Transmission of Infection by Flexible Gastrointestinal Endoscopy and Bronchoscopy

Abstract

SUMMARY Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.

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

“…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.…”

ERCP Scopes: What Can We Do to Prevent Infections?

“…Second, more healthcare-associated outbreaks have been linked to contaminated endoscopes than to any other reusable medical device. 7,9 However, until recently, these outbreaks have been traced to deficient practices such as inadequate cleaning and inappropriate disinfection (eg, failure to perfuse all channels), to damaged endoscopes or flaws in the design of endoscopes (eg, duodenoscope elevator channel), and to automated endoscope reprocessors (AERs). 7,9 Reprocessing failures have led to patient notifications and bloodborne pathogen testing in dozens of instances.…”

“…7,9 However, until recently, these outbreaks have been traced to deficient practices such as inadequate cleaning and inappropriate disinfection (eg, failure to perfuse all channels), to damaged endoscopes or flaws in the design of endoscopes (eg, duodenoscope elevator channel), and to automated endoscope reprocessors (AERs). 7,9 Reprocessing failures have led to patient notifications and bloodborne pathogen testing in dozens of instances. 10 Third, evidence-based endoscope reprocessing guidelines have been prepared by professional organizations, and the CDC as well as past data suggest that rigorous adherence to these guidelines would result in a pathogen-free endoscope.…”