ENDOSCOPE REPROCESSING AND INFECTION CONTROL FOR ENDOSCOPY

Transcription

1 ENDOSCOPE REPROCESSING AND INFECTION CONTROL FOR ENDOSCOPY Assist. Prof. Pochamana Phisalprapa, M.D., M.Sc. Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University

2 GI ENDOSCOPY Widely used diagnostic and therapeutic procedure Endoscope contamination during use Inappropriate cleaning and disinfection has lead to cross-transmission Although the incidence remains very low, endoscopes represent a risk of disease transmission

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4 TRANSMISSION OF INFECTION Gastrointestinal endoscopy >300 infections transmitted 70% agents Salmonella spp. and P. aeruginosa Clinical spectrum ranged from colonization to death (~4%) Bronchoscopy 90 infections transmitted M. tuberculosis, atypical Mycobacteria, P. aeruginosa Spach DH et al Ann Intern Med 1993: 118: Weber DJ, Rutala WA Gastroint Dis 2002

5 TWO CLASSIFICATIONS OF Critical Endoscope: ENDOSCOPES Endoscopes used in the examination of critical spaces such as joints and sterile cavities. Many of these endoscopes are rigid with no lumen. Arthroscopes and laproscopes Semicritical Endoscope: Fiberoptic used in the examination of the hollow viscera. These endoscopes generally invade only semicritical spaces Colonoscopes, gastroscopes, duodenoscopes, sigmoidoscopes, and enteroscopes

6 ENDOSCOPE REPROCESSING: CURRENT STATUS OF CLEANING AND DISINFECTION Guidelines British Society of Gastroenterology Endoscopy, 1998 Gastroenterological Society of Australia, 1999 Gastroenterological Nurses Society of Australia, 1999 Association for Professional in Infection Control and Epidemiology, 2000 European Society of Gastrointestinal Endoscopy, 2000 Multi-Society Guideline, 11 professional organizations, 2003 Centers for Disease Control and Prevention, 2008 American Society for Gastrointestinal Endoscopy, 2008 Society of Gastroenterology Nurses and Associates, 2012

7 ENDOSCOPE DISINFECTION CLEAN: mechanically cleaned with water and enzymatic cleaner High Level Disinfection (HLD)/STERILIZE: immerse scope and perfuse HLD/sterilant through all channels for exposure time RINSE: scope and channels rinsed with sterile water, filtered water, or tap water followed by alcohol DRY: use forced air to dry insertion tube and channels STORE-prevent recontamination

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9 ENDOSCOPE REPROCESSING, WORLDWIDE Endoscopy reprocessing India, of 133 endoscopy centers, only 1/3 performed even a minimum disinfection (1% glut for 2 min) Brazil, a high standard occur only exceptionally Western Europe, >30% did not adequately disinfection Japan, found exceedingly poor disinfection protocols US, 25% of endoscopes revealed >100,000 bacteria Schembre DB. Gastroint Endoscopy 2000;10:215

10 ENDOSCOPE REPROCESSING Source of contamination for infections 36 outbreaks transmitted by GI endoscopy from Cleaning = 3 Disinfection = 19 Rinse, Dry, Store = 3 Etiology unknown = 11

11 NOSOCOMIAL INFECTIONS VIA Observations GI ENDOSCOPY Number of reported infections is small, suggesting a very low incidence Endemic transmission may go unrecognized (e.g., inadequate surveillance, low frequency, asymptomatic infections) Infections traced to deficient practices Inadequate cleaning: clean all channels Inappropriate/ineffective disinfection: time exposure, perfuse channels, test concentration, ineffective disinfectant, inappropriate disinfectant Failure to follow recommended: tap water rinse Flaws is design of endoscopes or automated endoscope reprocessors (AERs)

