Outbreak of ertapenem-resistant Enterobacter cloacae urinary tract infections due to a contaminated ureteroscope

Urinary Tract Infection Predictors in Patients Undergoing Retrograde IntraRenal Surgery for Renal Stones: Does the Instrument Make the Difference?

Background: Retrograde intrarenal surgery (RIRS) using flexible ureterorenoscopes is a cornerstone approach for renal stone removal, yet it carries a significant risk of postoperative urinary tract infection (UTI). With the emergence of single-use ureterorenoscopes, there is growing interest in their potential to mitigate this risk. This study aimed to compare the postoperative infection rates between single-use and multi-use ureterorenoscopes in RIRS procedures and to identify predictors of postoperative UTI. Methods: Data were collected from 112 consecutive patients who underwent RIRS for renal stones between March 2022 and September 2023. Peri-operative variables including age, gender, body mass index (BMI), stone size, stone location, type of ureterorenoscope, Hounsfield Units (HU), pre-operative hydronephrosis, laboratory analysis, and operative time were evaluated. Univariate and multivariate logistic regression analyses were performed to assess the predictors of postoperative UTI. Results: Of the cohort, 77 surgeries (68.7%) utilized multi-use ureterorenoscopes, while 35 (31.3%) utilized single-use devices. Stone diameter, number of stones, type of ureterorenoscope, and operative time were significant predictors of postoperative UTI in the univariate analysis. Multivariable logistic regression showed that operative time (OR, 1.3; 95% CI, 0.55-0.99; p = 0.03) and type of ureterorenoscope (multi-use vs. single-use) (OR, 1.14; 95% CI, 1.08-1.2; p < 0.001) were independent predictors of postoperative UTI. Conclusions: In conclusion, this study highlights that multi-use ureterorenoscopes and prolonged operative time are associated with an increased risk of postoperative UTI in RIRS procedures. Careful pre-operative evaluation and meticulous patient selection are essential to minimize the occurrence of postoperative UTIs and optimize patient outcomes in RIRS for renal stones.

Achromobacter species (sp.) outbreak caused by hospital equipment containing contaminated water: risk factors for infection

BACKGROUND

Nosocomial outbreaks of urinary tract infections caused by Achromobacter spp. have been rare in recent decades.

AIM

To identify the origin of an Achromobacter sp. outbreak, conduct multi-modal infection control measures, and finally to stop the outbreak. To this end, an epidemiological outbreak investigation and risk factor analysis were performed.

METHODS

Achromobacter sp. was detected in 22 patients in our urology wards and six environmental cultures of specimens obtained from the operating rooms. Strains isolated were submitted for antimicrobial susceptibility testing. An on-site epidemiological investigation, evaluation of patient medical records, and environmental sampling were performed to identify the source of the outbreak, and implementation of infection control intervention. A case-control study was performed to analyse the potential risk factors.

FINDINGS

Environmental sampling showed that the source of the infection for 22 patients was an ISA-IIIA-type medical pressurizer containing contaminated water. A case-control analysis showed that the risk factors for infection were: diagnosis of kidney/ureteral stones, surgery, placement of a double-J stent, and history of hospitalization in the past three months.

CONCLUSION

It was concluded that the outbreak occurred in patients who underwent internal lithotripsy and double-J stent placement, due to contact transmission with the contaminated sensor and connecting tubes of the ISA-IIIA-type medical pressurizer.

Comparing outcomes of single-use vs reusable ureteroscopes: a systematic review and meta analysis

Flexible ureterolithotripsy is a frequent urological procedure, usually used to remove stones from the kidney and upper ureter. Reusable uretero-scopes were the standard tool for that procedure, but recent concerns related to sterility and maintenance and repair costs created the opportunity to develop new technologies. In 2016, the first single-use digital flexible ureteroscope was introduced. Since then, other single-use ureteroscopes were developed, and studies compared them with the reusable ureteroscopes with conflicting results. The purpose of this study is to describe the literature that compares the performance of single-use and reusable flexible ureteroscopes in retrograde intrarenal surgery for urinary stones. A Systematic Review was performed in October 2022 in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). A search in MEDLINE, EMBASE, Web of Science, Google Scholar and LILACS retrieved 10,039 articles. After screening, 12 articles were selected for the Meta-Analysis. No differences were found in stone-free rate (OR 1.31, CI 95% [0.88, 1.97]), operative time (MD 0.12, CI 95% [-5.52, 5.76]), incidence of post-operative fever (OR 0.64, CI 95% [0.22, 1.89]), or incidence of post-operative urinary tract infection (OR 0.63 CI 95% [0.30, 1.32]). No differences were observed in the studied variables. Hence, the device choice should rely on the availability, cost analysis and surgeons' preference.

Diversity of MrTolls and their regulation of antimicrobial peptides expression during Enterobacter cloacae infection in Macrobrachium rosenbergii

Toll/Toll-like receptor (TLR) is an important pattern recognition receptor that plays an important role in the immunity of animals. Six Toll genes were identified in Macrobrachium rosenbergii, namely, MrToll, MrToll1, MrToll2, MrToll3, MrToll4, and MrToll5. SMART analysis showed that all six Tolls have a transmembrane domain, a TIR domain, and different number of LRR domains. The phylogenetic tree showed that six Tolls were located in six different branches. Among these six Tolls, only MrToll4 contains the QHR motif, which is similar to insect Toll9. MrToll4 belongs to V-type/scc Toll with only one LRRCT domain. MrToll1 and MrToll5 are classical P-type/mcc Toll with two LRRCT domains and an LRRNT. MrTolls were distributed in the hemocytes, heart, hepatopancreas, gills, stomach, and intestine. During the infection of Enterobacter cloacae, the expression level of MrToll and MrToll1-4 was upregulated in the intestine of M. rosenbergii. RNA interference experiments showed that the expression of most antimicrobial peptide (AMP) genes was negatively regulated by MrTolls during E. cloacae infection. On the contrary, crustin (Cru) 3 and Cru4 were inhibited after the knockdown of MrToll, and Cru1 and Cru4 were significantly downregulated with the knockdown of MrToll4 during E. cloacae challenge. These results suggest that MrTolls may be involved in the regulation of AMP expression in the intestine during E. cloacae infection.

