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Risk-assessment-based approach to patients exposed to endoscopes contaminated with Pseudomonas spp.

https://doi.org/10.1016/j.jhin.2014.12.012Get rights and content

Summary

Patients exposed to bronchoscopes contaminated with Pseudomonas aeruginosa are at increased risk of pseudomonal infection. The optimal methods for management and mitigation of risk following exposure are controversial. This article describes a two-phase risk assessment following pseudomonal contamination of a family of 75 endoscopes, detected through routine surveillance and attributed to one endoscope washer-disinfector. An initial risk assessment identified 18 endoscopes as high risk, based on the presence of lumens used for irrigation or biopsy. Exposure was communicated to the patients' clinical teams and a further clinical risk assessment of the exposed patients was performed. No patients developed complications due to pseudomonal infection.

Introduction

Invasive Pseudomonas aeruginosa infection is a rare complication of bronchoscopy, usually resulting from inadequate scope disinfection. The risk of invasive infection, such as pneumonia or bacteraemia, following exposure to a contaminated bronchoscope has been estimated to be between 9% and 25%.1, 2, 3, 4, 5, 6 The risk is likely to vary according to the nature of the scope and the procedure undertaken, with lavage or biopsy of sterile sites considered to be higher risk. The risk is also likely to be dependent on patient comorbidities, such as immunosuppression, critical illness or chronic lung disease. Previous literature has focused on the retrospective recognition of bronchoscopic contamination following an outbreak of P. aeruginosa, by which point it is too late to institute preventative measures for exposed patients. Routine surveillance of endoscope washer-disinfector (EWD) rinse water for the presence of Pseudomonas spp. now enables early detection of exposure. However, good-quality evidence that would inform the prospective management of a cohort of patients exposed to Pseudomonas spp. via bronchoscopy is lacking. Reasoning that the risks of infection were specific to both the scope and the patient, a two-phase risk assessment was adopted following an episode of pseudomonal contamination of an EWD that had processed a family of endoscopes.

Section snippets

Setting

The Southern General Hospital is a 900-bed hospital in Glasgow with tertiary care services for neurology, and undertakes approximately 400 bronchoscopic procedures annually. The majority of bronchoscopic procedures are performed in a dedicated suite, but some are performed in operating theatres or the intensive care unit.

Cleaning and disinfection procedures

Endoscopes are cleaned in accordance with national guidance by trained personnel, and disinfected (peracetic acid) in one of three EWDs (Steris PTX, Steris Corp., Basingstoke,

Results

Initial scope risk stratification identified nine scopes as high risk, all of which were lumened intubation bronchoscopes used for assisting intubation rather than diagnostic procedures. The procedures performed and clinical details of the exposed patients are shown in Table I. The risk assessment was facilitated by the use of the Scantrack scope/patient tracking and traceability system (Scantrack Health Care, Bristol, UK), enabling rapid identification of at-risk patients. All scopes were used

Discussion

Previous evidence suggests that up to 25% of patients exposed to bronchoscopes contaminated with P. aeruginosa develop invasive infection. The wide range of risk estimates in the literature likely reflects the heterogeneity of scopes, procedures and patients involved.1, 2, 3, 4, 5, 6 Invasive pseudomonal infection is associated with poor outcomes, particularly when empirical antimicrobials lack antipseudomonal activity.8 Endoscope reprocessing guidance focuses on preventing cross-infection and

Conflict of interest statement

None declared.

Funding sources

None.

References (10)

There are more references available in the full text version of this article.

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