many veterinary practices use reusable forceps as a result of perceived decreased cost. With reusable forceps, it remains unknown whether sample quality declines with repeated use and becomes inferior to single‐use forceps and is therefore more or less cost effective than single‐use forceps.

Hypothesis/Objectives

The study hypothesis was that reusable forceps sample quality would deteriorate after repeated use as compared to single‐use forceps.

Animals

Sixty‐five dogs undergoing gastrointestinal endoscopy for diagnostic investigations at the Hospital for Small Animals, Edinburgh University.

Method

A prospective, pathologist‐blinded study comparing single‐use and reusable alligator standard cup biopsy forceps (Olympus 2.0 mm 1550 mm) with 5 randomized reusable forceps. Sample quality (stomach, duodenum, ileum, and colon) was assessed by a single pathologist using the WSAVA guidelines.

Results

There was no difference in the adequacy, depth, villi number, or crush artifact in the 4 intestinal areas between forceps type with at least 10, and up to 15, repeated uses of the reusable forceps.

Conclusions and clinical importance

This study demonstrates that reusable cup biopsy forceps provide equivalent biopsy quality after repeated uses to single‐use forceps and are cost effective at 10‐case use.

A novel self-propelled disposable colonoscope is effective for colonoscopy in humans (with video)

BACKGROUND AND AIMS

The self-propelled disposable colonoscope (SPDC) with a 360° view is designed to enhance visualization, minimize risks of perforation and infection transmission, and shorten operator training time associated with conventional colonoscopy (CC). We evaluated SPDC efficacy for cecal intubation and safety.

METHODS

Prospective patients presenting for colorectal cancer screening underwent SPDC immediately followed by CC. Initial patients necessary for SPDC operators to achieve proficiency comprised the training cohort. Subsequent enrolled patients comprised the study cohort. SPDC colonoscopy was performed up to the cecum, where anatomic landmarks were photographed and mucosal suction marks were placed. During SPDC withdrawal, polyps were recorded and similarly marked. On the second pass (by using CC), any potential mucosal damage and suction marks from the SPDC as well as polyps were recorded. Main endpoints included SPDC cecal intubation rates, confirmed by anatomic landmarks and residual marks seen on subsequent CC, and frequency and severity of adverse events and mucosal damage with SPDC. The secondary endpoint was subjective procedure proficiency, evaluated by the operator based on the training cohort. The tertiary endpoint was documenting pathologies visualized with SPDC.

RESULTS

Fifty-six of 58 enrolled subjects completed the study. Proficiency with SPDC was attained after 8 to 10 procedures. Cecal intubation was successful in 98.2% (55/56 subjects; 95% confidence interval [CI], 90.4%-99.9%), including 100% (95% CI, 90.7%-100%) of the study cohort and 94.4% (95% CI, 72.7%-99.9%) of the training cohort. No mucosal damage or adverse events were reported. SPDC detected 87.5% of polyps seen in tandem CC, including all polyps larger than 5 mm.

CONCLUSIONS

SPDC was highly successful, simple to use, and safe in achieving complete colonoscopy (cecal intubation). (

CLINICAL TRIAL REGISTRATION NUMBER

0692-12-TLV.).

Hygiene: The Looming Achilles Heel in Endoscopy

BACKGROUND

Since the late 1970s there have been sporadic reports of nosocomial infections linked to endoscopic procedures. Infections by multidrug-resistant organisms (MDRO) have an increasing impact on healthcare systems worldwide. Since 2010 outbreaks involving MDRO have been reported as a result of endoscopic retrograde cholangiopancreatography (ERCP) from the USA, France, Germany and the Netherlands.

METHODS

This article evaluates the recent outbreaks and developments and demonstrates a structural approach to how to prevent future infections. Current national and international guidelines were used as a basis for discussions.

RESULTS

In some cases insufficient cleaning or drying supported the outbreak. In the majority of cases, outbreaks occurred despite the apparently appropriate reprocessing protocols being in use. Microlesions were identified on a number of endoscopes, which supported the growth of bacteria and represented a vehicle for the transmission of infectious material. National official bodies responded with warnings. Manufacturers informed their customers accordingly. Separate, purpose-designed reprocessing rooms and a sufficient number of competent staff provide the structural quality for a safe reprocessing. The process quality includes a thorough cleaning of all endoscope channels and crucial instrument components, followed by an automated and validated reprocessing procedure. Strict adherence to manufacturers' recommendations is essential. The outcome quality should be evaluated by regular audits, validation of reprocessing procedures and microbiological surveillance. If outbreaks occur, a close co-operation with official bodies and manufacturers is essential.

