Eine systematische Analyse nosokomialer Ausbrüche von Infektionskrankheiten in der gastrointestinalen Endoskopie

Zusammenfassung

Die Ösophagogastroduodenoskopie (ÖGD), die endoskopische retrograde Cholangiopankreatikografie (ERCP) sowie die Koloskopie (KOLO) bergen stets das Risiko einer Transmission von Erregern. Leider gibt es bislang nur wenige Daten zu den Ursachen und Erregerspektren für diese Ereignisse.

In einer systematischen Literaturrecherche der Worldwide Outbreak Database, der PubMed und der Embase wurden entsprechende Ausbrüche hinsichtlich der Ausbruchsursache, des Erregerspektrums, der Attack Rate und Letalität sowie der daraufhin eingeleiteten Hygienemaßnahmen evaluiert.

Es wurden insgesamt 73 Ausbrüche (ÖDG: 24; ERCP: 42; KOLO: 7) eingeschlossen mit Attack Rates in Höhe von 3,5%, 7,1% und 12,8%. Die zugehörigen Letalitäten betrugen 6,3%, 12,7% und 10,0%. Im Rahmen der ÖGD ereigneten sich vor allem Transmissionen von Enterobakterien mit einem großen Anteil multiresistenter Isolate. Via ERCP wurden überwiegend Nonfermenter übertragen. Die häufigste Ursache für die akzidentelle Verwendung kontaminierter Endoskope war menschliches Versagen während der Endoskopaufbereitung.

Dem Anwender sollte das Risiko einer Übertragung stets bewusst sein, um diese frühestmöglich erkennen und fortan unterbinden zu können. Darüber hinaus müssen Mitarbeiter regelmäßig in der Aufbereitung von Medizinprodukten geschult werden. Die Verwendung von Einmalendoskopen senkt zwar das Übertragungsrisiko von Erregern, erhöht jedoch andererseits die Abfallmenge und ggf. auch die Kosten.

Abstract

Esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy (CLN) come with a potential risk of pathogen transmission. Unfortunately, up to now data on the causes and the distribution of pathogens is rather sparse.

We performed a systematic review of the medical literature using the Worldwide Outbreak Database, the PubMed, and Embase. We then checked so-retrieved articles for potential sources of the outbreak, the spectrum of pathogens, the attack rates, mortality and infection control measures.

In total 73 outbreaks (EGD: 24, ERCP: 42; CLN: 7) got included. The corresponding attack rates were 3.5%, 7.1% and 12.8% and mortality rates were 6.3%, 12.7% and 10.0% respectively. EGD was highly associated with transmission of enterobacteria including a large proportion of multi-drug resistant strains. ERCP led primarily to transmission of non-fermenting gram-negative rods. The most frequent cause was human failure during reprocessing regardless of the type of endoscope.

Staff working in the field of endoscopy should always be aware of the possibility of pathogen transmission in order to detect and terminate those events at the early most time point. Furthermore, proper ongoing education of staff involved in the reprocessing and maintenance of endoscopes is crucial. Single-use devices may be an alternative option and lower the risk of pathogen transmission, but on the downside may also increase costs and waste.

