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van der Ploeg K, Haanappel CP, Voor In 't Holt AF, de Groot W, Bulkmans AJC, Erler NS, Mason-Slingerland BCGC, Vos MC, Bruno MJ, Severin JA. Effect of a novel endoscope cleaning brush on duodenoscope contamination. Endoscopy 2024; 56:198-204. [PMID: 37848074 DOI: 10.1055/a-2193-4481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND Current duodenoscope reprocessing protocols are insufficient to prevent contamination and require adaptations to prevent endoscopy-associated infections (EAIs). This study aimed to investigate the effect of a new endoscope cleaning brush on the contamination rate of ready-to-use duodenoscopes. METHODS This retrospective before-and-after intervention study collected duodenoscope surveillance culture results from March 2018 to June 2022. Contamination was defined as ≥1 colony-forming unit of a microorganism of gut or oral origin (MGO). In December 2020, an endoscope cleaning brush with a sweeper design was introduced as an intervention in the manual cleaning of duodenoscopes. A logistic mixed-effects model was used to study the effects of this intervention. RESULTS Data were collected from 176 culture sets before the new brush's introduction and 81 culture sets afterwards. Pre-introduction, culture sets positive with an MGO comprised 45.5% (95%CI 38.3%-52.8%; 80/176), decreasing to 17.3% (95%CI 10.6%-26.9%; 14/81) after implementation of the new brush. Compared with the former brush, duodenoscopes cleaned with the new brush had lower odds of contamination with MGOs (adjusted odds ratio 0.25, 95%CI 0.11-0.58; P=0.001) CONCLUSIONS: Use of the new brush in manual cleaning reduced contamination with MGOs and is expected to prevent EAIs. These findings should be confirmed in future prospective randomized studies.
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Affiliation(s)
- Koen van der Ploeg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Cynthia P Haanappel
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Woutrinus de Groot
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Adriana J C Bulkmans
- Quality Assurance and Regulatory Affairs office Medical Technology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Bibi C G C Mason-Slingerland
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Juliëtte A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
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Uchoa-Junior FA, Barata TDJE, Leão-Vasconcelos LSNDO, Ribeiro EL, Tipple AFV. Biofilm on and structural damage of rotary cutting instruments after 5 cycles of clinical use and processing. J Am Dent Assoc 2023; 154:495-506. [PMID: 37115139 DOI: 10.1016/j.adaj.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/04/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Rotary cutting instruments (RCIs) are sterilized routinely. The authors aimed to analyze the structural integrity, presence of dirt, and microbial contamination of RCIs used in clinical practice after processing. METHODS Eighty-four RCIs (42 carbide burs, 42 diamond burs) were divided into baseline, control, and test groups. The RCIs were evaluated by means of scanning electron microscopy and microbiological analysis. Evaluation criteria included presence of structural damage, dirt, biofilm, and isolated cells and their phenotypic profile. RESULTS The carbide burs from all groups and diamond burs from the test groups had structural damage. Dirt was observed in the baseline and test groups. Three bacterial species were isolated from 4 RCIs (9.52%). An isolated cell was observed from 1 carbide bur. Biofilm was observed on 3 RCIs (7.14%). CONCLUSIONS RCIs should not be subjected to multiple uses; after the first clinical use they accumulate structural damage and dirt that hampers the cleaning step, causing failure in the sterilization process. PRACTICAL IMPLICATIONS The presence of microorganisms and structural damage on the RCIs confirmed that they are not amenable to processing, a fact that characterizes them as a single-use health care product.
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Heuvelmans M, Woudstra W, Wunderink HF, Monkelbaan JF, van der Mei HC. A dynamic flow model mimicking duodenoscope reprocessing after bacterial contamination for translational research. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e153. [PMID: 36483362 PMCID: PMC9726593 DOI: 10.1017/ash.2022.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Duodenoscopy-associated infections and outbreaks are reported globally despite strict adherence to duodenoscope reprocessing protocols. Therefore, new developments in the reprocessing procedure are needed. DESIGN We evaluated a novel dynamic flow model for an additional cleaning step between precleaning and manual cleaning in the reprocessing procedure. METHODS A parallel plate flow chamber with a fluorinated ethylene propylene bottom plate was used to mimic the duodenoscope channels. The flow chamber was inoculated with a suspension containing Klebsiella pneumoniae to simulate bacterial contamination during a duodenoscopic procedure. After inoculation the flow chamber was flushed with a detergent mimicking precleaning. Subsequently the flow chamber was subjected to different interventions: flow with phosphate-buffered saline (PBS), flow with 2 commercial detergents, flow with sodium dodecyl sulfate with 3 different concentrations, and flow with microbubbles. Adhering bacteria were counted using phase-contrast microscopy throughout the experiment, and finally, bacterial viability was assessed. RESULTS During precleaning both PBS and 1% (v/v) Neodisher Mediclean Forte were able to desorb bacteria, but neither proved superior. After precleaning only sodium dodecyl sulfate could desorb bacteria. CONCLUSIONS Flushing during precleaning is an essential step for reducing adhering luminal bacteria, and sodium dodecyl sulfate is a promising detergent for bacterial desorption from duodenoscope channels after precleaning.
