May 11, 2013 — Gastrointestinal (GI) endoscopes and other types of flexible endoscopes may become contaminated with infectious materials during their routine clinical use.
The rigorous, prompt and thorough reprocessing of these complex reusable instruments after each clinical exam is therefore required to prevent the healthcare-associated infections, or HAIs. “Reprocessing” is defined as the cleaning, high-level disinfection, water rinsing, and drying of many types of reusable medical instrumentation.
Click here (PDF format) or click here (in “html” format) to read Dr. Muscarella’s peer-reviewed article:
- “Risk of transmission of carbapenem-resistant Enterobacteriaceae and related ‘superbugs’ during gastrointestinal endoscopy.”
A primary reason why flexible endoscopes are reported to be associated with HAIs more frequently than any other reusable medical device is due to their complex physical designs, including their internal channels.
While essential both for the success of the endoscopic procedure and patient comfort, the designs of flexible endoscopes may not always necessarily facilitate their thorough cleaning and high-level disinfection.
Click here to read Dr. Muscarella’s important accompanying article that discusses the identification of “superbugs” in the GI endoscopic setting: “Overlooked Outbreaks of the Superbug ‘CRE’ Following Gastrointestinal Endoscopy?“
Endoscopic retrograde cholangiopancreatography (ERCP)
The side-viewing duodenoscope, or “ERCP endoscope” — which is used in the upper GI tract during endoscopic retrograde cholangiopancreatography, or “ERCP,” to diagnose and treat biliary and pancreatic diseases —- is arguably the most conspicuous example of a reusable medical instrument that displays the tension between designing the instrument both to accommodate its reprocessing requirements but, on the other hand, also to ensure its optimal function during the clinical exam.
The exposed elevator-wire channel
To prevent its contamination and an increased risk of disease transmission during ERCP, each one of the side-viewing duodenoscope’s physically complex internal surfaces, valves, and channels — including its elevator forceps mechanism and, if it is open and exposed, its long and narrow elevator-wire channel — requires special attention and thorough reprocessing.
This elevator wire channel houses a wire that is used by the physician to control and manipulate a forceps mechanism at the endoscope distal tip during, for example, cannulation of the common bile duct.
Click here to read Dr. Muscarella’s recent article “GI Endoscopy: Pushed Beyond its Reprocessing Limits?”
In addition to the exposed ERCP endoscope’s long and narrow elevator-wire channel, it is imperative that the surfaces of this specialty endoscope’s distal tip, namely, around and behind the elevator forceps mechanism, are promptly cleaned and high-level disinfected as instructed by the instrument’s manufacturer.
Transmission of an antibiotic-resistant “superbug” at a hospital outside of Chicago, IL, in 2013, with associated morbidity and possibly mortality, due to the ERCP endoscope’s distal tip reportedly having not been properly reprocessed, is discussed by the Centers for Disease Control and Prevention (CDC) it its recent MMWR publication — click here.
Reports of the risk of infection following ERCP, bronchoscopy
In years past, Pseudomonas aeruginosa was the gram-negative bacterium commonly responsible for infections, with associated morbidity and mortality, linked to ERCP.
Today, however, multidrug-resistant Klebsiella pneumoniae (and other types of carbapenem-resistant Enterobacteriaceae, or “CRE,” are more often responsible for these types of GI endoscopic infections. CRE infections linked to contaminated bronchoscopes have also been reported.
Click here to read Dr. Muscarella’s related article: “Early Identification and Control of Carbapenemase-Producing Klebsiella pneumoniae Originating from a Contaminated GI Endoscope.“
A seemingly hitherto overlooked, yet troubling trend, more than a dozen reports of infections and outbreaks of CRE (or another type of multidrug-resistant Enterbacteriaceae) following ERCP (and bronchoscopy) have been reported in the U.S. and Europe within just the past few years — several in 2013 and 2014.
These documented reports (which may significantly under-estimate the true incidence of these types of infections) include the following reports, several of which were filed by manufacturers with the FDA’s MAUDE — or, “Manufacturer and User Facility Device Experience” — database.
