Duodenoscope-Related Outbreak of a Carbapenem-Resistant Klebsiella pneumoniae Identified Using Advanced Molecular Diagnostics

Abstract

This outbreak demonstrated the previously underappreciated potential for duodenoscopes to transmit disease, even after undergoing high-level disinfection according to manufacturers' guidelines.

Australian infection control in endoscopy consensus statements on carbapenemase‐producing Enterobacteriaceae

“…Despite advances in endoscopic instrument reprocessing over the past 40 years, current reprocessing techniques remain suboptimal 17,[31][32][33][34] as evidenced by recent outbreaks of CPE. [7][8][9][10][11][12][13][14][15][18][19][20][21] Endoscopic units should be designed to facilitate patient flow minimizing interaction of pre-procedure and post-procedure patients and endoscope flow avoiding any contact between reprocessed (clean) and used (dirty) instruments. Facilities must provide appropriate equipment for endoscope reprocessing and adequate staff appropriately trained, supervised, and reassessed in their adherence to reprocessing protocols as stipulated by instrument manufacturers.…”

“…As detailed in Table 3, the majority of outbreaks of CPE related to endoscopic transmission were linked to duodenoscopes. [7][8][9][10][11][12][13][14][15] Further reports relate to linear echoendoscopes. 16,17 As discussed in Statement 2, this is related to the difficulties in cleaning the complex tips of these instruments.…”

“…Evidence level: III Recommendation grade: C Voting on recommendation: Accept completely: 83%, Accept with some reservation: 17% It is accepted that the complex tips of duodenoscopes and linear echoendoscopes are a source of transmission of CPE due to difficulties in achieving adequate removal of biologic material. [7][8][9][10][11][12][13][14][15][16][17] Other endoscopes, without complex tips, have also been linked to patient-to-patient transmission of CPE. 15,[18][19][20][21] Six out of 10 screened patients were colonized with KPC K. pneumoniae, and two developed clinical infections following gastroscopies using a colonized instrument.…”

“…[4][5][6] Patient-to-patient transmission of CPE by endoscopic instruments was first reported in 2010. [7][8][9] Whereas most attention has focused on transmission by duodenoscopes during endoscopic retrograde cholangiopancreatoscopy (ERCP), [7][8][9][10][11][12][13][14][15] positive (22/540 [4.2%]) microbiological cultures have been reported from linear echoendoscopes post-high-level disinfection. 16 There are also anecdotal reports of infectious transmission from linear echoendoscopes.…”

Elevating the standard of endoscope processing: Terminal sterilization of duodenoscopes using a hydrogen peroxide–ozone sterilizer

“…Duodenoscopes present a particular challenge because they contain multiple long and narrow lumens and are side-viewing endoscopes consisting of a recessed elevator used to direct endoscopic accessories. [3][4][5][6][7] This processing challenge is evidenced by documented cases of duodenoscope contamination 8 and by related patient infections, [9][10][11][12][13][14][15] even after adherence to the manufacturer's processing instructions, [16][17][18][19] which include highlevel disinfection (HLD). Several outbreaks of patient infections with carbapenem-resistant Enterobacteriaceae (CRE) were linked to contaminated duodenoscopes in the United States and around the world.…”