Single use flexible ureteroscopes: Current status and future directions

Introduction

Single use ureteroscopes are a technological innovation that have become available in the past decade and gained increased popularity. To this end, there are now an increasing number of both benchside and clinical studies reporting outcomes associated with their use. Our aim was to deliver a narrative review in order to provide an overview of this new technology.

Methods

A narrative review was performed to gain overview of the history of the technology's development, equipment specifications and to highlight potential advantages and disadvantages.

Results

Findings from preclinical studies highlight potenial advantages in terms of the design of single use ureteroscopes such as the lower weight and more recent modifications such as pressure control. However, concerns regarding plastic waste and environmental impact still remain unanswered. Clinical studies reveal them to have a non inferior status for outcomes such as stone free rate. However, the volume of evidence, especially in terms of randomised trials remains limited. From a cost perspective, study conclusions are still conflicting and centres are recommended to perform their own micro cost analyses.

Conclusions

Most clinical outcomes for single use ureteroscopes currently match those achieved by reusable ureteroscopes but the data pool is still limited. Areas of continued debate include their environmental impact and cost efficiency.

Prospective Analysis of Versatility and User Satisfaction with a Novel Single-Use Cystoscope with Working Channel

INTRODUCTION

In the present study, a prospective systematic assessment of the clinical utility of the Ambu® aScopeTM 4 Cysto Reverse Deflection with regard to image quality, maneuverability, and navigation in an outpatient and inpatient setting was performed.

MATERIALS AND METHODS

A prospective multicenter study was performed for evaluation of the instrument during routine cystoscopy. We evaluated the clinical performance of the instruments using a standardized user questionnaire in different categories including image quality, treatment success, imaging of all areas of the urinary bladder, quality of navigation, flexibility of the endoscope, and satisfaction with the device. Statistical analyses were performed by SPSS using the Kruskal-Wallis and Wilcoxon-Mann-Whitney tests. A p value of p ≤ 0.05 was defined as statistically significant.

RESULTS

A total of 200 cystoscopies were performed, and the questionnaire response rate was 100%. The image quality was rated as very good in 65.5% (n = 131), good in 30.5% (n = 61), and neutral in 4% (n = 8) of cases. The criteria for poor or very poor were not mentioned. The characteristic "treatment success based on image quality" was also evaluated as very good in 49% (n = 98) and good in 50.5% (n = 101). The analysis revealed a very good or good overall impression of the examiners in all cases. Replacement of the cystoscope was not necessary during any of the examinations. However, in 3 cases, technical difficulties were documented. Further analysis of the data showed that physicians with less professional experience rated the visualization of the urinary bladder (p = 0.007) and the treatment success with regard to image quality significantly worse (p = 0.007).

CONCLUSION

The Ambu® aScope™ 4 Cysto Reverse Deflection shows high satisfaction values among users in clinical routine. In analogy to other studies with flexible endoscopes, urologists with more professional experience show higher satisfaction values than examiners with less training in flexible endoscopy.

Evaluation of cold atmospheric plasma for the decontamination of flexible endoscopes

BACKGROUND

Despite adherence to standard protocols, residues including live microorganisms may remain on the various surfaces of reprocessed flexible endoscopes. Prions are infectious proteins notoriously difficult to eliminate.

AIM

We tested the potential of cold atmospheric plasma (CAP) for the decontamination of flexible endoscope various surfaces, measuring total proteins and prion-residual infectivity as an indicator of efficacy.

METHODS

New PTFE endoscope channels and metal test surfaces spiked with test soil or prion-infected tissues were treated using different CAP-generating prototypes. Surfaces were then examined for the presence of residues using very sensitive fluorescence epi-microscopy. Prion residual infectivity was determined using the wire implant animal model and a new, more sensitive cell infectivity assay.

FINDINGS

A CAP jet applied perpendicularly at close range on flat test surfaces removed soil within 3 minutes but left microscopic residues and failed to eliminate prion infectivity according to the wire implant animal assay. The longitudinal gas flow from CAP prototypes developed for the treatment of long channels led to the displacement and sedimentation of residual soil towards the distal end, when applied alone. Observations of the plasma inside glass tubes showed temporal and spatial heterogeneity within a limited range. After standard enzymatic manual pre-wash, "CAP-activated" gas effluents prevented prion transmission from treated endoscope channels according to our prion infectivity cell assay.

CONCLUSION

CAP shows promising results as a final step for surgical surfaces decontamination. Optimising CAP delivery could further enhance CAP efficacy, offering a safe, chemical-free alternative for the reprocessing of all luminal flexible endoscope surfaces.

High-level disinfection evaluation in the ambulatory setting

High level disinfection (HLD) is a complex process, requiring appropriate materials and highly trained personnel. An investigation of the HLD process was performed at an outpatient urology practice upon notification of expired chemical test strips being utilized. Infection Prevention (IP) identified various breaches in the reprocessing of flexible cystoscopes and transrectal prostate biopsy probes. Contributing factors identified were gaps in staff training, availability of all necessary supplies and staff supervision.

Borescope Examination and Microbial Culture Results of Endoscopes in a Tertiary Care Hospital Led to Changes in Storage Protocols to Improve Patient Safety

BACKGROUND

Flexible endoscopes are highly versatile and useful medical instruments, and their proper reprocessing is critical to patient health and safety. The value of routine visual inspections and surveillance of endoscopes in a tertiary care hospital was assessed by performing borescope examinations and microbial sampling on respiratory, gastro-intestinal (GI), and urological endoscopes.

METHODS

A total of 42 endoscopes were cultured, and 36 endoscopes were examined with a borescope. The flush-brush-flush method was used to culture the endoscopes. Microbiologic sampling water was vortexed prior to being suctioned through a membrane filter device. The membrane was plated on a blood agar plate and incubated at 37°C for 48 hours. A 1.9-meter borescope with a 1.6mm diameter was used to perform borescope examinations in an antegrade and retrograde approach.

RESULTS

Positive microbial cultures were seen in 28% of bronchoscopes, 22% of GI endoscopes, and 30% of urological endoscopes. Only Gram-positive colonies were identified in endoscopes that had microbial growth. Borescope examinations revealed multiple abnormalities and damage including channel shredding, filamentous debris, water retention, discoloration, dents, and red particles.

