Leading a Horse to Water: Are Crucial Lessons in Endoscopy and Outbreak Investigations Being Learned?

Other Possible Causes of a Well-Publicized Outbreak of <i>Pseudomonas aeruginosa</i> Following Arthroscopy in Texas

“…This article's review of the medical literature presents a number of additional findings. First, it identified several reports that document outbreaks (and pseudo-outbreaks) of P. aeruginosa associated with a number of different types of reusable medical instruments, including bronchoscopes, gastrointestinal endoscopes and transrectal ultrasound-guided prostate biopsy equipment [9][10][11][12][13][14][15][16][17]. These instruments, however, unlike the arthroscopic shaver handpieces and inflow/outflow cannulae discussed by Tosh et al (2011), are damaged by heat, and for each of these reported outbreaks disease transmission was linked, not to ineffective steam sterilization, but to inadequate high-level disinfection or liquid chemical sterilization.…”

“…These instruments, however, unlike the arthroscopic shaver handpieces and inflow/outflow cannulae discussed by Tosh et al (2011), are damaged by heat, and for each of these reported outbreaks disease transmission was linked, not to ineffective steam sterilization, but to inadequate high-level disinfection or liquid chemical sterilization. These latter two types of processes use a low-temperature liquid chemical disinfectant or sterilant to effect their outcome, and the cause of infection associated with either is often attributed to the terminal rinsing of heat-sensitive instruments with water that was contaminated with bacteria [10][11][12][13][14][15].…”

“…Outbreaks of P. aeruginosa have been associated with the improper reprocessing of flexible endoscopes, often due to their terminal rinsing with contaminated water following high-level disinfection or liquid chemical sterilization [9][10][11][12][13][14][15][16][17][18]. Yet, improper reprocessing of reusable medical equipment-whether of a flexible endoscope, an arthroscopic instrument, or another type of medical instrument-is but only one of many factors documented to be responsible for infections of P. aeruginosa in the healthcare setting.…”

“…3) The unwitting and unrecognized failure to have terminally sterilized the implicated arthroscopic instruments using any method [31]; 4) Ineffective sterilization of the implicated arthroscopic instruments due to a deficiency or unrecognized fault in one or more of the hospital's sterilization processes; 5) Immersion of the implicated arthroscopic equipment in a liquid chemical disinfectant or sterilant, followed by its rinsing with water contaminated with the outbreak's strain of P. aeruginosa [9,10,12,[15][16][17]; and/or 6) A factor unrelated to the reprocessing of the hospital's implicated arthroscopic instruments-for example, the possibility that the outbreak's strain of P. aeruginosa might have originated from a source hitherto not identified, such as an intrinsically contaminated irrigant used during the procedures, or due to retrograde flow from a contaminated suction canister [1]. steps."…”

“…from the outbreak's strain of P. aeruginosa [1]. If any of the implicated arthroscopic instruments were indeed high-level disinfected (accidentally, inadvertently, or unwittingly), then the microbial quality of the hospital's water would have been necessary to determine in order to evaluate whether this water-which would have been used to rinse the instruments terminally after their chemical immersion and, if contaminated with the outbreak's strain of P. aeruginosa, would most likely have been a source of this bacterial outbreak [10,13,15,17]might have played more of a role in causing this outbreak than has been recognized 9 . No matter, Tosh et al's (2011) use of these three different terms to describe this gas plasma processor and its outcome leaves unclear and unresolved which specific methods Methodist Hospital used to process at least some of its arthroscopic instrumentation during the time of its bacterial outbreak, in 2009.…”