ERCP and reprocessing in focus: what can we do to prevent or manage infection outbreaks?

Since the late 1970s, there have been sporadic reports of endoscopic transmission of exogenous infections in gastrointestinal endoscopy. The majority of documented cases were the result of noncompliance with national and international guidelines, including [1]:

• failures and mistakes in the reprocessing procedure, in combination with inadequate systems of work and insufficient training of staff;

• inadequate reprocessing equipment (e. g. inappropriate brushes);

• damaged and improperly maintained endoscopes and washer disinfectors;

• contaminated environment (e. g. contaminated surfaces, water);

• insufficient hand hygiene;

• inappropriate administration of intravenous medication.

Several endoscopic retrograde cholangiopancreatography (ERCP)-related outbreaks have been reported, caused by insufficiently reprocessed or stored endoscopes, contaminated washer disinfectors, or contaminated surfaces [1].

Infections by multidrug-resistant organisms have become more and more problematic for healthcare services worldwide. In recent years, outbreaks of multidrug-resistant pathogens associated with ERCP procedures have also been reported [2] [3] [4] [5] [6] [7]. In February 2015, an outbreak of carbapenem-resistant Enterobacteriaceae (CRE) in conjunction with ERCP procedures caused big media attention in the USA [8]. The FDA published several statements to raise awareness among healthcare professionals of the complex design of duodenoscopes that may impede effective reprocessing [8]. The American Society for Gastrointestinal Endoscopy (ASGE) and the Society of Gastroenterology Nurses and Associates (SGNA) informed their members accordingly.

The outbreak reported by Verfaillie et al. [7] in this issue of Endoscopy gives helpful information on how to manage infection outbreaks with the support of a multidisciplinary team. The structured approach can be used by others in similar situations. It also highlights a number of important issues around reprocessing. Despite manufacturers’ responsibilities, what can endoscopy departments do to prevent or manage infectious outbreaks?

• References

• 1 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
• 2 Muscarella LF. Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastrointestinal endoscopy. World J Gastrointest Endosc 2014; 6: 457-474
• 3 Aumeran C, Poincloux L, Souweine B et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010; 42: 895-899
• 4 Epstein L, Hunter J, Allison A et al. New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312: 1447-1455
• 5 Gastmeier P, Vonberg RP. Klebsiella spp. in endoscopy-associated infections: we may only be seeing the tip of the iceberg. Infection 2014; 42: 15-21
• 6 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
• 7 Verfaillie CF, 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
• 8 Food and Drug Administration. Safety communication. Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. Issued February and March 2015. Available from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm
• 9 Beilenhoff U, Neumann CS, Rey JF et al. ESGE-ESGENA guideline: cleaning and disinfection in gastrointestinal endoscopy. Endoscopy 2008; 40: 939-957
• 10 ASGE and SHEA. Multisociety guideline on reprocessing flexible gastrointestinal endoscopes. Gastrointest Endosc 2011; 73: 1075-1084
• 11 Working Party of the British Society of Gastroenterology Endoscopy Committee. BSG guidance on decontamination of equipment for gastrointestinal endoscopy. June 2014. Available from: http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/decontamination_2014.pdf
• 12 Professional standard handbook cleaning and disinfection. Flexible endoscopes. Version 3.1, 2014. Available from: http://www.infectiepreventieopleidingen.nl/downloads/SFERDHandbook3_1.pdf
• 13 Beilenhoff U, Neumann CS, Biering H et al. ESGE/ESGENA guideline for process validation and routine testing for reprocessing endoscopes in washer-disinfectors, according to the European Standard prEN ISO 15883 parts 1, 4 and 5. Endoscopy 2007; 39: 85-94
• 14 Beilenhoff U, Neumann CS, Rey JF et al. ESGE-ESGENA guideline for quality assurance in reprocessing: microbiological surveillance testing in endoscopy. Endoscopy 2007; 39: 175-181
• 15 Centers for Disease Control and Prevention (CDC). Interim duodenoscope surveillance protocol. Updated April 3, 2015. Available from: http://www.cdc.gov/hai/organisms/cre/cre-duodenoscope-surveillance-protocol.html
• 16 Buss AJ, Been MH, Borgers RP et al. Endoscope disinfection and its pitfalls – requirement for retrograde surveillance cultures. Endoscopy 2008; 40: 327-332
• 17 Kovaleva J, Meessen NE, Peters FT et al. Is bacteriologic surveillance in endoscope reprocessing stringent enough?. Endoscopy 2009; 41: 913-916