CONCLUSIONS

Borescope examination and microbial sampling should be used routinely to assure endoscopic safety. Borescope examination enabled us to visualize structural damage, foreign material, and moisture within endoscopes. The structural damages and the particles found in endoscopes resulted in timely repair and discontinuation of this type of distal end protectors in our facility.

WiScope® single use digital flexible ureteroscope versus reusable flexible ureteroscope for management of renal stones: a prospective randomized study

OBJECTIVES

To compare the clinical performance and surgical outcomes of the new digital single use flexible ureteroscope (WiScope^®) with a reusable digital flexible ureteroscope.

PATIENT AND METHODS

Our prospective study includes patients with renal stones less than 2 cm who underwent retrograde flexible ureteroscopy and laser lithotripsy. Patients were randomized into two groups: group A included patients who underwent laser lithotripsy using WiScope^® Single use digital flexible ureteroscope and group B included patients who underwent laser lithotripsy using reusable flexible ureteroscope. Image quality, deflection, ease of insertion, maneuverability, and overall performance were assessed using either a visual analog or Likert scale. Operative outcomes and complications were collected and analyzed in both groups.

RESULTS

A total of 242 patients were included in our study. There were 121 patients in the WiScope^® group and 121 patients in reusable ureteroscope group. The WiScope^® had higher maneuverability (9.3 ± 0.7 vs. 7.2 ± 0.8, P < 0.001) and less limb fatigue but had lower image quality when compared to reusable digital flexible ureteroscope (7.6 ± 0.9 vs. 9.2 ± 0.6, P < 0.001). There were no differences in operative time, complication rates and rates of relook ureteroscopy.

CONCLUSIONS

The WiScope^® single use flexible ureteroscope has comparable outcomes to the reusable flexible ureteroscope with regard to maneuverability, limb fatigue, and deflection. However, it has a lower image quality.

An outbreak of postoperative rapidly developing and multidrug-resistant Klebsiella pneumoniae urosepsis due to a contaminated ureteroscope

INTRODUCTION

Outbreaks caused by microorganisms contaminating the inside of rigid ureteroscopes are extremely rare. Some of these outbreaks, especially those caused by multidrug-resistant (MDR) infections, can cause serious problems, even death. Among these serious infections, we have no data about Klebsiellapneumoniae outbreaks caused by rigid ureteroscopes and their management and consequences.

Repair Rate and Associated Costs of Reusable Flexible Ureteroscopes: A Systematic Review and Meta-analysis

CONTEXT

The refined mechanics of a flexible ureteroscope (fURS) are vulnerable to damage. Sending the fURS for repair is costly and has driven interest toward estimating the resources used for fURS repairs.

OBJECTIVE

To systematically review available literature and to estimate the total weighted repair rate of an fURS and the average repair cost per ureteroscopy.

EVIDENCE ACQUISITION

A systematic review was conducted by searching the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The average costs of all repairs identified in the included studies were extracted. A random-effect model was used to calculate the pooled total fURS repair rate. The total weighted repair rate and average cost per repair were multiplied to provide an average cost of repair per ureteroscopy procedure.

EVIDENCE SYNTHESIS

We identified 18 studies that fulfilled the inclusion criteria, which included 411 repairs from 5900 investigated ureteroscopy procedures. The calculated weighted repair rate was 6.5% ± 0.745% (95% confidence interval: 5.0-7.9%; I2 = 75.3%), equivalent to 15 ureteroscopy procedures before repair. The average cost per repair was 6808 USD; according to the weighted repair rate of 6.5%, this corresponds to an average repair cost of 441 USD per procedure. Egger's regression test did not reveal a significant publication bias (p = 0.07).

CONCLUSIONS

This is the first meta-analysis to estimate the repair rate of the fURS used for ureteroscopy. Our analysis demonstrates a repair rate of 6.5%, equivalent to 15 ureteroscopy procedures between fURS repairs and a repair cost of 441 USD per procedure. Ureteroscopy practices should consider fURS breakage rates and repair costs to optimize the use of reusable versus disposable devices.

PATIENT SUMMARY

We reviewed available literature investigating the repair rate of a flexible ureteroscope (fURS). We found that fURSs are sent for repair after every 15 ureteroscopy procedures, corresponding to 441 USD per procedure in repair cost.

Molecular Epidemiology, Risk Factors and Clinical Outcomes of Carbapenem-Nonsusceptible Enterobacter cloacae Complex Infections in a Taiwan University Hospital

The genus Enterobacter is a member of the ESKAPE group, which contains the major resistant bacterial pathogens. Enterobacter cloacae complex (ECC) has emerged as a clinically significant cause of a wide variety of nosocomial infections. Carbapenem-nonsusceptible Enterobacter cloacae complex (CnsECC) has become an emerging threat to public health but there is still a lack of comprehensive molecular and clinical epidemiological analysis. A total of 157 CnsECC isolates were recovered during October 2011 to August 2017. hsp60 gene sequencing and pulsed-field gel electrophoresis (PFGE) were applied to discriminate the species, genetic clusters and clonal relatedness. All the isolates were subjected to polymerase chain reaction (PCR) analysis for carbapenemase, AmpC-type β-lactamase, and extended spectrum β-lactamase (ESBL) genes. Clinical data were collected on all patients for comparing clinical risks and outcomes between patients with carbapenemase-producing (CP)-CnsECC compared with non-CP-CnsECC infection. The most commonly identified species was E. hormaechei subsp. hoffmannii (47.1%), followed by E. hormaechei subsp. steigerwaltii (24.8%). Different species of CnsECC isolates showed heterogeneity in resistance patterns to piperacillin/tazobactam, cefepime and levofloxacin. In the present study, we observed that E. hormaechei subsp. hoffmannii was characterized with higher cefepime and levofloxacin resistance rate but lower piperacillin/tazobactam resistance rate relative to other species of CnsECC. CP-CnsECC comprised 41.1% (65 isolates) and all of these isolates carried IMP-8. In this study, 98% of patients had antimicrobial therapy prior to culture, with a total of 57/150 (38%) patients being exposed to carbapenems. Chronic pulmonary disease (OR: 2.51, 95% CI: 1.25–5.06), received ventilator support (OR: 5.54, 95% CI: 2.25–12.03), steroid exposure (OR: 3.88, 95% CI: 1.91–7.88) and carbapenems exposure (OR: 2.17, 95% CI: 1.10–4.25) were considered risk factors associated with CP-CnsECC infection. The results suggest that CP-CnsECC are associated with poorer outcomes including in-hospital mortality, 30-day mortality and 100-day mortality. Our study provides insights into the epidemic potential of IMP-8-producing E. cloacae for healthcare-associated infections and underscores the importance of understanding underlying resistance mechanisms of CnsECC to direct antibiotic treatment decisions.