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Affiliation(s)
- Maarten Heuvelmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Woudstra
- Department of Biomedical Engineering, University of Groningen, Groningen, The Netherlands
| | - Herman F. Wunderink
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan F. Monkelbaan
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Henny C. van der Mei
- Department of Biomedical Engineering, University of Groningen, Groningen, The Netherlands
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4
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Tahir S, Emanuel S, Inglis DW, Vickery K, Deva AK, Hu H. Mild Positive Pressure Improves the Efficacy of Benzalkonium Chloride against Staphylococcus aureus Biofilm. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9090461. [PMID: 36135007 PMCID: PMC9495741 DOI: 10.3390/bioengineering9090461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022]
Abstract
Current protocols using liquid disinfectants to disinfect heat-sensitive hospital items frequently fail, as evidenced by the continued isolation of bacteria following decontamination. The contamination is, in part, due to biofilm formation. We hypothesize that mild positive pressure (PP) will disrupt this biofilm structure and improve liquid disinfectant/detergent penetration to biofilm bacteria for improved killing. Staphylococcus aureus biofilm, grown on polycarbonate coupons in the biofilm reactor under shear at 35 °C for 3 days, was treated for 10 min and 60 min with various dilutions of benzalkonium chloride without PP at 1 atmosphere (atm), and with PP at 3, 5, 7, and 10 atm. The effect on biofilm and residual bacterial viability was determined by standard plate counts, confocal laser scanning microscopy, and scanning electron microscopy. Combined use of benzalkonium chloride and PP up to 10 atm significantly increased biofilm killing up to 4.27 logs, as compared to the treatment using disinfectant alone. Microscopy results were consistent with the viability plate count results. PP improved disinfectant efficacy against bacterial biofilm. The use of mild PP is possible in many flow situations or if equipment/contaminated surfaces can be placed in a pressure chamber.
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Affiliation(s)
- Shamaila Tahir
- Surgical Infection Research Group, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Sarah Emanuel
- Surgical Infection Research Group, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
- School of Engineering, Macquarie University, Sydney, NSW 2109, Australia
| | - David W. Inglis
- School of Engineering, Macquarie University, Sydney, NSW 2109, Australia
| | - Karen Vickery
- Surgical Infection Research Group, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Anand K. Deva
- Surgical Infection Research Group, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Honghua Hu
- Surgical Infection Research Group, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW 2109, Australia
- Correspondence:
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Meyer B, Eschborn S, Schmidt M, Gabriel H, Brill FHH. Advantage of pH-neutral peracetic acid over peracetic acid in reduction of viable count of biofilms. J Hosp Infect 2020; 104:603-604. [PMID: 31870889 DOI: 10.1016/j.jhin.2019.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/26/2022]
Affiliation(s)
- B Meyer
- Ecolab Deutschland GmbH, Monheim am Rhein, Germany.
