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Schoberleitner I, Lackner M, Coraça-Huber DC, Augustin A, Imsirovic A, Sigl S, Wolfram D. SMI-Capsular Fibrosis and Biofilm Dynamics: Molecular Mechanisms, Clinical Implications, and Antimicrobial Approaches. Int J Mol Sci 2024; 25:11675. [PMID: 39519227 PMCID: PMC11546664 DOI: 10.3390/ijms252111675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Revised: 10/23/2024] [Accepted: 10/25/2024] [Indexed: 11/16/2024] Open
Abstract
Silicone mammary implants (SMIs) frequently result in capsular fibrosis, which is marked by the overproduction of fibrous tissue surrounding the implant. This review provides a detailed examination of the molecular and immunological mechanisms driving capsular fibrosis, focusing on the role of foreign body responses (FBRs) and microbial biofilm formation. We investigate how microbial adhesion to implant surfaces and biofilm development contribute to persistent inflammation and fibrotic responses. The review critically evaluates antimicrobial strategies, including preoperative antiseptic protocols and antimicrobial-impregnated materials, designed to mitigate infection and biofilm-related complications. Additionally, advancements in material science, such as surface modifications and antibiotic-impregnated meshes, are discussed for their potential to reduce capsular fibrosis and prevent contracture of the capsule. By integrating molecular insights with clinical applications, this review aims to elucidate the current understanding of SMI-related fibrotic responses and highlight knowledge gaps. The synthesis of these findings aims to guide future research directions of improved antimicrobial interventions and implant materials, ultimately advancing the management of capsular fibrosis and enhancing patient outcomes.
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Affiliation(s)
- Ines Schoberleitner
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Michaela Lackner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Débora C. Coraça-Huber
- BIOFILM Lab, Department of Orthopedics and Traumatology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Angela Augustin
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Anja Imsirovic
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Stephan Sigl
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Chen H, Liu J, Zeng A, Qin N. Analysis of sterilization efficiency and application cost of three low temperature sterilization methods. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2024; 95:045112. [PMID: 38597749 DOI: 10.1063/5.0175121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE This paper discusses the sterilization efficiency of three low temperature sterilization methods used in thermosensitive medical devices and makes a preliminary analysis of sterilization costs so as to provide the basis for reasonable selection of low temperature sterilizer in Central Sterile Supply Department. METHODS Medical devices compatible with the three sterilization methods were selected for sterilization, and two packaging materials were selected for the three low-temperature sterilization equipment according to the compatibility of the packaging materials. The equipment packed with the same packaging materials were sterilized for five times, and each low-temperature sterilizer was sterilized for a total of ten times. The sterilization effect, sterilization cycle time, energy consumption, and cost of the three sterilizers were compared. RESULTS The cycle time of ethylene oxide sterilizer was 393.6 min, and the cycle time of hydrogen peroxide low temperature plasma sterilizer was 56.1 min. The cycle time of low temperature steam and formaldehyde sterilizer was 105.7 min. The hydrogen peroxide low temperature plasma sterilizes single cycle power consumption at a maximum of 5 kWh. The single cycle energy consumption of compressed air ethylene oxide sterilizer is up to 12 l. In terms of sterilization application cost, hydrogen peroxide low temperature plasma sterilization has the highest cost, followed by ethylene oxide sterilization, and low temperature steam and formaldehyde sterilization is the lowest. CONCLUSION The sterilization efficiency of hydrogen peroxide low temperature plasma sterilization is the highest, followed by low temperature steam and formaldehyde sterilization, and the lowest is ethylene oxide sterilization. The three low temperature sterilization methods can achieve effective sterilization of devices. Each hospital can choose an appropriate low temperature sterilization method according to the characteristics of thermosensitive instruments, turnover efficiency requirements, and financial status.
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Affiliation(s)
- Hui Chen
- West China Hospital/West China School of Nursing, Sichuan University, Guoxuexiang No. 37, Chengdu, Sichuan, China
| | - Jiawei Liu
- West China Hospital/West China School of Nursing, Sichuan University, Guoxuexiang No. 37, Chengdu, Sichuan, China
| | - Aiying Zeng
- West China Hospital/West China School of Nursing, Sichuan University, Guoxuexiang No. 37, Chengdu, Sichuan, China
| | - Nian Qin
- West China Hospital/West China School of Nursing, Sichuan University, Guoxuexiang No. 37, Chengdu, Sichuan, China
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Kakoullis L, Economidou S, Mehrotra P, Panos G, Karampitsakos T, Stratakos G, Tzouvelekis A, Sampsonas F. Bronchoscopy-related outbreaks and pseudo-outbreaks: A systematic review. Infect Control Hosp Epidemiol 2024; 45:509-519. [PMID: 38099453 DOI: 10.1017/ice.2023.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
OBJECTIVE To identify and report the pathogens and sources of contamination associated with bronchoscopy-related outbreaks and pseudo-outbreaks. DESIGN Systematic review. SETTING Inpatient and outpatient outbreaks and pseudo-outbreaks after bronchoscopy. METHODS PubMed/Medline databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, using the search terms "bronchoscopy," "outbreak," and "pseudo-outbreak" from inception until December 31, 2022. From eligible publications, data were extracted regarding the type of event, pathogen involved, and source of contamination. Pearson correlation was used to identify correlations between variables. RESULTS In total, 74 studies describing 23 outbreaks and 52 pseudo-outbreaks were included in this review. The major pathogens identified in these studies were Pseudomonas aeruginosa, Mycobacterium tuberculosis, nontuberculous mycobacteria (NTM), Klebsiella pneumoniae, Serratia marcescens, Stenotrophomonas maltophilia, Legionella pneumophila, and fungi. The primary sources of contamination were the use of contaminated water or contaminated topical anesthetics, dysfunction and contamination of bronchoscopes or automatic endoscope reprocessors, and inadequate disinfection of the bronchoscopes following procedures. Correlations were identified between primary bronchoscope defects and the identification of P. aeruginosa (r = 0.351; P = .002) and K. pneumoniae (r = 0.346; P = .002), and between the presence of a contaminated water source and NTM (r = 0.331; P = .004) or L. pneumophila (r = 0.280; P = .015). CONCLUSIONS Continued vigilance in bronchoscopy disinfection practices remains essential because outbreaks and pseudo-outbreaks continue to pose a significant risk to patient care, emphasizing the importance of stringent disinfection and quality control measures.
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Affiliation(s)
- Loukas Kakoullis
- Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Sofia Economidou
- Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Preeti Mehrotra
- Harvard Medical School, Boston, Massachusetts, United States
- Division of Infection Controland Hospital Epidemiology, Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - George Panos
- Department of Internal Medicine, Division of Infectious Diseases, University General Hospital of Patras, Patras, Greece
| | - Theodoros Karampitsakos
- Ubben Center and Laboratory for Pulmonary Fibrosis Research, University of South Florida, Tampa, Florida, United States
| | - Grigorios Stratakos
- Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Argyrios Tzouvelekis
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
| | - Fotios Sampsonas
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
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Veater JB, Jones-Manning C, Mellon J, Collins E, Jenkins DR. Pulling the plug on a pseudomonas outbreak: ancillary equipment as vectors of infection. J Hosp Infect 2023; 140:110-116. [PMID: 37562595 DOI: 10.1016/j.jhin.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES Outbreaks of infection related to flexible endoscopes are well described. However, flexible endoscopy also requires the use of ancillary equipment such as irrigation plugs. These are potential vectors of infection but are infrequently highlighted in the literature. This paper reports a cystoscopy-associated outbreak of Pseudomonas aeruginosa from contaminated irrigation plugs in a UK tertiary care centre. METHODS Laboratory, clinical and decontamination unit records were reviewed, and audits of the decontamination unit were performed. Flexible cystoscopes and irrigation plugs were assessed for contamination. Retrospective and prospective case finding was performed utilizing the microbiology laboratory information management system. Available P. aeruginosa isolates underwent variable nucleotide tandem repeat (VNTR) typing. Confirmed cases were defined as P. aeruginosa infection with an identical VNTR profile to an outbreak strain. RESULTS Three strains of P. aeruginosa were isolated from five irrigation plugs but none of the flexible cystoscopes. No acquired resistance mechanisms were detected. Fifteen confirmed infections occurred, including bacteraemia, septic arthritis and urinary tract infection. While failure of decontamination likely occurred because the plugs were not dismantled prior to reprocessing, the manufacturer's reprocessing instructions were also incompatible with standard UK practice. The Medicines and Healthcare Products Regulatory Agency was informed. A field safety notice was issued, and the manufacturer issued updated reprocessing instructions. CONCLUSIONS Ancillary equipment can represent an important vector for infection, and should be considered during outbreak investigations. Users should review the manufacturer's instructions for reprocessing ancillary equipment to ensure that they are compatible with available procedures.