Comparison of a single-use, digital flexible ureteroscope with a reusable, fiberoptic ureteroscope for management of patients with urolithiasis

OBJECTIVES

Ureteroscopy is one of the commonest procedures performed to manage urolithiasis. Flexible ureteroscopy has been traditionally based on reusable, fiber-optic ureteroscopes. Technology advancements permitted the development of single-use scopes with digital image. The aim of this study is to compare efficacy and safety between a reusable, fiberoptic ureteroscope with a single-use, digital scope.

PATIENTS AND METHODS

We collected data based on chart review from a prospectively collected database on a tertiary, high-volume hospital in Greece. Baseline, perioperative and postoperative data were gathered and analyzed. Chi-square and Fisher's exact test was used to compare qualitative data and unpaired t-test for continuous data, with a statistical significance set at a = 0.05.

RESULTS

40 patients underwent flexible ureteroscopy with a single- use digital scope, while 37 with the reusable scope. The two groups were matched regarding baseline characteristics and stone-related parameters. After data analysis, a shorter operative time in favor of single-use flexible ureteroscope was detected (45 vs 65 min, p = 0.001), while safety was also in favor of this type of scope with a significantly higher immediate stonefree rate (70% vs 43%, p = 0.005). Overall complications did not differ between the two groups, although a lower sepsis rate was detected in patients treated with single-use scope.

CONCLUSIONS

Our findings indicate that single-use, digital ureteroscopes are a viable alternative for flexible ureteroscopy and management of urolithiasis, especially in centers with deficient facilities for sterilization and ensured funds for more expensive reusable scopes.

Evolution of Single-Use Urologic Endoscopy: Benchtop and Initial Clinical Assessment of a New Single-Use Flexible Cystoscope

Introduction Office cystoscopy is one of the most frequently performed procedures by a urologist. However, single-use cystoscopes remain quite undeveloped. Ambu® has developed single-use broncoscopes, rhinolaryngoscopes and duodenoscopes. Recently, they released a single-use cystoscope. In this study, we performed a benchtop and initial clinical assessment of the Ambu® aScope™ (4) Cysto single-use cystoscope. Methods Ten new, never-used Ambu® aScope™ (4) Cysto single-use cystoscopes were assessed for optical performance, maximal tip flexion and irrigation flow rate with empty working channel, 365μm laser fiber, 0.035in hydrophilic-tipped wire, 1.9Fr nitinol basket and a 1.8mm flexible stent grasper. All cystoscopes were then fully flexed 25 times in each direction, and maximal flexion angles were re-measured with and without instruments. Optical resolution, distortion, and depth of field was measured and compared to our reusable digital flexible cystoscopes. Assessment of clinical use was performed for inpatient bedside procedures using a Likert feedback survey and the NASA Task-Load-Index. Results Maximal upward flexion exceeded 200^○ and 160^○ for all working instruments in upward and downward flexion. Downward flexion demonstrated different flexion between instrument groups in pre- and post-cycling (p<0.001). There was no clinical difference between the pre- or post-cycling flexion. Flow rate decreased with increasing working instrument size (p<0.001). The Olympus HD cystoscope resolution was superior at 3mm and 5mm distance, but not at other distances. The Ambu® scope was superior to the Olympus SD scope at all distances except 3mm. The aScope™ (4) Cysto had higher Likert scale survey scores for clinical use. Conclusions The new Ambu® single-use cystoscope demonstrates good flexion across instruments and comparable optics to reusable cystoscopes. Additionally, initial inpatient bedside use of the aScope™ (4) Cysto and Monitor system compares favorably to the Olympus reusable cystoscope. Further testing in clinical scenarios such as hematuria, urothelial carcinoma and operative endoscopy is warranted.

Current antibiotic resistance patterns of rare uropathogens: survey from Central European Urology Department 2011-2019

BACKGROUND

While the resistance rates of commonly detected uropathogens are well described, those of less frequent Gram-negative uropathogenic bacteria have seldom been reported. The aim of this study was to examine the resistance rates of less frequent uropathogenic Gram-negatives in a population of patients treated in a Department of Urology of a tertiary referral centre in Central Europe over a period of 9 years.

METHODS

Data on all positive urine samples from urological in- and out-patients were extracted form the Department of Clinical Microbiology database from 2011 to 2019. Numbers of susceptible and resistant isolates per year were calculated for these uropathogens: Acinetobacter spp. (n = 74), Citrobacter spp. (n = 60), Enterobacter spp. (n = 250), Morganella morganii (n = 194), Providencia spp. (n = 53), Serratia spp. (n = 82) and Stenotrophomonas maltophilia (n = 27). Antimicrobial agents selected for the survey included: ampicillin, amoxicillin/clavulanic acid, piperacillin/tazobactam; cefuroxime, cefotaxime, ceftazidime and cefepime; ciprofloxacin and ofloxacin; gentamicin and amikacin; ertapenem, meropenem and imipenem; trimethoprim-sulfamethoxazole (co-trimoxazole), nitrofurantoin and colistin.

RESULTS

Penicillin derivatives have generally poor effect except piperacillin/tazobactam. Cefuroxime is not efficient unlike cefotaxime (except against Acinetobacter spp. and S. maltophilia). Susceptibility to fluoroquinolones is limited. Amikacin is somewhat more efficient than gentamicine but susceptibilities for both safely exceed 80%. Nitrofurantoin shows virtually no efficiency. Cotrimoxazole acts well against Citrobacter spp., Serratia spp. and it is the treatment of choice for S. maltophilia UTIs. Among carbapenems, ertapenem was less efficient than meropenem and imipenem except for S. maltophilia whose isolates were mostly not suceptible to any carbapenems.

