Outbreak of Cystoscopy Related Infections With Pseudomonas Aeruginosa: New Mexico, 2007

An outbreak of Pseudomonas aeruginosa urinary tract infections following cystoscopy traceable to a malfunctioning drying cabinet

Background

Pseudomonas aeruginosa is an important bacterial pathogen, particularly as a cause of nosocomial infections in hospitalized patients. Only few reports exist in which cystoscopes were implicated as an outbreak source. We describe an investigation into the cause of a sudden increase in the number of urinary tract infections (UTI) with P. aeruginosa in patients after cystoscopy. In addition, we share the lessons learned and measures taken to reduce the risk of similar infections in the future.

Presentation of Case

Over a period of two weeks the urology outpatient department noticed a UTI in four patients following cystoscopy. An investigation was started for a common source of the outbreak in the urological treatment room. Additional screening of patients revealed a total of eleven males with P. aeruginosa UTI following cystoscopy. The infections were found to be due to a defective drying cabinet, which lacked an alarm signaling in case of loss of airflow. Amplified fragment length polymorphism (AFLP) analysis revealed that P. aeruginosa isolates from three patients and six isolates from environmental cultures (including cystoscopes from the drying cabinet) genotypically belonged to one strain.

Discussion

The AFLP results suggest that contaminated cystoscopes caused P. aeruginosa UTI in 11 patients, with the drying cabinet as site of transfer of the infective strain. To our knowledge, this is the first report describing a malfunctioning drying cabinet as source of an outbreak following cystoscopy.

Conclusion

In case of concomitant P. aeruginosa infections, cystoscopes and drying cabinets should be suspected as a potential source. Molecular techniques are helpful in investigating the epidemiology of an outbreak.

Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes

BACKGROUND

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection.

METHODS

Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection.

RESULTS

The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes.

CONCLUSIONS

Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.

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.

Environmental impact of single-use and reusable flexible cystoscopes

OBJECTIVES

To compare the carbon footprint and environmental impact of single-use and reusable flexible cystoscopes.

MATERIALS AND METHODS

We analysed the expected clinical lifecycle of single-use (Ambu aScope™ 4 Cysto) and reusable (Olympus CYF-V2) flexible cystoscopes, from manufacture to disposal. Performance data on cumulative procedures between repairs and before decommissioning were derived from a high-volume multispecialty practice. We estimated carbon expenditures per-case using published data on endoscope manufacturing, energy consumption during transportation and reprocessing, and solid waste disposal.

RESULTS

A fleet of 16 reusable cystoscopes in service for up to 135 months averaged 207 cases between repairs and 3920 cases per lifecycle. Based on a manufacturing carbon footprint of 11.49 kg CO₂ /kg device for reusable flexible endoscopes and 8.54 kg CO₂ /kg device for single-use endoscopes, the per-case manufacturing cost was 1.37 kg CO₂ for single-use devices and 0.0017 kg CO₂ for reusable devices. The solid mass of single-use and reusable devices was 0.16 and 0.57 kg, respectively. For reusable devices, the energy consumption of reusable device reprocessing using an automated endoscope reprocessor was 0.20 kg CO₂ , and per-case costs of device repackaging and repair were 0.005 and 0.02 kg CO₂ , respectively. The total estimated per-case carbon footprint of single-use and reusable devices was 2.40 and 0.53 kg CO₂ , respectively, favouring reusable devices.

CONCLUSION

In this lifecycle analysis, the environmental impact of reusable flexible cystoscopes is markedly less than single-use cystoscopes. The primary contributor to the per-case carbon cost of reusable devices is energy consumption of reprocessing.

Life Cycle Assessment of Reusable and Disposable Cystoscopes: A Path to Greener Urological Procedures

BACKGROUND

The environmental impact of reusable and disposable devices is unclear; reuse is expected to reduce the carbon footprint, but the environmental impact of reprocessing of reusable devices is increasingly being questioned.

