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Smith MW, Hernandez LV, Lee P, Martinello RA, Singh H, Sherman JD. Single-Use vs Reusable Duodenoscopes: How Infection Knowledge Gaps Are Driving Environmental Harm and What Can Be Done. Gastroenterology 2024; 167:426-431. [PMID: 38442783 DOI: 10.1053/j.gastro.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Matthew W Smith
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa; Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Lyndon V Hernandez
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin; GI Associates, Milwaukee, Wisconsin
| | - Pamela Lee
- Division of Infectious Diseases, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Richard A Martinello
- Departments of Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut; CT Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey, Veterans Affairs Medical Center, Houston, Texas; Medicine-Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Jodi D Sherman
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
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van der Ploeg K, Klaassen CHW, Vos MC, Severin JA, Mason-Slingerland BCGC, Bruno MJ. A search strategy for detecting duodenoscope-associated infections: a retrospective observational study. J Hosp Infect 2024; 147:56-62. [PMID: 38447805 DOI: 10.1016/j.jhin.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved multidrug-resistant micro-organisms (MDROs), outbreaks involving non-MDROs are also likely to occur. Detection challenges arise as these infections often resolve before culture or because causative strains are not retained for comparison with duodenoscope strains. AIM To identify and analyse DAIs spanning a seven-year period in a tertiary care medical centre. METHODS This was a retrospective observational study. Duodenoscope cultures positive for gastrointestinal flora between March 2015 and September 2022 were paired with duodenoscope usage data to identify patients exposed to contaminated duodenoscopes. Analysis encompassed patients treated after a positive duodenoscope culture and those treated within the interval from a negative to a positive culture. Patient identification numbers were cross-referenced with a clinical culture database to identify patients developing infections with matching micro-organisms within one year of their procedure. A 'pair' was established upon a species-level match between duodenoscope and patient cultures. Pairs were further analysed via antibiogram comparison, and by whole-genome sequencing (WGS) to determine genetic relatedness. FINDINGS Sixty-eight pairs were identified; of these, 21 exhibited matching antibiograms which underwent WGS, uncovering two genetically closely related pairs categorized as DAIs. Infection onset occurred up to two months post procedure. Both causative agents were non-MDROs. CONCLUSION This study provides crucial insights into DAIs caused by non-MDROs and it highlights the challenge of DAI recognition in daily practice. Importantly, the delayed manifestation of the described DAIs suggests a current underestimation of DAI risk.
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Affiliation(s)
- K van der Ploeg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - C H W Klaassen
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - J A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - B C G C Mason-Slingerland
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
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Chang PW, Bui A, Zhou S, Sahakian AB, Buxbaum JL, Phan J. Increasing Antibiotic-Resistant Infections With Inpatient Endoscopic Retrograde Cholangioscopies (ERCP) Is Associated With Higher Mortality in the United States: A Cross-sectional Cohort Study. J Clin Gastroenterol 2024; 58:487-493. [PMID: 37339277 DOI: 10.1097/mcg.0000000000001874] [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] [Received: 02/21/2023] [Accepted: 05/11/2023] [Indexed: 06/22/2023]
Abstract
GOALS This study aims to investigate associated mortality with inpatient endoscopic retrograde cholangiopancreatography (ERCP) with and without resistant infections. The co-primary objective compares frequencies of inpatient ERCP with resistant infections to overall hospitalizations with resistant infections. BACKGROUND The risks of inpatient antibiotic-resistant organisms are known, but the associated mortality for inpatient ERCP is unknown. We aim to use a national database of hospitalizations and procedures to understand trends and mortality for patients with antibiotic-resistant infections during inpatient ERCP. STUDY The largest publicly available all-payer inpatient database in the United States (National Inpatient Sample) was used to identify hospitalizations associated with ERCPs and antibiotic-resistant infections for MRSA, VRE, ESBL, and MDRO. National estimates were generated, frequencies were compared across years, and multivariate regression for mortality was performed. RESULTS From 2017 to 2020, national weighted estimates of 835,540 inpatient ERCPs were generated, and 11,440 ERCPs had coincident resistant infections. Overall resistant infection, MRSA, VRE, and MDRO identified at the same hospitalization of inpatient ERCPs were associated with higher mortality (OR CI(95%): Overall: 2.2(1.77-2.88), MRSA: 1.90 (1.34-2.69), VRE: 3.53 (2.16-5.76), and MDRO: 2.52 (1.39-4.55)). While overall hospitalizations with resistant infections have been decreasing annually, there has been a yearly increase in admissions requiring ERCPs with simultaneous resistant infections ( P =0.001-0.013), as well as infections with VRE, ESBL, and MDRO ( P =0.001-0.016). Required Research Practices for Studies Using the NIS scoring was 0, or the most optimal. CONCLUSIONS Inpatient ERCPs have increasing coincident resistant infections and are associated with higher mortality. These rising infections during ERCP highlight the importance of endoscopy suite protocols and endoscopic infection control devices.