CONCLUSIONS

Uropathogenic microorganisms covered in this report are noteworthy for their frequently multi-drug resistant phenotypes. Knowledge of resistance patterns helps clinicians choose the right empirical antibiotic treatment when the taxonomical assignment of the isolate is known but sensitivity results are pending.

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.

Disposable versus Reusable Ureteroscopes: A Prospective Multicenter Randomized Comparison

Purpose

To compare reusable and disposable flexible ureteroscopes in terms of efficacy and safety for patients undergoing Retrograde Intrarenal Surgery (RIRS).

Patients and Methods

Patients with a renal stone eligible for RIRS were enrolled in this multicenter, randomized, clinical trial study. Patients were randomized into two groups: group A (90 patients) underwent RIRS with a reusable flexible ureteroscope and group B (90 patients) were treated with a disposable one.

Results

The patients’ demographics, stone features and pre-operative urine cultures were comparable between the groups. The Stone Free Rates (SFRs) were not significantly different (86.6% and 90.0% for group A and group B, respectively, p=0.11) and the mean cost for each procedure was comparable (2321 € in group A vs 2543 € in group B, p=0.09). However, the days of hospitalization and of antibiotic therapy were higher in group A (p ≤ 0.05). The overall complication rate in group A was 8.8% whilst in group B it was 3.3% (p ≤ 0.05); in particular, group A exhibited a greater number of major complications (Clavien score IIIa-V). The overall postoperative infection rate was 16.6% in group A and 3.3% in group B (p ≤ 0.05). Furthermore, none of the patients in group B developed urosepsis or had a positive blood culture, while 3 patients in group A did (p<0.05).

Conclusion

The use of disposable ureteroscopes is characterized by significantly lower post-operative complications and infection rates, while having comparable costs and SFRs vis à vis reusable ureteroscopes. Clinical Trial Registration Number: ISRCTN92289221.

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.

A Single-Center Prospective Comparative Study of Two Single-Use Flexible Ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China)

Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to compare in vivo performance and surgical outcomes with two single-use ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China) with secondary objective being to compare in vivo vision by independent endourologist blinded to ureteroscope manufacturer. Materials and Methods: Fifty patients undergoing retrograde intrarenal surgery with <2 cm renal stones were prospectively allocated: Group 1 (25 patients) for LithoVue and group 2 (25 patients) for Uscope. Pre-, intra-, and postoperative parameters were evaluated. Vision of both ureteroscopes with and without accessory was evaluated by an independent endourologist, blinded to the make of the ureteroscope. Stone clearance was assessed with kidney, ureter, and bladder radiograph (KUB) and ultrasonography KUB at 1 month. Student's t-test for quantitative and chi-square for categorical data was used. Results: Pre- and intraoperative parameters such as need for ureteral dilatation (p > 0.05), ureteral access-sheath size (p = 0.78), accessibility to pelvicaliceal system (p > 0.05), and maneuverability (p > 0.05) were comparable in both groups. Lower-pole access was possible in all cases of LithoVue and slightly difficult in three cases of Uscope (p > 0.5). Intraoperative vision was hazy in four cases of LithoVue and eight cases of Uscope (p = 0.32) during lasing along with three cases of Uscope with accessory (p = 0.24). Blinded endourologist reported more cases of hazy vision with or without accessory or lasing in Uscope arm (p > 0.05). One device had malfunction in LithoVue arm. Complete stone clearance was achieved in all cases at 1 month. Conclusions: We conclude that performance of these two single-use ureteroscopes, LithoVue and Uscope, is comparable in clinical settings with similar clinical outcomes and complications.

Enterobacter cloacae infection of the shoulder in a 52-year-old woman without apparent predisposing risk factor: a case report and literature review

Background

Enterobacter cloacae (E. cloacae) is one of the commensal flora in the human intestinal tract and a prevalent nosocomial pathogen, which rarely causes infectious osteoarthritis in immunocompetent patients without recent trauma or surgery. Here, we report the first case of septic monoarthritis of the shoulder caused by E. cloacae in an immunocompetent patient.

Case presentation

A 52-year-old female with a 6-year history of right shoulder pain was referred to our emergency department due to fever, acute severe shoulder pain, and swelling. Blood test showed elevated inflammatory markers. The patient denied any recent invasive surgical procedure and trauma. She was misdiagnosed with a frozen shoulder, and the anti-inflammatory painkiller celecoxib for symptomatic treatment was ineffective. Magnetic resonance imaging (MRI) showed a shoulder joint abscess and supraspinatus tendon tear. The joint aspirate culture showed E. cloacae. After late diagnosis, she was treated with levofloxacin and underwent surgical debridement and irrigation. Her follow-up data revealed that she did not suffer from shoulder swelling and severe pain.

Conclusion

This is a rare case of E. cloacae infected arthritis of the shoulder in an immunocompetent patient with a rotator cuff tear, indicating that even if the symptoms and age of the patients match the characteristics of frozen shoulder, the possibility of septic arthritis should be considered in the presence of fever and increasing inflammatory markers. The cases of our literature review suggest that the patients subjected to invasive procedure may develop a subsequent E. cloacae osteoarticular infection, regardless of being asymptomatic after the procedure.

Benchtop Assessment of a New Single-Use Flexible Ureteroscope

Introduction: Single-use flexible ureteroscopes are an increasingly popular alternative to reusable ureteroscopes. In this study, we performed a benchtop examination of the physical and optical properties of the new Dornier Axis™ (Webling, Germany) single-use ureteroscope. Methods: Ten new, never-used Dornier Axis ureteroscopes were assessed for optical performance, maximal tip deflection, and irrigation flow rate with an empty working channel and with insertion of 200 and 365 μm laser fibers, and a 1.9F nitinol basket. All ureteroscopes were then fully deflected 100 times in each direction, and maximal deflection angles were re-measured with and without instruments in the working channel. All measurements were performed in duplicate. In vitro optical testing for resolution, image distortion, and depth of field was performed and compared vs the LithoVue™ (Boston Scientific, Marlborough, MA) single-use ureteroscope. Statistical analyses using paired Wilcoxon rank-sum tests and Kruskal-Wallis multiple-group comparison tests were performed in R. Results: Median maximal deflection angles exceeded 300° in both directions before and after 100 full deflection cycles for all groups except the 365 μm laser fiber group. After 100 deflection cycles, there was no change in the majority of working instruments, except a decrease in upward flexion with an empty channel and 200 μm Moses™ laser fiber, and downward flexion with 200 μm Flexiva™ laser fiber (all <10°). After excluding the 365 μm fiber, there was no difference in multi-group comparison for upward and downward flexion pre- and post-cycling. Median flow rate through an empty channel was 48.0 mL/min, and it decreased significantly with all used instruments (p < 0.001). Compared with the LithoVue, the Axis demonstrated superior resolution at all tested distances and less distortion. Conclusions: The new Dornier Axis single-use ureteroscope demonstrates excellent tip deflection, which remains unchanged after 100 manual flexions in each direction. The Axis also demonstrates superior optical performance compared with the LithoVue in benchtop testing.