OBJECTIVE

The aim was to provide the first rigorous life cycle assessment of reusable and disposable flexible cystoscopes.

DESIGN, SETTING, AND PARTICIPANTS

We performed a life cycle assessment of reusable flexible cystoscopes and the aS4C single-use cystoscope (aScope; Ambu, Ballerup, Denmark). For the aScope, the complete lifespan of the scope was evaluated, including raw material extraction, material formulation, component production, product assembly, distribution, transportation after use, and final disposal. For reusable cystoscopes, we limited our analysis to their reprocessing, using a model consisting of standard high-level disinfection with peracetic acid. The environmental impact was evaluated by an independent third-party consulting company APESA (Technopole Hélioparc, Pau, France) dedicated to such risk assessments.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The environmental footprint of both cystoscopes was assessed using five environmental impact categories, namely, climate change, mineral resource depletion, ecotoxicity, acidification, and eutrophication. To perform the life cycle assessment, Simapro v9.3.3 software was used and the Ecoinvent v3.5 database was employed as the primary life cycle inventory database. A Monte Carlo analysis was used to account for the inherent uncertainty in life cycle inventory data and the variability in material and energy consumption for each type of flexible cystoscope.

RESULTS AND LIMITATIONS

By only comparing the disinfection reprocessing of reusable cystoscopes with the complete lifespan of the single-use cystoscope, the use of the aScope would allow a reduction of at least 33% in the climate change category, 50% in the mineral resources' depletion category, 51% in the ecotoxicity category, 71% in the acidification category, and 49% in the eutrophication category. Our results cannot be generalized to all health care facilities as we studied only one type of reprocessing method and one disposable flexible cystoscope.

CONCLUSIONS

Disinfection reprocessing of reusable cystoscopes was found to have a significantly larger environmental footprint and impact than the whole lifespan of the single-use cystoscope aScope.

PATIENT SUMMARY

Using a cradle-to-grave life cycle analysis, we showed that the environmental footprint of a flexible cystoscopy procedure can be reduced by using a disposable cystoscope instead of a reusable cystoscope.

Cost and Environmental Impact of Disposable Flexible Cystoscopes Compared to Reusable Devices

Objectives: To quantify the environmental impact and costs associated with flexible cystoscopy procedures from an institutional perspective, with particular attention for the comparison between disposable and reusable cystoscopes. Materials and Methods: This is a single-center retrospective study, including all flexible cystoscopies performed between 2020 and 2021 using reusable or single-use devices. The Ambu aS4C single-use cystoscope (Ballerup, Denmark) gradually replaced the reusable device in our center, with exclusive use from October 2021. Reprocessing costs for reusable cystoscopes were evaluated using a micro-costing approach. The environmental impact of reusable and disposable cystoscopes was assessed by the amount of waste and water consumed for each procedure. Results: A total of 1578 flexible cystoscopies using reusable cystoscopes were performed in 2020, and 550 cystoscopies were performed using the Ambu aS4C cystoscope from October 2021 to February 2022. The cost of flexible cystoscopy with a reusable and a disposable endoscope was €196 and €192, respectively. The amount of waste generated by reprocessing reusable and disposable cystoscopes was 800 and 200 g per procedure, respectively. Water consumption for sterilization of the reusable cystoscope was 60 L per procedure, whereas no water consumption was required with the Ambu aS4C cystoscope. A 100% Ambu aS4C cystoscope use would reduce waste generation and water consumption by 946.8 kg and 94.68 m3 per year. Conclusion: In this study, implementing a strategy of using 100% disposable cystoscopes was associated with similar costs and reduced waste generation and water consumption compared to reusable devices. Future studies are needed to compare the carbon footprint of these devices, through a comprehensive and rigorous life cycle assessment from manufacturing to recycling.

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.

Outcomes and Cost Evaluation Related to a Single-Use, Disposable Ureteric Stent Removal System: a Systematic Review of the Literature

PURPOSE OF REVIEW

To present the latest evidence related to the outcomes and cost of single-use, disposable ureteric stent removal system (Isiris).

