Measures to improve microbial quality surveillance of gastrointestinal endoscopes

Background and study aim: Infectious outbreaks associated with the use of gastrointestinal endoscopes have increased in line with the spread of highly resistant bacteria. The aim of this study was to determine the measures required to improve microbial quality surveillance of gastrointestinal endoscopes.

Methods: We reviewed the results of all microbiological surveillance testing of gastrointestinal endoscopes and automatic endoscope reprocessors (AERs) performed at Brest Teaching Hospital from 1 January 2008 to 1 June 2015. We analyzed the influence of the time of incubation on the rate of positive results using the Kaplan – Meier method. We also studied risk factors for gastrointestinal endoscope contamination using a multivariable logistic regression model.

Results: Over the study period, 1100 microbiological tests of gastrointestinal endoscopes (n = 762) and AERs (n = 338) were performed. A total of 264 endoscope tests (34.6 %) showed a level of contamination higher than the target. After 2 days of incubation, contamination was apparent in only 55.5 % of the endoscopes that were later shown to be contaminated (95 % confidence interval [CI] 49.2 – 61.8). Multivariable analysis showed that the use of storage cabinets for heat-sensitive endoscopes significantly reduced the risk of endoscope contamination (odds ratio [OR] 0.23, 95 %CI 0.09 – 0.54; P  < 0.001) and that the use of endoscopes older than 4 years significantly increased this risk (OR_{≥ 6 vs. < 2 years} 2.92, 95 %CI 1.63 – 5.24; P < 0.001).

Conclusions: Microbiological culture technique, mainly incubation duration, strongly influenced the results of endoscope sampling. Samples should be cultured for more than 2 days to improve the detection of contaminated endoscopes. Particular attention should be paid to endoscopes older than 2 years and to those that are not stored in storage cabinets for heat-sensitive endoscopes.