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Affiliation(s)
- J B Veater
- Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - C Jones-Manning
- Intensive Care, Theatres, Anaesthetics, Pain & Sleep, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Mellon
- Department of Urology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - E Collins
- Infection Prevention, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - D R Jenkins
- Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
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Deb A, Perisetti A, Goyal H, Aloysius MM, Sachdeva S, Dahiya D, Sharma N, Thosani N. Gastrointestinal Endoscopy-Associated Infections: Update on an Emerging Issue. Dig Dis Sci 2022; 67:1718-1732. [PMID: 35262904 DOI: 10.1007/s10620-022-07441-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/07/2022] [Indexed: 02/06/2023]
Abstract
Over 17.7 million gastrointestinal (GI) endoscopic procedures are performed annually, contributing to 68% of all endoscopic procedures in the United States. Usually, endoscopic procedures are low risk, but adverse events may occur, including cardiopulmonary complications, bleeding, perforation, pancreatitis, cholangitis, and infection. Infections after the GI endoscopies most commonly result from the patient's endogenous gut flora. Although many studies have reported infection after GI endoscopic procedures, a true estimate of the incidence rate of post-endoscopy infection is lacking. In addition, the infection profile and causative organisms have evolved over time. In recent times, multi-drug-resistant microorganisms have emerged as a cause of outbreaks of endoscope-associated infections (EAI). In addition, lapses in endoscope reprocessing have been reported, with some but not all outbreaks in recent times. This systematic review summarizes the demographical, clinical, and management data of EAI events reported in the literature. A total of 117 articles were included in the systematic review, with the majority reported from North America and Western Europe. The composite infection rate was calculated to be 0.2% following GI endoscopic procedures, 0.8% following ERCP, 0.123% following non-ERCP upper GI endoscopic procedures, and 0.073% following lower GI endoscopic procedures. Pseudomonas aeruginosa was the most common culprit organism, followed by other Enterobacteriaceae groups of organisms and Gram-positive cocci. We have also elaborated different prevention methods such as antimicrobial prophylaxis, adequate sterilization methods for reprocessing endoscopes, periodic surveillance, and current evidence supporting their utilization. Finally, we discuss disposable endoscopes, which could be an alternative to reprocessing to minimize the chances of EAIs with their effects on the environmental and financial situation.
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Affiliation(s)
- Anasua Deb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA
| | - Abhilash Perisetti
- Advance Endoscopy, Interventional Oncology & Surgical Endoscopy (IOSE), Parkview Cancer Institute, 11050 Parkview Circle, Fort Wayne, IN, 46845, USA
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, 501 S. Washington Avenue, Scranton, PA, 18503, USA.
| | - Mark M Aloysius
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, 501 S. Washington Avenue, Scranton, PA, 18505, USA
- Geisinger Commonwealth School of Medicine, 525, Pine Street, Scranton, PA, 18510, USA
| | - Sonali Sachdeva
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Dushyant Dahiya
- Central Michigan University College of Medicine, 1000 Houghton Ave, Saginaw, MI, 48603, USA
| | - Neil Sharma
- Division of Interventional Oncology & Surgical Endoscopy (IOSE), Parkview Cancer Institute, 11050 Parkview Circle, Fort Wayne, IN, 46845, USA
- Indiana University School of Medicine, Fort Wayne, IN, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology & Nutrition, Center for Interventional Gastroenterology at UTHealth (iGUT), Atilla Ertan MD Chair in Gastroenterology, Hepatology & Nutrition, McGovern Medical School, UTHealth, Houston, USA
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Walker JT, Bak A, Marsden G, Spencer W, Griffiths H, Stanton GA, Williams C, White LJ, Ross E, Sjogren G, Bradley CW, Garvey M. Final rinse water quality for flexible endoscopy to minimise the risk of post-endoscopic infection. Report from Healthcare Infection Society Working Party. J Hosp Infect 2022; 124:79-96. [PMID: 35276281 DOI: 10.1016/j.jhin.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/02/2022] [Indexed: 01/10/2023]
Affiliation(s)
- James T Walker
- Central Sterilising Club, UK; Healthcare Infection Society, London, UK
| | - Aggie Bak
- Healthcare Infection Society, London, UK.
| | | | - Wayne Spencer
- Authorising Engineer, Spencer Nickson Ltd, Frodsham, UK
| | - Helen Griffiths
- Decontamination and TSE advisor, British Society of Gastroenterology, London, UK
| | | | - Craig Williams
- Healthcare Infection Society, London, UK; Consultant Microbiologist, University Hospitals of Morecambe Bay, UK
| | - Leila J White
- Healthcare Infection Society, London, UK; Lancashire Teaching Hospitals NHS Foundation Trusts, UK
| | - Elaine Ross
- Healthcare Infection Society, London, UK; Infection Prevention Society, Seafield, UK
| | - Geoff Sjogren
- Western Sussex Hospitals NHS Foundation Trust (retired), UK
| | - Christina W Bradley
- Healthcare Infection Society, London, UK; University Hospitals Birmingham NHS Foundation Trust, UK
| | - Mark Garvey
- Healthcare Infection Society, London, UK; University Hospitals Birmingham NHS Foundation Trust, UK
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Svonni E, Andreasson M, Fernström LL, Rydén A, Pringle J, Riihimäki M. Potential for residual contamination by Streptococcus equi subspp equi of endoscopes and twitches used in diagnosis of carriers of strangles. Equine Vet J 2020; 52:884-890. [PMID: 32052491 DOI: 10.1111/evj.13248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/07/2019] [Accepted: 01/31/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Endoscopic examinations are essential for diagnosis and treatment of strangles (S equi infection) in horses. However, even after disinfection, endoscopes may retain viable bacteria or bacterial DNA. Twitches are commonly used during endoscopic examinations and can thus also potentially transmit the organism to other horses. OBJECTIVES To evaluate the efficacy of different disinfectant methods to eliminate S equi from experimentally contaminated endoscopes and twitches and the effectiveness of field disinfection of endoscopes used in sampling carriers of S equi. STUDY DESIGN Experimental contamination and observational field study. METHODS One endoscope and 30 twitches were contaminated with standardised S equi broth solutions. The endoscope was disinfected following three protocols using various disinfectants for manual disinfection. A fourth protocol used an automated endoscope reprocessor (AER). The twitches (n = 30) were disinfected following eight different disinfecting protocols. Three endoscopes used in sampling for silent carriers were disinfected following a field-based protocol. After each protocol the endoscopes and twitches were sampled for S equi by culture and qPCR. RESULTS Following experimental contamination all endoscope disinfection protocols, apart from 1/6 of the ethanol protocol were S equi culture negative. However, no endoscope disinfection protocol completely eliminated retention of S equi DNA. Field disinfection of endoscopes after sampling carriers yielded no culture positives and all but one (13/14) were qPCR negative. All twitches disinfected following experimental contamination were culture negative but sodium hypochlorite was the only disinfectant that completely eliminated detection of S equi DNA. MAIN LIMITATIONS Experimental contamination may not reflect the numbers of S equi transferred to endoscopes or twitches during use on silent carriers and purulent secretions from infected horses may influence survival of S equi. CONCLUSIONS While most disinfection methods appear to ensure removal of cultivable S equi, residual DNA can remain on both endoscopes and twitches.
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Affiliation(s)
- Elin Svonni
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Mikaela Andreasson
- District Veterinarians, Swedish Board of Agriculture, Gothenburg, Sweden
| | - Lise-Lotte Fernström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Anneli Rydén
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - John Pringle
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Miia Riihimäki
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
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Mehta AC, Muscarella LF. Bronchoscope-Related “Superbug” Infections. Chest 2020; 157:454-469. [DOI: 10.1016/j.chest.2019.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 12/18/2022] Open
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Mouritsen JM, Ehlers L, Kovaleva J, Ahmad I, El-Boghdadly K. A systematic review and cost effectiveness analysis of reusable vs. single-use flexible bronchoscopes. Anaesthesia 2019; 75:529-540. [PMID: 31701521 PMCID: PMC7079200 DOI: 10.1111/anae.14891] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 12/15/2022]
Abstract
The cost effectiveness of reusable vs. single‐use flexible bronchoscopy in the peri‐operative setting has yet to be determined. We therefore aimed to determine this and hypothesised that single‐use flexible bronchoscopes are cost effective compared with reusable flexible bronchoscopes. We conducted a systematic review of the literature, seeking all reports of cross‐contamination or infection following reusable bronchoscope use in any clinical setting. We calculated the incidence of these outcomes and then determined the cost per patient of treating clinical consequences of bronchoscope‐induced infection. We also performed a micro‐costing analysis to quantify the economics of reusable flexible bronchoscopes in the peri‐operative setting from a high‐throughput tertiary centre. This produced an accurate estimate of the cost per use of reusable flexible bronchoscopes. We then performed a cost effectiveness analysis, combining the data obtained from the systematic review and micro‐costing analysis. We included 16 studies, with a reported incidence of cross‐contamination or infection of 2.8%. In the micro‐costing analysis, the total cost per use of a reusable flexible bronchoscope was calculated to be £249 sterling. The cost per use of a single‐use flexible bronchoscope was £220 sterling. The cost effectiveness analysis demonstrated that reusable flexible bronchoscopes have a cost per patient use of £511 sterling due to the costs of treatment of infection. The findings from this study suggest benefits from the use of single‐use flexible bronchoscopes in terms of cost effectiveness, cross‐contamination and resource utilisation.
