No relation between adenosine triphosphate after manual cleaning and presence of microorganisms on endoscopes after automated high-level disinfection

Abstract

Background and study aims Adenosine triphosphate (ATP) tests are increasingly used to detect biological material; however, their reliability to detect bacterial contamination in endoscopes is not proven. We investigated the predictive value of ATP tests after manual cleaning for presence or absence of microorganisms as shown by culture after automated high-level disinfection (HLD) in duodenoscopes and linear echoendoscopes (DLEs).

Patients and methods After manual cleaning, ATP tests were performed on swab samples taken from the detachable cap and forceps elevator, and on flush samples of the DLE working channels. These results were compared to the growth of any microorganisms in cultures acquired after automated HLD. ATP tests with > 200 relative light units (RLU) were considered positive. Receiver operator characteristic (ROC) curves were used to compare the RLU levels with microbial presence in cultures.

Results In total, 903 procedures were performed involving 26 distinct DLEs. Depending on sample site, 20.8 % (cap) to 63.8 % (channel brush) of the ATP negative samples were accompanied by positive post-HLD cultures. 54.4 % of the cap samples with a positive culture (growth of any kind of microorganism) and 91.8 % of the channel samples with a positive culture had a negative ATP test after manual cleaning. ROC curves per sample site, DLE type and microorganism type all had area under the curves below 0.6.

Conclusions In our study, ATP tests performed after manual cleaning could not predict presence or absence of microorganisms after automated HLD as shown by culture. More than half of the positive cultures were preceded by a negative ATP test.