These reports of CRE infections are primarily linked to contaminated ERCP endoscopes, although reports of bronchoscopes and “EUS” (ultrasound) endoscopes transmitting CRE have also been recently documented.
And, GI endoscopes marketed by all three of the leading manufacturers were linked to outbreaks of CRE in the U.S. during the past two years:
Quality and Safety Services for Hospitals, Manufacturers, Patients: Click here to read about Dr. Muscarella’s quality and safety services committed to reducing the risk of healthcare-associated infections, including CRE outbreaks linked to contaminated endoscopes and other reusable medical equipment.
— 1. FDA Report (FDA notified: 08/22/2014; adverse event date: 01/01/2013):
This report documents a large superbug outbreak, with 37 patients being likely infected (or colonized) with CRE following their ERCP procedures being performed with several different duodenoscopes. Four deaths were linked to this CRE outbreak. This report states that the endoscope’s manufacturer was additionally notified of 30 patient infections due to a “variant E. coli” strain cultured from the patients’ blood, bile, urine, or the respiratory tract — click here. These infections of a variant E. coli strain (which are not necessarily CRE) appear to be in addition to the 37 infections or colonizations of CRE.
- Note: The review performed during the writing of this article could not identify this CRE outbreak in a local or national news report, despite this MAUDE report suggesting that more than three dozen patients were infected or colonized with CRE, with four of these patients expiring.
Sidebar: A CRE outbreak publicized in an abstract, presented at an infection control conference in Philadelphia (PA) in October, 2014, discusses a CRE outbreak linked to the automated reprocessing of GI endoscopes used to perform both ERCP and endoscopic ultrasound (i.e., “EUS”).
The review performed during the writing of this article could not identify this CRE outbreak in the FDA’s MAUDE database, despite the aforementioned abstract documenting this outbreak’s association with the use of two different models of AERs and one manufacturer’s duodenoscope.
— 2. FDA Report (FDA notified: 06/20/2014; Adverse event date: 01/01/2014):
According to this report, three patient who had undergone ERCP at a hospital tested “positive” for CRE, and two of these three patients displaying symptoms of CRE infection.
— 3. FDA Report (FDA notified: 05/22/2014; Adverse event date: 01/27/2014):
The endoscope manufacturer reports that it was informed that 12 patients were either infected or colonized following ERCP (endoscopic retrograde cholangiopancreatography) with a strain of Escherichia coli (or, E. coli) that produces an extended-spectrum beta lactamase (“ESBL”) enzyme — click here. (This antibiotic-resistant strain is not CRE, but rather a related superbug that, unlike CRE, is susceptible to carbapenems.)
— 4. FDA Report (FDA notified: 03/07/2014; Adverse event date: 02/14/2014:
Nine patients were infected or colonized with CRE at one hospital after having undergone ERCP — click here. (Report No. 2518897-2014-00001)
— 5. FDA Report (FDA notified: 01/28/2014; Adverse event date: 06/14/2013:
Five patients tested “positive” (i.e., infection or colonization) for CRE that produced a New Delhi metallo-β-lactamase (which is an enzyme) after having undergone ERCP with the same duodenovideoscope — click here. (Report No. 2951238-2014-00027)
— 6. FDA Report (FDA notified: 01/17/2014; Adverse event date: 11/13/2013):
Several patients tested “positive” (i.e., colonization) for CRE after having undergone ERCP with the same video-duodenoscope — click here. (Report No. MW5033987)
–7. A hospital in Germany:
Zweigner et al. (2014) report hat 8 patients were infected or colonized with CRE linked to contaminated bronchoscopes.
— 8. A hospital outside of Chicago, USA:
This incident documents an outbreak of CRE following ERCP — click here to read a newspaper report discussing this outbreak at Advocate Lutheran General Hospital — which, to date, is the largest superbug outbreak in U.S. history.