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Affiliation(s)
- J M Mouritsen
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - L Ehlers
- Danish Center of Healthcare Improvements, Institute of Business and Management, Aalborg University, Aalborg, Denmark
| | - J Kovaleva
- Sint-Jozefkliniek Bornem and Willebroek, Bornem, Belgium
| | - I Ahmad
- Guy's and St. Thomas' NHS Foundation Trust, London, UK.,King's College London, UK
| | - K El-Boghdadly
- Guy's and St. Thomas' NHS Foundation Trust, London, UK.,King's College London, UK
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10
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Duodenoscope-Associated Infections: Update on an Emerging Problem. Dig Dis Sci 2019; 64:1409-1418. [PMID: 30569333 DOI: 10.1007/s10620-018-5431-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/12/2018] [Indexed: 02/07/2023]
Abstract
The duodenoscope is among the most complex medical instruments that undergo disinfection between patients. Transmission of infection by contaminated scopes has remained a challenge since its inception. Notable risk factors for pathogen transmission include non-adherence to disinfection guidelines, encouragement of biofilm deposition due to complex design and surface defects and contaminated automated endoscope reprocessors. The most common infections following endoscopy are endogenous infections involving the patient's own gut flora. Exogenous infections, on the other hand, are associated with contaminated scopes and can theoretically be prevented by effective reprocessing. Pseudomonas aeruginosa is currently the most common organism isolated from contaminated endoscopes. Of note, reports of multidrug-resistant duodenoscopy-associated outbreaks have surfaced recently, many of which occurred despite adequate reprocessing. The FDA and CDC currently recommend comprehensive cleaning followed with at least high-level disinfection for reprocessing of flexible GI endoscopes. Reports of duodenoscope-related outbreaks despite compliance with established guidelines have prompted professional and government bodies to revisit existing guidelines and offer supplementary recommendations for duodenoscope processing. For the purposes of this review, we identified reports of duodenoscope-associated infections from 2000 till date. For each outbreak, we noted the organisms isolated, the number of cases reported, any possible explanations of contamination, and the measures undertaken to end each outbreak. We have also attempted to present an overview of recent developments in this rapidly evolving field.
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11
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Multi-drug resistant Pseudomonas aeruginosa nosocomial strains: Molecular epidemiology and evolution. Microb Pathog 2018; 123:233-241. [DOI: 10.1016/j.micpath.2018.07.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/27/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022]
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12
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Terjesen CL, Kovaleva J, Ehlers L. Early Assessment of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes. PHARMACOECONOMICS - OPEN 2017; 1:133-141. [PMID: 29442335 PMCID: PMC5691847 DOI: 10.1007/s41669-017-0012-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Bronchoscopic procedures are common in the clinical setting, with estimates indicating 500,000 are undertaken per year in the USA alone. These procedures are generally regarded as safe. Unfortunately, a risk of cross-contamination between patients, with possible subsequent infection, is associated with the re-usable technology typically used in these procedures. OBJECTIVE Our objective was to conduct an early cost-effectiveness analysis (CEA) of single-use flexible video bronchoscope technology compared with the current reusable technology in a US hospital intensive care setting. METHODS We conducted a CEA to determine an incremental cost-effectiveness ratio (ICER), and constructed a decision analytic model based on the best available evidence from a literature search and a Delphi panel. We also conducted several one- and two-way sensitivity analyses and a probabilistic sensitivity analysis to illuminate the uncertainty associated with the estimates. RESULTS The literature search showed ample evidence of risk, albeit little of it was quantifiable. Estimates from the Delphi method found approximately a 3% risk of cross-contamination and approximately a 21% risk of subsequent infection. Pneumonia was estimated as the most likely manifestation of infection. The CEA showed a saving of $US118 per procedure and elimination of 0.7% of the risk of infection with the single-use technology. Relevant sensitivity analyses generally validated this result. CONCLUSION This study suggests that implementation of the single-use technology in the intensive care unit is cost effective in most scenarios. However, this result should be interpreted with caution because of the lack of certain knowledge on this particular topic.
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Affiliation(s)
| | | | - Lars Ehlers
- Danish Center for Healthcare Improvements, Aalborg University, Fibigerstraede 11, 9220, Aalborg, Denmark.
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13
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Terjesen CL, Kovaleva J, Ehlers L. Early Assessment of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes. PHARMACOECONOMICS - OPEN 2017; 1:133-141. [PMID: 29442335 DOI: 10.1007/s41669-017-0012-9lk] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Bronchoscopic procedures are common in the clinical setting, with estimates indicating 500,000 are undertaken per year in the USA alone. These procedures are generally regarded as safe. Unfortunately, a risk of cross-contamination between patients, with possible subsequent infection, is associated with the re-usable technology typically used in these procedures. OBJECTIVE Our objective was to conduct an early cost-effectiveness analysis (CEA) of single-use flexible video bronchoscope technology compared with the current reusable technology in a US hospital intensive care setting. METHODS We conducted a CEA to determine an incremental cost-effectiveness ratio (ICER), and constructed a decision analytic model based on the best available evidence from a literature search and a Delphi panel. We also conducted several one- and two-way sensitivity analyses and a probabilistic sensitivity analysis to illuminate the uncertainty associated with the estimates. RESULTS The literature search showed ample evidence of risk, albeit little of it was quantifiable. Estimates from the Delphi method found approximately a 3% risk of cross-contamination and approximately a 21% risk of subsequent infection. Pneumonia was estimated as the most likely manifestation of infection. The CEA showed a saving of $US118 per procedure and elimination of 0.7% of the risk of infection with the single-use technology. Relevant sensitivity analyses generally validated this result. CONCLUSION This study suggests that implementation of the single-use technology in the intensive care unit is cost effective in most scenarios. However, this result should be interpreted with caution because of the lack of certain knowledge on this particular topic.
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Affiliation(s)
| | | | - Lars Ehlers
- Danish Center for Healthcare Improvements, Aalborg University, Fibigerstraede 11, 9220, Aalborg, Denmark.
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Guy M, Vanhems P, Dananché C, Perraud M, Regard A, Hulin M, Dauwalder O, Bertrand X, Crozon-Clauzel J, Floccard B, Argaud L, Cassier P, Bénet T. Outbreak of pulmonary Pseudomonas aeruginosa and Stenotrophomonas maltophilia infections related to contaminated bronchoscope suction valves, Lyon, France, 2014. ACTA ACUST UNITED AC 2017; 21:30286. [PMID: 27458712 DOI: 10.2807/1560-7917.es.2016.21.28.30286] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 03/29/2016] [Indexed: 11/20/2022]
Abstract
In April 2014, pulmonary Pseudomonas aeruginosa and Stenotrophomonas maltophilia co-infections potentially related to bronchoscopic procedures were identified in the intensive care units of a university hospital in Lyon, France. A retrospective cohort of 157 patients exposed to bronchoscopes from 1 December 2013 to 17 June 2014 was analysed. Environmental samples of suspected endoscopes were cultured. Bronchoscope disinfection was reviewed. Ten cases of pulmonary P. aeruginosa/S. maltophilia co-infections were identified, including two patients with secondary pneumonia. Eight cases were linked to bronchoscope A1 and two to bronchoscope A2. Cultures deriving from suction valves were positive for P. aeruginosa/S. maltophilia. Exposure to bronchoscopes A1 and A2 was independently coupled with increased risk of co-infection (adjusted odds ratio (aOR) = 84.6; 95% confidence interval (CI): 9.3-771.6 and aOR = 11.8, 95% CI: 1.2-121.3). Isolates from suction valves and clinical samples presented identical pulsotypes. The audit detected deficiencies in endoscope disinfection. No further cases occurred after discontinuation of the implicated bronchoscopes and change in cleaning procedures. This outbreak of pulmonary P. aeruginosa/S. maltophilia co-infections was caused by suction valve contamination of two bronchoscopes of the same manufacturer. Our findings underscore the need to test suction valves, in addition to bronchoscope channels, for routine detection of bacteria.