Schlüsselwörter

Ausbruch - Endoskopie - Transmission - Infektion - Hygiene - Prävention

Keywords

Outbreak - Endoscopy - Transmission - Infection - Hygiene - Prevention

Publication History

Received: 11 January 2022

Accepted after revision: 06 October 2022

Article published online:
10 January 2023

• Literatur

• 1 Day LW, Muthusamy VR, Collins J. et al. Multisociety guideline on reprocessing flexible GI endoscopes and accessories. Gastrointest Endosc 2021; 93: 11-33 e16 DOI: 10.1016/j.gie.2020.09.048. (PMID: 33353611)
• 2 Leiß O, Martiny H. Infektionsprävention in der Endoskopie. Aufbereitung flexibler Endoskope und Maßnahmen zum Personalschutz – Update 2021. Gastroenterologie up2date 2021; 17: 185-204 DOI: 10.1055/a-1451-8095.
• 3 Spach DH, Silverstein FE, Stamm WE. Transmission of Infection by Gastrointestinal Endoscopy and Bronchoscopy. Ann Intern Med 1993; 118: 117-128 DOI: 10.7326/0003-4819-118-2-199301150-00008. (PMID: 8416308)
• 4 Kovaleva J, Peters FT, van der Mei HC. et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26: 231-254 DOI: 10.1128/CMR.00085-12. (PMID: 23554415)
• 5 Deb A, Perisetti A, Goyal H. et al. Gastrointestinal endoscopy‑asociated infections: updateon an emerging issue. Dig Dis Sci 2022; 67: 1718-1732 DOI: 10.1007/s10620-022-07441-8.
• 6 Gastmeier P, Stamm-Balderjahn S, Hansen S. et al. Use of information on nosocomial outbreaks for infection control. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2004; 47: 334-338 DOI: 10.1007/s00103-004-0808-5. (PMID: 15205775)
• 7 Gastmeier P, Stamm-Balderjahn S, Hansen S. et al. Where should one search when confronted with outbreaks of nosocomial infection?. Am J Infect Control 2006; 34: 603-605 DOI: 10.1016/j.ajic.2006.01.014.
• 8 Vonberg RP, Weitzel-Kage D, Behnke M. et al. Worldwide Outbreak Database: the largest collection of nosocomial outbreaks. Infection 2011; 39: 29-34 DOI: 10.1007/s15010-010-0064-6. (PMID: 21153042)
• 9 Szary NM, Al-Kawas FH. Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterol Hepatol (N Y) 2013; 9: 496-504 (PMID: 24719597)
• 10 Suresh S, Pande M, Patel K. et al. Education, training, and knowledge of infection control among endoscopy technicians and nurses. Am J Infect Control 2021; 49: 836-839 DOI: 10.1016/j.ajic.2021.01.010.
• 11 Shin HY, Jang DH, Jun JK. A nationwide survey on the effectiveness of training on endoscope reprocessing within the national cancer screening program in Korea. Am J Infect Control 2021; 49: 1031-1035 DOI: 10.1016/j.ajic.2021.02.005.
• 12 Casini B, Tuvo B, Marciano E. et al. Improving the Reprocessing Quality of Flexible Thermolabile Endoscopes: How to Learn from Mistakes. Int J Env Res Pub He 2021; 18 DOI: 10.3390/ijerph18052482.
• 13 Ofstead CL, Buro BL, Hopkins KM. et al. Duodenoscope-associated infection prevention: A call for evidence-based decision making. Endosc Int Open 2020; 8: E1769-E1781 DOI: 10.1055/a-1264-7173. (PMID: 33269310)
• 14 Alrabaa SF, Nguyen P, Sanderson R. et al. Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment. Am J Infect Control 2013; 41: 562-564 DOI: 10.1016/j.ajic.2012.07.008.
• 15 Epstein L, Hunter JC, Arwady MA. et al. New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312: 1447-1455 DOI: 10.1001/jama.2014.12720.
• 16 Kim S, Russell D, Mohamadnejad M. et al. Risk factors associated with the transmission of carbapenem-resistant Enterobacteriaceae via contaminated duodenoscopes. Gastrointest Endosc 2016; 83: 1121-1129 DOI: 10.1016/j.gie.2016.03.790.
• 17 Rauwers AW, Voor In 't Holt AF, Buijs JG. et al. High prevalence rate of digestive tract bacteria in duodenoscopes: a nationwide study. Gut 2018; 67: 1637-1645 DOI: 10.1136/gutjnl-2017-315082.
• 18 Rahman MR, Perisetti A, Coman R. et al. Duodenoscope-associated infections: update on an emerging problem. Dig Dis Sci 2019; 64: 1409-1418 DOI: 10.1007/s10620-018-5431-7. (PMID: 30569333)
• 19 Larsen S, Russell RV, Ockert LK. et al. Rate and impact of duodenoscope contamination: a systematic review and meta-analysis. EClinicalMedicine 2020; 25: 100451 DOI: 10.1016/j.eclinm.2020.100451. (PMID: 32954234)
