Independent root-cause analysis of contributing factors, including dismantling of 2 duodenoscopes, to investigate an outbreak of multidrug-resistant Klebsiella pneumoniae
Rauwers, Arjan W; Troelstra, Annet; Fluit, Ad C; Wissink, Camiel; Loeve, Arjo J; Vleggaar, Frank P; Bruno, Marco J; Vos, Margreet C; Bode, Lonneke G M; Monkelbaan, Jan F
(2019) Gastrointestinal Endoscopy, volume 90, issue 5, pp. 793 - 804
(Article)
Abstract
Background and Aims: Worldwide, an increasing number of duodenoscope-associated outbreaks are reported. The high prevalence rate of contaminated duodenoscopes puts patients undergoing ERCP at risk of exogenous transmission of microorganisms. The contributing factors of the duodenoscope design to contamination are not well understood. This article reports on the investigation after
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the outbreak of a multidrug-resistant Klebsiella pneumoniae (MRKP) related to 2 Olympus TJF-Q180V duodenoscopes. Methods: We conducted a contact patient screening and microbiologic laboratory database search. Reprocessing procedures were audited, and both duodenoscopes were fully dismantled to evaluate all potential contamination factors. Outcomes were reviewed by an experienced independent expert. Results: In total, 102 patients who had undergone an ERCP procedure from January to August 2015 were invited for screening. Cultures were available of 81 patients, yielding 27 MRKP-infected or -colonized patients. Ten patients developed an MRKP-related active infection. The 2 duodenoscopes had attack rates (the number of infected or colonized cases/number of exposed persons) of 35% (17/49) and 29% (7/24), respectively. Identical MRKP isolates were cultured from channel flushes of both duodenoscopes. The review revealed 4 major abnormalities: miscommunication about reprocessing, undetected damaged parts, inadequate repair of duodenoscope damage, and duodenoscope design abnormalities, including the forceps elevator, elevator lever, and instrumentation port sealing. Conclusions: Outbreaks are associated with a combination of factors, including duodenoscope design issues, repair issues, improper cleaning, and systemic monitoring of contamination. To eliminate future duodenoscope-associated infections, a multipronged approach is required, including clear communication by all parties involved, a reliable servicing market, stringent surveillance measures, and eventually new duodenoscope designs and reprocessing procedures with a larger margin of safety.
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Keywords: Gastroenterology, Radiology Nuclear Medicine and imaging, Journal Article
ISSN: 0016-5107
Publisher: Mosby Inc.
Note: Funding Information: We thank the reprocessing staff, medical devices experts, infection control practitioners, medical microbiologists, Bio Information Technology group, and gastroenterologists at the UMCU for their participation and effort in this outbreak investigation. The authors received no specific funding support for the research, authorship, and/or publication of this article. DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: F. P. Vleggaar: Consultant for and research grant recipient from Boston Scientific. M. J. Bruno: Consultant for 3M, Boston Scientific, and Cook Medical; speaker for Boston Scientific and Cook Medical; grant recipient from 3M, Boston Scientific, Cook Medical, and Pentax Medical. M. C. Vos: Grant recipient from 3M, Pentax Medical, and IMS Innovations. All other authors disclosed no financial relationships relevant to this publication. Publisher Copyright: © 2019 American Society for Gastrointestinal Endoscopy
(Peer reviewed)