Copyright ©2014 Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 16, 2014; 6(10): 457-474
Published online Oct 16, 2014. doi: 10.4253/wjge.v6.i10.457
Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastrointestinal endoscopy
Lawrence F Muscarella
Lawrence F Muscarella, LFM Healthcare Solutions, LLC, Montgomeryville, PA 18936, United States
Author contributions: Muscarella LF contributed to this paper.
Supported by An educational grant provided by FUJIFILM Medical Systems, USA, Inc., Endoscopy Division (Wayne, NJ; United States)
Correspondence to: Lawrence F Muscarella, PhD, President, LFM Healthcare Solutions, LLC, PO Box 684, Montgomyerville, PA 18936, United States.
Telephone: +1-215-4124088 Fax: +1-215-4124088
Received: June 13, 2014
Revised: August 14, 2014
Accepted: September 4, 2014
Published online: October 16, 2014

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: Endoscopy, Gastrointestinal, Carbapenem-resistant Enterobacteriaceae, Cross infection, Disease outbreaks, Healthcare-associated infections, Risk assessment, Disinfection, Sterilization, Anti-bacterial agents, Bacterial infections, Carbapenems, Beta-lactams

Core tip: Gastrointestinal (GI) endoscopy, particularly ERCP, is an emerging risk factor for transmission of carbapenem-resistant Enterobacteriaceae (CRE) and their related superbugs, as well as of other certain bacteria and viruses. Several recent reports associate outbreaks of CRE following ERCP, with associated morbidity and mortality. If performed properly, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, appear adequate to prevent disease transmission. Enhancing the quality and safety both of infection control in GI endoscopy departments and of the design of GI endoscopes to facilitate their thorough cleaning and reprocessing is recommended, as it is reasonable to conclude that these recent outbreaks of CRE causally linked to contaminated GI endoscopes may result in more robust and focused oversight and inspections both of manufacturers by regulatory agencies and of healthcare facilities by healthcare accrediting organizations and state health departments. Along with risk assessments, performing root cause analyses that identify the likely causes of CRE outbreaks and the actions required to prevent their recurrence is encouraged.