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.

Transcriptome analysis and immune-related genes expression reveals the immune responses of Macrobrachium rosenbergii infected by Enterobacter cloacae

Macrobrachium rosenbergii is an important cultural species in China and other Southeast Asian countries. However, Enterobacter cloacae infection has caused a great economic loss in M. rosenbergii culture industry. The immune responses of M. rosenbergii to the E. cloacae infection is not fully characterized. To investigate the immune response of M. rosenbergii against E. cloacae, we performed transcriptome analysis of the M. rosenbergii hepatopancreas with and without E. cloacae infection using RNA-seq. After assembly and annotation, 29,731 high quality unigenes were obtained from RNA-seq data. Differential expression analysis revealed the existence of 2498 significantly differently expressed genes (DEGs) at 12 h post infection, with 1365 up-regulated and 1133 down-regulated genes. Among these DEGs, some well-known immune-related genes were up-regulated significantly, including C-type lectin 1, lectin 3, anti-lipopolysaccharide factor 2, Cu/Zn superoxide dismutase and heat shock protein 70. GO analysis demonstrated 24 biological process subcategories, 14 cellular component subcategories, and 12 molecular function subcategories that were enriched among these DEGs, and some DEGs were clustered into immune related subcategories such as immune system process, response to stimulus, biological adhesion, and antioxidant activity. These DEGs were enriched into 216 KEGG pathways including a core set of immune correlated pathways notably in phagosome and lysosome. In addition, 5 up-regulated and 5 down-regulated immune-related DEGs were selected for further validation by quantitative real-time PCR and the results showed consistence with the RNA-seq data. Additionally, the expression level of six selected immune-related genes (ALF2, CLEC1, LEC3, hemocyanin1, HSP70 and SOD) based on the transcriptomic data were monitored at different point of time in hepatopancreas, gill, hemolymph and intestine. Results revealed these immune-related genes were significantly up-regulated in different tissues from 6 to 24 h after E. cloacae infection. Overall, these results provided valuable information for further studying the immune response of M. rosenbergii against E. cloacae infection.

Comparative investigation of reusable and single-use flexible endoscopes for urological interventions

In order to evaluate the technical adaptability of a type of disposable endoscope compared to reusable flexible endoscopes, in vitro and in vivo studies were conducted. A disposable digital ureteroscope ("chip on tip") and two reusable endoscopes were investigated with respect to spatial resolution, geometric distortion in air and water the maximum. Additionally, the clinical performance of the disposable device was tested during clinical procedures (n = 20). The disposable endoscope showed an optical resolution of 6.72 lines/mm at 10 mm distance, similar to the other devices. In comparison, the disposable endoscope showed a barrel-shaped image distortion in air of -24.2%, which is in the middle range, but was best under water (-8.6%). The bendability of 297° (275 µm fiber) and 316° (empty channel, 1.5 F basket) and the maximum irrigation (1 m: 58.1 ml/min, 2 m: 91.9 ml/min) were convincing. Clinically the maneuverability was very good in (13/20), good or satisfactory in (7/20). Visibility was evaluated as very good in (11/20), just in (1/20) either satisfactory or sufficient. The consistency of visibility was not affected in (19/20). In all cases there were no adverse events. The technical examination and clinical application of the disposable endoscope are of equal quality compared to reusable devices. Disposable endoscopes can be an alternative to reusable devices, but economic aspects such as reduction of repair costs, sterilization effort and additional waste must be taken into account.

Enhanced manual cleaning efficacy of duodenoscope in endoscopy units: Results of a multicenter comprehensive quality control program

BACKGROUND

Multiple outbreaks from contaminated duodenoscopes have been reported since 2008. This study assessed results of a multicenter comprehensive quality control (QC) program to enhance manual cleaning efficacy of duodenoscopes in endoscopy units.

METHODS

Digestive Endoscopy Society of Taiwan implemented a QC program with adenosine triphosphate (ATP) testing of patient-used duodenoscopes in 2 rounds of on-site audit in endoscopy units. ATP samples were obtained from 5 different locations of the duodenoscope after manual cleaning. Duodenoscope exceeding ATP benchmark of 200 relative light units indicated inadequate manual cleaning.

RESULTS

During the first round on-site audit, 12 hospitals and 27 patient-used duodenoscopes were analyzed. Distal end outer surface (29.6%), elevator mechanism (51.9%), distal attachment cap (59.3%), elevator wire channel (37.0%), and suction biopsy channel (37.0%) were inadequately cleaned. Overall, 19 (70.4%) duodenoscopes had inadequate manual cleaning, ranging widely from 0%-100% among endoscopy units. During the follow-up on-site audit, 32 patient-used duodenoscopes were analyzed, and 6 (18.8%) had inadequate manual cleaning.

CONCLUSIONS

ATP tests may provide real-time feedback on the cleaning efficacy of patient-used duodenoscopes. Implementing a comprehensive QC program could enhance the efficacy of manual cleaning in endoscopy units.

Cost-effectiveness analysis of a single-use digital flexible cystoscope for double J removal

Introduction and objective:

The novel single-use digital flexible cystoscope Isiris™ has been developed to perform in-office JJ stent removal, without the need of special equipment nor limitations linked to the disinfection of a reusable device. The aim of our study was to perform a cost-effectiveness analysis of Isiris™ in our institution.