RECENT FINDINGS

Our review suggests that compared to a reusable flexible cystoscope (re-FC), a disposable flexible cystoscope (d-FC) with built-in grasper (Isiris) significantly reduced procedural time and provided a cost benefit when the latter was used in a ward or outpatient clinic-based setting. The use of d-FC also allowed endoscopy slots to be used for other urgent diagnostic procedures. Disposable FCs are effective and safe for ureteric stent removal. They offer greater flexibility and, in most cases, have been demonstrated to be cost-effective compared to re-FCs. They are at their most useful in remote, low-volume centres, in less well-developed countries and in centres where large demand is placed on endoscopy resources.

A micro-costing analysis of outpatient flexible cystoscopy: implications for adoption of single-use flexible cystoscopes

PURPOSE

To evaluate the total cost of outpatient flexible cystoscopy associated with reusable device purchase, maintenance, and reprocessing, and to assess potential cost benefits of single-use flexible cystoscopes.

METHODS

Cost data regarding the purchasing, maintaining, and reprocessing of reusable flexible cystoscopes were collected using a micro-costing approach at a high-volume outpatient urology clinic. We estimated the costs to facilities with a range of annual procedure volumes (1000-3000) performed with a fleet of cystoscopes ranging from 10 to 25. We also compared the total cost per double-J ureteral stent removal procedure performed using single-use flexible cystoscopes versus reusable devices.

RESULTS

The cost associated with reusable flexible cystoscopes ranged from $105 to $224 per procedure depending on the annual procedure volume and cystoscopes available. As a practice became more efficient by increasing the ratio of procedures performed to cystoscopes in the fleet, the proportion of the total cost due to cystoscope reprocessing increased from 22 to 46%. For ureteral stent removal procedures, the total cost per procedure using reusable cystoscopes (range $165-$1469) was higher than that using single-use devices ($244-$420), unless the annual procedure volume was sufficiently high relative to the number of reusable cystoscopes in the fleet (≥ 350 for a practice with ten reusable cystoscopes, ≥ 700 for one with 20 devices).

CONCLUSION

The cost of reprocessing reusable cystoscopes represents a large fraction of the total cost per procedure, especially for high-volume facilities. It may be economical to adopt single-use cystoscopes specifically for stent removal procedures, especially for lower-volume facilities.

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.

The Centers for Disease Control and Prevention Guidance on Flexible Gastrointestinal Endoscopes: Lessons Learned from Outbreaks, Infection Control

Flexible endoscopes require cleaning, high-level disinfection, and sterilization between each patient use to reduce risk of transmitting pathogens. Public health investigations have identified concerns, including endoscope damage, mishandling, and reprocessing deficiencies, placing patients at risk for transmission of bacterial, viral, and other pathogens. Findings from outbreak investigations and other studies have led to innovations in endoscope design, use, and reprocessing, yet infection risks related to contaminated or damaged endoscopes remain. Strict adherence to infection control guidelines and manufacturer instructions for use, utilization of supplemental guidance, and training and oversight of reprocessing personnel, reduce risk of pathogen transmission by flexible endoscopes.

Comparison of ureteric stent removal procedures using reusable and single-use flexible cystoscopes following ureteroscopy and lasertripsy: a micro cost analysis

Introduction

Diagnostic pressure on endoscopy suite can lead to delay in flexible cystoscopic stent removal. We compare the cost and organizational impact of reusable flexible cystoscope versus single-use, flexible cystoscope with a built-in stent grasper (Isiris^®).

Material and methods

Data for the reusable cystoscopic stent removal performed in endoscopy room, group A (period 1) were compared to Isiris disposable stent removal performed in outpatient clinic, group B (period 2). We chose the same calendar months in successive years for these two different groups (9 months each). A micro cost analysis was performed evaluating the impact on costs, complications and organizational benefit.

