Gastrointestinal endoscope contamination rates – elevators are not only to blame: a systematic review and meta-analysis

 

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Abstract

Background and study aims Duodenoscopes that are contaminated due to inadequate reprocessing are well-documented. However, studies have demonstrated poor reprocessing of other kinds of endoscopes as well, including echoendoscopes, gastroscopes, and colonoscopes. We estimated the contamination rate beyond the elevator of gastrointestinal endoscopes based on available data.

Methods We searched PubMed and Embase from January 1, 2010 to October 10, 2020, for studies investigating contamination rates of reprocessed gastrointestinal endoscopes. A random-effects model was used to calculate the contamination rate of patient-ready gastrointestinal endoscopes. Subgroup analyses were conducted to investigate differences among endoscope types, countries, and colony-forming unit (CFU) thresholds.

Results Twenty studies fulfilled the inclusion criteria, including 1,059 positive cultures from 7,903 samples. The total contamination rate was 19.98 % ± 0.024 (95 % confidence interval [Cl]: 15.29 %–24.68 %; I² = 98.6 %). The contamination rates of colonoscope and gastroscope channels were 31.95 % ± 0.084 and 28.22 % ± 0.076, respectively. Duodenoscope channels showed a contamination rate of 14.41 % ± 0.029. The contamination rates among studies conducted in North America and Europe were 6.01 % ± 0.011 and 18.16% ± 0.053 %, respectively. The contamination rate among studies using a CFU threshold > 20 showed contamination of 30.36 % ± 0.094, whereas studies using a CFU threshold < 20 showed a contamination rate of 11 % ± 0.026.

Conclusions On average, 19.98 % of reprocessed gastrointestinal endoscopes may be contaminated when used in patients and varies between different geographies. These findings highlight that the elevator mechanism is not the only obstacle when reprocessing reusable endoscopes; therefore, guidelines should recommend more surveillance of the endoscope channels as well.

