Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines

American Journal of Infection Control

Volumn 43, Issue 8, 2015, Pages 794-801

  Ofstead, Cori L ^a,b   Wetzler, Harry P ^a   Doyle, Evan M ^a   Rocco, Catherine K ^a   Visrodia, Kavel H ^b   Baron, Todd H ^c   Tosh, Pritish K ^b  

^a CEO of Ofstead and Associates Inc   (United States)

^b MAYO CLINIC   (United States)

^c UNIVERSITY OF NORTH CAROLINA SCHOOL OF MEDICINE   (United States)

Author keywords

Colonoscope; Endoscope reprocessing; Epidemiology; Gastrointestinal endoscopy; High level disinfection; Reprocessing medical devices

Indexed keywords

HEMOGLOBIN; MEMBRANE PROTEIN;

AGROBACTERIUM TUMEFACIENS; ALPHA HEMOLYTIC STREPTOCOCCUS; ARTICLE; BACILLUS CIRCULANS; BACTERIUM CULTURE; CLEANING; CLINICAL INDICATOR; COLONOSCOPE; COLONOSCOPY; CONTROLLED STUDY; DISINFECTION; ENTEROCOCCUS; ESCHERICHIA COLI; GASTROSCOPE; GASTROSCOPY; MEDICAL DEVICE CONTAMINATION; NONHUMAN; PRACTICE GUIDELINE; STAPHYLOCOCCUS EPIDERMIDIS; STORAGE; HUMAN; INFECTION CONTROL; MICROBIOLOGY; PROCEDURES; WASTE MANAGEMENT;

COLONOSCOPES; DECONTAMINATION; DISINFECTION; GASTROSCOPES; GUIDELINE ADHERENCE; HUMANS; INFECTION CONTROL;

EID: 84938260312     PISSN: 01966553     EISSN: 15273296     Source Type: Journal    
DOI: 10.1016/j.ajic.2015.03.003     Document Type: Article

References (46)