Results

A total of 72 patients (37, group A; 35, group B) were included with no significant differences in age and gender ratio. The mean procedure time was 14.4 and 2.2 minutes, and the mean stent dwell time was 26.8 and 15.4 days in groups A and B respectively (p <0.001). In group A, 5 patients (14%) developed stent encrustation, of which 3 needed a ureteroscopic removal subsequently. No complication occurred in group B. More staff on average were needed for procedures done in group A, than group B (p <0.001).

The number of patients who had cancer diagnostic wait of >2 weeks for flexible cystoscopy and the mean number of days they waited, reduced from 16 to 3, and 21 days to 3 days respectively between period 1 to period 2. The cost per procedure between group A and group B was £267.2 and £252.62 (p <0.05) if the cost of managing complications was not considered, and £365.40 and £252.62 (p <0.001) if the cost of managing complications was also considered.

Conclusions

Isiris significantly reduced stent dwell time, procedural time and staff needed to carry out the stent removals. It also allowed the procedures to be done in the outpatient setting thereby reducing the organizational pressure on endoscopy related diagnostic procedures.

Referrals of Infection Control Breaches to Public Health Authorities: Ambulatory Care Settings Experience, 2017

BACKGROUND

Beginning in October 2016, the Centers for Medicare & Medicaid Services (CMS) issued expanded guidance requiring accrediting organizations and state survey agencies to report serious infection control breaches to relevant state health departments. This project sought to characterize and summarize The Joint Commission's early experiences and findings in applying this guidance to facilities accredited under the ambulatory and office-based surgery programs in 2017.

METHODS

Surveyor notes were retrospectively reviewed to identify individual breaches, and then the Centers for Disease Control and Prevention's Infection Prevention Checklist for Outpatient Settings was used to categorize and code documented breaches.

RESULTS

Of 845 ambulatory organizations, 39 (4.6%) had breaches observed during the survey process and reported to health departments. Within these organizations, surveyors documented 356 breaches, representing 52 different breach codes. Common breach domains were sterilization of reusable devices, device reprocessing observation, device reprocessing, disinfection of reusable devices, and infection control program and infrastructure. Eight of the 39 facilities (20.5%) were cited for not performing the minimum level of reprocessing based on the items' intended use, reusing single-use devices, and/or not using aseptic technique to prepare injections.

CONCLUSION

The CMS infection control breach reporting requirement has helped highlight some of the challenges faced by ambulatory facilities in providing a safe care environment for their patients. This analysis identified numerous opportunities for improved staff training and competencies as well as leadership oversight and investment in necessary resources. More systematic assessments of infection control practices, extending to both accredited and nonaccredited ambulatory facilities, are needed to inform oversight and prevention efforts.

Evaluation of Short-Term Exposure to 2.4 GHz Radiofrequency Radiation Emitted from Wi-Fi Routers on the Antimicrobial Susceptibility of Pseudomonas aeruginosa and Staphylococcus aureus

Background

Overuse of antibiotics is a cause of bacterial resistance. It is known that electromagnetic waves emitted from electrical devices can cause changes in biological systems. This study aimed at evaluating the effects of short-term exposure to electromagnetic fields emitted from common Wi-Fi routers on changes in antibiotic sensitivity to opportunistic pathogenic bacteria.

Materials and Methods

Standard strains of bacteria were prepared in this study. Antibiotic susceptibility test, based on the Kirby-Bauer disk diffusion method, was carried out in Mueller-Hinton agar plates. Two different antibiotic susceptibility tests for Staphylococcus aureus and Pseudomonas aeruginosa were conducted after exposure to 2.4-GHz radiofrequency radiation. The control group was not exposed to radiation.

Results

Our findings revealed that by increasing the duration of exposure to electromagnetic waves at a frequency of 2.4 GHz, bacterial resistance increased against S. aureus and P. aeruginosa, especially after 24 hours (P<0.05).

Conclusion

The use of electromagnetic waves with a frequency of 2.4 GHz can be a suitable method for infection control and treatment.

