Background and Aims
Worldwide, an increasing number of duodenoscope-associated outbreaks are reported.
The high prevalence rate of contaminated duodenoscopes puts patients undergoing ERCP
at risk of exogenous transmission of microorganisms. The contributing factors of the
duodenoscope design to contamination are not well understood. This article reports
on the investigation after the outbreak of a multidrug-resistant Klebsiella pneumoniae (MRKP) related to 2 Olympus TJF-Q180V duodenoscopes.
Methods
We conducted a contact patient screening and microbiologic laboratory database search.
Reprocessing procedures were audited, and both duodenoscopes were fully dismantled
to evaluate all potential contamination factors. Outcomes were reviewed by an experienced
independent expert.
Results
In total, 102 patients who had undergone an ERCP procedure from January to August
2015 were invited for screening. Cultures were available of 81 patients, yielding
27 MRKP-infected or -colonized patients. Ten patients developed an MRKP-related active
infection. The 2 duodenoscopes had attack rates (the number of infected or colonized
cases/number of exposed persons) of 35% (17/49) and 29% (7/24), respectively. Identical
MRKP isolates were cultured from channel flushes of both duodenoscopes. The review
revealed 4 major abnormalities: miscommunication about reprocessing, undetected damaged
parts, inadequate repair of duodenoscope damage, and duodenoscope design abnormalities,
including the forceps elevator, elevator lever, and instrumentation port sealing.
Conclusions
Outbreaks are associated with a combination of factors, including duodenoscope design
issues, repair issues, improper cleaning, and systemic monitoring of contamination.
To eliminate future duodenoscope-associated infections, a multipronged approach is
required, including clear communication by all parties involved, a reliable servicing
market, stringent surveillance measures, and eventually new duodenoscope designs and
reprocessing procedures with a larger margin of safety.
Abbreviations:
ESBL (extended-spectrum β-lactamase), IFU (instructions for use), ISO (independent service organization), MRKP (multidrug-resistant Klebsiella pneumoniae), UMCU (University Medical Center Utrecht)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: May 15, 2019
Accepted:
May 5,
2019
Received:
December 27,
2018
Footnotes
DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: F. P. Vleggaar: Consultant for and research grant recipient from Boston Scientific. M. J. Bruno: Consultant for 3M, Boston Scientific, and Cook Medical; speaker for Boston Scientific and Cook Medical; grant recipient from 3M, Boston Scientific, Cook Medical, and Pentax Medical. M. C. Vos: Grant recipient from 3M, Pentax Medical, and IMS Innovations. All other authors disclosed no financial relationships relevant to this publication.
If you would like to chat with an author of this article, you may contact Dr Monkelbaan at [email protected]
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© 2019 by the American Society for Gastrointestinal Endoscopy
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Access this article on ScienceDirectLinked Article
- Dissecting an outbreak one scope at a time: Is this the new reality?Gastrointestinal EndoscopyVol. 90Issue 5
- PreviewThe infectious risk of ERCP has historically been ascribed to biliary stasis and obstructive physiology from stones, strictures, or stents. Recent outbreaks, many of them from multidrug-resistant organisms (MDROs), have been attributed to the infectious carriage of the duodenoscope itself: so-called exogenous infection. This has drawn considerable attention and research efforts intended to better characterize the contributory risk of each of the following factors: instrument design, reprocessing measures (eg, manual and automated cleaning), surveillance strategies for detecting instrument contamination, and other quality metrics.
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