World J Gastrointest Endosc. 2014 Oct 16;6(10):457-74. doi: 10.4253/wjge.v6.i10.457.
Risk of transmission of carbapenem-resistant Enterobacteriaceae and related "superbugs" during gastrointestinal endoscopy.
World journal of gastrointestinal endoscopy
Lawrence F Muscarella
Affiliations
Affiliations
- Lawrence F Muscarella, LFM Healthcare Solutions, LLC, Montgomeryville, PA 18936, United States.
PMID: 25324917
PMCID: PMC4198391 DOI: 10.4253/wjge.v6.i10.457
Abstract
To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae (CRE) and their related superbugs during gastrointestinal (GI) endoscopy. Reports of outbreaks linked to GI endoscopes contaminated with different types of infectious agents, including CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE's emergence, these reports were obtained by searching the peer-reviewed medical literature (via the United States National Library of Medicine's "MEDLINE" database); the Food and Drug Administration's Manufacturer and User Facility Device Experience database, or "MAUDE"; and the Internet (via Google's search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at "Hospital X" located in the suburbs of Chicago (IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital's patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Control and Prevention (CDC), which published a report about this outbreak in Morbidity and Mortality Weekly Report (MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X's infection control practices following this CRE outbreak, were also reviewed. While this article focuses primarily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infectious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently associated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospital X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer's labeling, supplemented as needed with professional organizations' published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including bronchoscopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endoscopy. Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind and near the forceps elevator located at the distal end of the ERCP endoscope, are recommended. If the ERCP endoscope features a narrow and exposed channel that houses a wire connecting the GI endoscope's control head to this forceps elevator, then this channel's complete reprocessing, including its flushing with a detergent using a procedure validated for effectiveness, is also emphasized.
Keywords: Anti-bacterial agents; Bacterial infections; Beta-lactams; Carbapenem-resistant Enterobacteriaceae; Carbapenems; Cross infection; Disease outbreaks; Disinfection; Endoscopy; Gastrointestinal; Healthcare-associated infections; Risk assessment; Sterilization
References
- MMWR Recomm Rep. 2003 Jun 6;52(RR-10):1-42 - PubMed
- Am J Med. 1993 Nov;95(5):489-98 - PubMed
- Clin Microbiol Rev. 2013 Apr;26(2):231-54 - PubMed
- MMWR Recomm Rep. 2002 Oct 25;51(RR-16):1-45, quiz CE1-4 - PubMed
- Endoscopy. 2010 Nov;42(11):895-9 - PubMed
- AORN J. 1998 Mar;67(3):552-3, 556 - PubMed
- MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750 - PubMed
- Emerg Infect Dis. 2014 Jul;20(7):1170-5 - PubMed
- J Antimicrob Chemother. 2010 Jun;65(6):1305-6 - PubMed
- Emerg Infect Dis. 2012 Mar;18(3):532-4 - PubMed
- J Hosp Infect. 2013 Apr;83(4):341-3 - PubMed
- Infect Control Hosp Epidemiol. 1997 Jun;18(6):417-21 - PubMed
- Gastroenterol Nurs. 2004 Nov-Dec;27(6):271-8 - PubMed
- BJU Int. 2012 Dec;110(11 Pt C):E922-6 - PubMed
- Infect Control Hosp Epidemiol. 2001 Jul;22(7):409-13 - PubMed
- AORN J. 2001 Jun;73(6):1159-63 - PubMed
- MMWR Morb Mortal Wkly Rep. 2014 Jan 3;62(51-52):1051 - PubMed
- MMWR Morb Mortal Wkly Rep. 2013 Mar 8;62(9):165-70 - PubMed
- Gastrointest Endosc. 2011 Jun;73(6):1075-84 - PubMed
- Lancet Infect Dis. 2011 May;11(5):355-62 - PubMed
- Gut. 1983 Feb;24(2):171-4 - PubMed
- MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212 - PubMed
- Am J Infect Control. 2013 Jun;41(6):562-4 - PubMed
- N Engl J Med. 1997 Jul 24;337(4):237-40 - PubMed
- Med J Aust. 2013 Mar 18;198(5):267-9 - PubMed
- Am J Infect Control. 2013 Dec;41(12):1188-94 - PubMed
- Am J Med. 1991 Sep 16;91(3B):272S-280S - PubMed
- J Hosp Infect. 2006 Jul;63(3):345-7 - PubMed
- JAMA. 2014 Oct 8;312(14):1447-55 - PubMed
- Endoscopy. 2010 Nov;42(11):957-9 - PubMed
- Infect Control Hosp Epidemiol. 2004 Apr;25(4):342-5 - PubMed
- AORN J. 2014 Mar;99(3):396-406 - PubMed
- J Hosp Infect. 2012 Oct;82(2):122-4 - PubMed
- Can J Gastroenterol. 2013 Jun;27(6):347-50 - PubMed
- Infect Control Hosp Epidemiol. 2002 May;23(5):285-9 - PubMed
- Clin Gastroenterol Hepatol. 2010 Jul;8(7):577-80.e1 - PubMed
- Antimicrob Agents Chemother. 2011 Aug;55(8):3929-31 - PubMed
- Infect Control Hosp Epidemiol. 2001 Nov;22(11):669 - PubMed
- Euro Surveill. 2010 Dec 02;15(48): - PubMed
- J Hosp Infect. 2013 Oct;85(2):118-24 - PubMed
- Am J Gastroenterol. 2006 Sep;101(9):2147-54 - PubMed
- Gastroenterology. 1987 Mar;92(3):759-63 - PubMed
- J Hosp Infect. 1984 Dec;5(4):371-6 - PubMed
- Int J Surg. 2014;12(7):720-4 - PubMed
- Infection. 2014 Feb;42(1):15-21 - PubMed
- Am J Infect Control. 2004 Aug;32(5):282-6 - PubMed
- World J Gastroenterol. 2006 Jul 7;12(25):3953-64 - PubMed
Publication Types