Pseudomonas aeruginosa cross-infection following endoscopic retrograde cholangiopancreatography

Risk of transmission of carbapenem-resistantEnterobacteriaceaeand related “superbugs” during gastrointestinal endoscopy

“…Cryan et al [11] (1984) report an outbreak of P. aeruginosa following ERCP, with associated patient morbidity and mortality. This report concludes that this outbreak was related to inadequate high-level disinfection of the ERCP endoscope's air/water channels.…”

“…[Note: The ERCP endoscope's unique and complex physical design -coupled with the increased invasiveness of, and complication rate associated with, ERCP especially in the presence of biliary tract obstruction and tissue injury -may explain why bacterial infections including those caused by CRE are more often associated with ERCP than with any other type of GI endoscopic procedure (Figure 1) [7,11,[20][21][22]25] ]. Providing crucial insight into both the causes and prevention of CRE transmissions during GI endoscopy, several of these recently published reports conclude that the ERCP endoscope's physical design likely contributed to the transmission of CRE or a related superbug [13,[20][21][22][24][25][26][27][28][29][30] .…”

“…Although the risk of disease transmission during GI endoscopy is reported to be low, infections and outbreaks due to contaminated GI endoscopes, with associated patient morbidity and mortality, have been documented a number of times during the past 30 years, both prior to and since CRE's emergence [2,[4][5][6][7][8][9][10][11][12]14,33,34] . These cases include infections of bacteria, including P. aeruginosa, and viruses, namely, the hepatitis B (HBV) or C virus (HCV).…”

“…(Prior to 2001 the resistance of these transmitted strains of Enterobacteriaceae to carbapenems in the United States and globally was rare). The specific breach typically responsible for these instances of disease transmission was reported to be, as much if not more so than faulty cleaning and inadequate high-level disinfection, insufficient drying of one or more of the GI endoscope's several internal channels, particularly the exposed elevator wire channel of some models of ERCP endoscopes, using either manual reprocessing procedures or an AER [7][8][9]11,12,14] . In only a very few cases has the transmission of a bloodborne virus (i.e., HBV or HCV) been reported during GI endoscopy, with the un-sterile administration of an iv medication typically being identified as, or suspected of being, the outbreak's proximate cause or a likely contributing factor [9,10] .…”

“…Bacterial and viral outbreaks following GI endoscopy, with associated morbidity and mortality, have been reported (albeit infrequently) during the past 30 years, but the cause of virtually every one of these outbreaks was attributed to one or more infection control breaches -for example, to: (1) an endoscope reprocessing lapse, including the failure to clean the GI endoscope's instrument channel with a brush; or, the faulty reprocessing of the GI endoscope by an automated endoscope reprocessor, or AER, with a flawed internal design; (2) a damaged or improperly maintained or serviced GI endoscope; or (3) the unsterile administration of an intravenous (iv) medication [6][7][8][9][10][11][12][13][14] . Cleaning, high-level disinfection, and drying of the GI endoscope, either in strict accordance with the endoscope's labeling or, alternatively, consistent with any one of a number of recently published endoscope reprocessing guidelines, form the tridental cornerstone of infection control in the GI endoscopic setting.…”