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Affiliation(s)
- Marine Guy
- Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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15
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Abstract
Sterilization and disinfection are the basic components of hospital infection control activities. Every day, a number of hospitals are performing various surgical procedures. Even more number of invasive procedures are being performed in different health care facilities. The medical device or the surgical instrument that comes in contact with the sterile tissue or the mucus membrane of the patient during the various processes is associated with increased risk of introduction of pathogens into the patient's body. Moreover, there is chance of transmission of infection from patient to patient; from patient or to health care personnel, and vice versa; or from the environment to the patient through the improper sterilized or disinfected devices. Hence, medical personnel, laboratory people and the health care providers should have better knowledge regarding these techniques to prevent the spread of these pathogens.
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16
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McGrath BA, Ruane S, McKenna J, Thomas S. Contamination of single-use bronchoscopes in critically ill patients. Anaesthesia 2016; 72:36-41. [PMID: 27747865 DOI: 10.1111/anae.13622] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2016] [Indexed: 11/29/2022]
Abstract
Disposable bronchoscopes such as the Ambu aScopeTM 3 are marketed as 'single use' The risks of contamination from prolonged device storage before possible re-use are unknown. Following clinical bronchoscopy in patients whose lungs were mechanically ventilated, 20 aScopeTM 3's bronchoscopes received a standard 'social clean' and were then stored. Subsequent paired saline flush and swab samples were taken at time zero, and at 24 h and 48 h. Positive microbiological cultures were obtained from at least one time point from 16 of the 20 bronchoscopes. Pathogens considered at high risk of causing pneumonia were isolated from seven bronchoscopes, with significant quantities from six of them. Our study demonstrates that aScopeTM 3's should not be re-used on the same patient, as clinically significant growth of micro-organisms occurs frequently, despite adequate social cleaning. Culture of bronchoscopes themselves may be a potentially useful diagnostic tool in the context of pulmonary infection. Our data make it clear that these devices are single use and not single patient use.
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Affiliation(s)
- B A McGrath
- University Hospital South Manchester, Manchester, UK.,Manchester Academic Health Sciences Campus, Manchester, UK
| | - S Ruane
- Health Education North-West, Manchester, UK
| | - J McKenna
- University Hospital South Manchester, Manchester, UK
| | - S Thomas
- University Hospital South Manchester, Manchester, UK
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17
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Infectious complications in gastrointestinal endoscopy and their prevention. Best Pract Res Clin Gastroenterol 2016; 30:689-704. [PMID: 27931630 DOI: 10.1016/j.bpg.2016.09.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
Gastrointestinal endoscopes are medical devices that have been associated with outbreaks of health care-associated infections. Because of the severity and limited treatment options of infections caused by multidrug-resistant Enterobacteriaceae and Pseudomonas aeruginosa, considerable attention has been paid to detection and prevention of these post-endoscopic outbreaks. Endoscope reprocessing involves cleaning, high-level disinfection/sterilization followed by rinsing and drying before storage. Failure of the decontamination process implies the risk of settlement of biofilm producing species in endoscope channels. This review covers the infectious complications in gastrointestinal endoscopy and their prevention and highlights the problem of infection risk associated with different steps of endoscope reprocessing.
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18
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Gould D, Gammon J, Salem RB, Chudleigh J, Fontenla M. Flowers in the clinical setting: Infection risk or workload issue? J Res Nurs 2016. [DOI: 10.1177/136140960400900507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Healthcare-associated infection has become a topic of interest to the general public in the United Kingdom, kindled by media accounts of poor hygiene and the risks of cross-infection. In the spring of 2003, one of the broadsheet newspapers published an article debating the hygiene and infection risks associated with cut flowers brought into clinical areas. There were reports that in many wards this practice is no longer allowed because flowers are considered dirty, trigger allergies and the water is regarded as harbouring bacteria, leading to infection. Discussion with infection control experts revealed that questions concerning the risks associated with flowers are among those most frequently asked. A literature search was undertaken to establish the evidence base, and a questionnaire study was performed with a purposive sample of 39 nurses to document how they manage flowers in the clinical setting. Empirical research studies were difficult to obtain. Early work had been undertaken to explore the added workload associated with maintaining fresh flowers and ways of reducing it. Later studies revealed that the water in flower vases and cut plants both harbour large numbers of Gram-negative pathogens. Cross-infection and cases of clinical infection have never been documented, thus flowers have not been considered a risk, except to severely immunocompromised patients. However, scrutiny of the more general literature relating to Gram-negative sepsis indicated that cross-infection has been documented from a wide range of environmental sources and it is possible that it may take place from flowers via the hands of staff if they are not properly decontaminated. Nevertheless, these risks can be reduced by scrupulous attention to hand hygiene and commonsense measures. Over half the nurses (n = 26, 66.6%) thought that flowers constituted an infection risk and a number of other disadvantages were cited. Most nurses (n = 31, 80%) were not in favour of flowers in the clinical setting and there was some evidence that this attitude was related to the amount of work generated, with infection and other risks used to justify it. Interest in the topic was considerable and the results can be used to stimulate discussion and emphasise the importance of controlling health-related infection.
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Affiliation(s)
- Dinah Gould
- St Bartholomew School of Nursing and Midwifery, City University, London
| | - John Gammon
- Swansea Institute of Higher Education, Townhill, Swansea
| | | | | | - Marina Fontenla
- St Bartholomew School of Nursing and Midwifery, City University, London
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19
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Vanhems P, Gayet-Ageron A, Ponchon T, Bernet C, Chayvialle JA, Chemorin C, Morandat L, Bibollet MA, Chevallier P, Ritter J, Fabry J. Follow-up and Management of Patients Exposed to a Flawed Automated Endoscope Washer-Disinfector in a Digestive Diseases Unit. Infect Control Hosp Epidemiol 2016; 27:89-92. [PMID: 16418997 DOI: 10.1086/500004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2003] [Accepted: 04/21/2005] [Indexed: 11/03/2022]
Abstract
The possible transmission of pathogens to 236 persons exposed to an endoscope processed in a flawed automated endoscope washer-disinfector in a gastrointestinal endoscopy unit was investigated. During 6 months, 197 patients (83.5%) were followed up, and no cases of acute human immunodeficiency virus, hepatitis C virus, or hepatitis B virus infection were observed. This event created the conditions for improvements in safety procedures.
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Affiliation(s)
- Philippe Vanhems
- Unite d'Epidemiologie et d'Hygiene Hospitaliere, Hopital Edouard Herriot, Lyon, France.
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20
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Fukada T, Tsuchiya Y, Iwakiri H, Ozaki M. Is the Ambu aScope 3 Slim single-use fiberscope equally efficient compared with a conventional bronchoscope for management of the difficult airway? J Clin Anesth 2016; 30:68-73. [DOI: 10.1016/j.jclinane.2015.12.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 12/16/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
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21
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Gonzalez EA, Nandy P, Lucas AD, Hitchins VM. Ability of cleaning-disinfecting wipes to remove bacteria from medical device surfaces. Am J Infect Control 2015; 43:1331-5. [PMID: 26654235 DOI: 10.1016/j.ajic.2015.07.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/13/2015] [Accepted: 07/14/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nosocomial infections are a serious problem in health care facilities. Bacteria can be transferred from patient to patient via contaminated reusable medical devices and equipment. METHODS An anesthesia machine and objects representative of smooth and ridged machine knobs were contaminated with Staphylococcus aureus, Bacillus atrophaeus spores, and Clostridium sporogenes spores. The ability of 5 commercially available cleaning-disinfecting wipes to remove bacteria was compared with gauze soaked with water or bleach. Gauze soaked with water was used to determine the optimal wetness for bacteria removal, which was then used to evaluate the efficacy of the wipe ingredients. RESULTS All of the wipes cleaned the device surfaces significantly better than the no wipe control. Some wipes performed equally well as gauze with water, whereas others performed worse. Overall, the wipe containing sodium hypochlorite was the most effective at removing bacteria. When the wipe ingredients were re-evaluated using the determined optimal wipe wetness on gauze, their effectiveness at cleaning S aureus, but not spores, significantly improved. CONCLUSION Physically removing bacteria from device surfaces with water was often as effective as the cleaning-disinfecting wipes. Of the wipe active ingredients evaluated, sodium hypochlorite was the most effective overall. The wetness of the wipes may also play a role in their effectiveness.