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Affiliation(s)
- Patrick W Chang
- Department of Internal Medicine, Division of Gastroenterology, University of Southern CA
| | - Aileen Bui
- Department of Internal Medicine, Division of Gastroenterology, University of Southern CA
| | - Selena Zhou
- Keck School of Medicine and Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Ara B Sahakian
- Department of Internal Medicine, Division of Gastroenterology, University of Southern CA
| | - James L Buxbaum
- Department of Internal Medicine, Division of Gastroenterology, University of Southern CA
| | - Jennifer Phan
- Department of Internal Medicine, Division of Gastroenterology, University of Southern CA
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Suleyman G, Shallal A, Ruby A, Chami E, Gubler J, McNamara S, Miles-Jay A, Tibbetts R, Alangaden G. Use of whole genomic sequencing to detect New Delhi metallo-B-lactamase (NDM)-producing Escherichia coli outbreak associated with endoscopic procedures. Infect Control Hosp Epidemiol 2024:1-8. [PMID: 38495009 DOI: 10.1017/ice.2024.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Whole-genome sequencing (WGS) has emerged as an alternative genotyping tool for outbreak investigations in the healthcare setting. We describe the investigation and control of a New Delhi metallo-B-lactamase (NDM)-producing Escherichia coli cluster in Southeast Michigan. METHODS Michigan Bureau of Laboratories identified several closely related NDM-producing E. coli isolates with WGS. An epidemiologic investigation, including case-control study, assessment of infection control practices, and endoscope culturing, was performed to identify source of transmission. Targeted screening of potentially exposed patients was performed following identification of probable source. RESULTS Between July 2021 and February 2023, nine patients were identified. Phylogenetic analysis confirmed the isolates were closely related with less than 26 single nucleotide polymorphism (SNP) differences between isolates, suggesting an epidemiological link. Eight (89%) patients had a duodenoscope and/or gastroscope exposure. Cases were compared with 23 controls. Cases had significantly higher odds of exposure to duodenoscopes (odds ratio 15.0; 95% CI, 1.8-142.2; P = .015). The mean incubation period, estimated as date of procedure to positive index culture, was 86 days (range, 1-320 days). No lapses in endoscope reprocessing were identified; NDM-producing E. coli was not recovered from reprocessed endoscopes or during targeted screening. No additional cases were identified after removal of implicated gastroscopes and replacement of duodenoscope with disposable end caps. CONCLUSIONS In this investigation, WGS was utilized to identify transmission of an NDM-producing E. coli outbreak associated with endoscope exposure. Coupled with epidemiologic data, WGS can facilitate outbreak investigations by rapidly identifying linked cases and potential sources to prevent further transmission.
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Affiliation(s)
- Geehan Suleyman
- Division of Infectious Diseases, Henry Ford Health, Detroit, MI, USA
| | - Anita Shallal
- Division of Infectious Diseases, Henry Ford Health, Detroit, MI, USA
| | - Abigail Ruby
- Performance Excellence & Quality Department, Henry Ford Hospital, Detroit, MI, USA
| | - Eman Chami
- Performance Excellence & Quality Department, Henry Ford Hospital, Detroit, MI, USA
| | - Jenny Gubler
- Ambulatory Nursing and Quality Department, Henry Ford Health, Detroit, MI, USA
| | - Sara McNamara
- Surveillance for Healthcare-associated and Resistant Pathogens (SHARP) Unit, Michigan Department of Health and Human Services, Lansing, MI, USA
| | - Arianna Miles-Jay
- Bureau of Laboratories, Division of Infectious Diseases, Michigan Department of Health & Human Services, Lansing, MI, USA
| | - Robert Tibbetts
- Department of Pathology, Henry Ford Health, Detroit, MI, USA
| | - George Alangaden
- Division of Infectious Diseases, Henry Ford Health, Detroit, MI, USA
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Cimen C, Bathoorn E, Loeve AJ, Fliss M, Berends MS, Nagengast WB, Hamprecht A, Voss A, Lokate M. Uncovering the spread of drug-resistant bacteria through next-generation sequencing based surveillance: transmission of extended-spectrum β-lactamase-producing Enterobacterales by a contaminated duodenoscope. Antimicrob Resist Infect Control 2024; 13:31. [PMID: 38459544 PMCID: PMC10924313 DOI: 10.1186/s13756-024-01386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/03/2024] [Indexed: 03/10/2024] Open
Abstract
Contamination of duodenoscopes is a significant concern due to the transmission of multidrug-resistant organisms (MDROs) among patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), resulting in outbreaks worldwide. In July 2020, it was determined that three different patients, all had undergone ERCP with the same duodenoscope, were infected. Two patients were infected with blaCTX-M-15 encoding Citrobacter freundii, one experiencing a bloodstream infection and the other a urinary tract infection, while another patient had a bloodstream infection caused by blaSHV-12 encoding Klebsiella pneumoniae. Molecular characterization of isolates was available as every ESBL-producing isolate undergoes Next-Generation Sequencing (NGS) for comprehensive genomic analysis in our center. After withdrawing the suspected duodenoscope, we initiated comprehensive epidemiological research, encompassing case investigations, along with a thorough duodenoscope investigation. Screening of patients who had undergone ERCP with the implicated duodenoscope, as well as a selection of hospitalized patients who had ERCP with a different duodenoscope during the outbreak period, led to the discovery of three additional cases of colonization in addition to the three infections initially detected. No microorganisms were detected in eight routine culture samples retrieved from the suspected duodenoscope. Only after destructive dismantling of the duodenoscope, the forceps elevator was found to be positive for blaSHV-12 encoding K. pneumoniae which was identical to the isolates detected in three patients. This study highlights the importance of using NGS to monitor the transmission of MDROs and demonstrates that standard cultures may fail to detect contaminated medical equipment such as duodenoscopes.
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Affiliation(s)
- Cansu Cimen
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
| | - Erik Bathoorn
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Arjo J Loeve
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Monika Fliss
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Matthijs S Berends
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
- Certe Medical Diagnostics and Advice Foundation, Department of Medical Epidemiology, Groningen, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Axel Hamprecht
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
| | - Andreas Voss
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands
| | - Mariëtte Lokate
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700RB, Groningen, The Netherlands.
