Parameters exerting Influence on Cleaning of flexible Endoscops

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1 Parameters exerting Influence on Cleaning of flexible Endoscops Heike Martiny Technische Hygiene Campus Benjamin Franklin Charité Universitätsmedizin Berlin ÖGSV Jahrestagung und wfhss-kongress Mai 2007, Baden bei Wien

2 Is biofilm accumulation on endoscope tubing a contributor to the failure of cleaning and decontamination? Pajkos, Vickery, Cossart; J Hosp Infect (2004)

3 Reprocessing of angioscopes after contamination with duck- HBV Chaufour et al, J Vasc Surg (1999) Ducks infected (%) Cleaning: Detergent + Brush Disinfection: GDA, 2%ig Sterilisation: Ethylenoxid, 6h min 10 min 20 min 6 Std Puffer Puffer + Des Reinig + Des Puffer + Ster Reinig + Ster

4 3 Definitionen pren ISO As at: Microbial inactivation factor measured change in microbial population, expressed as log 10, caused by the lethal effect of the germicide

5 pren ISO As at: Efficacy of the disinfectant log 10 6 inactivation of vegetative bacteria including yeasts and yeast-like fungi log 10 5 inactivation of mycobacteria log 10 4 inactivation of fungal spores and viruses log 10 6 reduction of bacterial spores within 5 h exposure

6 Max. bioburden after patient use Type cfu/ endoscope air water instrum. -channel suction Gastroscope Coloscope Bronchoscope 7.3 Duodenoscope 7.5 Chu et al, AJIC (1997) Vesley et al, Gastroenterology Nursing (1999) Alfa et al, Am J Infect Control 1999

7 3 Definitionen pren ISO As at: Microbial reduction factor measured change in microbial population, expressed as log 10, caused by the combination microbial inactivation factor and the physical removal of microorganisms

8 Alfa, Degagne, Olson Am J Infect Control 1999 Flexible endoscopes after use (log 10 cfu) Manual cleaning before after. Bronchoscopes Duodenoscopes Colonoscopes

9 Nelson et al Gastrointest Endosc 2003 Consensus Paper 11 societies (u. a. SHEA, APIC) Change of the enzymatic cleaner after each Endoscope

Bloß, Martiny, J Hosp Infect (2004) Type of

Peracetic acid I After disinfection After

10 Surface fixation of dried blood by glutaraldehyde and peracetic acid Kampf, Bloß, Martiny, J Hosp Infect (2004) Type of active agent Photograph Stage of process Peracetic acid I After disinfection After cleaning Glutaraldehyde I After disinfection After cleaning QAC After disinfection After cleaning QAC + Amines After disinfection After cleaning

11 Surface fixation of dried blood by glutaraldehyde and peracetic acid Kampf, Bloß, Martiny, J Hosp Infect (2004) Active agent Peracetic acid Peracetic acid No. 1 2 Rate of blood removal by exposure to disinfectant 8.1% 39.0% Mean weight of blood soil on metal carriers after exposure to one of 12 disinfectants ( soiled and disinfected ); means of eight parallel experiments Peracetic acid % Peracetic acid % Glutaraldehyde % Glutaraldehyde % Glutaraldehyde 7 8.1% QAC % QAC % QAC + Amine % Phenole % Tenside %

12 DIN ISO/TS Test soils for flexible endoscopes AT Annex DE Annex I DE Annex J FR Annex F NL Annex L UK Annex R US Annex S Nigrosin, wheat flour, hens egg, E. faecium Blood, E. faecium Tetramethylbenzidine, hydrogenperoxide solution, bovine haemoglobin Biofilm formed by Pseudomonas aeruginosa Bovine serum albumin, procine mucin, bovin thrombin, bovin fibrinogen Glycerol, dehydrated hog mucin, horse serum, unbleached plain flour, aqueous safranine solution, water Protein/organic soil (user preference), B. atrophaeus endospores

13 Annex I DIN ISO/TS Washer-Disinfectors E. faecium 1 x cfu/ml PTFE tubes 2 m, Ø 2 mm (transparent) Test soil Sheeps blood, 0.2 % Heparin 9.50 ml Susp. of test organism Protamin 1000 LAM 0.35 ml 0.15 ml Liquefied-(Kanamycin Äsculin Azid) -Agar-Method

14 Intra-laboratory reproducibility of the German test method Zühlsdorf, Floss, Martiny, J Hosp Infect (2005) N = 12 Bacteria suspension Bakteriensuspension 12 Test soil Testanschmutzung 12 Control Kontrolle 12 Reductionrate with water Reduktionsfaktor

15 German test method Test pieces Test pieces cleaned Liquid-Agar-Method LAM T E C H N I S C H E H YG I E N E - H EIKE M ART INY

16 The importance of cleaning for the overall results of processing endoscopes Martiny et al, J Hosp Infect (2004) Log 10 Reduction (mean) ( n = 28) A: Cleaning with water B: Pre-rinsing and cleaning with water C: Pre-rinsing, cleaning with water and interim rinsing 3.0

17 Efficacy of ten different cleaning processes in a WD for flexible endoscopes Zühlsdorf, Floss, Martiny, J Hosp Infect 56: (2004) 5,0 Reduktionsfaktor (lg KBE/mL) 4,0 3,0 2,0 1,0 0, ,0 1,0 2,0 3,0 4,0 8 Optische Sauberkeit C, 10 B 9 A, 6

18 Comparison of the cleaning efficacy and the cleaning and disinfecting efficacy of four washerdisinfectors for flexible endoscopes Kircheis and Martiny, J Hosp Infect (accepted) reduction factor (lg cfu/ml) Figure 1: Medians of reduction factors (lg cfu) of the cleaning processes in the AdaptaScope (Cidezyme GI and water ) and in the LS 2000 (Cidezyme GI, Liquid 52, and water ) (n = 57) AdaptaScope Cidezyme GI n = 12 LS 2000 Cidezyme GI n= 12 LS 2000 Liquid 52 n = 12 AdaptaScope water n = 9 LS 2000 water n = 12

19 Cheetham, Berentsveig Australien Infection control 7 (2002) Cleaning efficay and enzyme activity of 18 cleaner P. aeruginosa - Biofilm Edinburgh soil Protease - activity Amylase - activity

20 Cheetham, Berentsveig Australien Infection Control 7 (2002) Cleaner 3M Rapid Auto Arbest BF Sterizime Endofresh S Endokleen Endozyme AW plus Manufact. 3M Arbos Maruishi Olympus Kendall Ruhof Enzyme activity fresh Protease old 14 d, 40 C fresh 13, , Amylase old 14 d, 40 C 13, ,725 0

21 The importance of cleaning for the overall results of processing endoscopes Martiny et al, J Hosp Infect (2004) Cleaning only Cleaner A Cleaner B Disinfecting only Disinfectant A Disinfectant B Cleaning and Disinfecting Cleaner A + Disinfectant A Cleaner B + Disinfectant B Log 10 Reduction (mean) (n = 36) > 5.0 > 5.8 > 8.7 > 9.6 > 8.7 > < 5.8

22 Summary Inportant parameter affecting cleaning Level of burden Cleaning Efficacy of cleaning Manually Automatically Efficacy of the cleaner

23 What we still need Cleaning assurance level Disinfection assurance level respec. Process assurance level

The importance of cleaning for the overall results of processing endoscopes

Journal of Hospital Infection (2004) 56, S16 S22 www.elsevierhealth.com/journals/jhin The importance of cleaning for the overall results of processing endoscopes H. Martiny*, H. Floss, B. Zühlsdorf Charité