CONCLUSION

Health care professionals and manufacturers should be aware of their responsibility to ensure patient safety. A structural approach is key in prevention of endoscopy-associated infections.

Clinical Practice Guidelines for Endoscope Reprocessing

Gastrointestinal endoscopy is effective and safe for the screening, diagnosis, and treatment of gastrointestinal disease. However, issues regarding endoscope-transmitted infections are emerging. Many countries have established and continuously revise guidelines for endoscope reprocessing in order to prevent infections. While there are common processes used in endoscope reprocessing, differences exist among these guidelines. It is important that the reprocessing of gastrointestinal endoscopes be carried out in accordance with the recommendations for each step of the process.

Infectious diseases linked to cross-contamination of flexible endoscopes

Flexible endoscopes are widely used to examine, diagnose, and treat medical disorders. While the risk of endoscopy-related transmission of infection is estimated to be very low, more health care-associated infections are related to contaminated endoscopes than to any other medical device. Flexible endoscopes can get highly contaminated with microorganisms, secretions and blood during use. The narrow lumens and multiple internal channels make the cleaning of flexible endoscopes a complex and difficult task. Despite the availability of international, national and local endoscope reprocessing guidelines, contamination and transmission of microorganisms continue to occur. These transmissions are mostly related to the use of defective equipment, endoscope reprocessing failures, and noncompliance with recommended guidelines. This article presents an overview of publications about case reports and outbreaks related to contamination of flexible endoscopes.

Superbugs on Duodenoscopes: the Challenge of Cleaning and Disinfection of Reusable Devices

Inadequate flexible endoscope reprocessing has been associated with infection outbreaks, most recently caused by carbapenem-resistant Enterobacteriaceae. Lapses in essential device reprocessing steps such as cleaning, disinfection/sterilization, and storage have been reported, but some outbreaks have occurred despite claimed adherence to established guidelines. Recommended changes in these guidelines include the use of sterilization instead of high-level disinfection or the use of routine microbial culturing to monitor efficacy of reprocessing. This review describes the current standards for endoscope reprocessing, associated outbreaks, and the complexities associated with both microbiological culture and sterilization approaches to mitigating the risk of infection associated with endoscopy.

Results from a Large-Scale Epidemiologic Look-Back Investigation of Improperly Reprocessed Endoscopy Equipment

Objective.

To determine whether improper high-level disinfection practices during endoscopy procedures resulted in bloodborne viral infection transmission.

Design.

Retrospective cohort study.

Setting.

Four Veterans Affairs medical centers (VAMCs).

Patients.

Veterans who underwent colonoscopy and laryngoscopy (ear, nose, and throat [ENT]) procedures from 2003 to 2009.

Methods.

Patients were identified through electronic health record searches and serotested for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Newly discovered case patients were linked to a potential source with known identical infection, whose procedure occurred no more than 1 day prior to the case patient's procedure. Viral genetic testing was performed for case/proximate pairs to determine relatedness.

Results.

Of 10,737 veterans who underwent endoscopy at 4 VAMCs, 9,879 patients agreed to viral testing. Of these, 90 patients were newly diagnosed with 1 or more viral bloodborne pathogens (BBPs). There were no case/proximate pairings found for patients with either HIV or HBV; 24 HCV case/proximate pairings were found, of which 7 case patients and 8 proximate patients had sufficient viral load for further genetic testing. Only 2 of these cases, both of whom underwent laryngoscopy, and their 4 proximates agreed to further testing. None of the 4 remaining proximate patients who underwent colonoscopy agreed to further testing. Mean genetic distance between the 2 case patients and 4 proximate patients ranged from 13.5% to 19.1%.

Conclusions.

Our investigation revealed that exposure to improperly reprocessed ENT endoscopes did not result in viral transmission in those patients who had viral genetic analysis performed. Any potential transmission of BBPs from colonoscopy remains unknown.

Results from a Large-Scale Epidemiologic Look-Back Investigation of Improperly Reprocessed Endoscopy Equipment

Objective.

To determine whether improper high-level disinfection practices during endoscopy procedures resulted in bloodborne viral infection transmission.

Design.

Retrospective cohort study.

Setting.

Four Veterans Affairs medical centers (VAMCs).

Patients.

Veterans who underwent colonoscopy and laryngoscopy (ear, nose, and throat [ENT]) procedures from 2003 to 2009.

Methods.

Patients were identified through electronic health record searches and serotested for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Newly discovered case patients were linked to a potential source with known identical infection, whose procedure occurred no more than 1 day prior to the case patient's procedure. Viral genetic testing was performed for case/proximate pairs to determine relatedness.

Results.