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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, Severin JA, Vos MC, Bruno MJ. Unveiling 8 years of duodenoscope contamination: insights from a retrospective analysis in a large tertiary care hospital. Gut 2024; 73:613-621. [PMID: 38182137 DOI: 10.1136/gutjnl-2023-330355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/12/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE Contaminated duodenoscopes caused several hospital outbreaks. Despite efforts to reduce contamination rates, 15% of patient-ready duodenoscopes are still contaminated with gastrointestinal microorganisms. This study aimed to provide an overview of duodenoscope contamination over time, identify risk factors and study the effects of implemented interventions. DESIGN Duodenoscope culture sets between March 2015 and June 2022 at a Dutch tertiary care centre were analysed. Contamination was defined as (1) the presence of microorganisms of oral or gastrointestinal origin (MGO) or (2) any other microorganism with ≥20 colony-forming units/20 mL (AM20). A logistic mixed effects model was used to identify risk factors and assess the effect of interventions, such as using duodenoscopes with disposable caps, replacing automated endoscope reprocessors (AER) and conducting audits in the endoscopy department. RESULTS A total of 404 culture sets were analysed. The yearly contamination rate with MGO showed great variation, ranging from 14.3% to 47.5%. Contamination with AM20 increased up to 94.7% by 2022. For both MGO and AM20, the biopsy and suction channels were the most frequently contaminated duodenoscope components. The studied interventions, including audits, AER replacement and implementation of duodenoscopes with disposable caps, did not show a clear association with contamination rates. CONCLUSION Duodenoscope contamination remains a significant problem, with high contamination rates despite several interventions. Reprocessing the biopsy and suction channels is especially challenging. Changes in the design of reusable duodenoscopes, such as enabling sterilisation or easily replaceable channels, are necessary to facilitate effective duodenoscope reprocessing and to eliminate the risk of duodenoscope-associated infections.
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Affiliation(s)
- Koen van der Ploeg
- Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, South Holland, Netherlands
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Cynthia P Haanappel
- Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, South Holland, Netherlands
| | - Anne F Voor In 't Holt
- Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, South Holland, Netherlands
| | - Woutrinus de Groot
- Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, South Holland, Netherlands
| | - Adriana J C Bulkmans
- Quality Assurance and Regulatory Affairs office Medical Technology, Erasmus MC, Rotterdam, South Holland, Netherlands
| | - Nicole S Erler
- Biostatistics, Erasmus MC, Rotterdam, Netherlands
- Epidemiology, Erasmus MC, Rotterdam, Netherlands
| | | | - Juliëtte A Severin
- Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, South Holland, Netherlands
| | - Margreet C Vos
- Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, South Holland, Netherlands
| | - Marco J Bruno
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, Netherlands
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7
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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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Kremer T, Rowan NJ, McDonnell G. A proposed cleaning classification system for reusable medical devices to complement the Spaulding classification. J Hosp Infect 2024; 145:88-98. [PMID: 38103694 DOI: 10.1016/j.jhin.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/19/2023]
Abstract
A central tenet in infection prevention is application of the Spaulding classification system for the safe use of medical devices. Initially defined in the 1950s, this system defines devices and surfaces as being critical, semi-critical or non-critical depending on how they will be used on a patient. Different levels of antimicrobial treatment, defined as various levels of disinfection or sterilization, are deemed appropriate to reduce patient risk of infection. However, a focus on microbial inactivation is insufficient to address this concern, which has been particularly highlighted in routine healthcare facility practices, emphasizing the underappreciated importance of cleaning and achieving acceptable levels of cleanliness. A deeper understanding of microbiology has evolved since the 1950s, which has led to re-evaluation of the Spaulding classification along with a commensurate emphasis on achieving appropriate cleaning. Albeit underappreciated, cleaning has always been important as the presence of residual materials on surfaces can interfere with the efficacy of the antimicrobial process to inactivate micro-organisms, as well as other risks to patients including device damage, malfunction and biocompatibility concerns. Unfortunately, this continues to be relevant, as attested by reports in the literature on the occurrence of device-related infections and outbreaks due to failures in processing expectations. This reflects, in part, increasing sophistication in device features and reuse, along with commensurate manufacturer's instructions for use. Consequently, this constitutes the first description and recommendation of a new cleaning classification system to complement use of the traditional Spaulding definitions to help address these modern-day technical and patient risk challenges. This quantitative risk-based classification system highlights the challenge of efficient cleaning based on the complexity of device features present, as an isolated variable impacting cleaning. This cleaning classification can be used in combination with the Spaulding classification to improve communication of cleaning risk of a reusable medical device between manufacturers and healthcare facilities, and improve established cleaning practices. This new cleaning classification system will also inform future creation, design thinking and commensurate innovations for the sustainable safe reuse of important medical devices.