Challenges in achieving effective high-level disinfection in endoscope reprocessing

Endoscope reprocessing is often ineffective, and microbes frequently remain on endoscopes after the use of high-level disinfectants (HLDs). Several factors impact reprocessing effectiveness, including non-adherence to guidelines, use of damaged endoscopes, use of insoluble products during endoscopy, insufficient cleaning, contaminated rinse water, and inadequate drying before storage. Our team suspected that issues with HLD chemistries and monitoring could also contribute to reprocessing failures. We conducted a mixed-methods analysis of published literature, our interviews with frontline personnel, and evidence from our previous studies. The evidence showed that reusable HLDs commonly failed tests for minimum effective concentration (MEC) before their maximum usage periods. MEC tests also detected failures associated with single-use HLDs that did not fully deploy. These failures were due to product issues, process complexities, and personnel non-adherence with guidelines and manufacturer instructions. HLDs will likely continue to be used for the foreseeable future. More research is needed to assess real-world practice patterns related to the high-level disinfection step and MEC testing and to establish more realistic usage periods for reusable HLD chemistries. Manufacturers and researchers should evaluate the ability of technological solutions and engineered safeguards to overcome human error. Recognition of the need for quality improvement is growing, and infection preventionists should take action to build on this momentum and collaborate with manufacturers, endoscopists, and reprocessing personnel to improve the effectiveness of high-level disinfection.

An outbreak of Pseudomonas aeruginosa urinary tract infections following outpatient flexible cystoscopy

The investigation of an outbreak of Pseudomonas aeruginosa urinary tract infections after ambulatory cystoscopies identified a damaged cystoscope contaminated by P aeruginosa and acting as a relay object. This outbreak urges us not to trivialize urinary tract infections occurring after an elective cystoscopy. Patients should be advised to signal the occurrence of urologic symptoms after urologic exploration.

Reprocessing semicritical items: Outbreaks and current issues

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

A Systematic Review of Disposable Sheath Use During Flexible Endoscopy

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outbreak of Hospital Infection from Biofilm-embedded Pan Drug-resistant Pseudomonas aeroginosa, Due to a Contaminated Bronchoscope

Background

Colistin-resistant Pseudomonas aeruginosa (P. aeruginosa) has been defined as pandrug-resistant (PDR) strain. Outbreaks of PDR P. aeruginosa especially in pulmonary tract infections due to contaminated bronchoscopes have rarely been reported. The emergence of pandrug-resistant strains in both CF (Cystic Fibrosis) and non-CF clinical isolates over recent years remains of a great concern. Hospital wards contaminated with PDR P. aeruginosa infection, must be shot down until their eradication. Health Authorities must be informed immediately and infection control strategies must be implemented.

Aim

To report such an outbreak and modify the infection control strategy in an academic hospital in Ankara Turkey.

Methods

From October to December 2013, PDR-Pseudomonas aerogionsa were identified from bronchial cultures of 15 patients who had undergone bronchoscopy prior to the infection. Three batches of surveillance cultures were obtained from the environmental objects and healthcare workers related to the procedures. Pulsed-field gel electrophoresis (PFGE) was used for bacterial typing. Antimicrobial susceptibility was assessed by disc diffusion and E-test methods.

Findings

A total of 70 specimens were obtained during the first surveillance operation. One Colistin-resistant P. aeroginosa was isolated from a bronchoscope. Although the disinfection protocols for bronchoscope were revised and implemented, seven additional bronchial cases were identified thereafter. The pathogen was identified from two subsequent surveillance cultures and was not eliminated until Ethylene oxide sterilization was added to the disinfection protocol. PFGE revealed that all 15 isolates from the patients and the three isolates from the bronchoscope shared a common pattern with minor variance. XbaI restriction enzyme turned out better than SpeI in interpreting bacterial pulse types with BioNumerics 6.0. The most suitable cut off value for SpeI was above 80% Dice similarity while for XbaI above 95%Dice similarity with BioNumerics 6.0.

