Endoscopy 2010; 42(11): 895-899
DOI: 10.1055/s-0030-1255647
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography

C.  Aumeran1 , L.  Poincloux2 , B.  Souweine3 , F.  Robin4 , H.  Laurichesse5 , O.  Baud1 , G.  Bommelaer2 , O.  Traoré1
  • 1Service d’Hygiène Hospitalière, CHU Clermont-Ferrand, France
  • 2Hépatogastroentérologie, CHU Clermont-Ferrand, France
  • 3CLIN, CHU Clermont-Ferrand, France
  • 4Bactériologie, CHU Clermont-Ferrand, France
  • 5Maladies Infectieuses, CHU Clermont-Ferrand, France
Further Information

Publication History

submitted 7 April 2010

accepted after revision 11 June 2010

Publication Date:
19 August 2010 (online)

Background and study aims: Infection is a recognized complication of endoscopic retrograde cholangiopancreatography (ERCP). We describe the epidemiologic and molecular investigations of an outbreak of ERCP-related severe nosocomial infection due to Klebsiella pneumoniae producing extended-spectrum beta-lactamase (ESBL).

Patients and methods: We conducted epidemiologic and molecular investigations to identify the source of the outbreak in patients undergoing ERCP. We carried out reviews of the medical and endoscopic charts and microbiological data, practice audits, surveillance cultures of duodenoscopes and environmental sites, and molecular typing of clinical and environmental isolates.

Results: Between December 2008 and August 2009, 16 patients were identified post-ERCP with Klebsiella pneumoniae that produced extended-spectrum beta-lactamase type CTX-M-15. There were 8 bloodstream infections, 4 biliary tract infections, and 4 cases of fecal carriage. The microorganism was isolated only from patients who had undergone ERCP. Environmental investigations found no contamination of the washer-disinfectors or the surfaces of the endoscopy rooms. Routine surveillance cultures of endoscopes were repeatedly negative during the outbreak but the epidemic strain was finally isolated from one duodenoscope by flushing and brushing the channels. Molecular typing confirmed the identity of the clinical and environmental strains. Practice audits showed that manual cleaning and drying before storage were insufficient. Strict adherence to reprocessing procedures ended the outbreak.

Conclusions: The endoscopes used for ERCP can act as a reservoir for the emerging ESBL-producing K. pneumoniae. Regular audits to ensure rigorous application of cleaning, high-level disinfection, and drying steps are crucial to avoid contamination.