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Affiliation(s)
- T Kremer
- Centre for Sustainable Disinfection and Sterilization, Bioscience Research Institute, Technological University of the Shannon Midlands Midwest, Athlone, Ireland; Microbiological Quality and Sterility Assurance, Johnson & Johnson, Raritan, NJ, USA.
| | - N J Rowan
- Centre for Sustainable Disinfection and Sterilization, Bioscience Research Institute, Technological University of the Shannon Midlands Midwest, Athlone, Ireland; Department of Nursing and Healthcare, Technological University of the Shannon Midwest Mideast, Athlone, Ireland; SFI-funded CURAM Centre for Medical Device Research, University of Galway, Galway, Ireland
| | - G McDonnell
- Microbiological Quality and Sterility Assurance, Johnson & Johnson, Raritan, NJ, USA
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van der Ploeg K, de Jonge PJ, Lammers WJ, Koch AD, Vos MC, Paulsen V, Aabakken L, Bruno M. Performance of a single-use gastroscope for esophagogastroduodenoscopy: Prospective evaluation. Endosc Int Open 2024; 12:E428-E434. [PMID: 38504741 PMCID: PMC10948268 DOI: 10.1055/a-2271-2303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/12/2024] [Indexed: 03/21/2024] Open
Abstract
Background and study aims Reprocessing reusable endoscopes is challenging due to their non-sterilizable nature. Disinfection has been shown to have a significant risk of failure with serious consequences. Single-use endoscopes can eliminate contamination risk and reduce workflow delays caused by reprocessing. This study evaluated the clinical performance of single-use gastroscopes in patients undergoing esophagogastroduodenoscopy (EGD). Patients and methods In this case series, 60 patients underwent EGD using single-use gastroscopes, with 34 procedures in the endoscopy department and 26 in the intensive care unit. The primary outcome was successful completion of the intended EGD objective. Furthermore, certified endoscopists assessed device performance on a five-point Likert scale (ranging from 1-"much worse" to 5-"much better"), considering their experience with a reusable gastroscope. Results Successful completion of EGDs using only the single-use gastroscope was achieved in 58 of 60 cases (96.7%). In two cases, crossover to an ultra-slim endoscope was necessary to either reach the esophageal stenosis or to transverse the stenosis. Overall satisfaction was rated as comparable to reusable scopes in 51 of 56 cases (91.1%) and inferior in five cases (8.9%). The lower weight of the single-use gastroscope was rated as superior in 42 of 60 cases (70.0%). Drawbacks included reduced image quality (23 of 45 cases; 51.1%). Feedback included the absence of a freeze button, lens cleaning issues, and small image size. Conclusions Single-use gastroscopes exhibited a high EGD completion rate and effectiveness for various indications. Further research should focus on evaluating the implementation of single-use gastroscopes in a comprehensive context, considering clinical effectiveness, costs, and environmental impact.
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Affiliation(s)
- Koen van der Ploeg
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Centre, Rotterdam, Netherlands
| | - Pieter J.F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Centre, Rotterdam, Netherlands
| | - Wim J. Lammers
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Centre, Rotterdam, Netherlands
| | - Arjun Dave Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Centre, Rotterdam, Netherlands
| | - Margreet C. Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, Netherlands
| | - Vemund Paulsen
- Department of Clinical Medicine, Oslo University Hospital, Oslo, Norway
| | - Lars Aabakken
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Centre, Rotterdam, Netherlands
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10
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Nabi Z, Tang RSY, Sundaram S, Lakhtakia S, Reddy DN. Single-use accessories and endoscopes in the era of sustainability and climate change-A balancing act. J Gastroenterol Hepatol 2024; 39:7-17. [PMID: 37859502 DOI: 10.1111/jgh.16380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/21/2023]
Abstract
Gastrointestinal (GI) endoscopy is among the highest waste generator in healthcare facilities. The major reasons include production of large-volume non-renewable waste, use of single-use devices, and reprocessing or decontamination processes. Single-use endoscopic accessories have gradually replaced reusable devices over last two decades contributing to the rising impact of GI endoscopy on ecosystem. Several reports of infection outbreaks with reusable duodenoscopes raised concerns regarding the efficacy and adherence to standard disinfection protocols. Even the enhanced reprocessing techniques like double high-level disinfection have not been found to be the perfect ways for decontamination of duodenoscopes and therefore, paved the way for the development of single-use duodenoscopes. However, the use of single-use endoscopes is likely to amplify the net waste generated and carbon footprint of any endoscopy unit. Moreover, single-use devices challenge one of the major pillars of sustainability, that is, "reuse." In the era of climate change, a balanced approach is required taking into consideration patient safety as well as financial and environmental implications. The possible solutions to provide optimum care while addressing the impact on climate include selective use of disposable duodenoscopes and careful selection of accessories during a case. Other options include use of disposable endcaps and development of effective high-level disinfection techniques. The collaboration between the healthcare professionals and the manufacturers is paramount for the development of environmental friendly devices with low carbon footprint.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, S. H. Ho Center for Digestive Health Faculty of Medicine, Chinese University of Hong Kong, Endoscopy Center, Prince of Wales Hospital, Hong Kong, China
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, India
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11
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Ramai D, Smit E, Kani HT, Papaefthymiou A, Warner L, Chandan S, Dhindsa B, Facciorusso A, Gkolfakis P, Ofosu A, Barakat M, Adler DG. Cannulation rates and technical performance evaluation of commericially available single-use duodenoscopes for endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis. Dig Liver Dis 2024; 56:123-129. [PMID: 37003844 DOI: 10.1016/j.dld.2023.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Single use duodenoscopes were developed to reduce the risk of infection transmission from contaminated reusable duodenoscopes. To this end, we examined various biliary interventions using single use duodenoscopes in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS Medline, Embase, Scopus, and Cochrane databases were searched from inception through Aug 2022 to identify studies reporting on the performance of single use duodenoscopes for ERCP. RESULTS Seven articles were included in the final analysis that included 642 patients (318 males). The Exalt Model D duodenoscope was used in most cases (88.8%) followed by the aScope Duodeno (11.2%) for ERCP. Most ERCPs had a complexity grade of 2 (n = 303) and 3 (n = 198). The pooled cumulative rate of successful cannulation was 95% (95% Confidence Interval (CI): 93-96%, I2=0%, P = 0.46). Sphincterotomy was successfully performed in all cases. The pooled cumulative rate of PEP was 2% (95% CI: 0.4-3.4%, I2=0%, P = 0.80). The pooled cumulative rate of total adverse events was 7% (95% CI: 4-10%, I2=47%, P = 0.08). CONCLUSIONS The results of this systematic review and meta-analysis show that single use duodenoscopes are associated with high cannulation rates, technical performance, and safety profile.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology & Hepatology, University of Utah Health, Salt Lake City, UT, USA
| | - Eric Smit
- Department of Medicine, Baylor Scott & White Health, Round Rock, TX, USA
| | - Haluk Tarik Kani
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | | | - Lynn Warner
- University of Cincinnati Libraries, Donald C. Harrison Health Sciences Library, Cincinnati, OH, USA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE, USA
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Andrew Ofosu
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Monique Barakat
- Division of Gastroenterology, Stanford University, California, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Porter Adventist Hospital/PEAK Gastroenterology, Denver, Colorado, USA.