Conclusion

The outbreak of "Colistin" pan drug-resistant Pseudomonas aeroginosa was caused by a contaminated bronchoscope and was terminated by the implementation of a revised disinfection protocol for bronchoscope.

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.

Longitudinal assessment of reprocessing effectiveness for colonoscopes and gastroscopes: Results of visual inspections, biochemical markers, and microbial cultures

BACKGROUND

Flexible endoscopes are currently reused following cleaning and high-level disinfection. Contamination has been found on endoscopes, and infections have been linked to gastrointestinal, respiratory, and urologic endoscopes.

METHODS

This longitudinal study involved visual inspections with a borescope, microbial cultures, and biochemical tests for protein and adenosine triphosphate to identify endoscopes in need of further cleaning or maintenance. Three assessments were conducted over a 7-month period. Control group endoscopes reprocessed using customary practices were compared with intervention group endoscopes subjected to more rigorous reprocessing.

RESULTS

At final assessment, all endoscopes (N = 20) had visible irregularities. Researchers observed fluid (95%), discoloration, and debris in channels. Of 12 (60%) endoscopes with microbial growth, 4 had no growth until after 48 hours. There were no significant differences in culture results by study group, assessment period, or endoscope type. Similar proportions of control and intervention endoscopes (~20%) exceeded postcleaning biochemical test benchmarks. Adenosine triphosphate levels were higher for gastroscopes than colonoscopes (P = .014). Eighty-five percent of endoscopes required repair due to findings.

CONCLUSIONS

More rigorous reprocessing was not consistently effective. Seven-day incubation allowed identification of slow-growing microbes. These findings bolster the need for routine visual inspection and cleaning verification tests recommended in new reprocessing guidelines.

Assessing residual contamination and damage inside flexible endoscopes over time

Researchers evaluated flexible endoscope damage and contamination levels at baseline and 2 months later. Postcleaning test results exceeded benchmarks for all gastroscopes and no colonoscopes. Microbial growth was found in samples from 47% of fully reprocessed endoscopes at baseline and 60% at follow-up. Borescope examinations identified scratches, discoloration, debris, and fluid inside endoscopes. Irregularities changed over time. Study evaluations allowed damaged and contaminated endoscopes to be identified and re-reprocessed or sent for repairs.

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

INTRODUCTION

Cystoscopes are used for diagnostic and therapeutic purposes and can be vehicles for transmitting healthcare-associated infections. Performing urine cultures before manipulation or administering prophylaxis is determined by the presence or not of risk factors for urinary tract infection.

METHODS

Between October and November 2014, we identified an unusual aggregation of Salmonella spp. isolates in urine cultures at the University Hospital Santa Lucía of Cartagena (Murcia). An epidemiological investigation was conducted to assess the possible relationship between the cases.

RESULTS

Four patients had a urinary tract infection by Salmonella spp. within a short period, which suggests the presence of an outbreak. All of the patients had undergone cystoscopy. The index case had a urinary colonisation by Salmonella spp. prior to the procedure, and none of the reported cases had received prophylaxis. The environmental control cultures and the involved material cultures resulted negative. Intensification of the cystoscope cleaning and disinfection protocol achieved eradication of the outbreak.

CONCLUSION

This is the first reported outbreak of Salmonella spp. related to the use of cystoscopes. The indication for a urine culture should be carefully assessed before conducting invasive urological procedures, as should the need for antibiotic prophylaxis, for patients with risk factors for severe infection. Strict control in the cleaning and disinfection of endoscopy material can prevent the transmission of infections related to this type of procedure.

Disinfection and Sterilization in Health Care Facilities: An Overview and Current Issues

When properly used, disinfection and sterilization can ensure the safe use of invasive and noninvasive medical devices. The method of disinfection and sterilization depends on the intended use of the medical device: critical items (contact sterile tissue) must be sterilized before use; semicritical items (contact mucous membranes or nonintact skin) must be high-level disinfected; and noncritical items (contact intact skin) should receive low-level disinfection. Cleaning should always precede high-level disinfection and sterilization. Current disinfection and sterilization guidelines must be strictly followed.