12 NOSOCOMIAL OUTBREAKS VIA Infections associated with accessories Biopsy forceps GI ENDOSCOPY Contaminated biopsy forceps. (Dwyer DM. Gastroint Endosc 1987;33:84) Contaminated biopsy forceps: no cleaning between cases (Graham DY. Am J Gastroenterol 1988;83:974) Biopsy forceps not sterilized: glut exposed?, time? (Bronowicki JP. NEJM 1997;334:237)

13 IDEAL HLD/CHEMICAL STERILANT Rapid HLD (< 10 min) No disinfectant residue after rinsing Excellent material compatibility Long shelf-life Nontoxic (no odor or irritation issues) No disposal problems Monitor minimum effective concentration

14 ENDOSCOPE REPROCESSING MANUAL/AER HLD High level disinfection is the standard of care for reprocessing GI endoscopes The process can be completed manually or with an AER Until recently no AER substitutes for manual cleaning For manual disinfection, immerse completely in HLD and fill each channel with the HLD Flush channels with air before removing the scope from HLD

15 AUTOMATED ENDOSCOPE REPROCESSORS (AERS) Advantages: automate and standardize reprocessing steps, reduce personnel exposure to chemicals, filtered tap water Disadvantages: failure of AERs linked to outbreaks, does not eliminate pre-cleaning, does not monitor HLD concentration Problems: incompatible AER (side-viewing duodenoscope); biofilm buildup; contaminated AER; inadequate channel connectors Used wrong set-up or connector Must ensure exposure of internal surfaces with HLD

16 DISINFECTION AND STERILIZATION OF EMERGING PATHOGENS Hepatitis C virus Clostridium difficile Cryptosporidium Helicobacter pylori E.coli 0157:H7 SARS coronavirus Antibiotic-resistant microbes (MDR-TB, VRE, MRSA) Creutzfeldt-Jakob disease (no brain, eye, spinal cord contact)

17 INFECTION ASSOCIATED WITH UPPER GI ENDOSCOPY

18 INFECTION ASSOCIATED WITH LOWER GI ENDOSCOPY

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21 BACTERIAL BIOBURDEN ASSOCIATED WITH ENDOSCOPY Gastroscope, log 10 CFU Colonoscope, log 10 CFU After procedure Gastro Nursing 1998;22: Am J Inf Cont 1999;27:392 After cleaning Gastro Endosc 1997;48:137

22 VIRAL BIOBURDEN FROM ENDOSCOPES USED WITH AIDS PATIENTS Dirty Cleaned Disinfected Gastroscopes HIV (PCR) 7/20 0/20 0/20 HBsAg 1/20 0/20 0/7 Bronchoscopes HIV (cdna) 7/7 0/7 0/7 HBsAg 1/10 0/10 0/10 Hanson et al. Lancet 1989;2:86; Hanson et al. Thorax 1991;46:410

23 DISINFECTION AND STERILIZATION OF EMERGING PATHOGENS Standard disinfection and sterilization procedures for patient care equipment are adequate to sterilize or disinfect instruments or devices contaminated with blood and other body fluids from persons infected with emerging pathogens

24 CONCLUSION Contaminated endoscopes have been linked to many outbreaks of device-related nosocomial infections. The true incidence of endoscopy-related infections is unknown because of inadequate surveillance or no surveillance at all. Endoscopy-related infections can cause serious harm and can give rise to concerns over these procedures by physicians and patients. Flexible endoscopes can be cleaned and disinfected but not sterilized after use.

25 CONCLUSION Process control of the cleaning and disinfection procedure does not guarantee prevention of biofilm formation during endoscopy. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope. However, it should be reasonably in balance with costs of technical and laboratory procedures resulting from surveillance and the costs of reprocessing or servicing of the contaminated endoscope.

26 CONCLUSION Endoscopes represent a nosocomial hazard Proper cleaning and disinfection will prevent nosocomial transmission Current guidelines should be strictly followed Compliance must be monitored Safety and efficacy of new technologies must be validated

27 THANK YOU