1. W.A. Rutala, and D.J. Weber Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008 2008 Centers for Disease Control and Prevention, Department of Health and Human Services Atlanta [GA]
2. B.T. Petersen, J. Chennat, J. Cohen, P.B. Cotton, D.A. Greenwald, T.E. Kowalski, and et al. Multisociety guideline on reprocessing flexible GI endoscopes: 2011 Infect Control Hosp Epidemiol 32 2011 527 537
3. Society of Gastroenterology Nurses and Associates (SGNA) Standards of infection control in reprocessing of flexible gastrointestinal endoscopes 2012 Society of Gastroenterology Nurses and Associates Chicago [IL] 1 23
4. M.J. Alfa, P. Degagne, and N. Olson Worst-case soiling levels for patient-used flexible endoscopes before and after cleaning Am J Infect Control 27 1999 392 401
5. Association for the Advancement of Medical Instrumentation (AAMI) Standard 58: Chemical sterilization and high-level disinfection in health care facilities 2013 Association for the Advancement of Medical Instrumentation Arlington [VA] 1-154
6. C.L. Ofstead, A.M. Dirlam Langlay, N.J. Mueller, P.K. Tosh, and H.P. Wetzler Re-evaluating endoscopy-associated infection risk estimates and their implications Am J Infect Control 41 2013 734 736
7. D.B. Nelson, and L.F. Muscarella Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy World J Gastroenterol 12 2006 3953 3964
8. D.H. Spach, F.E. Silverstein, and W.E. Stamm Transmission of infection by gastrointestinal endoscopy and bronchoscopy Ann Intern Med 118 1993 117 128
9. J. Kovaleva, F.T. Peters, H.C. van der Mei, and J.E. Degener Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy Clin Microbiol Rev 26 2013 231 254
10. L. Epstein, J.C. Hunter, M.A. Arwady, V. Tsai, L. Stein, M. Gribogiannis, and et al. New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes JAMA 312 2014 1447 1455
11. S. McCool, C.A. Muto, A. Querry, K. McGrath, A. Slivka, J. Zonker, and et al. High level disinfection failure (HLD) in gastrointestinal scopes with elevator channels - is it time to switch to ethylene oxide (ETO) sterilization? Abstract presented at: ID Week 2014 October 8-12, 2014 Arlington [VA]. Available at: https://idsa.confex.com/idsa/2014/webprogram/Paper47957.html. Accessed April 17, 2015
12. K. Wendorf, M. Kay, C. Baliga, P. Verma, S. Weissman, M. Gluck, and et al. Endoscope-associated multidrug-resistant Escherichia coli outbreak - King County, Washington, 2012-2014 Abstract presented at: ID Week 2014 October 8-12, 2014 Arlington [VA]. Available at: https://idsa.confex.com/idsa/2014/webprogram/Paper48240.html. Accessed April 17, 2015
13. J. Kovaleva, N.E. Meessen, F.T. Peters, M.H. Been, J.P. Arends, R.P. Borgers, and et al. Is bacteriologic surveillance in endoscope reprocessing stringent enough? Endoscopy 41 2009 913 916
14. P.C. Obee, C.J. Griffith, R.A. Cooper, R.P. Cooke, N.E. Bennion, and M. Lewis Real-time monitoring in managing the decontamination of flexible gastrointestinal endoscopes Am J Infect Control 33 2005 202 206
15. D. Hansen, D. Benner, M. Hilgenhoner, T. Leisebein, A. Brauksiepe, and W. Popp ATP measurement as method to monitor the quality of reprocessing flexible endoscopes Ger Med Sci 2 2004 Doc04
16. M.J. Alfa, N. Olson, P. Degagne, and P.J. Simner Development and validation of rapid use scope test strips to determine the efficacy of manual cleaning for flexible endoscope channels Am J Infect Control 40 2012 860 865
17. R. Fushimi, M. Takashina, H. Yoshikawa, H. Kobayashi, T. Okubo, S. Nakata, and et al. Comparison of adenosine triphosphate, microbiological load, and residual protein as indicators for assessing the cleanliness of flexible gastrointestinal endoscopes Am J Infect Control 41 2013 161 164
18. M.J. Alfa, I. Fatima, and N. Olson Validation of adenosine triphosphate to audit manual cleaning of flexible endoscope channels Am J Infect Control 41 2013 245 248
19. J.N. Mazurek, D. Hudesman, A.S. Korman, F. Glennon, and B.B. Bernstein 218 dramatic improvement in endoscope cleanliness using a commercial bioburden detection system and implementation of a modified cleaning algorithm Gastrointest Endosc 79 2014 AB121
20. D.E. Turner, E.K. Daugherity, C. Altier, and K.J. Maurer Efficacy and limitations of an ATP-based monitoring system J Am Assoc Lab Anim Sci 49 2010 190 195
21. K.H. Visrodia, C.L. Ofstead, H.L. Yellin, H.P. Wetzler, P.K. Tosh, and T.H. Baron The use of rapid indicators for the detection of organic residues on clinically-used gastrointestinal endoscopes with and without visually-apparent debris Infect Control Hosp Epidemiol 35 2014 987 994
