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The Journal of Hospital Infection May 2024Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved... (Observational Study)
Observational Study
BACKGROUND
Duodenoscope-associated infections (DAIs) are exogenous infections resulting from the use of contaminated duodenoscopes. Though numerous outbreaks of DAI have involved multidrug-resistant micro-organisms (MDROs), outbreaks involving non-MDROs are also likely to occur. Detection challenges arise as these infections often resolve before culture or because causative strains are not retained for comparison with duodenoscope strains.
AIM
To identify and analyse DAIs spanning a seven-year period in a tertiary care medical centre.
METHODS
This was a retrospective observational study. Duodenoscope cultures positive for gastrointestinal flora between March 2015 and September 2022 were paired with duodenoscope usage data to identify patients exposed to contaminated duodenoscopes. Analysis encompassed patients treated after a positive duodenoscope culture and those treated within the interval from a negative to a positive culture. Patient identification numbers were cross-referenced with a clinical culture database to identify patients developing infections with matching micro-organisms within one year of their procedure. A 'pair' was established upon a species-level match between duodenoscope and patient cultures. Pairs were further analysed via antibiogram comparison, and by whole-genome sequencing (WGS) to determine genetic relatedness.
FINDINGS
Sixty-eight pairs were identified; of these, 21 exhibited matching antibiograms which underwent WGS, uncovering two genetically closely related pairs categorized as DAIs. Infection onset occurred up to two months post procedure. Both causative agents were non-MDROs.
CONCLUSION
This study provides crucial insights into DAIs caused by non-MDROs and it highlights the challenge of DAI recognition in daily practice. Importantly, the delayed manifestation of the described DAIs suggests a current underestimation of DAI risk.
Topics: Humans; Retrospective Studies; Duodenoscopes; Tertiary Care Centers; Microbial Sensitivity Tests; Male; Female; Bacteria; Equipment Contamination
PubMed: 38447805
DOI: 10.1016/j.jhin.2024.02.015 -
Gastrointestinal Endoscopy Dec 2021
Topics: Cross Infection; Duodenoscopes; Equipment Contamination; Humans
PubMed: 34607702
DOI: 10.1016/j.gie.2021.08.010 -
Annals of Internal Medicine Dec 2015
Topics: Cholangiopancreatography, Endoscopic Retrograde; Duodenoscopes; Equipment Contamination; Humans; Infection Control; Infections; Risk Factors; Sterilization
PubMed: 26390309
DOI: 10.7326/M15-1719 -
Antimicrobial Resistance and Infection... Aug 2021Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to...
BACKGROUND
Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias.
CASE PRESENTATION
We describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients' blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences.
CONCLUSION
This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored.
Topics: Amplified Fragment Length Polymorphism Analysis; Cross Infection; Duodenoscopes; Enterobacter cloacae; Enterobacteriaceae Infections; Equipment Contamination; Humans; Multilocus Sequence Typing
PubMed: 34454611
DOI: 10.1186/s13756-021-00996-7 -
Gastrointestinal Endoscopy 1992
Topics: Adult; Aged; Catheterization; Cholangiopancreatography, Endoscopic Retrograde; Duodenoscopes; Female; Humans; Male; Middle Aged; Pancreatic Ducts; Pancreatitis; Sphincterotomy, Endoscopic
PubMed: 1397917
DOI: 10.1016/s0016-5107(92)70524-0 -
Digestive Endoscopy : Official Journal... Jan 2022
Topics: Duodenoscopes; Humans; Stents; Surgical Instruments
PubMed: 34800927
DOI: 10.1111/den.14183 -
Zeitschrift Fur Gastroenterologie Feb 2016
Topics: Cross Infection; Drug Resistance, Multiple, Bacterial; Duodenoscopes; Equipment Contamination; Equipment Failure Analysis; Humans; Sterilization
PubMed: 27280257
DOI: 10.1055/s-0041-110815 -
Journal of Personalized Medicine May 2021Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone a Billroth II gastrectomy is a major challenge. This study aimed to evaluate the...
Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone a Billroth II gastrectomy is a major challenge. This study aimed to evaluate the outcomes of the road-map technique for duodenal intubation using a side-viewing duodenoscope for ERCP in Billroth II gastrectomy patients with naïve papilla, and to analyze the formation and release patterns of common bowel loops that occur when the duodenoscope navigates the afferent limb. The duodenoscopy approach success rate was 85.8% (97/113). In successful duodenoscopy approach patients, there were five bowel looping patterns that occurred when the preceding catheter-connected duodenoscope was advanced into the duodenum: (1) reverse ɣ-loop (29.9%), (2) fixed reverse ɣ-loop (5.2%), (3) simple U-loop (22.7%), (4) N-loop (28.9%), and (5) reverse alpha loop (13.4%). The duodenoscopy cannulation and duodenoscopy therapeutic success rates were 81.4% (92/113) and 80.5% (91/113), respectively, while the overall cannulation and therapeutic success rates were 92.0% (104/113) and 87.6% (99/113), respectively. Bowel perforation occurred in three patients (2.7%). The road-map technique may benefit duodenoscope-based ERCP in Billroth II gastrectomy patients by minimizing the tangential axis alignment between the duodenoscopic tip and driving of the afferent limb, and by predicting and counteracting bowel loops that occur when the duodenoscope navigates the afferent limb.
PubMed: 34066235
DOI: 10.3390/jpm11050404 -
BMJ (Clinical Research Ed.) Aug 2015
Topics: Disease Outbreaks; Disinfection; Drug Resistance, Multiple, Bacterial; Duodenoscopes; Enterobacteriaceae Infections; Equipment Safety; Humans; Pseudomonas Infections; United States; United States Food and Drug Administration
PubMed: 26293320
DOI: 10.1136/bmj.h4544 -
The Lancet. Gastroenterology &... Jul 2018
Topics: Duodenoscopes; Endoscopy; Humans
PubMed: 29893228
DOI: 10.1016/S2468-1253(18)30168-7