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12
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Scholz PM, Kirstein MM, Solbach PC, Vonberg RP. [A systematic analysis of nosocomial outbreaks of nosocomial infections after gastrointestinal endoscopy]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:536-543. [PMID: 37146632 PMCID: PMC10162863 DOI: 10.1055/a-1983-4100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy (CLN) come with a potential risk of pathogen transmission. Unfortunately, up to now data on the causes and the distribution of pathogens is rather sparse.We performed a systematic review of the medical literature using the Worldwide Outbreak Database, the PubMed, and Embase. We then checked so-retrieved articles for potential sources of the outbreak, the spectrum of pathogens, the attack rates, mortality and infection control measures.In total 73 outbreaks (EGD: 24, ERCP: 42; CLN: 7) got included. The corresponding attack rates were 3.5%, 7.1% and 12.8% and mortality rates were 6.3%, 12.7% and 10.0% respectively. EGD was highly associated with transmission of enterobacteria including a large proportion of multi-drug resistant strains. ERCP led primarily to transmission of non-fermenting gram-negative rods. The most frequent cause was human failure during reprocessing regardless of the type of endoscope.Staff working in the field of endoscopy should always be aware of the possibility of pathogen transmission in order to detect and terminate those events at the early most time point. Furthermore, proper ongoing education of staff involved in the reprocessing and maintenance of endoscopes is crucial. Single-use devices may be an alternative option and lower the risk of pathogen transmission, but on the downside may also increase costs and waste.
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Affiliation(s)
- Paulina Marie Scholz
- Insitute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Martha Maria Kirstein
- 1st Department of Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Philipp Christoph Solbach
- 1st Department of Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ralf-Peter Vonberg
- Insitute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
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13
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van der Ploeg K, Bruno MJ. The potential benefits of an automated flexible endoscope channel brushing system for manual cleaning of endoscopes. Endoscopy 2023. [PMID: 37068516 DOI: 10.1055/a-2065-0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Affiliation(s)
- Koen van der Ploeg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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14
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van der Ploeg K, Bruno MJ. Search better and you will find more: an important lesson in endoscope contamination. Endosc Int Open 2023; 11:E366-E367. [PMID: 37077661 PMCID: PMC10110357 DOI: 10.1055/a-2017-3933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Affiliation(s)
- Koen van der Ploeg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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15
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Ofstead CL, Smart AG, Hopkins KM, Lamb LA, Daniels FE, Berg DS. Improving mastery and retention of knowledge and complex skills among sterile processing professionals: A pilot study on borescope training and competency testing. Am J Infect Control 2023; 51:624-632. [PMID: 36907359 DOI: 10.1016/j.ajic.2023.03.002] [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: 02/03/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Healthcare is shifting toward minimally invasive procedures requiring increasingly complex instruments and sophisticated processing technologies. Effective training methods are needed to ensure sterile processing professionals acquire and retain essential skills. OBJECTIVE This study aimed to develop and evaluate a new training model that supports mastery and retention of complex key skills. METHODS The model was pilot-tested with training focused on visual inspection of endoscopes. Pre- and post-training tests were administered to enhance learning during a face-to-face workshop that interspersed lectures and hands-on practice, followed by structured homework, and an online booster session. Surveys assessed satisfaction and confidence levels. RESULTS Mean test scores for nine certified sterile processing employees increased significantly following the workshop (41% vs. 84%, p<0.001). After the workshop, all trainees identified actionable visible defects on patient-ready endoscopes in their facilities. Test scores remained high after two months (90%), and trainees reported higher technical confidence and satisfaction levels after training. CONCLUSIONS This study demonstrated effectiveness and clinical relevance of a new, evidence-based model for training sterile processing professionals that incorporated pre-testing, lectures, hands-on practice, a training booster, and post-testing to enhance learning. This model may be applicable to other complex skills necessary for infection prevention and patient safety.
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Affiliation(s)
| | | | | | | | - Frank E Daniels
- Virginia Commonwealth University Health System, Richmond, VA
| | - Damien S Berg
- Healthcare Sterile Processing Association, Chicago, IL
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16
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Sebastian S, Dhar A, Baddeley R, Donnelly L, Haddock R, Arasaradnam R, Coulter A, Disney BR, Griffiths H, Healey C, Hillson R, Steinbach I, Marshall S, Rajendran A, Rochford A, Thomas-Gibson S, Siddhi S, Stableforth W, Wesley E, Brett B, Morris AJ, Douds A, Coleman MG, Veitch AM, Hayee B. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut 2023; 72:12-26. [PMID: 36229172 PMCID: PMC9763195 DOI: 10.1136/gutjnl-2022-328460] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/12/2022] [Indexed: 12/08/2022]
Abstract
GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.