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Affiliation(s)
- Elizabeth A Gonzalez
- Division of Biology, Chemistry, and Material Sciences, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD.
| | - Poulomi Nandy
- Division of Biology, Chemistry, and Material Sciences, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Anne D Lucas
- Division of Biology, Chemistry, and Material Sciences, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Victoria M Hitchins
- Division of Biology, Chemistry, and Material Sciences, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
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22
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Kenters N, Huijskens EGW, Meier C, Voss A. Infectious diseases linked to cross-contamination of flexible endoscopes. Endosc Int Open 2015; 3:E259-65. [PMID: 26355428 PMCID: PMC4554517 DOI: 10.1055/s-0034-1392099] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Flexible endoscopes are widely used to examine, diagnose, and treat medical disorders. While the risk of endoscopy-related transmission of infection is estimated to be very low, more health care-associated infections are related to contaminated endoscopes than to any other medical device. Flexible endoscopes can get highly contaminated with microorganisms, secretions and blood during use. The narrow lumens and multiple internal channels make the cleaning of flexible endoscopes a complex and difficult task. Despite the availability of international, national and local endoscope reprocessing guidelines, contamination and transmission of microorganisms continue to occur. These transmissions are mostly related to the use of defective equipment, endoscope reprocessing failures, and noncompliance with recommended guidelines. This article presents an overview of publications about case reports and outbreaks related to contamination of flexible endoscopes.
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Affiliation(s)
- Nikki Kenters
- Albert Schweitzer Hospital, Department of Infection Prevention and Control, Dordrecht, Netherlands
| | | | - Corianne Meier
- Rivierenland Hospital, Department of Infection Prevention and Control, Tiel, Netherlands
| | - Andreas Voss
- Canisius-Wilhelmina Hospital, Department of Medical Microbiology, Nijmegen, Netherlands,Radboud University Medical Centre, Nijmegen, NL,Corresponding author: Prof. Andreas Voss Canisius-Wilhelmina Hospital, Department of Medical MicrobiologyP.O. Box 9015NijmegenNetherlands+31243657516
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23
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Chiu KW, Lu LS, Chiou SS. High-level disinfection of gastrointestinal endoscope reprocessing. World J Exp Med 2015; 5:33-39. [PMID: 25699232 PMCID: PMC4308530 DOI: 10.5493/wjem.v5.i1.33] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/19/2014] [Accepted: 11/17/2014] [Indexed: 02/06/2023] Open
Abstract
High level disinfection (HLD) of the gastrointestinal (GI) endoscope is not simply a slogan, but rather is a form of experimental monitoring-based medicine. By definition, GI endoscopy is a semicritical medical device. Hence, such medical devices require major quality assurance for disinfection. And because many of these items are temperature sensitive, low-temperature chemical methods, such as liquid chemical germicide, must be used rather than steam sterilization. In summarizing guidelines for infection prevention and control for GI endoscopy, there are three important steps that must be highlighted: manual washing, HLD with automated endoscope reprocessor, and drying. Strict adherence to current guidelines is required because compared to any other medical device, the GI endoscope is associated with more outbreaks linked to inadequate cleaning or disinfecting during HLD. Both experimental evaluation on the surveillance bacterial cultures and in-use clinical results have shown that, the monitoring of the stringent processes to prevent and control infection is an essential component of the broader strategy to ensure the delivery of safe endoscopy services, because endoscope reprocessing is a multistep procedure involving numerous factors that can interfere with its efficacy. Based on our years of experience in the surveillance of culture monitoring of endoscopic reprocessing, we aim in this study to carefully describe what details require attention in the GI endoscopy disinfection and to share our experience so that patients can be provided with high quality and safe medical practices. Quality management encompasses all aspects of pre- and post-procedural care including the efficiency of the endoscopy unit and reprocessing area, as well as the endoscopic procedure itself.
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24
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Weber DJ, Rutala WA. Lessons Learned From Outbreaks and Pseudo-Outbreaks Associated with Bronchoscopy. Infect Control Hosp Epidemiol 2015; 33:230-4. [DOI: 10.1086/664495] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Contamination of a purified water system by Aspergillus fumigatus in a new endoscopy reprocessing unit. Am J Infect Control 2014; 42:1337-9. [PMID: 25444308 DOI: 10.1016/j.ajic.2014.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/12/2014] [Accepted: 08/13/2014] [Indexed: 11/21/2022]
Abstract
Use of purified water for the final rinse stage of disinfected endoscopes is an important element of quality control. We describe the detection and management of Aspergillus fumigatus contamination of a new reverse osmosis unit supplying 10 automated endoscope reprocessor basins. Prompt detection and reaction to this contaminant were possible because of the introduction of a comprehensive program for microbiological monitoring of rinse waters, which included total viable counts, endotoxin, conductivity, and Pseudomonas spp.
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26
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Johansson E, Welinder-Olsson C, Gilljam M. Genotyping of Pseudomonas aeruginosa isolates from lung transplant recipients and aquatic environment-detected in-hospital transmission. APMIS 2014; 122:85-91. [PMID: 24450429 DOI: 10.1111/apm.12243] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 01/09/2013] [Indexed: 11/30/2022]
Abstract
Lung infection with Pseudomonas aeruginosa is common in lung transplant recipients and may lead to severe complications. Bacteriological surveillance aims to detect transmission of microbes between hospital environment and patients. We sought to determine whether genotyping of P. aeruginosa isolates could improve identifications of pathways of infection. From 2004 to 2009, we performed genotyping with multiple-locus variable number of tandem repeats analysis (MLVA) and pulsed-field gel electrophoresis (PFGE) of P. aeruginosa isolates cultured from lung transplant recipients at Sahlgrenska University Hospital, Gothenburg. During a small outbreak in 2008, cultivation and genotyping of isolates from sink and drains samples from the hospital ward were performed. Pseudomona aeruginosa from 11/18 patients were genotyped to unique strains. The remaining seven patients were carriers of a P. aeruginosa strain of cluster A genotype. Pseudomona aeruginosa was isolated in 4/8 water samples, typed by MLVA also as cluster A genotype and confirmed by PFGE to be similar or identical to the isolates from four transplanted patients. In conclusion, genotyping of isolates revealed a clonal relationship between patient and water isolates, indicating in-hospital transmission of P. aeruginosa. We suggest genotyping with MLVA for rapid routine surveillance, with the PFGE method used for extended, confirmatory analyses.
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Affiliation(s)
- Ewa Johansson
- Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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27
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The role of the environment in the spread of emerging pathogens in at-risk hospital wards. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/mrm.0b013e328365c506] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26:231-54. [PMID: 23554415 DOI: 10.1128/cmr.00085-12] [Citation(s) in RCA: 307] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.
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29
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Diagnostics method for the rapid quantitative detection and identification of low-level contamination of high-purity water with pathogenic bacteria. J Ind Microbiol Biotechnol 2013; 40:1005-13. [PMID: 23783648 DOI: 10.1007/s10295-013-1295-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
High-purity water (HPW) can be contaminated with pathogenic microorganisms, which may result in human infection. Current culture-based techniques for the detection of microorganisms from HPW can be slow and laborious. The aim of this study was to develop a rapid method for the quantitative detection and identification of pathogenic bacteria causing low-level contamination of HPW. A novel internally controlled multiplex real-time PCR diagnostics assay was designed and optimized to specifically detect and identify Pseudomonas aeruginosa and the Burkholderia genus. Sterile HPW, spiked with a bacterial load ranging from 10 to 10(3) cfu/100 ml, was filtered and the bacterial cells were removed from the filters by sonication. Total genomic DNA was then purified from these bacteria and subjected to testing with the developed novel multiplex real-time PCR diagnostics assay. The specific P. aeruginosa and Burkholderia genus assays have an analytical sensitivity of 3.5 genome equivalents (GE) and 3.7 GE, respectively. This analysis demonstrated that it was possible to detect a spiked bacterial load of 1.06 × 10(2) cfu/100 ml for P. aeruginosa and 2.66 × 10(2) cfu/100 ml for B. cepacia from a 200-ml filtered HPW sample. The rapid diagnostics method described can reliably detect, identify, and quantify low-level contamination of HPW with P. aeruginosa and the Burkholderia genus in <4 h. We propose that this rapid diagnostics method could be applied to the pharmaceutical and clinical sectors to assure the safety and quality of HPW, medical devices, and patient-care equipment.
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30
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Fujitani S, Sun HY, Yu VL, Weingarten JA. Pneumonia Due to Pseudomonas aeruginosa. Chest 2011; 139:909-919. [DOI: 10.1378/chest.10-0166] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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31
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Zinder SM, Basler RSW, Foley J, Scarlata C, Vasily DB. National athletic trainers' association position statement: skin diseases. J Athl Train 2011; 45:411-28. [PMID: 20617918 DOI: 10.4085/1062-6050-45.4.411] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To present recommendations for the prevention, education, and management of skin infections in athletes. BACKGROUND Trauma, environmental factors, and infectious agents act together to continually attack the integrity of the skin. Close quarters combined with general poor hygiene practices make athletes particularly vulnerable to contracting skin diseases. An understanding of basic prophylactic measures, clinical features, and swift management of common skin diseases is essential for certified athletic trainers to aid in preventing the spread of infectious agents. RECOMMENDATIONS These guidelines are intended to provide relevant information on skin infections and to give specific recommendations for certified athletic trainers and others participating in athletic health care.
