Biomedical subjects
Publications and source records attributed to Lawrence F Muscarella.
The purpose of this article is to review the evidence regarding transmission of infection during gastrointestinal endoscopy, factors important in endoscope reprocessing and infection control, areas to focus on to improve compliance, and recent developments and advances in the field.
INTRODUCTION: Endoscope reprocessing is a multi-stepped process that renders a contaminated endoscope safe for reuse. Its steps include meticulous cleaning, complete immersion in a liquid chemical sterilant (LCS) or disinfectant to achieve high-level disinfection (or "liquid sterilization"), water rinsing, and proper handling and storage. Surveys and reports indicate that not all health-care facilities dry their endoscopes after reprocessing. Endoscope drying can be easily, quickly, and inexpensively achieved by flushing the endoscope's internal channels, and wiping its external surfaces, with 70-90% ethyl or isopropyl alcohol, to facilitate drying after reprocessing, followed by compressed or forced air. METHODS: The medical literature was reviewed to evaluate the importance of endoscope drying to the prevention of disease transmission. Several national and international endoscope-reprocessing and infection-control guidelines and a public health advisory were also reviewed and compared for consistency and to evaluate the emphasis each places on endoscope drying. If a guideline recommends endoscope drying, this study clarified whether this step is recommended after reprocessing throughout the day (i.e., between patient procedures), before storage, or both. These guidelines were also reviewed to determine whether any of them recommend reprocessing endoscopes before the first patient of the day. RESULTS: This review identified several published reports and clinical studies that demonstrate the significant contribution of endoscope drying to the prevention of disease transmission. This review also identified significant differences and inconsistencies regarding the emphasis different published guidelines and a public health advisory place on endoscope drying. Some guidelines recommend drying the endoscope after completion of every reprocessing cycle, both throughout the day and before storage, while others deemphasize its importance and recommend endoscope drying only before storage, if at all. Instead of recommending endoscope drying before storage, some guidelines recommend reprocessing endoscopes before the first patient of the day. DISCUSSION AND CONCLUSION: The finding that several guidelines are inconsistent with one another and that some are remiss and fail to recommend endoscope drying is of concern. Endoscope drying is as important to the prevention of nosocomial infection as cleaning and high-level disinfection (or "liquid sterilization"). Whereas wet or inadequately dried endoscopes pose an increased risk of contamination and have been associated with transmission of waterborne microorganisms and nosocomial infection, thoroughly dried (and properly cleaned and high-level disinfected) endoscopes have not been linked to nosocomial infection. Moreover, inconsistent guidelines can confuse reprocessing staff members and result in noncompliance, variations in the standard of care, and ineffective reprocessing. To minimize the risk of disease transmission and nosocomial infection, modification and revision of guidelines are recommended as required to be consistent with one another and to unconditionally recommend endoscope drying after completion of every reprocessing cycle, both between patient procedures and before storage, no matter the label claim of the LCS or disinfectant, the label claim of the automated reprocessing system, or the microbial quality of the rinse water. According to the medical literature, adoption of this recommendation may reduce the importance of not only monitoring the microbial quality of the rinse water, but also reprocessing endoscopes before the first patient of the day, both of which can be costly practices that a few guidelines recommend.
Several infection control practices and procedures crucial to the prevention of disease transmission in the health care setting are reviewed and discussed. Emphasis is placed on the importance of infection control to gastrointestinal endoscopy. Recommendations that minimize the risk of nosocomial infection during the preparation, handling, and administration of intravenous medications, particularly propofol, are provided. These recommendations include the labeling of predrawn syringes; use of sterile single-use syringes, needles, and administration sets for each patient; and, whenever feasible, administration of intravenous medications promptly after opening their prefilled syringes or after opening their ampoules or vials and filling the sterile syringes.
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The routine sampling of environmental surfaces within a healthcare facility is generally not recommended by the Centers for Disease Control and Prevention (CDC), the Association for the Advancement of Medical Instrumentation (AAMI), and several other healthcare organizations. There are a few circumstances, however, for which some organizations do recommend this practice. For instance, the CDC and the Association for Professionals in Infection Control and Epidemiology (APIC) recommend environmental sampling as clinically required during an outbreak investigation. The CDC and AAMI also recommend routine sampling of the rinse water used during hemodialyzer (but not endoscope) reprocessing. The rationale for this recommendation is based in part on reports of pyrogenic responses, patient infections, and bacteremia due to waterborne, gram-negative bacteria during hemodialysis. To determine whether the basis for this rationale might similarly apply to the rinse water used during endoscope reprocessing, the Food and Drug Administration's medical device reporting database, the endoscope reprocessing literature, and other sources were reviewed. The results of this review indicate that nosocomial outbreaks linked to endoscopes contaminated with gram-negative bacteria have been frequently reported. As a result, for several reasons, including to minimize the risk of patient infection due to gram-negative bacteria following endoscopy, this article recommends routine microbiologic sampling of the rinse water used during endoscope reprocessing.
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Bacillus anthracis is a large, gram-positive, spore-forming bacterium responsible for human anthrax. Review of the medical literature indicates specific instrument reprocessing instructions addressing the prevention of B. anthracis transmission are limited. Although nosocomial anthrax infection has not been reported, strict adherence to well-established instrument reprocessing guidelines for cleaning and high-level disinfection is recommended to prevent patient-to-patient transmission of B. anthracis (or any other pathogen) via gastrointestinal endoscopes or bronchoscopes. All liquid chemical sterilants labeled for high-level disinfection of endoscopes would be expected to destroy B. anthracis. Additional instrument cleaning or disinfection procedures appear to be unnecessary. Reprocessing the endoscope immediately following the procedure is emphasized.
UNLABELLED: This is the second in a series of articles that review media reports investigating the risk of disease transmission associated with gastrointestinal flexible endoscopy. The first article in this series, " COMMENTARY: Do Scopes Spread Sickness?'' was published in this journal in 1999 (Gastroenterology Nursing, 22(4), 179-180).