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Affiliation(s)
- Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, East Riding of Yorkshire, UK .,Clinical Sciences Centre, Hull York Medical School, Hull, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, Darlington, UK,School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Robin Baddeley
- Institute for Therapeutic Endoscopy, King's College Hospital, London, UK,Department of Gastroenterology, St Mark's National Bowel Hospital & Academic Institute, London, UK
| | - Leigh Donnelly
- Department of Gastroenterology, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Rosemary Haddock
- Department of Gastroenterology, Ninewells Hospital & Medical School, Dundee, UK
| | - Ramesh Arasaradnam
- Applied Biological and Experimental Sciences, Coventry University, Coventry, UK,Department of Gastroenterology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Archibald Coulter
- Department of Gastroenterology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Benjamin Robert Disney
- Department of Gastroenterology, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Helen Griffiths
- Department of Gastroenterology, Brecon War Memorial Hospital, Brecon, UK
| | - Christopher Healey
- Department of Gastroenterology, Airedale NHS Foundation Trust, Keighley, UK
| | | | | | - Sarah Marshall
- Bowel Cancer Screening & Endoscopy, London North West University Healthcare NHS Trust, Harrow, UK,Joint Advisory Group on GI Endoscopy, London, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Andrew Rochford
- Department of Gastroenterology, Royal Free Hospitals, London, UK
| | - Siwan Thomas-Gibson
- Department of Gastroenterology, St Mark's National Bowel Hospital & Academic Institute, London, UK
| | - Sandeep Siddhi
- Department of Gastroenterology, NHS Grampian, Aberdeen, UK
| | - William Stableforth
- Departments of Gastroenterology & Endoscopy, Royal Cornwall Hospital, Truro, UK
| | - Emma Wesley
- Departments of Gastroenterology & Endoscopy, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Bernard Brett
- Department of Gastroenterology, Norfolk and Norwich Hospitals NHS Trust, Norwich, UK
| | | | - Andrew Douds
- Department of Gastroenterology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Mark Giles Coleman
- Joint Advisory Group on GI Endoscopy, London, UK,Department of Colorectal Surgery, Plymouth University Hospitals Trust, Plymouth, UK
| | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Bu'Hussain Hayee
- King's Health Partners Institute for Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, UK
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17
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Houri H, Aghdaei HA, Firuzabadi S, Khorsand B, Soltanpoor F, Rafieepoor M, Tanhaei M, Soleymani G, Azimirad M, Sadeghi A, Ebrahimi Daryani N, Zamani F, Talaei R, Yadegar A, Mohebi SR, Sherkat G, Hagh Azalli M, Malekpour H, Hemmasi G, Zali MR. High Prevalence Rate of Microbial Contamination in Patient-Ready Gastrointestinal Endoscopes in Tehran, Iran: an Alarming Sign for the Occurrence of Severe Outbreaks. Microbiol Spectr 2022; 10:e0189722. [PMID: 36173304 PMCID: PMC9602500 DOI: 10.1128/spectrum.01897-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/06/2022] [Indexed: 12/31/2022] Open
Abstract
An alarmingly increasing number of outbreaks caused by contaminated gastrointestinal (GI) endoscopes are being reported as a particularly concerning issue. This study is the first large-scale multicenter survey to evaluate the contamination of GI endoscopes in Tehran, Iran. This multicenter study was conducted among 15 tertiary referral and specialized gastrointestinal settings. Reprocessed GI endoscopes were sampled by the sequence of the flush-brush-flush method. Bacterial and viral contamination, as well as antimicrobial resistance, were explored by culture and molecular assays. A total of 133 reprocessed and ready-to-use GI endoscopes were investigated. In phase I and phase II, 47% and 32%, respectively, of the GI endoscopes were determined to be contaminated. GI flora was the most prevalent contaminant isolated from GI endoscopes, in which the most predominant bacteria were Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae, in both phase I and II evaluations. The majority of the isolated bacteria in the current study were considered multidrug-resistant organisms (MDROs). More importantly, we recovered carbapenem-resistant nonfermentative Gram-negative bacilli (CRNFGNB), carbapenem-resistant Enterobacterales (CRE), extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-E), multidrug-resistant Clostridioides difficile, vancomycin-resistant Enterococcus (VRE), and drug-resistant Candida spp. Disconcertingly, our molecular assays revealed contamination of some reprocessed GI endoscopes with hepatitis B virus (HBV), hepatitis C virus (HCV), and even HIV. This multicenter study indicates a higher-than-expected contamination rate among reprocessed and ready-for-patient-use GI endoscopes, which suggests a higher-than-expected endoscopy-associated infection (EAI) risk, and potentially, morbidity and mortality rate, associated with endoscopy procedures in Tehran, Iran. IMPORTANCE In the light of severe outbreaks caused by multidrug-resistant microorganisms due to contaminated GI endoscopes, understanding to what extent GI endoscopes are inadequately reprocessed is crucial. Several studies assessed contamination of GI endoscopes with various outcomes across the world; however, the prevalence and risk factors of contaminated GI endoscopes and potential subsequent nosocomial spread are still unknown in Iran. The present study is the first large-scale multicenter survey to evaluate the microbial contamination of repossessed and ready-to-use GI endoscopes in Tehran, Iran. Our study showed a higher-than-expected contamination rate among reprocessed GI endoscopes, which suggests potential seeding of deadly but preventable outbreaks associated with endoscopy procedures in Iran. These results suggest that the current reprocessing and process control guidelines do not suffice in Iran. The current study is of particular importance and could provide insights into unrecognized and unidentified endoscopy-associated outbreaks in Iran.