Practical toolkit for monitoring endoscope reprocessing effectiveness: Identification of viable bacteria on gastroscopes, colonoscopes, and bronchoscopes

BACKGROUND

Experts have recommended microbiologic surveillance by external reference laboratories for certain flexible endoscopes. There is currently insufficient evidence on the feasibility and utility of cultures. Researchers evaluated a preassembled toolkit for collecting and processing samples from endoscopes.

METHODS

A pilot study was performed in a large academic medical center. A toolkit was used to aseptically sample biopsy ports and suction/biopsy channels of 5 gastroscopes, 5 colonoscopes, and 5 bronchoscopes after full reprocessing. Blinded specimens were packaged and transported on icepacks to a reference laboratory that used standard methodologies for microbial cultures.

RESULTS

The laboratory detected bacteria in samples from 60% of patient-ready endoscopes, including gram-positive and gram-negative species. Viable microbes (<10 CFU) were recovered from 2 gastroscopes, 3 colonoscopes, and 4 bronchoscopes. Stenotrophomonas maltophilia and Delftia acidovorans were recovered from all 3 endoscope types. Subsequent environmental testing detected S maltophilia in the reprocessing rinse water.

CONCLUSIONS

A preassembled toolkit facilitated the aseptic collection of samples for culturing by a reference laboratory that detected viable microbes on fully reprocessed endoscopes. Speciation allowed identification of potential pathogens and a possible common contamination source, demonstrating that microbial cultures may have value even when colony counts are low.

Reprocessing semicritical items: Current issues and new technologies

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 minimally require high-level disinfection. Because many of these items are temperature sensitive, low-temperature chemical methods are usually used rather than steam sterilization. Strict adherence to current guidelines is required because more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items undergoing high-level disinfection than any other reusable medical device.

[Microbiological evaluation of cystoscope reprocessing at Brest university hospital from January 2007 through December 2014]

PURPOSE

Flexible cystoscopes are high temperature sensitive devices that must undergo high-level disinfection according to Spaulding classification. The objective of this study is to provide epidemiological data on the monitoring of microbiological quality of cystoscopes used in a teaching hospital, in order to determine the compliance rate of disinfection and to describe the main identified microorganisms.

MATERIAL

Prospective study of all the results of microbiological samples taken for 8 years at the Brest teaching hospital. The analysis results were interpreted according to the ministerial recommendations.

RESULTS

During the study, 87 microbiological tests were performed. The rate of non-compliant samples was 19.5% (17/87). This rate reached 24.5% (12/49) of the programmed controls. The microorganisms identified were present in small amounts, corresponding mainly to bacteria from the environment.

CONCLUSION

The rate of non-compliance of the microbiological tests performed on cystoscopes is relatively high (19.5%), but the infectious risk seems limited. Hidden microorganisms are present in small quantities and identified germs are not known to be responsible for urinary tract infections. Educating professionals responsible for cystoscopes reprocessing and conducting regular audits may help to ensure a good level of cystoscope disinfection.

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.

A microbiological evaluation of level of disinfection for flexible cystoscopes protected by disposable endosheaths

BACKGROUND

Flexible cystoscopy is used in urological outpatient departments for diagnostic cystoscopy of bladder cancer and requires a high-level disinfection between each patient. The purpose of this study was to make a microbiological post disinfection efficacy assessment of flexible cystoscopes (FC) using disposable sterile endosheaths.