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32
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Dynamics of the action of biocides in Pseudomonas aeruginosa biofilms. Antimicrob Agents Chemother 2011; 55:2648-54. [PMID: 21422224 DOI: 10.1128/aac.01760-10] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The biocidal activity of peracetic acid (PAA) and benzalkonium chloride (BAC) on Pseudomonas aeruginosa biofilms was investigated by using a recently developed confocal laser scanning microscopy (CLSM) method that enables the direct and real-time visualization of cell inactivation within the structure. This technique is based on monitoring the loss of fluorescence that corresponds to the leakage of a fluorophore out of cells due to membrane permeabilization by the biocides. Although this approach has previously been used with success with various Gram-positive species, it is not directly applicable to the visualization of Gram-negative strains such as P. aeruginosa, particularly because of limitations regarding fluorescence staining. After adapting the staining procedure to P. aeruginosa, the action of PAA and BAC on the biofilm formed by strain ATCC 15442 was investigated. The results revealed specific inactivation patterns as a function of the mode of action of the biocides. While PAA treatment triggered a uniform loss of fluorescence in the structure, the action of BAC was first localized at the periphery of cell clusters and then gradually spread throughout the biofilm. Visualization of the action of BAC in biofilms formed by three clinical isolates then confirmed the presence of a delay in penetration, showing that diffusion-reaction limitations could provide a major explanation for the resistance of P. aeruginosa biofilms to this biocide. Biochemical analysis suggested a key role for extracellular matrix characteristics in these processes.
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33
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Iversen BG. Contaminated mouth swabs caused a multi-hospital outbreak of Pseudomonas aeruginosa infection. J Oral Microbiol 2010; 2. [PMID: 21523228 PMCID: PMC3084570 DOI: 10.3402/jom.v2i0.5123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bjørn G Iversen
- Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
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Sánchez-Carrillo C, Padilla B, Marín M, Rivera M, Cercenado E, Vigil D, Sánchez-Luna M, Bouza E. Contaminated feeding bottles: the source of an outbreak of Pseudomonas aeruginosa infections in a neonatal intensive care unit. Am J Infect Control 2009; 37:150-4. [PMID: 19059675 DOI: 10.1016/j.ajic.2008.04.259] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 04/09/2008] [Accepted: 04/14/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND Outbreaks of Pseudomonas aeruginosa have been reported in relationship with contamination of staff fingernails, hands, water baths, hand lotions and others. To our knowledge, contamination of milk and feeding bottles as a source of an outbreak of P aeruginosa infections has not been reported. The incidence of P aeruginosa infection/colonization in our neonatal intensive care unit increased from 1.9 per 1000 patient-days in August 2004 to 8.8 per 1000 patient-days in September 2004. METHODS Samples were collected including hand and body lotions, water from the incubator humidifying system, the health care worker hands, and the feeding bottle preparation room. Strains were epidemiologically characterized by pulsed-field gel electrophoresis of SpeI-digested genomic DNA. P aeruginosa was isolated from a total of 30 neonates during the period September 2004 to December 2004. RESULTS All cultures (139) of hand and body lotions, water from the incubator humidifying system, and hands of health care personnel were negative. Nine out of 48 samples collected from the feeding bottle preparation room were positive for P aeruginosa (6 samples of in-house prepared milk and 3 samples of water from dishwashers). Pulsed-field gel electrophoresis with SpeI showed that the strains isolated from neonates and from environmental samples were identical. Discontinuation of in-house preparation of feeding bottles and incorporation of unidose milk bottles stopped the outbreak. CONCLUSION The preparation and solution of milk from multidose powder preparation may be a source of P aeruginosa infections in a neonatal intensive care unit. The use of manufactured, nonmanipulated, unidose feeding bottles should be considered more adequate.
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Affiliation(s)
- Carlos Sánchez-Carrillo
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Abstract
Summary Processing of bronchoscopes after a physical examination has to eliminate all micro-organisms that could have contaminated the endoscope and that may harm the following patient. The aim of this analysis is to define those micro-organisms that may contaminate the bronchoscope during the examination and that may cause disease in other patients. Methods Research of literature and analysis of laboratory data. Results During the passage of the respiratory tract the bronchoscope will be contaminated by the physiological flora of oral cavity, nasopharynx, trachea, bronchi, and pulmonary tissues. Whilst the oral cavity, the nasopharynx and the pharynx are the habitat for a great variety of bacteria the lower respiratory tract is virtually free of micro-organisms. However, in ventilated patients trachea and bronchi can become colonized as the result of bypassing the cleansing effect of the ciliated epithelium. In addition all agents that can cause bronchitis or pneumonia in immunocompromised or otherwise healthy individuals are potential contaminants of bronchoscopes. These microorganisms include bacteria, mycobacteria, yeasts and moulds, enveloped and non-enveloped viruses and rarely parasites. The bronchoscopic procedure can result in epithelial injury with subsequent bleeding. Therefore, all blood-borne pathogens, e.g. HIV or HBV are also potential contaminants of the bronchoscope. There are several reports of transmission of micro-organisms due to incomplete or faulty cleaning and disinfection procedures of bronchoscopes. These incidents include nearly all classes of micro-organisms but not parasites or viruses. However, the incubation period of viruses can be long and the association between bronchoscopy and infection may be obscure. Endospore forming micro-organisms and parasites are not part of the normal flora of the respiratory tract and may rarely cause disease, usually only in severely immunocompromised patients, but transmission of such organisms by bronchoscopy has never been reported. Conclusion The antimicrobial activity of the disinfection process, including chemical disinfectants for endoscopes has to include bacteria, fungi and viruses. Sporicidal activity may be only warranted in specific patient populations, i.e. after bronchoscopy of suspected anthrax patients or before examination of severely immunocompromised patients.
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Affiliation(s)
- Constanze Wendt
- Hygiene-Institut, University of Heidelberg, Heidelberg, Germany.
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Martin DJH, Denyer SP, McDonnell G, Maillard JY. Resistance and cross-resistance to oxidising agents of bacterial isolates from endoscope washer disinfectors. J Hosp Infect 2008; 69:377-83. [PMID: 18602194 DOI: 10.1016/j.jhin.2008.04.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 04/04/2008] [Indexed: 11/30/2022]
Abstract
Bacteria isolated from washer disinfectors using chlorine dioxide as a high-level disinfectant were exposed to peracetic acid, chlorine dioxide and hydrogen peroxide to investigate their susceptibility and possible bacterial cross-resistance to these highly reactive oxidising biocides. A standard suspension test was used to establish a rate of kill of these biocides against two stable isolates (Bacillus subtilis and Micrococcus luteus). Suspension tests demonstrated that 'in use' concentrations were not always effective to provide the required disinfection efficacy within recommended exposure times and in some instances a 60min exposure was necessary to achieve a reduction in number by a factor of 10(5). It appears that vegetative Gram-positive isolates can become resistant to oxidising agents in vitro, and that cross-resistance to related compounds can occur. Since these bacteria are deemed to be susceptible to highly reactive biocides, there should be further study of the resistance mechanisms in these isolates to explain their survival.
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Affiliation(s)
- D J H Martin
- Welsh School of Pharmacy, Cardiff University, Cardiff, UK
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Cholley P, Thouverez M, Floret N, Bertrand X, Talon D. The role of water fittings in intensive care rooms as reservoirs for the colonization of patients with Pseudomonas aeruginosa. Intensive Care Med 2008; 34:1428-33. [PMID: 18425499 PMCID: PMC2491418 DOI: 10.1007/s00134-008-1110-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 03/12/2008] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the role of the water environment in the Pseudomonas aeruginosa colonization of patients in intensive care units in the absence of a recognized outbreak. DESIGN AND SETTING Prospective, single-centre study over an 8-week period in two adult ICUs at a university hospital. Environmental samples were taken from the water fittings of rooms once per week, during a 8-week period. Patients were screened weekly for P. aeruginosa carriage. Environmental and humans isolates were genotyped by using pulsed-field gel electrophoresis. RESULTS P. aeruginosa was detected in 193 (86.2%) of the 224 U-bend samples and 10 of the 224 samples taken from the tap (4.5%). Seventeen of the 123 patients admitted were colonized with P. aeruginosa. Only one of the 14 patients we were able to evaluate was colonized by a clone present in the water environment of his room before the patient's first positive sample was obtained. CONCLUSION The role of the water environment in the acquisition of P. aeruginosa by intensive care patients remains unclear, but water fittings seem to play a smaller role in non-epidemic situations than expected by many operational hospital hygiene teams.