| | - S Eschborn
- Olympus Winter & Ibe GmbH, Hamburg, Germany
| | - M Schmidt
- Dr. Brill + Partner GmbH Institute for Hygiene and Microbiology, Hamburg, Germany
| | - H Gabriel
- Dr. Brill + Partner GmbH Institute for Hygiene and Microbiology, Hamburg, Germany
| | - F H H Brill
- Dr. Brill + Partner GmbH Institute for Hygiene and Microbiology, Hamburg, Germany
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Balan GG, Sfarti CV, Chiriac SA, Stanciu C, Trifan A. Duodenoscope-associated infections: a review. Eur J Clin Microbiol Infect Dis 2019; 38:2205-2213. [PMID: 31482418 DOI: 10.1007/s10096-019-03671-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Abstract
Flexible digestive endoscopes are used for the management of various conditions with hundreds of thousands of therapeutic procedures performed worldwide each year. Duodenoscopes are indispensable tools for the delivery of minimally invasive vital care of numerous pancreaticobiliary disorders. Despite the fact that nosocomial infections after endoscopic retrograde cholangiopancreatography (ERCP) have always been among the most frequently cited postprocedural complications, recent emergence of duodenoscope-transmitted multiple drug-resistant bacterial infections has led to intense research and debate yet with no clearly delineated solution. Duodenoscope-transmitted nosocomial infections have become one of the most visible topics in the recent literature. Hundreds of high-impact articles have therefore been published in the last decade. This review article discusses how such infections were seen in the past and what is the current situation in both research and practice and thus tries to solve some of the unanswered questions for the future. With the persistence of nosocomial infections despite strict adherence to both manufacturer-issued reprocessing protocols and international guidelines and regulations, an urgent and proper microbiologically driven common action is needed for controlling such nosocomial worldwide threat.
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Affiliation(s)
- Gheorghe G Balan
- Grigore T. Popa, University of Medicine and Pharmacy of Iași, Iași, Romania
| | | | | | - Carol Stanciu
- Institute of Gastroenterology and Hepatology, St. Spiridon Emergency Hospital of Iași, Iași, Romania
| | - Anca Trifan
- Grigore T. Popa, University of Medicine and Pharmacy of Iași, Iași, Romania
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Alfa MJ. Biofilms on instruments and environmental surfaces: Do they interfere with instrument reprocessing and surface disinfection? Review of the literature. Am J Infect Control 2019; 47S:A39-A45. [PMID: 31146849 DOI: 10.1016/j.ajic.2019.02.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
There is a growing appreciation for the role of biofilm-embedded microbes in many different aspects of infection transmission. The format of biofilm includes traditional hydrated biofilm, build-up biofilm, and dry surface biofilm. The objectives of this article are to discuss how traditional biofilm differs from build-up biofilm and dry surface biofilm, and to review the evidence supporting infection transmission from biofilm that accumulates in reprocessed instruments and from dry biofilm that forms environmental reservoirs.
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Affiliation(s)
- Michelle J Alfa
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada.
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Rubin ZA, Kim S, Thaker AM, Muthusamy VR. Safely reprocessing duodenoscopes: current evidence and future directions. Lancet Gastroenterol Hepatol 2019; 3:499-508. [PMID: 29893234 DOI: 10.1016/s2468-1253(18)30122-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/28/2018] [Accepted: 04/03/2018] [Indexed: 12/23/2022]
Abstract
Highly publicised outbreaks of various infections related to the use of duodenoscopes have increased public awareness of the once arcane and largely ignored subject of endoscope reprocessing. Since 2015, national professional societies, multiple federal agencies, and even the US Senate have written reports and guidelines on duodenoscope reprocessing. However, their recommendations are sometimes contradictory and difficult to implement, and new research on the topic is published regularly which further complicates the situation. With this flood of new and sometimes contradictory information, clinicians can feel confused about how to assure the safety of their patients undergoing duodenosocopy. This Review summarises the most salient current research on duodenoscope-associated outbreaks and reprocessing, and aims to provide clinicians with practical information applicable to their practice.
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Affiliation(s)
- Zachary A Rubin
- Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
| | - Stephen Kim
- University of California Los Angeles Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Adarsh M Thaker
- University of California Los Angeles Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - V Raman Muthusamy
- University of California Los Angeles Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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Alfa MJ, Singh H, Nugent Z, Duerksen D, Schultz G, Reidy C, DeGagne P, Olson N. Sterile Reverse Osmosis Water Combined with Friction Are Optimal for Channel and Lever Cavity Sample Collection of Flexible Duodenoscopes. Front Med (Lausanne) 2017; 4:191. [PMID: 29164124 PMCID: PMC5681997 DOI: 10.3389/fmed.2017.00191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/23/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction Simulated-use buildup biofilm (BBF) model was used to assess various extraction fluids and friction methods to determine the optimal sample collection method for polytetrafluorethylene channels. In addition, simulated-use testing was performed for the channel and lever cavity of duodenoscopes. Materials and methods BBF was formed in polytetrafluorethylene channels using Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa. Sterile reverse osmosis (RO) water, and phosphate-buffered saline with and without Tween80 as well as two neutralizing broths (Letheen and Dey-Engley) were each assessed with and without friction. Neutralizer was added immediately after sample collection and samples concentrated using centrifugation. Simulated-use testing was done using TJF-Q180V and JF-140F Olympus duodenoscopes. Results Despite variability in the bacterial CFU in the BBF model, none of the extraction fluids tested were significantly better than RO. Borescope examination showed far less residual material when friction was part of the extraction protocol. The RO for flush-brush-flush (FBF) extraction provided significantly better recovery of E. coli (p = 0.02) from duodenoscope lever cavities compared to the CDC flush method. Discussion and conclusion We recommend RO with friction for FBF extraction of the channel and lever cavity of duodenoscopes. Neutralizer and sample concentration optimize recovery of viable bacteria on culture.
