Persistent residual contamination in endoscope channels; a fluorescence epimicroscopy study

Background and study aims: The increasing demand for endoscopic procedures poses new contamination challenges, given developing antimicrobial resistance worldwide and potential viral or prion diseases in populations at risk. We examined working channels from reusable luminal endoscopes used in recent years.

Methods: Very sensitive fluorescence epimicroscopy was used to examine working channels from 6 decommissioned and 6 factory-new channels, as received, or following spiking and washing in the laboratory.

Results: After a single contamination and wash test cycle, new channels retained approximately 75 pg/mm² of proteins; through 7 subsequent cycles residual proteins fluctuated between 25 and 75 pg/mm². Decommissioned channels harbored 1 – 4 µg of proteins each, except in one gastroscope (33 µg), including up to 2 % amyloid proteins except in one gastroscope and one sigmoidoscope (with over 80 %); lumens showed wearing with established abraded biofilms in 3 cases. After spiking with scrapie-infected blood components and washing, residual protein levels in new channels varied following standard (17.23 pg/mm²), duplicated (2.39 pg/mm²) or extended (11.3 pg/mm²) washing; no changes were measured among the long-established contamination in old channels.

Conclusions: Our observations suggest that wear effects in endoscope lumens may contribute to the adsorption of proteins, thus facilitating retention and survival of bacteria. As demonstrated by recent outbreaks worldwide despite recommended reprocessing, the development of antimicrobial-resistant bacterial strains, and the estimated prevalence of variant Creutzfeldt-Jakob disease (vCJD) in the UK particularly, combined with increasing demand for endoscopic procedures, call for sustained precautions and improved methods for the reprocessing of nonautoclavable, reusable surgical instruments.

• References

• 1 Epstein L, Hunter JC, Arwady MA et al. New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312: 1447-1455
• 2 Alrabaa SF, Nguyen P, Sanderson R et al. Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment. Am J Infect Control 2013; 41: 562-564
• 3 Aumeran C, Poincloux L, Souweine B et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010; 42: 895-899
• 4 Wendorf KA, Kay M, Baliga C et al. Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol 2015; 36: 634-642
• 5 Bajolet O, Ciocan D, Vallet C et al. Gastroscopy-associated transmission of extended-spectrum beta-lactamase-producing Pseudomonas aeruginosa. J Hosp Infect 2013; 83: 341-343
• 6 Wendelboe AM, Baumbach J, Blossom DB et al. Outbreak of cystoscopy related infections with Pseudomonas aeruginosa: New Mexico, 2007. J Urol 2008; 180: 588-592
• 7 Chang CL, Su LH, Lu CM et al. Outbreak of ertapenem-resistant Enterobacter cloacae urinary tract infections due to a contaminated ureteroscope. J Hosp Infect 2013; 85: 118-124
• 8 Giao MS, Blanc S, Porta S et al. Improved recovery of Listeria monocytogenes from stainless steel and polytetrafluoroethylene surfaces using air/water ablation. J Appl Microbiol 2015; 119: 253-262
• 9 Ofstead CL, Wetzler HP, Doyle EM et al. Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines. Am J Infect Control 2015; 43: 794-801
• 10 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
• 11 Rutala WA, Weber DJ. ERCP scopes: what can we do to prevent infections?. Infect Control Hosp Epidemiol 2015; 36: 643-648
• 12 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
• 13 Kressel AB, Kidd F. Pseudo-outbreak of Mycobacterium chelonae and Methylobacterium mesophilicum caused by contamination of an automated endoscopy washer. Infect Control Hosp Epidemiol 2001; 22: 414-418
• 14 Nelson DB, Muscarella LF. Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy. World J Gastroenterol 2006; 12: 3953-3964
• 15 Ren-Pei W, Hui-Jun X, Ke Q et al. Correlation between the growth of bacterial biofilm in flexible endoscopes and endoscope reprocessing methods. Am J Infect Control 2014; 42: 1203-1206
• 16 Carbonne A, Thiolet JM, Fournier S et al. Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009. Euro Surveill 2010; 15. pii: 19734
• 17 Alfa MJ, Howie R. Modeling microbial survival in buildup biofilm for complex medical devices. BMC Infect Dis 2009; 9: 56
• 18 Kampf G, Fliss PM, Martiny H. Is peracetic acid suitable for the cleaning step of reprocessing flexible endoscopes?. World J Gastrointest Endosc 2014; 6: 390-406
• 19 Kovaleva J, Peters FT, van der Mei HC et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26: 231-254
• 20 Ribeiro MM, de Oliveira AC. Analysis of the air/water channels of gastrointestinal endoscopies as a risk factor for the transmission of microorganisms among patients. Am J Infect Control 2012; 40: 913-916
• 21 Prusiner SB. Novel proteinaceous infectious particles cause scrapie. Science 1982; 216: 136-144
• 22 Axon AT, Beilenhoff U, Bramble MG et al. Variant Creutzfeldt-Jakob disease (vCJD) and gastrointestinal endoscopy. Endoscopy 2001; 33: 1070-1080
• 23 Gill ON, Spencer Y, Richard-Loendt A et al. Prevalent abnormal prion protein in human appendixes after bovine spongiform encephalopathy epizootic: large scale survey. BMJ 2013; 347: f5675
• 24 Hervé R, Collin R, Pinchin HE et al. Rapid detection of biofilms and adherent pathogens using scanning confocal laser microscopy and episcopic differential interference contrast microscopy. J Microbiol Methods 2009; 77: 90-97
• 25 Keevil CW. Rapid detection of biofilms and adherent pathogens using scanning confocal laser microscopy and episcopic differential interference contrast microscopy. Water Sci Technol 2003; 47: 105-116
• 26 Hervé R, Keevil CW. Current limitations about the cleaning of luminal endoscopes. J Hosp Infect 2013; 83: 22-29
• 27 Bridier A, Sanchez-Vizuete MP, Le CD et al. Biofilms of a Bacillus subtilis hospital isolate protect Staphylococcus aureus from biocide action. PLoS One 2012; 7: e44506
• 28 Hennequin C, Aumeran C, Robin F et al. Antibiotic resistance and plasmid transfer capacity in biofilm formed with a CTX-M-15-producing Klebsiella pneumoniae isolate. J Antimicrob Chemother 2012; 67: 2123-2130
• 29 Kampf G, Bloss R, Martiny H. Surface fixation of dried blood by glutaraldehyde and peracetic acid. J Hosp Infect 2004; 57: 139-143
• 30 Darbord JC. Importance of cleaning for reprocessing endoscopes and thermolabile sterile medical devices: French use and regulations. J Hosp Infect 2004; 56: S40-S43
• 31 Aumeran C, Thibert E, Chapelle FA et al. Assessment on experimental bacterial biofilms and in clinical practice of the efficacy of sampling solutions for microbiological testing of endoscopes. J Clin Microbiol 2012; 50: 938-942
• 32 Ofstead CL, Dirlam Langlay AM, Mueller NJ et al. Re-evaluating endoscopy-associated infection risk estimates and their implications. Am J Infect Control 2013; 41: 734-736
• 33 Andreoletti O, Litaise C, Simmons H et al. Highly efficient prion transmission by blood transfusion. PLoS Pathog 2012; 8: e1002782
• 34 Axon AT, Beilenhoff U, Bramble MG et al. Variant Creutzfeldt-Jakob disease (vCJD) and gastrointestinal endoscopy. Endoscopy 2001; 33: 1070-1080
• 35 Ross AS, Baliga C, Verma P et al. A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli. Gastrointest Endosc 2015; 82: 477-483