Publication History

Received: 06 May 2022

Accepted after revision: 08 July 2022

Article published online:
14 September 2022

• References

• 1 Rauwers AW, Voor Inʼt Holt AF, Buijs JG. et al. Nationwide risk analysis of duodenoscope and linear echoendoscope contamination. Gastrointest Endosc 2020; 92: 681-691.e1
• 2 Rauwers AW, Voor Inʼt Holt AF, Buijs JG. et al. High prevalence rate of digestive tract bacteria in duodenoscopes: a nationwide study. Gut 2018; 67: 1637-1645
• 3 McCafferty CE, Aghajani MJ, Abi-Hanna D. et al. An update on gastrointestinal endoscopy-associated infections and their contributing factors. Ann Clin Microbiol Antimicrob 2018; 17: 36
• 4 Chapman CG, Siddiqui UD, Manzano M. et al. Risk of infection transmission in curvilinear array echoendoscopes: results of a prospective reprocessing and culture registry. Gastrointest Endosc 2017; 85: 390-397 e391
• 5 Beilenhoff U, Neumann CS, Rey JF. et al. ESGE-ESGENA guideline for quality assurance in reprocessing: microbiological surveillance testing in endoscopy. Endoscopy 2007; 39: 175-181
• 6 Hansen D, Benner D, Hilgenhöner M. et al. ATP measurement as method to monitor the quality of reprocessing flexible endoscopes. Ger Med Sci 2004; 2: Doc04
• 7 Batailler P, Saviuc P, Picot-Gueraud R. et al. Usefulness of adenosinetriphosphate bioluminescence assay (ATPmetry) for monitoring the reprocessing of endoscopes. Infect Control Hosp Epidemiol 2015; 36: 1437-1443
• 8 Alfa MJ, Fatima I, Olson N. Validation of adenosine triphosphate to audit manual cleaning of flexible endoscope channels. Am J Infect Control 2013; 41: 245-248
• 9 Olafsdottir LB, Whelan J, Snyder GM. A systematic review of adenosine triphosphate as a surrogate for bacterial contamination of duodenoscopes used for endoscopic retrograde cholangiopancreatography. Am J Infect Control 2018; 46: 697-705
• 10 Visrodia K, Hanada Y, Pennington KM. et al. Duodenoscope reprocessing surveillance with adenosine triphosphate testing and terminal cultures: a clinical pilot study. Gastrointest Endosc 2017; 86: 180-186
• 11 Sethi S, Huang RJ, Barakat MT. et al. Adenosine triphosphate bioluminescence for bacteriologic surveillance and reprocessing strategies for minimizing risk of infection transmission by duodenoscopes. Gastrointest Endosc 2017; 85: 1180-1187 e1181
• 12 Kenters N, Tartari E, Hopman J. et al. Worldwide practices on flexible endoscope reprocessing. Antimicrob Resist Infect Control 2018; 7: 153
• 13 Chang WK, Liu TC, Liu TL. et al. Enhanced manual cleaning efficacy of duodenoscope in endoscopy units: Results of a multicenter comprehensive quality control program. Am J Infect Control 2019; 47: 1233-1239
• 14 Quan E, Mahmood R, Naik A. et al. Use of adenosine triphosphate to audit reprocessing of flexible endoscopes with an elevator mechanism. Am J Infect Control 2018; 46: 1272-1277
• 15 Rauwers AW, Voor In 't Holt AF, Buijs JG. et al. Assessment of post-manual cleaning adenosine triphosphate tests to prevent the use of contaminated duodenoscopes and linear echoendoscopes: the DETECT study. Gastrointest Endosc 2022; 96: 282-290.e5
• 16 Alfa MJ, Olson N, Murray BL. Comparison of clinically relevant benchmarks and channel sampling methods used to assess manual cleaning compliance for flexible gastrointestinal endoscopes. Am J Infect Control 2014; 42: e1-5
• 17 Dutch Association for Medical Microbiology. Guideline control of microbiological safety of thermolabile flexible high-risk gastrointestinal endoscopes. https://www.nvmm.nl/media/2222/180627-richtlijn-controle-op-microbiologische-veiligheid-van-thermolabiele-flexibele-gi-endoscopen-juiste-versie.pdf
• 18 Larsen S, Russell RV, Ockert LK. et al. Rate and impact of duodenoscope contamination: A systematic review and meta-analysis. EClinicalMedicin 2020; 25: 100451
• 19 Ridtitid W, Pakvisal P, Chatsuwan T. et al. Performance characteristics and optimal cut-off value of triple adenylate nucleotides test versus adenosine triphosphate test as point of care testing for predicting inadequacy of duodenoscope reprocessing. J Hosp Infect 2020; 106: 348-356
• 20 Fernando G, Collignon P, Beckingham W. ATP bioluminescence to validate the decontamination process of gastrointestinal endoscopes. Healthcare infection 2014; 19: 59-64
• 21 Fushimi R, Takashina M, Yoshikawa H. et al. Comparison of adenosine triphosphate, microbiological load, and residual protein as indicators for assessing the cleanliness of flexible gastrointestinal endoscopes. Am J Infect Control 2013; 41: 161-164
• 22 Washburn RE, Pietsch JJ. Assessment of test methods for evaluating effectiveness of cleaning flexible endoscopes. Am J Infect Control 2018; 46: 685-688
• 23 Cattoir L, Vanzieleghem T, Florin L. et al. Surveillance of endoscopes: Comparison of different sampling techniques. Infect Control Hosp Epidemiol 2017; 38: 1062-1069
• 24 Ji X-Y, Ning P-Y, Fei C-N. et al. The importance of sampling technique and rinse water for assessing flexible gastrointestinal endoscope reprocessing: A 3-year study covering 59 centers. Am J Infect Control 2020; 48: 19-25
• 25 McCafferty CE, Abi-Hanna D, Aghajani MJ. et al. The validity of adenosine triphosphate measurement in detecting endoscope contamination. J Hosp Infect 2018; 100: e142-e145
• 26 Perumpail RB, Marya NB, McGinty BL. et al. Endoscope reprocessing: Comparison of drying effectiveness and microbial levels with an automated drying and storage cabinet with forced filtered air and a standard storage cabinet. Am J Infect Control 2019; 47: 1083-1089
• 27 Pineau L, Villard E, Duc DL. et al. Endoscope drying/storage cabinet: interest and efficacy. J Hosp Infect 2008; 68: 59-65
• 28 Alfa MJ. Quality systems approach for endoscope reprocessing: You donʼt know what you don't know!. Gastrointest Endosc Clin N Am 2020; 30: 693-709