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Affiliation(s)
- Michelle J Alfa
- St. Boniface Research Centre, Winnipeg, MB, Canada.,Department of Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Zoann Nugent
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Donald Duerksen
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Gale Schultz
- Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | | | | | - Nancy Olson
- St. Boniface Research Centre, Winnipeg, MB, Canada
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Alfa MJ, Ribeiro MM, da Costa Luciano C, Franca R, Olson N, DeGagne P, Singh H. A novel polytetrafluoroethylene-channel model, which simulates low levels of culturable bacteria in buildup biofilm after repeated endoscope reprocessing. Gastrointest Endosc 2017; 86:442-451.e1. [PMID: 28551023 DOI: 10.1016/j.gie.2017.05.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Clinical studies have shown variable culture results from flexible endoscope channels possibly because of low levels of bacteria that are difficult to extract. The aim of this study was to develop a simulated-use buildup biofilm (BBF) model that mimics low levels of viable bacteria after repeated rounds of aldehyde fixation and accumulation. METHODS New endoscope channels were exposed to 8 days of repeated rounds of biofilm formation using ATS2015 containing Enterococcus faecalis and Pseudomonas aeruginosa, rinsing, fixation with glutaraldehyde, and rinsing. Viable count and scanning electron microscopy and borescope examination were used to compare the impact of dry storage over 26 weeks on the level of culturable bacteria and to compare the Centers for Disease Control and Prevention flush method of channel harvesting with a flush-brush-flush method. RESULTS E faecalis (log10 6.6) and P aeruginosa (log10 8.6) accumulated over 8 days of cyclic biofilm formation and partial glutaraldehyde fixation, but after a final exposure to 2.6% glutaraldehyde the level of culturable bacteria was less than 2 log10. The Centers for Disease Control and Prevention channel harvesting method appeared by borescope to be inferior to a flush-brush-flush sample collection method for detection of viable bacteria. P aeruginosa increased up to 7 log10 after 26 weeks of dry storage, indicating there were viable but nonculturable bacteria present initially that recovered during storage. CONCLUSIONS Viable but nonculturable P aeruginosa within the BBF model are able to recover, and this phenomenon may explain the variability of culture in patient-used endoscopes. Our data also indicated that friction may be a critical part of sample collection from endoscope channels.
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Affiliation(s)
- Michelle J Alfa
- St Boniface Research Centre, Winnipeg, Manitoba, Canada; Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maira M Ribeiro
- Clinical Hospital of Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Rodrigo Franca
- Department of Dentistry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nancy Olson
- St Boniface Research Centre, Winnipeg, Manitoba, Canada
| | - Pat DeGagne
- St Boniface Research Centre, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Infectious complications in gastrointestinal endoscopy and their prevention. Best Pract Res Clin Gastroenterol 2016; 30:689-704. [PMID: 27931630 DOI: 10.1016/j.bpg.2016.09.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
Gastrointestinal endoscopes are medical devices that have been associated with outbreaks of health care-associated infections. Because of the severity and limited treatment options of infections caused by multidrug-resistant Enterobacteriaceae and Pseudomonas aeruginosa, considerable attention has been paid to detection and prevention of these post-endoscopic outbreaks. Endoscope reprocessing involves cleaning, high-level disinfection/sterilization followed by rinsing and drying before storage. Failure of the decontamination process implies the risk of settlement of biofilm producing species in endoscope channels. This review covers the infectious complications in gastrointestinal endoscopy and their prevention and highlights the problem of infection risk associated with different steps of endoscope reprocessing.
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