Publication History

Received: 28 April 2021

Accepted after revision: 31 January 2022

Article published online:
10 June 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Beg S, Ragunath K, Wyman A. et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUgastrointestinalS). Gut 2017; 66: 1886-1899
  CrossrefPubMedGoogle Scholar
• 2 Rubin ZA, Kim S, Thaker AM. et al. Safely reprocessing duodenoscopes: current evidence and future directions. Lancet Gastroenterol Hepatol 2018; 3: 499-508
  CrossrefPubMedGoogle Scholar
• 3 Humphries RM, Yang S, Kim S. et al. Duodenoscope-related outbreak of a carbapenem-resistant klebsiella pneumoniae identified using advanced molecular diagnostics. Clin Infect Dis 2017; 65: 1159-1166
  CrossrefPubMedGoogle Scholar
• 4 Ross AS, Tombs D, Verma P. et al. Culture and quarantine following high level disinfection of duodenoscopes: Results of ongoing surveillance. Gastrointest Endosc 2016; 83: AB531
  CrossrefPubMedGoogle Scholar
• 5 Nerandzic M, Antloga K, Litto C. et al. Efficacy of flexible endoscope drying using novel endoscope test articles that allow direct visualization of the internal channel systems. Am J Infect Control 2021; 49: 614-621
  CrossrefPubMedGoogle Scholar
• 6 Thaker AM, Kim S, Sedarat A. et al. Inspection of endoscope instrument channels after reprocessing using a prototype borescope. Gastrointest Endosc 2018; 88: 612-619
  PubMedGoogle Scholar
• 7 Petersen BT. Current state and future of infection prevention in endoscopy. Gastrointest Endosc Clin N Am 2021; 31: 625-640
  CrossrefPubMedGoogle Scholar
• 8 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
  PubMedGoogle Scholar
• 9 Olafsdottir LB, Wright SB, Smithey A. et al. Adenosine triphosphate quantification correlates poorly with microbial contamination of duodenoscopes. Infect Control Hosp Epidemiol 2017; 38: 678-684
  CrossrefPubMedGoogle Scholar
• 10 Ofstead CL, Wetzler HP, Heymann OL. et al. Longitudinal assessment of reprocessing effectiveness for colonoscopes and gastroscopes: Results of visual inspections, biochemical markers, and microbial cultures. Am J Infect Control 2017; 45: e26-e33
  CrossrefPubMedGoogle Scholar
• 11 Liu T-C, Peng C-L, Wang H-P. et al. SpyGlass application for duodenoscope working channel inspection: Impact on the microbiological surveillance. World J Gastroenterol 2020; 26: 3767-3779
  CrossrefPubMedGoogle Scholar
• 12 MAUDE Adverse Event Report. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/detail.cfm?mdrfoi__id=8811666&pc=FDS
  PubMedGoogle Scholar
• 13 Mark J, Underberg K, Kramer R. Results of duodenoscope culture and quarantine after manufacturer-recommended cleaning process. Gastrointest Endosc 2020; 91: 1328-1333
  CrossrefPubMedGoogle Scholar
• 14 Snyder G, Wright S, Mizrahi M. et al. Sa1023 DISINFECTS Study: Prospective randomized trial comparing three duodenoscope high-level disinfection and sterilization procedures. Gastrointest Endosc 2016; 83: AB207-AB208
  CrossrefPubMedGoogle Scholar
• 15 Cristina ML, Sartini M, Schinca E. et al. Is Post-reprocessing microbiological surveillance of duodenoscopes effective in reducing the potential risk in transmitting pathogens?. Int J Environ Res Public Health 2019; 17: 140
  CrossrefPubMedGoogle Scholar
• 16 US Food and Drug Administration. https://www.fda.gov/medical-devices/safety-communications/fda-recommending-transition-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication
  PubMed
• 17 Ridtitid W, Pakvisal P, Chatsuwan T. et al. A newly designed duodenoscope with detachable distal cap significantly reduces organic residue contamination after reprocessing. Endoscopy 2020; 52: 754-760
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 Mouritsen JM, Ehlers L, Kovaleva J. et al. A systematic review and cost effectiveness analysis of reusable vs. single-use flexible bronchoscopes. Anaesthesia 2020; 75: 529-540
  CrossrefPubMedGoogle Scholar
• 19 Kovaleva J. Infectious complications in gastrointestinal endoscopy and their prevention. Best Pract Res Clin Gastroenterol 2016; 30: 689-704
  CrossrefPubMedGoogle Scholar
• 20 Kovaleva J, Peters FTM, van der Mei HC. et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26: 231-254
  CrossrefPubMedGoogle Scholar
• 21 Troiano G, Lo Nostro A, Calonico C. et al. Microbiological surveillance of flexible bronchoscopes after a high-level disinfection with peracetic acid: preliminary results from an Italian teaching hospital. Ann Ig 2019; 31: 13-20
  PubMedGoogle Scholar
• 22 Moher D, Liberati A, Tetzlaff J. et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med 2009; 151: 264
  CrossrefPubMedGoogle Scholar
• 23 Guideline for use of high-level disinfectants and sterilants for reprocessing flexible gastrointestinal endoscopes. Gastroenterol Nurs 2015; 38: 70-80
  PubMedGoogle Scholar
