Endoscope-associated infections: A microbiologist's perspective on current technologies

Thornhill, Grace; David, Maren

doi:10.1016/j.tgie.2019.150625

Cited by 13 publications

(18 citation statements)

References 81 publications

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“…Only in a few outbreaks, WGS was used to distinguish the microorganisms found on the duodenoscopes and in the affected patients [ 11 – 13 ]. WGS is superior to other types of molecular typing such as AFLP or pulsed-field gel electrophoresis (PFGE) in strain typing [ 7 , 14 ].…”

Section: Discussionmentioning

confidence: 99%

Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report

Kwakman

Rauwers

Klaassen

et al. 2021

Antimicrob Resist Infect Control

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Background Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias. Case presentation We describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients’ blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences. Conclusion This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored.

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Section: Discussionmentioning

confidence: 99%

Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report

Kwakman

Rauwers

Klaassen

et al. 2021

Antimicrob Resist Infect Control

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“…The microbiological culture of endoscopes is critical to understanding the e cacy of reprocessing and transmission of microorganisms during outbreak investigations [8,17,18,[21][22][23]. However, the existing guidelines are inconsistent in terms of the recommended frequency and method of microbiological monitoring [7,9,24] (Table 6). In Europe [7] and Australia [9,10], endoscopy microbiology surveillance is regarded as a critical indicator of endoscope reprocessing quality.…”

Section: Discussionmentioning

confidence: 99%

Monthly endoscopy surveillance culture facilitates detection of breaches in the scope reprocessing procedure: 5 year-experience in an endoscopy center

Yen

Chen

Lai

et al. 2019

Preprint

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AIM To review the clinical impact of monthly microbiology surveillance culture for monitoring endoscope contamination after high-level disinfection.METHODS Monthly surveillance culture of the endoscopes was conducted from January 2014 to December 2018 at our endoscopy center. A total of 1931 cultures were collected, including 765 cultures from 16 gastroscopes, 730 cultures from 18 colonoscopes, 379 cultures from 8 duodenalscopes, 46 cultures from 1 echoscopes, and 11 cultures from 1 enterscope. Cultures were obtained from ready-to-use endoscopes after a full reprocessing cycle and storage. Samples were cultured to test for aerobic and anaerobic bacteria.RESULTS The positive culture rates for the endoscope were 2% (15/765) for gastroscopes, 1.9% (14/730) for colonoscopes, 0.8% (3/379) for duodenscopes, 4.3% (2/46) for echoscopes, and 9.1% (1/11) for enterscopes. These findings were predominantly attributed to human factors (71.4%, 25/35) followed by storage cabinet failure (14.3%, 5/35), automatic endoscope reprocessing failure (11.4%, 4/35), and endoscope channel damage (2.8%, 1/35). Multivariate analysis showed that the years 2015 [odds ratio (OR) 0.19, 0.04 to 0.91], 2016 (OR 0.21, 0.05 to 0.80), and 2017 (OR 0.22, 0.06 to 0.83) were associated with decreased risk of endoscope contamination. The age, type, and number of times the scope was used were not related to contamination.CONCLUSIONS A low risk of endoscope contamination was found over a 5-year period in our endoscopy center. The most common cause of contamination was human factor. Duodenalscopes showed the lowest scope contamination rate. We suggested the implantation of a systematic endoscope culture regardless of the type of scope to facilitate early detection of breaches in the scope reprocessing procedure in clinical practice.

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“…9 Other studies have shown contamination rates of patient-ready reusable duodenoscopes to be as high as 60%. 10 Infections of endogenous origin are thought to be caused by translocation of normal flora into the blood stream during endoscopic procedures. 2 11 12 It is currently unknown which fraction of ERCP-related infections are endogenous in origin and which fraction results from exogenous bacteria that originate in the environment (e.g., from a contaminated duodenoscope).…”

Section: Identifying Risk Factors For Infection In Patients Undergoing Endoscopic Retrograde Cholangiopancreatograpymentioning

confidence: 99%

Duodenoscope-Acquired Infections: Risk Factors to Consider

Thornhill

Dunkin

2021

Journal of Digestive Endoscopy

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In 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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Endoscope-associated infections: A microbiologist's perspective on current technologies

Cited by 13 publications

References 81 publications

Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report

Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report

Monthly endoscopy surveillance culture facilitates detection of breaches in the scope reprocessing procedure: 5 year-experience in an endoscopy center

Duodenoscope-Acquired Infections: Risk Factors to Consider

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