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Affiliation(s)
- Pascal Cholley
- Service d’Hygiène Hospitalière, CHU Jean Minjoz, Bd Fleming, 25030 Besançon Cedex, France
| | - Michelle Thouverez
- Service d’Hygiène Hospitalière, CHU Jean Minjoz, Bd Fleming, 25030 Besançon Cedex, France
| | - Nathalie Floret
- Service d’Hygiène Hospitalière, CHU Jean Minjoz, Bd Fleming, 25030 Besançon Cedex, France
| | - Xavier Bertrand
- Service d’Hygiène Hospitalière, CHU Jean Minjoz, Bd Fleming, 25030 Besançon Cedex, France
| | - Daniel Talon
- Service d’Hygiène Hospitalière, CHU Jean Minjoz, Bd Fleming, 25030 Besançon Cedex, France
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Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control 2007; 35:S165-93. [PMID: 18068814 DOI: 10.1016/j.ajic.2007.10.006] [Citation(s) in RCA: 697] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jane D Siegel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007; 35:S65-164. [PMID: 18068815 PMCID: PMC7119119 DOI: 10.1016/j.ajic.2007.10.007] [Citation(s) in RCA: 1687] [Impact Index Per Article: 93.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Iversen BG, Eriksen HM, Bø G, Hagestad K, Jacobsen T, Engeset E, Lassen J, Aavitsland P. Pseudomonas aeruginosa contamination of mouth swabs during production causing a major outbreak. Ann Clin Microbiol Antimicrob 2007; 6:3. [PMID: 17355630 PMCID: PMC1831477 DOI: 10.1186/1476-0711-6-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 03/13/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2002 we investigated an outbreak comprising 231 patients in Norway, caused by Pseudomonas aeruginosa and linked to the use of contaminated mouth swabs called Dent-O-Sept. Here we describe the extent of contamination of the swabs, and identify critical points in the production process that made the contamination possible, in order to prevent future outbreaks. METHODS Environmental investigation with microbiological examination of production, ingredients and product, molecular typing of bacteria and a system audit of production. RESULTS Of the 1565 swabs examined from 149 different production batches the outbreak strain of P. aeruginosa was detected in 76 swabs from 12 batches produced in 2001 and 2002. In total more than 250 swabs were contaminated with one or more microbial species. P. aeruginosa was detected from different spots along the production line. The audit revealed serious breeches of production regulations. Health care institutions reported non-proper use of the swabs and weaknesses in their purchasing systems. CONCLUSION Biofilm formation in the wet part of the production is the most plausible explanation for the continuous contamination of the swabs with P. aeruginosa over a period of at least 30 weeks. When not abiding to production regulations fatal consequences for the users may ensue. For the most vulnerable patient groups only documented quality-controlled, high-level disinfected products and items should be used in the oropharynx.
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Affiliation(s)
- Bjørn G Iversen
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Hanne-Merete Eriksen
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Gjermund Bø
- The Norwegian Food Safety Authority, district office of Vest-Agder, Kristiansand, Norway
| | - Kristian Hagestad
- The Norwegian Board of Health in the County of Vest-Agder, Kristiansand, Norway
| | | | - Eva Engeset
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Jørgen Lassen
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Preben Aavitsland
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
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Iversen BG, Jacobsen T, Eriksen HM, Bukholm G, Melby KK, Nygård K, Aavitsland P. An outbreak of Pseudomonas aeruginosa infection caused by contaminated mouth swabs. Clin Infect Dis 2007; 44:794-801. [PMID: 17304450 DOI: 10.1086/511644] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Accepted: 11/13/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pseudomonas aeruginosa is an opportunistic bacterium that can cause severe infection in susceptible patients. During the winter of 2001-2002, we investigated an outbreak of P. aeruginosa infection among patients in several hospitals across Norway. METHODS A nationwide outbreak investigation was performed with case finding, questionnaires, and product sampling. All available clinical and environmental P. aeruginosa strains were genotyped. Detailed information was collected from patients with the outbreak strain or with any P. aeruginosa in blood or cerebrospinal fluid samples. To identify risk factors, we conducted a case-control study among patients with P. aeruginosa isolated from blood or cerebrospinal fluid samples during October 2001-December 2002. Case patients were patients infected with the outbreak genotype, and control subjects were patients infected with other genotypes. RESULTS A total of 231 patients from 24 hospitals were identified as having the outbreak strain; 39 of these patients had positive blood culture results. Seventy-one patients (31%) died while hospitalized; all of the patients who died had severe underlying disease. Among 39 case patients and 159 control subjects, use of the moist mouth swab (adjusted odds ratio, 5.3; 95% confidence interval, 2.0-13.6) and receipt of mechanical ventilation (adjusted odds ratio, 6.4; 95% confidence interval, 2.3-17.2) were associated with infection due to the outbreak strain. Genotypically identical strains of P. aeruginosa were identified in 76 mouth swabs from 12 different batches and from the production line. CONCLUSIONS Contamination of mouth swabs during production caused the largest-ever outbreak of P. aeruginosa infection in Norway. Susceptible patient groups should use only documented quality-controlled, high-level-disinfected products and items in the oropharynx.
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Falagas ME, Koletsi PK, Bliziotis IA. The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter baumannii and Pseudomonas aeruginosa. J Med Microbiol 2006; 55:1619-1629. [PMID: 17108263 DOI: 10.1099/jmm.0.46747-0] [Citation(s) in RCA: 306] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Different definitions of the terms multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter baumannii and Pseudomonas aeruginosa have been used in the biomedical literature. The authors searched for relevant studies indexed in the PubMed database (01/2000-09/2005) to systematically examine the various definitions of MDR and PDR for these bacteria. Initially 107 retrieved relevant studies were reviewed. Ninety-two studies were further analysed, 50 of which focused on A. baumannii and 42 on P. aeruginosa. A considerable diversity of definitions of the terms MDR and PDR A. baumannii and P. aeruginosa was found. Of note, the term PDR was inappropriately used in all five studies that used it. The review reveals that various definitions have been used for the terms MDR and PDR A. baumannii and P. aeruginosa, a fact that causes confusion to researchers and clinicians. The authors believe that at least a widely accepted definition for PDR A. baumannii and P. aeruginosa should be uniformly used worldwide.
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Affiliation(s)
- Matthew E Falagas
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23 Marousi, Athens, Greece
| | - Patra K Koletsi
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23 Marousi, Athens, Greece
| | - Ioannis A Bliziotis
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23 Marousi, Athens, Greece
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Muscarella LF. Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying. Am J Gastroenterol 2006; 101:2147-54. [PMID: 16968511 DOI: 10.1111/j.1572-0241.2006.00712.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Endoscope reprocessing is a multi-stepped process that renders a contaminated endoscope safe for reuse. Its steps include meticulous cleaning, complete immersion in a liquid chemical sterilant (LCS) or disinfectant to achieve high-level disinfection (or "liquid sterilization"), water rinsing, and proper handling and storage. Surveys and reports indicate that not all health-care facilities dry their endoscopes after reprocessing. Endoscope drying can be easily, quickly, and inexpensively achieved by flushing the endoscope's internal channels, and wiping its external surfaces, with 70-90% ethyl or isopropyl alcohol, to facilitate drying after reprocessing, followed by compressed or forced air. METHODS The medical literature was reviewed to evaluate the importance of endoscope drying to the prevention of disease transmission. Several national and international endoscope-reprocessing and infection-control guidelines and a public health advisory were also reviewed and compared for consistency and to evaluate the emphasis each places on endoscope drying. If a guideline recommends endoscope drying, this study clarified whether this step is recommended after reprocessing throughout the day (i.e., between patient procedures), before storage, or both. These guidelines were also reviewed to determine whether any of them recommend reprocessing endoscopes before the first patient of the day. RESULTS This review identified several published reports and clinical studies that demonstrate the significant contribution of endoscope drying to the prevention of disease transmission. This review also identified significant differences and inconsistencies regarding the emphasis different published guidelines and a public health advisory place on endoscope drying. Some guidelines recommend drying the endoscope after completion of every reprocessing cycle, both throughout the day and before storage, while others deemphasize its importance and recommend endoscope drying only before storage, if at all. Instead of recommending endoscope drying before storage, some guidelines recommend reprocessing endoscopes before the first patient of the day. DISCUSSION AND CONCLUSION The finding that several guidelines are inconsistent with one another and that some are remiss and fail to recommend endoscope drying is of concern. Endoscope drying is as important to the prevention of nosocomial infection as cleaning and high-level disinfection (or "liquid sterilization"). Whereas wet or inadequately dried endoscopes pose an increased risk of contamination and have been associated with transmission of waterborne microorganisms and nosocomial infection, thoroughly dried (and properly cleaned and high-level disinfected) endoscopes have not been linked to nosocomial infection. Moreover, inconsistent guidelines can confuse reprocessing staff members and result in noncompliance, variations in the standard of care, and ineffective reprocessing. To minimize the risk of disease transmission and nosocomial infection, modification and revision of guidelines are recommended as required to be consistent with one another and to unconditionally recommend endoscope drying after completion of every reprocessing cycle, both between patient procedures and before storage, no matter the label claim of the LCS or disinfectant, the label claim of the automated reprocessing system, or the microbial quality of the rinse water. According to the medical literature, adoption of this recommendation may reduce the importance of not only monitoring the microbial quality of the rinse water, but also reprocessing endoscopes before the first patient of the day, both of which can be costly practices that a few guidelines recommend.