• References

• 1 Spaulding EH. Chemical disinfection and antisepsis in the hospital. J Hosp Res 1972; 9: 5-31
• 2 Ofstead CL, Dirlam Langlay AM, Mueller NJ et al. Re-evaluating endoscopy-associated infection risk estimates and their implications. Am J Infect Control 2013; 41: 734-736
• 3 Kovaleva J, Peters FTM, van der Mei HC et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26: 231-254
• 4 Epstein L, Hunter JC, Arwady MA et al. New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312: 1447-1455
• 5 Aumeran C, Poincloux L, Souweine B et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010; 42: 895-899
• 6 Carbonne A, Thiolet JM, Fournier S et al. Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009. Euro Surveill 2010; 15: pii: 19734
• 7 Kola A, Piening B, Pape UF et al. An outbreak of carbapenem-resistant OXA-48 – producing Klebsiella pneumonia associated to duodenoscopy. Antimicrob Resist Infect Control 2015; 4: 8
• 8 Wendorf KA, Kay M, Baliga C et al. Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol 2015; 36: 634-642
• 9 Verfaillie C, Bruno M, in ’t holt Voor AF et al. Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa . Endoscopy 2015; 47: 493-502
• 10 Kovaleva J, Meessen NEL, Peters FTM et al. Is bacteriologic surveillance in endoscope reprocessing stringent enough?. Endoscopy 2009; 41: 913-916
• 11 Petersen BT, Chennat J, Cohen J et al. Multisociety guideline on reprocessing flexible GI endoscopes: 2011. Infect Control Hosp Epidemiol 2011; 32: 527-537
• 12 Direction générale de la santé (DGS). Circulaire DHOS/E 2/DGS/SD 5 C n° 2003-591 du 17 décembre 2003 relative aux modalités de traitement manuel pour la désinfection des endoscopes non autoclavables dans les lieux de soins. Available from: http://social-sante.gouv.fr/fichiers/bo/2004/04-01/a0010011.htm Accessed 8 January 2016
• 13 Advisory Board Cleaning and Disinfection Flexible Endoscopes (SFERD). Professional standard handbook. Flexible endoscopes – Cleaning and disinfection. 2011 Available from: http://sterilisatievereniging.nl/wp-content/uploads/2015/07/2011-09-28-SFERD-handbook-2.1.pdf Accessed: 8 January 2016
• 14 Beilenhoff U, Neumann C, Rey J et al. ESGE–ESGENA guideline: cleaning and disinfection in gastrointestinal endoscopy. Endoscopy 2008; 40: 939-957
• 15 Gastroenterological Society of Australia, Gastroenterological Nurses College of Australia and Australian Gastrointestinal Endoscopy Association. Infection control in Endoscopy. 2010 Available from: http://www.gesa.org.au/files/editor_upload/File/DocumentLibrary/Professional/Infection_Control_in_Endoscopy_Guidelines_2014.pdf Accessed: 8 January 2016
• 16 Muscarella LF. Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying. Am J Gastroenterol 2006; 101: 2147-2154
• 17 Saliou P, Cholet F, Jézéquel J et al. The use of channel-purge storage for gastrointestinal endoscopes reduces microbial contamination. Infect Control Hosp Epidemiol 2015; 36: 1100-1102
• 18 Commission for Hospital Hygiene and Infection Prevention (KRINKO), Federal Institute for Drugs and Medical Devices (BfArM). [Hygiene requirements for the reprocessing of medical devices. Recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI) and the Federal Institute for Drugs and Medical Devices (BfArM)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55: 1244-1310
• 19 Leung JW. Reprocessing of flexible endoscopes. J Gastroenterol Hepatol 2000; 15: G73-G77
• 20 Paula H, Presterl E, Tribl B et al. Microbiologic surveillance of duodenoscope reprocessing at the Vienna University Hospital from November 2004 through March 2015. Infect Control Hosp Epidemiol 2015; 36: 1233-1235
• 21 Gillespie EE, Kotsanas D, Stuart RL. Microbiological monitoring of endoscopes: 5-year review. J Gastroenterol Hepatol 2008; 23: 1069-1074
• 22 Ofstead CL, Wetzler HP, Doyle EM et al. Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines. Am J Infect Control 2015; 43: 794-801
• 23 Alfa MJ, Sepehri S, Olson N et al. Establishing a clinically relevant bioburden benchmark: a quality indicator for adequate reprocessing and storage of flexible gastrointestinal endoscopes. Am J Infect Control 2012; 40: 233-236
• 24 Gabard A, Borderan G-C, Chevrie N et al. Microbiological monitoring of endoscopes: factors determining non-conformities. Hygienes 2013; 21: 141-144
• 25 Direction générale de la santé (DGS), CTINILS. Eléments d’assurance qualité en hygiène relatifs au contrôle microbiologique des endoscopes et à la traçabilité en endoscopie. 2007 Available from: http://social-sante.gouv.fr/IMG/pdf/microbio_endoscopes-2.pdf Accessed: 8 January 2016
• 26 Centers for Disease Control and Prevention (CDC). Interim Protocol for Healthcare Facilities Regarding Surveillance for Bacterial Contamination of Duodenoscopes after Reprocessing. 2015 Available from: http://www.cdc.gov/hai/pdfs/cre/interim-duodenoscope-surveillance-Protocol.pdf Accessed: 8 January 2016
• 27 Brock AS, Steed LL, Freeman J et al. Endoscope storage time: assessment of microbial colonization up to 21 days after reprocessing. Gastrointest Endosc 2015; 81: 1150-1154
• 28 Chiu K-W, Tsai M-C, Wu K-L et al. Surveillance cultures of samples obtained from biopsy channels and automated endoscope reprocessors after high-level disinfection of gastrointestinal endoscopes. BMC Gastroenterol 2012; 12: 120
• 29 Saliou P, Garlantézec R, Baron R et al. Microbiological investigation of endoscopes at Brest Hospital over a period from 2007 to 2009. Pathol Biol 2011; 59: 88-93
• 30 Buss AJ, Been MH, Borgers RP et al. Endoscope disinfection and its pitfalls – requirement for retrograde surveillance cultures. Endoscopy 2008; 40: 327-332
• 31 Brown SA, Merritt K, Woods TO et al. Effects of different disinfection and sterilization methods on tensile strength of materials used for single-use devices. Biomed Instrum Technol 2002; 36: 23-27
• 32 Otter JA, Vickery K, Walker JT et al. Surface-attached cells, biofilms and biocide susceptibility: implications for hospital cleaning and disinfection. J Hosp Infect 2015; 89: 16-27
• 33 Smith ZL, Oh YS, Saeian K et al. Transmission of carbapenem-resistant Enterobacteriaceae during ERCP: time to revisit the current reprocessing guidelines. Gastrointest Endosc 2015; 81: 1041-1045