Patients and methods:

A total of 127 consecutive patients undergoing in-office stent removal with Isiris™ were prospectively included in study. After each procedure, the urologist filled a questionnaire specifically developed to evaluate the efficiency of the device and the invasiveness of the procedure. We performed a cost analysis of the main variables involved in JJ removal using Isiris™ versus the traditional Storz™ reusable flexible cystoscope used for all our previous patients.

Results:

The procedure was successful in all cases except for one, where the device did not work due to the failure of the grasper and had to be replaced. Overall, the performance of Isiris™ was judged by the physician “very good” and “good” in 90.6% of the cases. Both median pain and invasiveness felt by the patient were 0 (range = 0–8). The mean cost of procedure was estimated at €361 for in-office stent removal with Isiris™, and €1.126.8 for stent removal in operatory room with a reusable flexible cystoscope. Considering the 127 procedures performed in office, 64 h of operatory room time was saved.

Conclusion:

In institutions where JJ removal is performed in the operatory room, Isiris™ leads to a significant advantage in terms of money saved per procedure, operatory room time gained and patient satisfaction.

Medical instrument reprocessing: current issues with cleaning and cleaning monitoring

The complexity of medical devices has increased over the past 10 years, and outbreaks of infections due to contaminated devices have focused attention on the need to adequately clean medical devices in order to ensure the adequacy of disinfection and sterilization. There has been a paradigm shift in reprocessing of medical devices, with increased emphasis on a quality management systems approach that requires validated cleaning instructions from manufacturers and ongoing monitoring by reprocessing personnel to ensure adequacy of cleaning. This article reviews the current issues related to medical device reprocessing and summarizes the approaches used for monitoring cleaning efficacy for surgical instruments and flexible endoscopes.

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.

Single-Use Ureteroscopes

A PubMed search using the terms "single use" and "ureteroscope" was performed to identify published studies on this topic. In addition, the abstracts of the annual meeting of the World Congress of Endourology and the American Urologic Association since 2010 were reviewed. Here we present a review of published studies on single-use ureteroscopes.

Australian infection control in endoscopy consensus statements on carbapenemase-producing Enterobacteriaceae

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.

Which flexible ureteroscope is the best for upper tract urothelial carcinoma treatment?

PURPOSE

To present attributes of currently available flexible ureteroscopes to define the best flexible ureteroscope for upper tract urothelial carcinoma (UTUC) treatment.

MATERIALS AND METHODS

Scopus and Medline databases were searched for articles relating to performance of flexible ureteroscopes. A consensus for final inclusion of articles judged to be relevant for UTUC treatment was reached between the authors. Instrument characteristics were extracted from manufacturers' product brochures.

RESULTS

Smaller cross-sectional size of instruments is associated with increased probability for successful primary access to the upper urinary tract. The smallest flexible ureteroscopes are fiberoptic scopes. Smaller ureteroscopes also allow comparatively increased irrigation flow at constant intrarenal pressure. Digital flexible ureteroscopes achieve superior image quality compared to their fiberoptic counterparts, at the price of lower end-deflection ability. Image enhancement technologies such as narrow-band imaging (NBI), photodynamic diagnosis (PDD) and Image 1-S (formerly SPIES) are based on subjective image interpretation by the operator. NBI and PDD significantly increase tumor detection rate. The highest subjective image quality score of the Image 1-S technology is reached by the "Clara + Chroma" mode. Single-use ureteroscopes offer potential advantages over reusable scopes, including sterility, absence of contamination, immediate availability and exemption of previous instrument wear.

CONCLUSIONS

Miniaturization, digital image caption and image enhancement technologies seem to be the major determinants defining the best flexible ureteroscope for UTUC treatment. The impact of further factors, such as distal tip design, torque, working channel position, risk of contamination, as well as upcoming technological innovations should be evaluated in randomized controlled trials.

A clinical evaluation of the new digital single-use flexible ureteroscope (UscopePU3022): an international prospective multicentered study

Introduction

We assessed the clinical performance of a new digital single-use flexible ureteroscope (UscopePU3022).

Material and methods

A prospective cohort study was carried out across 11 centers (July-Oct. 2017). The UscopePU3022 was assessed regarding ease of insertion; deflection, image quality, maneuverability and overall performance using either a visual analog* or Likert scale.

Results

A total of 56 procedures were performed in 11 centers (16 surgeons) with the indication being renal stones in 83%. The median score for ease of scope insertion was 10 (3-10). Intraoperative maneuverability was rated as 'good' in 38% and 'very good' in 52%. Visual quality was rated as 'poor or bad' in 18%, 'fair' in 37% and 'good or very good' in 43%. Two scopes failed intraoperatively (4%). Preoperative and postoperative median upward and downward deflection was 270 degrees. Compared to standard flexible ureteroscopy (f-URS) maneuverability was rated as 'equivalent' in 30% and 'better' in 60%; visual quality was 'worse' in 38% and 'equivalent or better' in 62%; limb fatigue scores were 'better' in 86%; and overall performance was 'worse' in 55% and 'equivalent or better' in 45%.

Conclusions

UscopeTM3022 performed well with regards to maneuverability, deflection and limb fatigue and appears to be at least non-inferior to standard f-URS with regards to these parameters. Poor image quality is a concern for UscopePU3022 with it receiving a low overall performance rating when compared to standard f-URS. Despite this it scored highly when investigators were asked if they would use it in their practice if it was cost-effective to do so.

Complex gene response of herbicide-resistant Enterobacter strain NRS-1 under different glyphosate stresses

Knowledge of biological evolution and genetic mechanisms is gained by studying the adaptation of bacteria to survive in adverse environmental conditions. In this regard, transcriptomic profiling of a glyphosate-tolerant Enterobacter strain NRS-1 was studied under four different treatments to investigate the gene-regulatory system for glyphosate tolerance. A total of 83, 83, 60 and 74 genes were up-regulated and 108, 87, 178 and 117 genes down-regulated under 60-NPG, 110-NPG, NaCl (355 mM) and HCl (pH 4.46) stress treatments, respectively. Complex gene network was identified to be involved in regulating tolerance to glyphosate. This study revealed that NRS-1 has gained glyphosate tolerance at the cost of osmotic and acidic resistance. The 25 differentially expressed genes are reported to may have partly changed the function for providing resistance to glyphosate directly, among them genes metK, mtbK, fdnG and wzb that might detoxify/degrade the glyphosate. However, under 110-NPG condition, NRS-1 might have utilized economical and efficient ways by depressing its metabolism and activity to pass through this stress. Hence, the present study provides insights into the genes involved in glyphosate tolerance, which can be effectively utilized to engineer herbicide-resistant crop varieties after their proper validation to manage weed growth.