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45
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Nelson DB, Muscarella LF. Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy. World J Gastroenterol 2006; 12:3953-64. [PMID: 16810740 PMCID: PMC4087702 DOI: 10.3748/wjg.v12.i25.3953] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The purpose of this article is to review the evidence regarding transmission of infection during gastrointestinal endoscopy, factors important in endoscope reprocessing and infection control, areas to focus on to improve compliance, and recent developments and advances in the field.
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46
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Falagas ME, Kopterides P. Risk factors for the isolation of multi-drug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa: a systematic review of the literature. J Hosp Infect 2006; 64:7-15. [PMID: 16822583 DOI: 10.1016/j.jhin.2006.04.015] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Accepted: 04/18/2006] [Indexed: 02/06/2023]
Abstract
An understanding of the epidemiology of multi-drug-resistant (MDR) Acinetobacter baumannii and Pseudomonas aeruginosa infections is necessary in order to develop strategies to curtail their spread. For this purpose, the evidence linking the isolation of MDR A. baumannii and P. aeruginosa with specific risk factors was evaluated. PubMed was searched for the 20-year period from September 1985 to September 2005, and eligible studies were considered to be those that: (1) linked the isolation of A. baumannii and P. aeruginosa with specific risk factors; (2) described the characteristics of the affected patients in detail; and (3) provided data on the antibiotic resistance profile of the isolated micro-organisms. Fifty-five studies were found referring to A. baumannii (28 with case-control methodology and 27 outbreak investigations without case-control methodology), and 42 studies were found referring to P. aeruginosa (25 with case-control methodology and 17 outbreak investigations without case-control methodology). Although heterogeneous study designs and investigated risk factors limited this analysis, it was concluded that acquisition and spread of these micro-organisms appear to be related to a large number of variables. Among the most important were deficiencies in the implementation of infection control guidelines and the use of broad-spectrum antibiotics. Use of carbapenems and third-generation cephalosporins appear to be related to the development of an MDR phenotype by A. baumannii, while carbapenems and fluoroquinolones are implicated in MDR P. aeruginosa. The diversity of risk factors associated with the development of MDR A. baumannii and P. aeruginosa suggests that a separate outbreak investigation should be performed in each hospital setting. The development of innovative control strategies is needed in order to limit the spread of these pathogens.
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Affiliation(s)
- M E Falagas
- Alfa Institute of Biomedical Sciences, Athens, Greece.
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47
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Willis C. Bacteria-free endoscopy rinse water -- a realistic aim? Epidemiol Infect 2006; 134:279-84. [PMID: 16490131 PMCID: PMC2870398 DOI: 10.1017/s0950268805005066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2005] [Indexed: 11/06/2022] Open
Abstract
A number of outbreaks and pseudo-outbreaks have been associated with contaminated rinse water in endoscope washer-disinfectors. Health Technical Memorandum 2030 specifies that final rinse water should be 'bacteria-free'. In this study, results of rinse-water testing from 20 endoscopy units were reviewed over a 4-month period. Over 60% of samples were of an unsatisfactory quality (i.e. not bacteria-free) and none of the endoscopy units consistently achieved sterile water throughout the study period. Poor microbiology results caused anxiety to endoscopy staff and infection control teams who had to decide whether or not to take washer-disinfectors out of use, possibly resulting in delays to medical procedures. There was no common policy on how to react to poor results, with staff at each unit developing their own action levels. Here, it is suggested that future guidelines would be of more practical use if they specified a series of action levels of increasing severity based on the bacterial count in a water sample.
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Affiliation(s)
- C Willis
- Wessex Environmental Microbiology Services, Health Protection Agency, Southampton, UK.
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Cêtre JC, Nicolle MC, Salord H, Pérol M, Tigaud S, David G, Bourjault M, Vanhems P. Outbreaks of contaminated broncho-alveolar lavage related to intrinsically defective bronchoscopes. J Hosp Infect 2005; 61:39-45. [PMID: 15893850 DOI: 10.1016/j.jhin.2004.12.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 12/20/2004] [Indexed: 11/24/2022]
Abstract
From 5 March 2001 to 19 October 2001, outbreaks of broncho-alveolar lavage (BAL) contamination with Enterobacteraceae were detected in our 700-bed institution. We report the investigation of these outbreaks. A case was defined as the occurrence of pairs of specific Enterobacteraceae in BAL specimens among any patients who underwent bronchoscopy in the respiratory unit during the period of the outbreak. Contamination was identified in 117 BAL samples during three outbreaks among 418 patients, and was associated with bronchoscopes 11 and 12 (P<0.001). The other five devices in use were not linked with the outbreaks. During the first outbreak, particular pairs of micro-organisms were associated with a specific bronchoscope (Klebsiella pneumoniae/Proteus vulgaris with bronchoscope 11, and Morganella morganii/Proteus mirabilis with bronchoscope 12). Cultures of sputa from two patients also yielded M. morganii some days after bronchoscopic examination. Isolates from contaminated BAL samples and bronchoscope 11 had similar patterns by pulsed-field gel electrophoresis. No further cases occurred after removal of the implicated bronchoscopes. No deficiencies in disinfection procedures were detected and the source of contamination was found to be a loose port of the biopsy channel of the bronchoscope. Our findings underscore the urgent need to test bronchoscopic samples regularly and to improve the design and structure of bronchoscopes.
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Affiliation(s)
- J-C Cêtre
- Hygiene and Epidemiology Unit, Hôpital Croix-Rousse, 69317 Lyon cedex 04, France.
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Corne P, Godreuil S, Jean-Pierre H, Jonquet O, Campos J, Jumas-Bilak E, Parer S, Marchandin H. Unusual implication of biopsy forceps in outbreaks of Pseudomonas aeruginosa infections and pseudo-infections related to bronchoscopy. J Hosp Infect 2005; 61:20-6. [PMID: 16019111 DOI: 10.1016/j.jhin.2005.01.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2004] [Accepted: 01/27/2005] [Indexed: 11/23/2022]
Abstract
Between January and April 2003, a sudden increase in positive respiratory tract specimens for Pseudomonas aeruginosa was observed in an intensive care unit of the University Teaching Hospital of Montpellier, France. Most of the strains were cultured from bronchoalveolar lavage fluid samples, suggesting that bronchoscopic procedures could be implicated. The relationships between isolates were investigated by antibiotyping and pulsed-field gel electrophoresis. Both phenotypic and molecular markers allowed identification of two consecutive nosocomial outbreaks of respiratory infections related to two different bronchoscopes. These two outbreaks implicated nine and seven patients, respectively. Four of these 16 patients had true infections and recovered with antibiotic therapy. Inspection of both bronchoscopes revealed a damaged internal channel caused by defective biopsy forceps. These defects led to improper cleaning and disinfection of the bronchoscopes despite adherence to all current reprocessing procedures. The two outbreaks were controlled after replacing the inner channels of the bronchoscopes and switching from use of re-usable to disposable biopsy forceps. These outbreaks emphasize the need to establish surveillance procedures for detecting contamination of bronchoscopes, and the importance of recording each endoscopic procedure to facilitate further investigations if needed.
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Affiliation(s)
- P Corne
- Service de Réanimation Médicale Assistance Respiratoire, Hôpital Gui de Chauliac, 80 avenue Augustin Fliche, 34295 Montpellier, France.
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Mehta AC, Prakash UBS, Garland R, Haponik E, Moses L, Schaffner W, Silvestri G. American College of Chest Physicians and American Association for Bronchology [corrected] consensus statement: prevention of flexible bronchoscopy-associated infection. Chest 2005; 128:1742-1755. [PMID: 16162783 PMCID: PMC7094662 DOI: 10.1378/chest.128.3.1742] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 03/11/2005] [Indexed: 12/16/2022] Open
Affiliation(s)
- Atul C Mehta
- Department of Pulmonary and Critical Care Medicine, Head Section of Bronchoscopy, The Cleveland Clinic Foundation, 9500 Euclid Ave, A-90, Cleveland, OH 44195, USA.
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