• 24 Calderwood AH, Chapman FJ, Cohen J. et al. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointest Endosc 2014; 79: 363-372
  CrossrefPubMedGoogle Scholar
• 25 Beilenhoff U, Bieing H, Blum R. et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) – Up. Endoscopy 2018; 50: 1205-1234
  Article in Thieme ConnectPubMedGoogle Scholar
• 26 Petersen BT, Chennat J, Cohen J. et al. Multisociety Guideline on Reprocessing Flexible gastrointestinal Endoscopes: 2011. Infect Control Hosp Epidemiol 2011; 32: 527-537
  CrossrefPubMedGoogle Scholar
• 27 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
  Article in Thieme ConnectPubMedGoogle Scholar
• 28 Lin L. Bias caused by sampling error in meta-analysis with small sample sizes. PLoS One 2018; 13: 1-19
  CrossrefPubMedGoogle Scholar
• 29 Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539-1558
  CrossrefPubMedGoogle Scholar
• 30 Higgins JPT, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. Br Med J 2003; 327: 557-560
  CrossrefPubMedGoogle Scholar
• 31 Becq A, Snyder GM, Heroux R. et al. Prospective assessment of the effectiveness of standard high-level disinfection for echoendoscopes. Gastrointest Endosc 2019; 89: 984-989
  CrossrefPubMedGoogle Scholar
• 32 Larsen S, Russell RV, Ockert LK. et al. Rate and impact of duodenoscope contamination: A systematic review and meta-analysis. E Clin Med 2020; 25: 100451
  CrossrefPubMedGoogle Scholar
• 33 Rauwers AW, Voor in 't Holt AF, Buijs JG. et al. Nationwide risk analysis of duodenoscope and linear echoendoscope contamination. Gastrointest Endosc 2020; 92: 681-691.e1
  CrossrefPubMedGoogle Scholar
• 34 Wang P, Xu T, Ngamruengphong S. et al. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut 2018; 67: 1626-1636
  CrossrefPubMedGoogle Scholar
• 35 Lin JN, Wang CB, Yang CH. et al. Risk of infection following colonoscopy and sigmoidoscopy in symptomatic patients. Endoscopy 2017; 49: 754-764
  Article in Thieme ConnectPubMedGoogle Scholar
• 36 Sundermann AJ, Chen J, Miller JK. et al. Outbreak of Pseudomonas aeruginosa infections from a contaminated gastroscope detected by whole genome sequencing surveillance. Clin Infect Dis 2021; 73: e638-e642
  CrossrefPubMedGoogle Scholar
• 37 Naas T, Cuzon G, Babics A. et al. Endoscopy-associated transmission of carbapenem-resistant Klebsiella pneumoniae producing KPC-2-lactamase. J Antimicrob Chemother 2010; 65: 1305-1306
  CrossrefPubMedGoogle Scholar
• 38 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
  CrossrefPubMedGoogle Scholar
• 39 Jousset AB, Bonnin RA, Rosinski-Chupin I. et al. A 4.5-Year within-patient evolution of a colistin-resistant Klebsiella pneumoniae carbapenemase-producing K. pneumoniae sequence type 258. Clin Infect Dis 2018; 67: 1388-1394
  CrossrefPubMedGoogle Scholar
• 40 Sun S, Wang C, Wang S. Remember, interventional EUS is performed using an elevator-containing scope as well. Endosc Ultrasound 2018; 7: 73-75
  CrossrefPubMedGoogle Scholar
• 41 Chapman CG, Siddiqui UD, Konda VJ. et al. Risk of infection transmission in curvilinear array echoendoscopes: Results of a prospective reprocessing and culture registry. Gastrointest Endosc 2016; 83: AB128
  CrossrefPubMedGoogle Scholar
• 42 Olympus Corporation. Urgent field safety notice re: updated instructions for use for several Olympus ultrasound endoscopes Attention: Operating Room Manager, Risk Management Department and Reprocessing Units. 2020 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi96_-glt32AhXNTd8KHdjJBHoQFnoECAYQAQ&url=https%3A%2F%2Fncmdr.sfda.gov.sa%2FFileDownLoad.ashx%3Ff%3Dca%26fid%3D9007&usg=AOvVaw2ZbAfTt_yrHSwTJ9KqvbpJ
  PubMedGoogle Scholar
• 43 Thaker AM, Kim S, Sedarat A. et al. Inspection of endoscope instrument channels after reprocessing using a prototype borescope. Gastrointest Endosc 2018; 88: 612-619
  CrossrefPubMedGoogle Scholar
• 44 Gavaldà L, Olmo AR, Hernández R. et al. Microbiological monitoring of flexible bronchoscopes after high-level disinfection and flushing channels with alcohol: Results and costs. Respir Med 2015; 109: 1079-1085
  CrossrefPubMedGoogle Scholar
• 45 Larsen S, Kalloo A, Hutfless S. The hidden cost of colonoscopy including cost of reprocessing and infection rate: The implications for disposable colonoscopes. Gut 2019; 1: 1-4
  PubMedGoogle Scholar
• 46 Travis HS, Ehlers LH, Thornton J. The total cost of reusable duodenoscopes-are single-use duodenoscopes the future of ERCP?. Pharmacoeconom Open 2020; 5: 3-5
  PubMedGoogle Scholar
• 47 Bang JY, Sutton B, Hawes R. et al. Concept of disposable duodenoscope: at what cost?. Gut 2019; DOI: 10.1136/gutjnl-2019-318227.
  CrossrefPubMedGoogle Scholar
• 48 Borenstein M, Hedges LV, Higgins JPT. et al. Introduction to Meta-Analysis. Wiley Online; 2009
  PubMedGoogle Scholar

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