September 4, 2013 — The following is a discussion of an article by Alrabaa et al. (2013) entitled, “Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment.”

This article’s abstract reads: “Klebsiella producing carbapenemase is an emerging pathogen. We report transmission of this organism by contaminated endoscopic instruments. Quick identification of source, staff education, contact precautions, and emphasis on hand and environmental hygiene led to case control and prevention of outbreak.”

According to Alrabaa et al. (2013), this report confirms for the first time contaminated endoscopic instrument as the source of transmission of the deadly ‘superbug’ carbapenemase-producing Klebsiella pneumoniae, or CRKP.

This article was recently published in APIC’s The American Journal of Infection Control.

Findings by Alraaba et al. (2013)

Alrabaa et al.’s (2013) article discusses the transmission of antibiotic-resistant bacteria during ERCP, or endoscopic retrograde cholangiopancreatography — a specific type of gastrointestinal (GI) procedure often used to diagnose and treat disorders of the pancreatic and biliary ducts.

Alrabaa et al.’s (2013) report states that:

  • “We report early identification and control of CRKP at 2 tertiary hospitals epidemiologically linked to gastrointestinal procedures at an endoscopy center.”
  • “(This outbreak) resulted from inadequate cleaning of the complex terminal part of the ERCP scope that contains the scope elevator. This part of the scope needs additional manual cleaning using a brush prior to standard scope processing.”
  • “An inadequate ERCP cleaning technique was identified at the endoscopy center. The ERCP scope is particularly hard to clean because the tip of the scope consists of a small tube with a complex design including a small mobile metal piece called the elevator.”
  • “Adherence with manufacturers instruction to clean this piece was not adequately followed. Biodebris remained under the elevator piece of the implicated scope after it was presumably cleaned.”

This article is as insightful as its findings proved to be portentous.


Based on the report by Alrabaa et al. (2013), the following recommendations or corrective actions are provided to prevent the spread of CRKP (carbapenemase-producing Klebsiella pneumoniae) and related ‘superbugs’ following ERCP:

1. More active or robust screening of patients at risk for infections with CRKP following ERCP is encouraged, for its early identification and control.

2. Place patients infected with CRKP on Contact Precautions, as required — “Isolation Precautions for the Prevention of the Transmission of Ebola, Enterovirus-D68 and Other Infectious Agents in Healthcare Settings.”

  • For example, isolate or cohort patients colonized or infected with CRKP or another types of similar antibiotic-resistant organism (in accordance with the U.S. Centers for Disease Control and Prevention [CDC] guidelines).

3. Ensure that environmental surfaces in the healthcare setting are being cleaned in accordance with the CDC’s “Guidelines for Environmental Infection Control in Health-Care Facilities.”

4. Ensure that staff are practicing proper hand hygiene measures — read more by clicking here.

5. Proper stewardship and administration of antibiotics are crucial.

6. Review the operator’s manuals of all GI endoscopes in inventory — especially those used during ERCP — to ensure proper cleaning and high-level disinfection of all of the endoscope’s internal channels and exposed surfaces.

  • It is recommended that focus and diligence be placed on the elevator-wire channel and “the complex terminal part of the ERCP endoscope that contains the scope elevator” (Alrabaa et al., 2013).

• This part of the ERCP endoscope requires manual cleaning using a brush — no matter whether an automated device will be subsequently used to reprocess (e.g., clean and/or high-level disinfect) the endoscope (Alrabaa et al., 2013) — in strict accordance with the manufacturers’ reprocessing instructions.

Article by Lawrence F Muscarella, PhD; posted 9/4/2013; updated: 10/5/2015.


Alrabaa SF, Nguyen P, Sanderson R, et al. Early Detection and control of carbapenemase-producing Klebsiella pneumonia, originating from contaminated endoscopic equipment. Am J Infect Control 2013;41:562-4.

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