Of 10,737 veterans who underwent endoscopy at 4 VAMCs, 9,879 patients agreed to viral testing. Of these, 90 patients were newly diagnosed with 1 or more viral bloodborne pathogens (BBPs). There were no case/proximate pairings found for patients with either HIV or HBV; 24 HCV case/proximate pairings were found, of which 7 case patients and 8 proximate patients had sufficient viral load for further genetic testing. Only 2 of these cases, both of whom underwent laryngoscopy, and their 4 proximates agreed to further testing. None of the 4 remaining proximate patients who underwent colonoscopy agreed to further testing. Mean genetic distance between the 2 case patients and 4 proximate patients ranged from 13.5% to 19.1%.

Conclusions.

Our investigation revealed that exposure to improperly reprocessed ENT endoscopes did not result in viral transmission in those patients who had viral genetic analysis performed. Any potential transmission of BBPs from colonoscopy remains unknown.

Ensuring patient safety and optimizing efficiency during gastrointestinal endoscopy

The volume of outpatient gastrointestinal (GI) endoscopy has grown dramatically in the past three decades, fueled by advancing technologies and evolving payment policies. This magnifies the need to ensure high-quality, safe, and cost-effective endoscopic services. In recent years, publicized breaches in standards of care for GI endoscopy have intensified the focus on patient safety. Because of these patient safety concerns and changes in regulatory policies, some ambulatory surgery center surveyors and inspectors have held GI endoscopy suites to the same standards as hospital ORs. The American Society for Gastrointestinal Endoscopy and other endorsing organizations drafted the Guidelines for Safety in the Gastrointestinal Endoscopy Unit, which published in January 2014. These safety guidelines relevant to sedation, infection control, staffing, training, technical equipment, traffic patterns, and personal protective equipment differ from other published guidelines for the outpatient surgical setting.

High-level endoscope disinfection processes in emerging economies: financial impact of manual process versus automated endoscope reprocessing

BACKGROUND

The use of flexible endoscopes is growing rapidly around the world. Dominant approaches to high-level disinfection among resource-constrained countries include fully manual cleaning and disinfection and the use of automated endoscope reprocessors (AERs). Suboptimal reprocessing at any step can potentially lead to contamination, with consequences to patients and healthcare systems.

AIM

To compare the potential results of guideline-recommended AERs to manual disinfection along three dimensions - productivity, need for endoscope repair, and infection transmission risk in India, China, and Russia.

METHODS

Financial modelling using data from peer-reviewed published literature and country-specific market research.

FINDINGS

In countries where revenue can be gained through productivity improvements, conversion to automated reprocessing has a positive direct impact on financial performance, paying back the capital investment within 14 months in China and seven months in Russia. In India, AER-generated savings and revenue offset nearly all of the additional operating costs needed to support automated reprocessing.

CONCLUSION

Among endoscopy facilities in India and China, current survey-reported practices in endoscope reprocessing using manual soaking may place patients at risk of exposure to pathogens leading to infections. Conversion from manual soak to use of AERs, as recommended by the World Gastroenterology Organization, may generate cost and revenue offsets that could produce direct financial gains for some endoscopy units in Russia and China.

Guidelines for safety in the gastrointestinal endoscopy unit

Historically, safety in the gastrointestinal (GI) endoscopy unit has focused on infection control, particularly around the reprocessing of endoscopes. Two highly publicized outbreaks where the transmission of infectious agents were related to GI endoscopy have highlighted the need to address potential gaps along the endoscopy care continuum that could impact patient safety.

Flexible colonoscopy in mice to evaluate the severity of colitis and colorectal tumors using a validated endoscopic scoring system

The use of modern endoscopy for research purposes has greatly facilitated our understanding of gastrointestinal pathologies. In particular, experimental endoscopy has been highly useful for studies that require repeated assessments in a single laboratory animal, such as those evaluating mechanisms of chronic inflammatory bowel disease and the progression of colorectal cancer. However, the methods used across studies are highly variable. At least three endoscopic scoring systems have been published for murine colitis and published protocols for the assessment of colorectal tumors fail to address the presence of concomitant colonic inflammation. This study develops and validates a reproducible endoscopic scoring system that integrates evaluation of both inflammation and tumors simultaneously. This novel scoring system has three major components: 1) assessment of the extent and severity of colorectal inflammation (based on perianal findings, transparency of the wall, mucosal bleeding, and focal lesions), 2) quantitative recording of tumor lesions (grid map and bar graph), and 3) numerical sorting of clinical cases by their pathological and research relevance based on decimal units with assigned categories of observed lesions and endoscopic complications (decimal identifiers). The video and manuscript presented herein were prepared, following IACUC-approved protocols, to allow investigators to score their own experimental mice using a well-validated and highly reproducible endoscopic methodology.