References

  • 1 Freeman M L. Adverse outcomes of endoscopic retrograde cholangiopancreatography.  Rev Gastroenterol Disord. 2002;  2 147-168
  • 2 Anderson D J, Shimpi R A, McDonald J R. et al . Infectious complications following endoscopic retrograde cholangiopancreatography: an automated surveillance system for detecting postprocedure bacteremia.  Am J Infect Control. 2008;  36 592-594
  • 3 Cotton P B, Connor P, Rawls E, Romagnuolo J. Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years.  Gastrointest Endosc. 2008;  67 471-475
  • 4 Allen J I, Allen M O, Olson M M. et al . Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope.  Gastroenterology. 1987;  92 759-763
  • 5 Struelens M J, Rost F, Deplano A. et al . Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.  Am J Med. 1993;  95 489-498
  • 6 Fraser T G, Reiner S, Malczynski M. et al . Multidrug-resistant Pseudomonas aeruginosa cholangitis after endoscopic retrograde cholangiopancreatography: failure of routine endoscope cultures to prevent an outbreak.  Infect Control Hosp Epidemiol. 2004;  25 856-859
  • 7 Kovaleva J, Meessen N E, Peters F T. et al . Is bacteriologic surveillance in endoscope reprocessing stringent enough?.  Endoscopy. 2009;  41 913-916
  • 8 Lewis 2nd J S, Herrera M, Wickes B. et al . First report of the emergence of CTX-M-type extended-spectrum beta-lactamases (ESBLs) as the predominant ESBL isolated in a U.S. health care system.  Antimicrob Agents Chemother. 2007;  51 4015-4021
  • 9 Falagas M E, Karageorgopoulos D E. Extended-spectrum beta-lactamase-producing organisms.  J Hosp Infect. 2009;  73 345-354
  • 10 Robin F, Delmas J, Schweitzer C, Bonnet R. Evaluation of the Vitek-2 extended-spectrum beta-lactamase test against non-duplicate strains of Enterobacteriaceae producing a broad diversity of well-characterised beta-lactamases.  Clin Microbiol Infect. 2008;  14 148-154
  • 11 Dutour C, Bonnet R, Marchandin H. et al . CTX-M-1, CTX-M-3, and CTX-M-14-β-lactamases from Enterobacteriaceae isolated in France.  Antimicrobi Agents Chemother. 2002;  46 534-537
  • 12 EN 13727 Chemical disinfectants and antiseptics. Quantitative suspension test for the evaluation of bactericidal activity of chemical disinfectants for instruments used in the medical area. Test method and requirements (phase 2, step 1). Brussel; Comité Européen de Normalisation (CEN) 2003
  • 13 Tenover F C, Arbeit R D, Goering R V. et al . Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing.  J Clin Microbiol. 1995;  33 2233-2239
  • 14 Agence française de sécurité sanitaire des produits de santé (afssaps) .Information de sécurité concernant les duodénoscopes TJF 145 – Société Olympus, 12 Octobre 2009. Saint Denis, France. http://www.afssaps.fr/Infos-de-securite/Autres-mesures-de-securite/Information-de-securite-concernant-les-duodenoscopes-TJF145-Societe-Olympus
  • 15 Pitout J D, Laupland K B. Extended-spectrum beta-lactamase-producing Enterobacteriaceae: an emerging public-health concern.  Lancet Infect Dis. 2008;  8 159-166
  • 16 Balestrino D, Ghigo J M, Charbonnel N. et al . The characterization of functions involved in the establishment and maturation of Klebsiella pneumoniae in vitro biofilm reveals dual roles for surface exopolysaccharides.  Environ Microbiol. 2008;  10 685-701
  • 17 Muscarella L F. Contribution of tap water and environmental surfaces to nosocomial transmission of antibiotic-resistant Pseudomonas aeruginosa.  Infect Control Hosp Epidemiol. 2004;  25 342-345
  • 18 Welch K C, Cohen M B, Doghramji L L. et al . Clinical correlation between irrigation bottle contamination and clinical outcomes in post-functional endoscopic sinus surgery patients.  Am J Rhinol Allergy. 2009;  23 401-404
  • 19 Pajkos A, Vickery K, Cossart Y. Is biofilm accumulation on endoscope tubing a contributor to the failure of cleaning and decontamination?.  J Hosp Infect. 2004;  58 224-229
  • 20 Nelson D B. Recent advances in epidemiology and prevention of gastrointestinal endoscopy related infections.  Curr Opin Infect Dis. 2005;  18 326-330
  • 21 Seoane-Vazquez E, Rodriguez-Monguio R. Endoscopy-related infection: relic of the past?.  Curr Opin Infect Dis. 2008;  21 362-366
  • 22 Muscarella L F. Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying.  Am J Gastroenterol. 2006;  101 2147-2154
  • 23 Banerjee S, Shen B, Nelson D B. ASGE Standards of Practice Committee, . Infection control during GI endoscopy.  Gastrointest Endosc. 2008;  67 781-790
  • 24 Systchenko R, Marchetti B, Canard J N. et al . Guidelines of the French Society of Digestive Endoscopy: recommendations for setting up cleaning and disinfection procedures in gastrointestinal endoscopy.  Endoscopy. 2000;  32 807-818
  • 25 Beilenhoff U, Neumann C S, Rey J F. et al . ESGE Guidelines Committee. ESGE-ESGENA guideline for quality assurance in reprocessing: microbiological surveillance testing in endoscopy.  Endoscopy. 2007;  39 175-181

O. TraoréMD 

Service d’Hygiène Hospitalière
Hôpital G. Montpied

Rue Montalembert, BP 69
63003 Clermont Ferrand CEDEX 1
France

Fax: +33-473-754871

Email: otraore@chu-clermontferrand.fr

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