22. M.J. Alfa, N. Olson, P. DeGagne, and M. Jackson A survey of reprocessing methods, residual viable bioburden, and soil levels in patient-ready endoscopic retrograde choliangiopancreatography duodenoscopes used in Canadian centers Infect Control Hosp Epidemiol 23 2002 198 206
23. 3M Clean-Trace ATP Surface Test October 2010 ed. 2010 3M Health Care Saint Paul [MN] 1 4
24. 3M Clean-Trace ATP Water Test 2011 3M Health Care Saint Paul [MN] 1 4
25. 3M Clean-Trace Surface Protein-High Sensitivity 2007 3M Microbiology Saint Paul [MN] 1 4
26. Healthmark Industries Instructions for Use: ChannelCheck 2013 Healthmark Industries Fraser [MI] 1-3
27. 3M Petrifilm aerobic count plate interpretation guide 2005 3M Microbiology Saint Paul [MN] 1 6
28. ASGE Quality Assurance In Endoscopy Committee B.T. Petersen, J. Chennat, J. Cohen, P.B. Cotton, D.A. Greenwald, and et al. Multisociety guideline on reprocessing flexible gastrointestinal endoscopes Gastrointest Endosc 73 2011 1075 1084
29. C.L. Ofstead, H.P. Wetzler, A.K. Snyder, and R.A. Horton Endoscope reprocessing methods: a prospective study on the impact of human factors and automation Gastroenterol Nurs 33 2010 304 311
30. M.J. Alfa, N. Olson, and P. DeGagne Automated washing with the Reliance Endoscope Processing System and its equivalence to optimal manual cleaning Am J Infect Control 34 2006 561 570
31. O. Bajolet, D. Ciocan, C. Vallet, C. De Champs, V. Vernet-Garnier, T. Guillard, and et al. Gastroscopy-associated transmission of extended-spectrum beta-lactamase-producing Pseudomonas aeruginosa J Hosp Infect 83 2013 341 343
32. C.A. DiazGranados, M.Y. Jones, T. Kongphet-Tran, N. White, M. Shapiro, Y.F. Wang, and et al. Outbreak of Pseudomonas aeruginosa infection associated with contamination of a flexible bronchoscope Infect Control Hosp Epidemiol 30 2009 550 555
33. J. Zweigner, P. Gastmeier, A. Kola, F.R. Klefisch, C. Schweizer, and M. Hummel A carbapenem-resistant Klebsiella pneumoniae outbreak following bronchoscopy Am J Infect Control 42 2014 936 937
34. A.M. Wendelboe, J. Baumbach, D.B. Blossom, P. Frank, A. Srinivasan, and C.M. Sewell Outbreak of cystoscopy related infections with Pseudomonas aeruginosa: New Mexico, 2007 J Urol 180 2008 588 592 discussion 592
35. S.F. Alrabaa, P. Nguyen, R. Sanderson, A. Baluch, R.L. Sandin, D. Kelker, and et al. Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment Am J Infect Control 41 2013 562 564
36. J. Hunter, and L. Epstein Epi-Aid trip report: cluster of plasmid-mediated AmpC-producing carbapenem-resistant Enterobacteriaceae (CRE)-Washington, 2014 2014 Department of Health and Human Services Atlanta [GA]
37. C. Aumeran, L. Poincloux, B. Souweine, F. Robin, H. Laurichesse, O. Baud, and et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography Endoscopy 42 2010 895 899
38. A. Carbonne, J.M. Thiolet, S. Fournier, N. Fortineau, N. Kassis-Chikhani, I. Boytchev, and et al. Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009 Euro Surveill 15 2010 19734
39. M.J. Alfa, and R. Howie Modeling microbial survival in buildup biofilm for complex medical devices BMC Infect Dis 9 2009 56
40. Food and Drug Administration Mitigating the risk of cross-contamination from valves and accessories used for irrigation through flexible gastrointestinal endoscopes 2014 United States Department of Health and Human Services Rockville [MD] 1 9
41. Gastoenterological Society of Australia (GESA), Gastroenterological Nurses College of Australia (GENCA), and Australian Gastrointestinal Endoscopy Association (AGEA) Infection control in endoscopy Clinical update 3rd ed. 2010 Diagnostic Health Foundation Vienna, Austria
42. Standards New Zealand Microbiological surveillance of flexible hollow endoscopes 2001 New Zealand Ministry of Health: Standards Council Wellington, New Zealand
43. U. Beilenhoff, C.S. Neumann, J.F. Rey, H. Biering, R. Blum, V. Schmidt, and et al. ESG-ESGENA guideline for quality assurance in reprocessing: microbiological surveillance testing in endoscopy Endoscopy 39 2007 175 181
44. Public Health Agency of Canada Infection prevention and control guideline for flexible gastrointestinal endoscopy and flexible bronchoscopy 2010 Infection Prevention and Control Guideline Development Process Winnipeg, Manitoba, Canada
45. Z.A. Aiken, M. Wilson, and J. Pratten Evaluation of ATP bioluminescence assays for potential use in a hospital setting Infect Control Hosp Epidemiol 32 2011 507 509
46. A.M. Dirlam Langlay, C.L. Ofstead, N.J. Mueller, P.K. Tosh, T.H. Baron, and H.P. Wetzler Reported gastrointestinal endoscope reprocessing lapses: the tip of the iceberg Am J Infect Control 41 2013 1188 1194