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Affiliation(s)
- Hamidreza Houri
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepideh Firuzabadi
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Khorsand
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Soltanpoor
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maedeh Rafieepoor
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Microbiology and Microbial Biotechnology, Faculty of Life Sciences and Biotechnology, Shahid Beheshti University, Tehran, Iran
| | - Mohammad Tanhaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Microbiology and Microbial Biotechnology, Faculty of Life Sciences and Biotechnology, Shahid Beheshti University, Tehran, Iran
| | - Ghazal Soleymani
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Azimirad
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Sadeghi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasser Ebrahimi Daryani
- Department of Gastroenterology and Hepatology, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Zamani
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Talaei
- Department of Gastroenterology and Hepatology, School of Medicine, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Reza Mohebi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghazal Sherkat
- Faculty of Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | | | - Habib Malekpour
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Hemmasi
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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18
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Analysis of reported adverse events related to single-use duodenoscopes and duodenoscopes with detachable endcaps. Gastrointest Endosc 2022; 96:67-72. [PMID: 35183542 DOI: 10.1016/j.gie.2022.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Single-use duodenoscopes and duodenoscopes with detachable/disposable caps emerged in the market to mitigate the risk of ERCP-related infections. We aimed to investigate adverse events associated with these devices occurring after U.S. Food and Drug Administration (FDA) approval. METHODS We analyzed postmarketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from July 2018 to June 2021. RESULTS One hundred eighty-five reports comprising 201 device issues and 118 patient adverse events were identified from July 2018 through June 2021. Most device issues related to the single-use duodenoscope were due to optical problems (7 reports). Other reported device issues included difficulty in advancing the duodenoscope (2 reports), fluid leak (2 reports), and use-of-device problems (2 reports). Among the duodenoscopes with detachable/disposable caps, most device issues were related to bacterial contamination (53 reports), followed by issues with device use (31 reports), detachment/separation of the device (25 reports), and crack/dent in device material (16 reports). Overall, the most frequently reported patient adverse events were tissue injury (63 reports), perforation (8 reports), and bleeding (7 reports). Ninety reports of microbial contamination of duodenoscopes with detachable/disposable caps were identified, of which Pseudomonas aeruginosa was most common. CONCLUSIONS Findings from the MAUDE database highlight patient and device adverse events that endoscopists should be aware of in using single-use duodenoscopes and duodenoscopes with detachable/disposable caps. Whereas these devices mitigate the risk of transmitting infection, they are associated with additional device-associated adverse events.
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19
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Lisotti A, Fusaroli P, Napoleon B, Cominardi A, Zagari RM. Single-use duodenoscopes for the prevention of endoscopic retrograde cholangiopancreatography -related cross-infection – from bench studies to clinical evidence. World J Methodol 2022; 12:122-131. [PMID: 35721249 PMCID: PMC9157629 DOI: 10.5662/wjm.v12.i3.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/16/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several strategies have been implemented to reduce or abolish the life-threatening risk of endoscopic retrograde cholangiopancreatography (ERCP)-related multidrug-resistant infections due to duodenoscopes contaminations; among those strategies, serial microbiologic tests, thorough reprocessing schedules, and use of removable scope cap have been adopted, but the potential cross-infection risk was not eliminated.
AIM To review available evidence in the field of single-use duodenoscopes (SUD) use for ERCP.
METHODS An overview on ongoing clinical studies was also performed to delineate which data will become available in the next future.
RESULTS One bench comparative study and four clinical trials performed with EXALT model-D (Boston Scientific Corp., United States) have been identified. Of them, one is a randomized controlled trial, while the other three studies are prospective single-arm, cross-over studies. Pooled technical success rate (4 studies, 368 patients) was 92.9% [95% confidence interval (CI): 89.9-95.5; I2: 11.8%]. Pooled serious adverse event (4 studies, 381 patients) rate was 5.9% [3.7%-8.5%; I2: 0.0%].
CONCLUSION Although few clinical trials are available, evidence is concordant in identifying an absolute feasibility and safety and feasibility for SUD use for ERCP. The expertise and quality of evidence in this field are going to be improved by further large clinical trials; data on cost-effectiveness and environmental impact will be needed for a worldwide spread of SUD use for ERCP.
