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Accurate reprocessing of flexible endoscopes is a multistep procedure involving cleaning followed by high-level disinfection (HLD) with further rinsing and drying before storage. Endoscope reprocessing can be performed with the use of automated endoscope reprocessors (AERs) and manual methods. Since almost all outbreaks are related to breaches in reprocessing techniques, it is crucial that endoscope cleaning, disinfection, and drying are performed according to a strict protocol. However, process control of endoscope reprocessing does not guarantee prevention of settlement of biofilm during endoscopy (2).
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Endoscopy-related infections can be divided into two types: endogenous and exogenous. Endoscopic procedures most often result in endogenous infections (i.e., infections resulting from the patient's own microbial flora), and Escherichia coli, Klebsiella spp., Enterobacter spp., and enterococci are the species most frequently isolated (8). Examples of endogenous infections include pneumonia resulting from aspiration of oral secretions in a sedated patient during flexible bronchoscopy and bacteremia in patients with biliary obstruction during endoscopic retrograde cholangiopancreaticography (ERCP). Endogenous infections are associated with endoscopy but cannot be prevented by well-controlled disinfection procedures (9). The exogenous microorganisms most frequently associated with transmission are Pseudomonas aeruginosa and Salmonella spp. during flexible gastrointestinal (GI) endoscopy and P. aeruginosa and mycobacteria during bronchoscopy (10). These microorganisms can be transmitted from previous patients or contaminated reprocessing equipment by contaminated endoscopes or its accessory equipment. Exogenous infection should be prevented by strict endoscope disinfection procedures (9).
Flexible endoscopes for therapeutic procedures (bronchoscopy and ERCP) and reusable accessories, such as biopsy forceps, are used in sterile body cavities and should be classified as critical devices (12, 13). They should be sterilized after each procedure. Due to their material composition, most flexible endoscopes cannot be steam sterilized (9). They tolerate ethylene oxide and hydrogen peroxide plasma sterilization, which are expensive and are not preferred by most institutions (14). No data are available demonstrating that sterilization results in a lower frequency of postendoscopic infection than does HLD. Ethylene oxide and hydrogen peroxide plasma sterilization have rapid and reliable efficacy compared to HLD (15). However, both sterilizers destroy chemical, biological, and mechanical properties of instruments, including flexible endoscopes. Gas sterilization with ethylene oxide may fail in the presence of organic debris after inadequate cleaning (16, 17) and when biofilm has settled in internal endoscope channels (2, 18).
Natural bioburden levels detected on flexible GI endoscopes range from 105 CFU/ml to 1010 CFU/ml after clinical use (19, 20). Cleaning must precede HLD or sterilization to remove organic debris (e.g., blood, feces, and respiratory secretions) from the external surface, lumens, and channels of flexible endoscopes (4, 21). Inadequate cleaning of flexible endoscopes has been frequently associated with microbial transmission during endoscopic procedures. Appropriate cleaning reduces the number of microorganisms and organic debris by 4 logs, or 99.99% (20).
The manual cleaning procedure for flexible endoscopes includes brushing of the external surface and removable parts (e.g., suction valves) and immersion in a detergent solution followed by irrigation of internal channels with a detergent. The endoscope and accessories should be inspected for damage, and a leak test should be performed before disinfection (4).
Microorganisms possessing resistance to glutaraldehyde include atypical mycobacteria (Mycobacterium chelonae and Mycobacterium avium complex) (39, 40) and Cryptosporidium parvum (41). P. aeruginosa resistance to glutaraldehyde was responsible for three separate clinical episodes of ERCP-associated cholangitis (42). The mechanism of the high biocide resistance of mycobacteria is probably associated with the decreased penetration of a disinfectant through the hydrophobic lipid-rich cell wall (35). Two percent alkaline glutaraldehyde completely inactivated M. tuberculosis in bronchoscopes after 10 min of incubation (43). M. avium, Mycobacterium gordonae, and Mycobacterium intracellulare were more resistant to inactivation by 2% alkaline glutaraldehyde and survived the treatment for more than 10 min (38). Since mycobacteria are more resistant to glutaraldehyde than other bacteria, the manufacturers' instructions for flexible endoscopes and this high-level disinfectant should followed to determine the correct conditions.
Peracetic acid is an oxidizing agent usually used for HLD of flexible endoscopes in AERs. It rapidly deactivates a large variety of pathogenic microorganisms, viruses, and spores at low concentrations (
Among healthy adults, P. aeruginosa can colonize many body sites, as evidenced by isolation from throat, sputum, and stool (92). Hospitalized patients, as well as patients with certain chronic lung diseases, have higher colonization rates. During health care-related outbreaks, Pseudomonas transmission can result in colonization of involved patients in the GI and respiratory tract with an absence of clinical symptoms and negative blood cultures, which was determined by molecular typing (93). Severe health care-associated postendoscopic infections due to P. aeruginosa include sepsis, liver abscess, and ascending cholangitis after flexible GI endoscopy (particularly after ERCP) and bloodstream infection and pneumonia after bronchoscopy. Post-ERCP P. aeruginosa infectious complications occur most frequently in patients with biliary obstruction undergoing endoscopic biliary stenting (94).
A wide variety of other pathogens can be transmitted during endoscopic procedures. Health care-associated transmission of Strongyloides stercoralis (150), Trichosporon spp. (151, 152), and the yeast Rhodotorula rubra (69, 153) have been reported. Cross-contaminations of Blastomyces dermatitidis (154), Legionella pneumophila (155), and Bacillus spp. (156) after flexible bronchoscopy were related to inadequate cleaning and disinfection and a contaminated suction valve of the instrument.
During endoscopy, the environment provides optimal conditions for contamination and subsequent growth of biofilms. Modern flexible endoscopes contain multiple channels and ports which can easily collect organic material. Even if valid endoscope reprocessing protocols are applied, microbial accumulation can lead to development of a biofilm inside narrow endoscope channels over time (89). Biofilm formation on the inner surface of endoscope channels, especially when these become scratched or damaged, can result in failure of the decontamination process. It can create a vicious circle of growth, disinfection, partial killing or inhibition, and regrowth, resulting in outbreaks of endoscopy-related infections in patients who underwent endoscopy with a biofilm-containing endoscope (2, 3).
Biofilms can be removed from artificial surfaces by physical and chemical methods (368). Physical methods such as ultrasound and manual cleaning are generally effective but difficult to control in practice. Chemical methods can be unsuccessful because of the resistance of biofilms to antibiotics, disinfectants, and biocides (363). The cleaning process is most critical for biofilm removal because multiple internal channels of flexible endoscopes cannot be inspected for cleanliness. The cleaning product must show good penetration and solubilization of organic debris and biofilms. In a study reported by Vickery et al. (368), enzymatic cleaners failed to reduce viable bacterial numbers more than 2 logs in E. coli biofilms in polyvinyl chloride tubing. Another study reported the failure of a commonly used enzymatic cleaner to completely remove test soil from endoscope channels (369). Nonenzymatic detergents showed a better inhibition of biofilm formation than enzymatic detergents (368, 370). The most efficient methods for biofilm removal were autoclaving and treatment with a concentrated bleach solution (49). High-temperature treatments (80C to 90C) were not effective for biofilm removal. e24fc04721
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