Investigation and prevention of infectious outbreaks during endoscopic retrograde cholangiopancreatography

Introduction: the side-viewing duodenoscope

Gastrointestinal and other types of flexible endoscopes may become contaminated during clinical use, and therefore rigorous and thorough cleaning, high-level disinfection, and drying after each procedure is required to prevent the transmission of potentially infectious agents [1] [2] [3] [4] [5] [6] [7] [8] [9]. With important public health implications, flexible endoscopes are reportedly associated with more documented cases of healthcare-acquired infections than any other type of reusable medical device [1]. A primary reason for this salient distinction is the complex physical design of these devices, including the structures of their internal channels. While their complex designs are essential both for the success of the procedure and patient comfort, not all types of flexible endoscopes necessarily facilitate reprocessing [1].

The side-viewing duodenoscope, used in the upper gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) to diagnose and treat biliary and pancreatic diseases, is arguably the best example of a flexible endoscope whose physical design displays this tension between an accommodation of its reprocessing requirements and optimal function during the clinical procedure. To prevent their contamination and an increased risk of disease transmission during ERCP, it is essential that specific attention be given to the reprocessing requirements of each one of the physically complex internal surfaces, valves, and channels of the flexible endoscope; these include, if exposed, the long, narrow channel for the elevator wire which may be difficult to reprocess [2] [3] [4] [5] [7].

References

• 1 Healthcare Infection Control Practices Advisory Committee (HICPAC) .Guideline for disinfection and sterilization in healthcare facilities. Atlanta; Centers for Disease Control and Prevention 2008 http://Available at: www.cdc.gov/hicpac/Disinfection_Sterilization/toc.html ; Publication date: 2008
• 2 Fraser T G, Reiner S, Malczynski M. et al . Multidrug-resistant Pseudomonas aeruginosa cholangitis after endoscope retrograde cholangio-pancreatography: Failure of routine endoscope cultures to prevent an outbreak.  Infect Control Hosp Epidemiol. 2004;  25 856-859
• 3 Aumeran C, Poincloux L, Souweine B. et al . Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography.  Endoscopy. 2010;  42 895-899
• 4 Struelens M J, Rost F, Deplano A. et al . Pseudomonas aeruginosa and Enterobacteriaceae bacteria after biliary endoscope: an outbreak investigation using DNA macrorestriction analysis.  Am J Med. 1993;  95 489-498
• 5 Allen J I, O’Connor-Allen M, Olson M M. et al . Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope.  Gastroenterology. 1987;  92 759-763
• 6 ASGE Standards of Practice Committee . Infection control during GI endoscopy.  Gastrointest Endosc. 2008;  67 781-790
• 7 Watts R. VIHA warns 500 patients of possible blood-borne virus infection. Victoria Times Colonist. April 23, 2010
• 8 Hennepin County Medical Center .Error in manufacturer’s disinfecting instructions prompts patient notificiation. [News release]. June 22, 2010
• 9 Alvardo C J, Stolz S M, Maki D G. Nosocomial infections from contaminated endoscopes: A flawed automated endoscope washer. An investigation using molecular epidemiology.  Am J Med. 1991;  91 (Suppl. 3B) 272S-280S
• 10 Muscarella L F. The study of a contaminated colonoscope.  Clin Gastroenterol Hepatol. 2010;  8 577-580
• 11 Muscarella L F. Contribution of tap water and environmental surfaces to nosocomial transmission of antibiotic-resistant Pseudomonas aeruginosa.  Infect Control Hosp Epidemiol. 2004;  25 342-345
• 12 Hota S, Hirji Z, Stockton K. et al . Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design.  Infect Control Hosp Epidemiol. 2009;  30 25-33
• 13 Welch K C, Cohen M B, Doghramji L L. et al . Clinical correlation between irrigation bottle contamination and clinical outcomes in post-functional endoscopic sinus surgery patients.  Am J Rhinol Allergy. 2009;  23 401-404
• 14 Sorin M, Segal-Maurer S, Mariano N. et al . Nosocomial transmission of imipenem-resistant Pseudomonas aeruginosa following bronchoscopy associated with improper connection to the Steris System 1 processor.  Infect Control Hosp Epidemiol. 2001;  22 409-413
• 15 Srinivasan A, Wolfenden L L, Song X. et al . An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes.  N Engl J Med. 2003;  348 221-227
• 16 Muscarella L F. Leading a horse to water: are crucial lessons in endoscopy and outbreak investigations being learned?.  Infect Control Hosp Epidemiol. 2002;  23 358-360
• 17 Muscarella L F. Dear Los Angeles Times: The risk of disease transmission during gastrointestinal endoscopy.  Gastroenterol Nurs. 2004;  27 271-278