Bacterial contamination of complex gastrointestinal endoscopes

The worldwide surge of duodenoscope-associated outbreaks since the new millennium show that current reprocessing practices do not guarantee adequately decontaminated endoscopes. To prevent future outbreaks, identification of risk factors contributing to outbreaks and endoscope contamination is essential. The discussion of this thesis is divided into three themes. First, it describes the background of reprocessing of duodenoscopes and linear echoendoscopes (DLE), the multiple parties that are involved, and potential pathways leading to an outbreak. Secondly, it gains insight in the true size of the underlying problem of DLE contamination by showing the enduring high prevalence of DLE contamination with digestive tract bacteria in Dutch hospitals. In the third part of this thesis we show the results of a study of a cleaning test as a potential marker to check for residue to lower the contamination rate

Bacterial contamination of complex gastrointestinal endoscopes

The worldwide surge of duodenoscope-associated outbreaks since the new millennium show that current reprocessing practices do not guarantee adequately decontaminated endoscopes. To prevent future outbreaks, identification of risk factors contributing to outbreaks and endoscope contamination is essential. The discussion of this thesis is divided into three themes. First, it describes the background of reprocessing of duodenoscopes and linear echoendoscopes (DLE), the multiple parties that are involved, and potential pathways leading to an outbreak. Secondly, it gains insight in the true size of the underlying problem of DLE contamination by showing the enduring high prevalence of DLE contamination with digestive tract bacteria in Dutch hospitals. In the third part of this thesis we show the results of a study of a cleaning test as a potential marker to check for residue to lower the contamination rate

Bacterial contamination of complex gastrointestinal endoscopes

The worldwide surge of duodenoscope-associated outbreaks since the new millennium show that current reprocessing practices do not guarantee adequately decontaminated endoscopes. To prevent future outbreaks, identification of risk factors contributing to outbreaks and endoscope contamination is essential. The discussion of this thesis is divided into three themes. First, it describes the background of reprocessing of duodenoscopes and linear echoendoscopes (DLE), the multiple parties that are involved, and potential pathways leading to an outbreak. Secondly, it gains insight in the true size of the underlying problem of DLE contamination by showing the enduring high prevalence of DLE contamination with digestive tract bacteria in Dutch hospitals. In the third part of this thesis we show the results of a study of a cleaning test as a potential marker to check for residue to lower the contamination rate

High prevalence rate of digestive tract bacteria in duodenoscopes: A nationwide study

Objective Increasing numbers of outbreaks caused by contaminated duodenoscopes used for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures have been reported, some with fatal outcomes. We conducted a nationwide cross-sectional study to determine the prevalence of bacterial contamination of reprocessed duodenoscopes in The Netherlands. Design All 73 Dutch ERCP centres were invited to sample ≥2 duodenoscopes using centrally distributed kits according to uniform sampling methods, explained by video instructions. Depending on duodenoscope type, four to six sites were sampled and centrally cultured. Contamination was defined as (1) any microorganism with ≥20 colony forming units (CFU)/20 mL (AM20) and (2) presence of microorganisms with gastrointestinal or oral origin, independent of CFU count (MGO). Results Sixty-seven out of 73 centres (92%) sampled 745 sites of 155 duodenoscopes. Ten different duodenoscope types from three distinct manufacturers were sampled including 69 (46%) Olympus TJF-Q180V, 43 (29%) Olympus TJF-160VR, 11 (7%) Pentax ED34-i10T, 8 (5%) Pentax ED-3490TK and 5 (3%) Fujifilm ED-530XT8. Thirty-three (22%) duodenoscopes from 26 (39%) centres were contaminated (AM20). On 23 (15%) duodenoscopes MGO were detected, including Enterobacter cloacae, Escherichia coli, Klebsiella pneumonia and yeasts. For both definitions, contamination was not duodenoscope type dependent (p values: 0.20 and higher). Conclusion In 39% of all Dutch ERCP centres, at least one AM20-contaminated patient-ready duodenoscope was identified. Fifteen per cent of the duodenoscopes harboured MGO, indicating residual organic material of previous patients, that is, failing of disinfection. These results suggest that the present reprocessing and process control procedures are not adequate and safe

Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope: A case report

Background: Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias. Case presentation: We describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients’ blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences. Conclusion: This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored

Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report

Abstract Background Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias. Case presentation We describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients’ blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences. Conclusion This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored. </jats:sec