Prevention and management of urosepsis triggered by ureteroscopy

Urosepsis is a potentially life-threatening phenomenon that may occur after an ureteroscopic procedure. With the increasingly widespread adoption of ureteroscopy, there is a concern that the rates of urosepsis may increase. This review examines the current work being undertaken to minimize postprocedure infections both in the field of device development and in clinical care. Guidelines for the diagnosis and management of urosepsis will be discussed.

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.

A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.

Antimicrobial resistance of 3 types of gram-negative bacteria isolated from hospital surfaces and the hands of health care workers

BACKGROUND

There has been an increased focus in recent years on antimicrobial resistance of bacteria isolated from clinical samples. However, resistance of bacteria from hospital environments has been less frequently investigated.

METHODS

According to hygienic standard for disinfection in hospitals, samples were collected from hospital inanimate surfaces and the hands of health care workers after daily cleaning. An automatic microorganism analyzer was used to identify bacteria and test for antimicrobial susceptibility. Polymerase chain reaction was used to detect antimicrobial resistance genes.

RESULTS

The detection rate of bacteria in general wards was significantly higher than that in intensive care units. The isolates were predominantly gram-negative (GN) bacteria, with Pseudomonas aeruginosa, Enterobacter cloacae, and Klebsiella pneumoniae being the most common. P aeruginosa isolates from other surfaces were much higher than those from medical instruments. E cloacae was isolated more frequently from the hands of other staff than medical staff. Most P aeruginosa and K pneumoniae were resistant to sulfonamides and β-lactam antimicrobials. Only 1 strain of P aeruginosa and 1 strain of K pneumoniae showed multiple antimicrobials resistance.

CONCLUSIONS

The GN bacteria isolated from hospital environments demonstrate variable resistance to antimicrobials.

Outbreak of CTX-M-15-producing Enterobacter cloacae associated with therapeutic beds and syphons in an intensive care unit

An outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae (ESBL-ECL) occurred in our intensive care unit (ICU) and involved 18 patients (8 infected and 10 colonized). The mean age of patients was 69 years, and all infected patients had underlying medical conditions. Within hours' recognition of the spread of ESBL-ECL, the infection control team requested for staff education, reinforcement of infection control measures, and environmental screening. New transmissions were observed in the institution after weeks of enhanced infection control measures. Microbial swabbing revealed bacterial contamination of some mattresses and syphons with epidemiologic links between environmental, screening, and clinical isolates. This outbreak resulted in the temporary closure of the ICU for complete biocleaning.

Defining the Costs of Reusable Flexible Ureteroscope Reprocessing Using Time-Driven Activity-Based Costing

PURPOSE

Careful decontamination and sterilization of reusable flexible ureteroscopes used in ureterorenoscopy cases prevent the spread of infectious pathogens to patients and technicians. However, inefficient reprocessing and unavailability of ureteroscopes sent out for repair can contribute to expensive operating room (OR) delays. Time-driven activity-based costing (TDABC) was applied to describe the time and costs involved in reprocessing.

MATERIALS AND METHODS

Direct observation and timing were performed for all steps in reprocessing of reusable flexible ureteroscopes following operative procedures. Estimated times needed for each step by which damaged ureteroscopes identified during reprocessing are sent for repair were characterized through interviews with purchasing analyst staff. Process maps were created for reprocessing and repair detailing individual step times and their variances. Cost data for labor and disposables used were applied to calculate per minute and average step costs.

RESULTS

Ten ureteroscopes were followed through reprocessing. Process mapping for ureteroscope reprocessing averaged 229.0 ± 74.4 minutes, whereas sending a ureteroscope for repair required an estimated 143 minutes per repair. Most steps demonstrated low variance between timed observations. Ureteroscope drying was the longest and highest variance step at 126.5 ± 55.7 minutes and was highly dependent on manual air flushing through the ureteroscope working channel and ureteroscope positioning in the drying cabinet. Total costs for reprocessing totaled $96.13 per episode, including the cost of labor and disposable items.

CONCLUSIONS

Utilizing TDABC delineates the full spectrum of costs associated with ureteroscope reprocessing and identifies areas for process improvement to drive value-based care. At our institution, ureteroscope drying was one clearly identified target area. Implementing training in ureteroscope drying technique could save up to 2 hours per reprocessing event, potentially preventing expensive OR delays.

The effectiveness of sterilization for flexible ureteroscopes: A real-world study

BACKGROUND

There are no guidelines or quality benchmarks specific to ureteroscope reprocessing, and patient injuries and infections have been linked to ureteroscopes. This prospective study evaluated ureteroscope reprocessing effectiveness.

METHODS

Reprocessing practices at 2 institutions were assessed. Microbial cultures, biochemical tests, and visual inspections were conducted on sterilized ureteroscopes.

RESULTS

Researchers examined 16 ureteroscopes after manual cleaning and sterilization using hydrogen peroxide gas. Every ureteroscope had visible irregularities, such as discoloration, residual fluid, foamy white residue, scratches, or debris in channels. Tests detected contamination on 100% of ureteroscopes (microbial growth 13%, adenosine triphosphate 44%, hemoglobin 63%, and protein 100%). Contamination levels exceeded benchmarks for clean gastrointestinal endoscopes for hemoglobin (6%), adenosine triphosphate (6%), and protein (100%). A new, unused ureteroscope had hemoglobin and high protein levels after initial reprocessing, although no contamination was found before reprocessing.

CONCLUSIONS

Flexible ureteroscope reprocessing methods were insufficient and may have introduced contamination. The clinical implications of residual contamination and viable microbes found on sterilized ureteroscopes are unknown. Additional research is needed to evaluate the prevalence of suboptimal ureteroscope reprocessing, identify sources of contamination, and determine clinical implications of urinary tract exposure to reprocessing chemicals, organic residue, and bioburden. These findings reinforce the need for frequent audits of reprocessing practices and the routine use of cleaning verification tests and visual inspection as recommended in reprocessing guidelines.