• 20 Verfaillie CJ, Bruno MJ, Voor in 't Holt AF. et al. Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa. Endoscopy 2015; 47: 493-502 DOI: 10.1055/s-0034-1391886.
• 21 Brunke MS, Konrat K, Schaudinn C. et al. Tolerance of biofilm of a carbapenem-resistant Klebsiella pneumoniae involved in a duodenoscopy-associated outbreak to the disinfectant used in reprocessing. Antimicrob Resist Infect Control 2022; 11: 81 DOI: 10.1186/s13756-022-01112-z. (PMID: 35659363)
• 22 Brandabur JJ, Leggett JE, Wang L. et al. Surveillance of guideline practices for duodenoscope and linear echoendoscope reprocessing in a large healthcare system. Gastrointest Endosc 2016; 84: 392-399 e393 DOI: 10.1016/j.gie.2016.03.1480. (PMID: 27032883)
• 23 Rauwers AW, Troelstra A, Fluit AC. et al. Independent root-cause analysis of contributing factors, including dismantling of 2 duodenoscopes, to investigate an outbreak of multidrug-resistant Klebsiella pneumoniae. Gastrointest Endosc 2019; 90: 793-804 DOI: 10.1016/j.gie.2019.05.016. (PMID: 31102643)
• 24 ASGE Quality Assurance in Endoscopy Committee. et al. ASGE guideline for infection control during GI endoscopy. Gastrointest Endosc 2018; 87: 1167-1179 DOI: 10.1016/j.gie.2017.12.009..
• 25 Food and Drug Administration. The FDA Continues to Remind Facilities of the Importance of Following Duodenoscope Reprocessing Instructions: FDA Safety Communication. 2019 Accessed September 09, 2022 at: https://public4.pagefreezer.com/content/FDA/16–06–2022T13:39/https://www.fda.gov/medical-devices/safety-communications/fda-continues-remind-facilities-importance-following-duodenoscope-reprocessing-instructions-fda
• 26 Trindade AJ, Copland A, Bhatt A. et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc 2021; 93: 997-1005 DOI: 10.1016/j.gie.2020.12.033.
• 27 Ehrlich D, Muthusamy VR. Device profile of the EXALT Model D single-use duodenoscope for endoscopic retrograde cholangiopancreatography: overview of its safety and efficacy. Expert Rev Med Devices 2021; 18: 421-427 DOI: 10.1080/17434440.2021.1917990.
• 28 Napoleon B, Gonzalez JM, Grandval P. et al. Evaluation of the performances of a single-use duodenoscope: prospective multi-center national study. Dig Endosc 2022; 34: 215-221 DOI: 10.1111/den.13965. (PMID: 33666280)
• 29 Muthusamy VR, Bruno MJ, Kozarek RA. et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2020; 18: 2108-2117 e2103 DOI: 10.1016/j.cgh.2019.10.052. (PMID: 31706060)
• 30 Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut 2021; 70: 838-844 DOI: 10.1136/gutjnl-2020-321836. (PMID: 32895332)
• 31 Enns RA, Hookey L, Armstrong D. et al. Clinical practice guidelines for the use of video capsule endoscopy. Gastroenterology 2017; 152: 497-514 DOI: 10.1053/j.gastro.2016.12.032. (PMID: 28063287)
• 32 Agrawal DTZ. Sustainability of single-use endoscopes. Tech Innov Gastrointest Endosc 2021; 23: 353-362 DOI: 10.1016/j.tige.2021.06.001.
• 33 Eiland JE, Adams SJ. Ofstead CQ, MR, . A glimpse at the true cost of reprocessing endoscopes: results of a pilot project. 2017 Accessed September 09, 2022 at: https://www.bostonscientific.com/content/dam/bostonscientific/uro-wh/portfolio-group/LithoVue/pdfs/Sterilization-Resource-Handout.pdf
• 34 Larsen S, Kalloo A, Hutfless S. The hidden cost of colonoscopy including cost of reprocessing and infection rate: the implications for disposable colonoscopes. Gut 2020; 69: 197-200 DOI: 10.1136/gutjnl-2019-319108. (PMID: 31413166)
• 35 Pohl H, von Renteln D. Environmental impact of disposable endoscopic equipment and endoscopes – a volumetric analysis. Endoscopy 2020; 52: S11 DOI: 10.1055/s-0040-1704041.
• 36 Hernandez LV, Le NNT, Patnode C. et al. Comparing the impact of reusable and singe-use duodenoscopies using life cycle assessment. Clin Endoscopic Pract 2021; 93: AB29 DOI: 10.10106/j.gie.2021.03.123.
• 37 Boston cientific. 2020 Accessed September 09, 2022 at: https://www.bostonscientific.com/en-US/corporate-social-responsibility/planet/climate-change.html