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Affiliation(s)
- Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Bertrand Napoleon
- Gastroenterology Unit, Hôpital privé Jean Mermoz - Ramsay Générale de Santé, Lyon 69008, FR, France
| | - Anna Cominardi
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Rocco Maurizio Zagari
- Dipertimento Di Scienze Mediche e Chirurgiche, Università di Bologna, Policlinico San Orsola Malpighi, Bologna 40138, Italy
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20
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Sivek AD, Davis J, Tremoulet P, Smith M, Lavanchy C, Sparnon E, Kommala D. Healthcare worker feedback on duodenoscope reprocessing workflow and ergonomics. Am J Infect Control 2022; 50:1038-1048. [PMID: 35108583 DOI: 10.1016/j.ajic.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The objectives of this survey study were to assess duodenoscope precleaning and manual cleaning times, identify human factors issues in duodenoscope reprocessing workflow or ergonomics, and ascertain any best practices in duodenoscope reprocessing. METHODS Researchers developed the confidential, qualitative, online Duodenoscope Reprocessing Workflow and Ergonomic Design Human Factors Survey with an intended audience of healthcare workers (HCWs) who routinely perform duodenoscope precleaning or manual cleaning. The unrestricted survey link was distributed to target HCW email addresses in December 2020; the survey closed in January 2021. RESULTS Three hundred and forty-one individuals completed the survey. Most respondents complete duodenoscope precleaning in 10 minutes or less and manual cleaning in 16-to-30 minutes. Most respondents' facilities use fixed distal endcap duodenoscopes. Most respondents experience pressure to work faster when cleaning duodenoscopes and reported that cleaning duodenoscopes caused fatigue or discomfort in at least one body part. Mentoring HCWs and retaining experienced staff were 2 primary duodenoscope reprocessing best practices identified by respondents. DISCUSSION AND CONCLUSIONS To enhance duodenoscope cleaning, facilities should provide ample reprocessing work spaces with incorporated height-adjustable work surfaces, train HCWs on validated duodenoscope reprocessing instructions, provide step-by-step instructions for HCWs when duodenoscope cleaning is performed, mentor reprocessing HCWs, and retain experienced staff.
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Affiliation(s)
| | | | - Patrice Tremoulet
- ECRI, Plymouth Meeting, PA; Department of Psychology, Rowan University, Glassboro, NJ
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21
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Thornhill G, Dunkin B. Duodenoscope-Acquired Infections: Risk Factors to Consider. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1739562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractIn the wake of highly publicized duodenoscope-associated outbreaks caused by multidrug-resistant organisms (MDRO), a herculean effort was made to understand the conditions that led to these transmission events. Although there is now a clearer picture on how these outbreaks happened, there are still significant data gaps when it comes to understanding the rate of duodenoscope-acquired infections (DAIs), especially in nonoutbreak situations. Recent publications indicate that DAIs are still occurring and suggest that infection rates are higher than currently believed. Given this data gap, it is important to identify those patient populations that are most at risk of postprocedure infection, so that appropriate infection control measures may be implemented. Although those patients receiving antibiotic prophylaxis are most at risk for infection, there are additional risk factors that should be considered. For the purposes of this review, risk factors for infection were divided into three broad categories as follows: (1) those that increase patient susceptibility to infection, (2) those related to the endoscopic procedure, and (3) those factors that put reusable duodenoscope inventories at risk of contamination. Infection risk is a complex interaction between the immune status of the patient, the characteristics of the infectious agent (antibiotic sensitivity, virulence factors, and epidemiology), and the environment of care. Because of this complexity, any assessment of the risk of infection should be performed on a case-by-case basis. There is a dearth of information on infection risk for those patients undergoing endoscopic retrograde cholangiopancreatograpy (ERCP), especially in the context of the development and implementation of new device technology, and new endoscopic procedures that are increasing in complexity. This narrative review was developed using the Medical Subject Heading (MeSH) terms to perform an electronic search in PubMed with the goal of generating a summary of the patient, procedural, and duodenoscope-associated factors that increase the risk of infection in patients undergoing ERCP. This review provides practical information regarding the segmentation of ERCP patients by infection risk, so that endoscopists can make informed decisions about the risk benefits of using enhanced duodenoscope technologies in the care of their patients.
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Affiliation(s)
- Grace Thornhill
- Infection Prevention Fellow, Boston Scientific—Endoscopy, Marlborough, Massachusetts, United States
| | - Brian Dunkin
- Chief Medical Officer, Boston Scientific—Endoscopy, Marlborough, Massachusetts, United States
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22
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A nationwide survey on the effectiveness of training on endoscope reprocessing within the national cancer screening program in Korea. Am J Infect Control 2021; 49:1031-1035. [PMID: 33582222 DOI: 10.1016/j.ajic.2021.02.005] [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: 12/06/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The National Cancer Center has provided nationwide endoscope reprocessing training to hospitals annually performing national gastric and colorectal cancer screening in Korea since 2012. This study aimed to evaluate the adherence of past participants of endoscope reprocessing training to the reprocessing guidelines and their satisfaction with the current training. METHODS Training on endoscope reprocessing was implemented 18 times across the country, from June 2019 to November 2019. Immediately after the training, participants filled a paper questionnaire related to reprocessing practices and satisfaction with the current training anonymously. RESULTS A total of 1,132 participants trained responded to the survey (response rate, 95.4%). Of the study participants, 45.7% participated in the past endoscope reprocessing training, and 94.6% of them answered that they have adhered to the endoscope reprocessing guidelines. Experience of participation in endoscope reprocessing training was significantly associated with practical adherence to endoscope reprocessing guidelines (aOR, 6.55; 95% CI, 3.93 to 10.91). And, 91% of study participants were satisfied with the current endoscope reprocessing training. CONCLUSIONS The current training on endoscope reprocessing provided at the national level could help ensure adherence to reprocessing guidelines, resulting in obtaining quality control for endoscopy. However, about half of practitioners currently working in endoscopy units had not received sufficient reprocessing training, and thus more training is needed for them.
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23
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Hutfless S. Challenges in Defining and Preventing Suspected Duodenoscope Infections. Gastroenterol Hepatol (N Y) 2021; 17:136-138. [PMID: 34035774 PMCID: PMC8132713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Susan Hutfless
- Assistant Professor Director, Gastrointestinal Epidemiology Research Center Division of Gastroenterology Johns Hopkins University School of Medicine Baltimore, Maryland
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