Infection Control Today

AUG 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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15 August 2018 ICT properties of instruments and are not preferred by most insti- tutions. Accurate endoscope drying and storage are crucial, whereas a humid environment facilitates microbial growth during storage. The fnal drying steps greatly reduce the risk of remaining pathogens as well as the possibility of recontam- ination of the endoscope by waterborne microorganisms such as Pseudomonas spp. a n d A c i n e to b a c t e r s p p. According to the literature, endoscopes stay bacterium free after prolonged storage if an adequate drying procedure is applied. The most common factor associated with microbial transmission is inadequate cleaning and disinfection of flexible bronchoscopes (60 percent of outbreaks). These outbreaks were related to inadequate manual cleaning and brushing, use of contaminated endoscope accessories, use of inappropriate disinfectants with low and intermediate potency, and resistance of microorganisms to disinfectants. Use of the contaminated or defective automated endoscope reprocessors (AERs) and contam- inated water for rinsing of the endoscope channels after disinfection were associated with 33 percent of outbreaks. Insuffcient drying and inadequate storage resulted in 29 percent of outbreaks, design limitations and defective bronchoscopes in 14 percent of outbreaks. It is important that contamination of fexible bronchoscopes was detected in 65 percent of outbreaks." Kovaleva (2015) adds, "Modern broncho- scopes contain multiple channels and ports which are diffcult to clean and disinfect and allow for the collection of organic material and the forming of bioflms. A bioflm is an assemblage of microbial cells attached to a surface and enclosed in a matrix of exopolymeric substances. Bioflms are extremely diffcult to remove, show increased resistance to disinfectants and antibiotics and can result in failure of reprocessing of endoscopes and outbreaks of endoscopy-related infections. Two outbreaks of bronchoscopy-related infection and cross-contamination of P. aeruginosa, Mycobacterium chelonae and Methylobacterium mesophilicum involving 28 patients were attributed to contaminated AERs with the presence of bioflm deposits on the internal plumbing." Kovaleva (2015) acknowledges that routine microbiological testing for endoscopes and AERs remains a controversial issue in many guidelines: "Microbiological surveillance of endoscope reprocessing has been recom- mended by several medical specialist organizations but there are no standards for the frequency of testing intervals of surveillance cultures. It is appropriate to trace contam- inations of endoscopes and to prevent contaminations and infections in patients after endoscopic procedures. The use of environmental endoscope culturing is a rapid and simple method to monitor the effectiveness of standard reprocessing procedures. Contaminated bronchoscopes have been linked to many outbreaks of device-related nosocomial infections. The true incidence of bronchoscopy-related infections is unknown because of inadequate surveillance or no surveillance at all. Endoscopy-related infections can cause serious harm and can give rise to concerns over these procedures by physicians and patients. A continuous search for ways to improve the disinfection process and to construct such endoscopes that the risk of bioflm formation will be reduced, remains warranted." "There is a grand debate going on about whether we should be high-level disinfecting versus sterilizing all scopes and certainly bronchoscopes are at the top of the list of how we should be doing things," Ofstead remarked during her presentation at APIC. "Almost wherever you go, people are doing HLD for bronchoscopes and I think it is important to start thinking about this with critically. My stance is that this should be classifed as a critical device and should be sterilized." As Ofstead, Quick, et al. (2018) emphasize, "Damaged and contaminated bronchoscopes were in use at all sites. Inadequate reprocessing practices may have contributed to bioburden found on bronchoscopes. However, even when guidelines were followed, high-level disinfection was not effective. A shift toward the use of sterilized bronchoscopes is recommended. In the meantime, quality management programs and updated repro- cessing guidelines are needed." Ofstead continues, "We know that contamination accumulates over time and creates bioflm. We know this happens under the best circumstances and there have been numerous reprocessing failures associated with bronchoscopy. We know all the steps that are supposed to be done, they just don't happen much of the time. And because the patients undergoing bronchoscopy are extremely high risk, this becomes more problematic than using a dirty colonoscope, for example, because the colon can handle exposure to pathogens. But the patients receiving bronchoscopy often are critically ill, immunosuppressed, and unfortunately we know there are a whole lot of outbreaks and colonization associated with contaminated bronchoscopes." Ofstead pointed to a recent study in which Sarmand, et al. (2018) found that following bronchoscopy, seven colonized patients underwent a change in their fora. "I think patients undergoing bronchoscopy are at an extremely high risk of infection and if we are using a scope and we are not sterilizing it, we are introducing pathogens into their lungs. In our study, we found that not only were scopes not sterile, but they weren't even clean — patient-ready scopes were not clean. And they were not free of pathogens, and I think IPs must get in there because if these are being handled by the GI suite, that isn't good enough. We need to have an IP presence there, we need to get those quality assurance programs in place, and think about how we can move toward sterilization." Ofstead emphasized the importance of optimizing system-wide policies that move toward the use of sterilized bronchoscopes. Additionally, she urged APIC attendees to address the following issues that may be contributing to risk: • The co-mingling of GI endoscopes and bronchoscopes • The use of lubricants that cannot be removed • Water-quality issues in the reprocessing department • Inadequate bedside pre-cleaning • Delayed reprocessing • Reprocessing protocol for evenings and weekends References: Kovaleva J. Transmission of infection by fexible bronchoscopy. Sept. 2, 2015. Accessible at: http:// www.airwayelearning.com/awel/articles/articles-1. aspx?Action=1&NewsId=2397&M=NewsV2&PID=71655 Ofstead CL, Quick MR, Wetzler HP, Eiland JE, Heymann OL, Sonetti DA and Ferguson S. Effectiveness of reprocessing for fexible bronchoscopes and endobronchial ultrasound bronchoscopes. Chest. May 2018. Ofstead CL, Wetzler HP, Heymann OL, Johnson EA, Eiland JE, Shaw MJ. Longitudinal assessment of reprocessing effectiveness for colonoscopes and gastroscopes: Results of visual inspections, biochemical markers, and microbial cultures. Am J Infect Control. 2017;45(2):e26-e33. Tere is a grand debate going on about whether we should be high-level disinfecting versus sterilizing all scopes and certainly bronchoscopes are at the top of the list of how we should be doing things. Ò

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