METHODS

One hundred endosheaths underwent a leak-test for barrier integrity after cystoscopy. Microbiological samples from these cystoscopies were obtained; after removal of the endosheath, and after cleaning the scope with a detergent cloth, rinsing with tap water followed by 70% ethanol disinfection and subsequent drying. The number of colony forming units (cfu) from the samples was counted after 72 hours and then divided in three categories, Clean FC (<5 cfu/sample), Critical FC (5-50 cfu/sample) and High-risk FC (>50 cfu/sample). The result was compared with data of 10 years continuous control sampling recorded in the Copenhagen Clean-Endoscope Quality Control Database (CCQCD) and analyzed with a Chi-square test for homogeneity.

RESULTS

All 100 endosheaths passed the leak-test. All samples showed a Clean FC and low means of cfu. A query to the CCQCD, showed that 99.8% (1264/1267) of all FC with a built-in work-channel reprocessed in a WD were clean before use.

CONCLUSION

The reprocessing of FC using endosheaths, as preformed in this study, provides a patient-ready procedure. The results display a reprocessing procedure with low risk of pathogen transmission, high patient safety and a valid alternative to the recommended high-level disinfection procedure of FC. However, the general impression was that sheaths slightly reduced vision and resulted in some patient discomfort.

Difficult-to-detect carbapenem-resistant IMP13-producing P. aeruginosa: experience feedback concerning a cluster of urinary tract infections at a surgical clinic in France

Background

We report a carbapenem-resistant P. aeruginosa clone responsible for a cluster of urinary tract infections in elderly surgery patients, diagnosed during a three-month period in a 59-bed surgical clinic.

Findings

The clonal nature of the cluster was established by molecular study of the P. aeruginosa isolates (PFGE and MLST). Despite an MIC of imipenem in the susceptibility range for two isolates, all were metallo-β-lactamase-producers (IMP13-type, clone ST621). We conducted a review of the medical and surgical procedures. We tested water delivered into the clinic and urological devices for the presence of the epidemic strain. The hygiene nurse observed hygiene practices. A week after the implementation of barrier precautions around the fourth infected patient, we studied the extent to which the patients hospitalised were colonised to assess whether the spread of the epidemic strain had been controlled.

Conclusions

1/ Our findings indicate the difficulties in the detection of the metallo-β-lactamase in this clone, that resulted in the alert being delayed. 2/ Unlike most investigations of UTI outbreaks described in urology wards, we did not detect any contaminated urological devices or water colonisation. 3/ Consistent with outbreaks involving the IMP-13 clone in critical care units, the observation of inadequate application of standard precautions argued for patient-to-patient transmission during urinary management of the urology patients. 4/ The implementation of barrier precautions around infected patients resulted in control of the spread of the epidemic clone. This report serves as an alert concerning a difficult-to-detect multidrug-resistant P. aeruginosa clone in elderly urology patients.

Flexible cysto-urethroscopy findings in young adults investigated for lower urinary tract symptoms, urinary tract infection and haematuria

Diagnostic flexible cysto-urethroscopy (FC) is widely performed to investigate a variety of symptoms, including haematuria, lower urinary tract symptoms (LUTS) and urinary tract infections (UTIs). The purpose of this study was to examine if FC provides useful diagnostic information in young patients investigated for urological symptoms. All patients under the age of 40 years who underwent FC in a single institution over a 12-month period from April 2009 were identified. Electronic records and case notes were then examined. A total of 270 procedures were performed in the study period. Sixty were excluded and data were unavailable in 28. Of the remaining 182, the median age was 31 and 53.8% were male. UTI was the most common indication for the procedure. Abnormalities were found at FC in only seven patients (3.8%), comprising strictures in three and inflammation in four. Of the 63 patients in whom UTI was the sole indication for performing an FC, a single stricture was the only abnormal finding. One hundred and forty (76.9%) patients underwent upper urinary tract imaging, with abnormalities present in 7.9%. This study has demonstrated a very low detection rate of clinically significant disease in patients under the age of 40 years undergoing FC for the investigation of haematuria, LUTS and UTI. We propose that before FC is used in younger patients, careful thought be given to whether it is absolutely necessary and to whether non-invasive tests may allow FC to be avoided altogether.