- Note: A review of an FDA’s database shows that the following two medical devices were involved in Advocate Lutheran General Hospital’s CRE outbreak: (i) at least one manufacturer’s duodenoscope (click here); and (ii) at least one manufacturer’s automated endoscope reprocessor, or AER (click here). (Refer to MAUDE Report No. 2518897-2013-00005; FDA notified: 10/28/2013; Adverse event date: 09/17/2013.)
- UPDATE (12-4-2014): Recently published data indicate that at least two of this hospital’s patients that were infected with this outbreak strain of CRE died — click here to read Dr. Muscarella’s “Alert: Association of GI Endoscopy with Two Patient Deaths in Illinois, 2013.“
— 9. Two hospitals in Germany (2013) — click here.
Two outbreaks of the superbug carbapenemase-producing Klebsiella pneumoniae (CPKP) were recently observed in two German hospitals.
- Note: In agreement with Dr. Muscarella’s findings, this article concludes that: “There were only two reports of nosocomial outbreaks due to Klebsiella spp. in the first three decades of endoscopic procedures, but seven additional outbreaks of this kind have been reported within the last 4 years. It is very likely that many of such outbreaks have been missed in the past because this pathogen belongs to the physiological gut flora. However, with the emergence of highly resistant (carbapenemase-producing) strains, strict adherence to infection control guidelines is more important than ever.”
— 10. FDA Report (FDA notified: 04/25/2013; Adverse event date: 3/27/2013):
Several patients treated with an ERCP endoscope were infected with Klebsiella spp. — click here. (Report No. 8010047-2013-00092) (This report does not necessarily describe an outbreak of CRE or a related superbug.)
— 11. FDA Report (FDA notified: 03/04/2013; Adverse event date: 02/27/2013):
Patients over a 2 year period who underwent ERCP were infected with the superbug “KPC” (or, K. pneumoniae carbapenemase-producing bacteria). During an investigation of the cause of these infections, an ERCP endoscope tested “positive” for KPC following disinfection — click here. (Report No. MW5029305)
— 12. United Kingdom (2013):
A patient’s death due to infection with antibiotic-resistant strain of E. coli following ERCP — click here.
— 13. Two unpublished confidential communications (USA-2010 and USA-2013):
Two other outbreaks of Kl. pneumonia infections following ERCP performed at two different, unrelated hospitals, one in the southern U.S. and the other in New England (USA). (The details of these two outbreaks have not been made public.)
— 14. France – 2010: “Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography” — click here to read this report by Aumeran et al., 2010.
Click here to read Dr. Muscarella’s accompanying editorial review of this report by Aumeran et al. 2010 by clicking here.
Attention Healthcare Facilities: Could your GI endoscopy unit be harboring “superbugs”? Click here to read about an safety/auditing program specifically designed by Dr. Muscarella – this article’s author – to prevent infection-control breaches and disease transmission during ERCP and other GI endoscopic procedures.
— 15. France – 2009: “Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009” — click here (Carbonne et al., 2010):
“In total, 13 KPC-producing K. pneumoniae type 2 cases (four with infections and nine with digestive-tract colonisations) were identified, including a source case transferred from a Greek hospital. Of the 13 cases, seven were secondary cases associated with use of a contaminated duodenoscope used to examine the source case (attack rate: 41%) and five were secondary cases associated with patient-to-patient transmission in hospital.”
— 16. Florida (USA) – 2008-2009: “Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment” — click here to read the abstract of this report by Alrabaa et al. (2013), who linked an outbreak of K. pneumoniae to ERCP and, more specifically, to the inadequate cleaning of the “complex terminal part of the ERCP scope that contains the scope elevator.”
What are these several bacterial outbreaks following ERCP telling us? That something is amiss and that improved, prompt infection controls and effective corrective actions are needed.
An o-ring design
The causes of these several reports of bacterial infections are often not reported, but appear to be due to a faulty design that prevents adequate cleaning and disinfection of the side-viewing duodenoscope, in general, and of its “complex terminal part” that contains this endoscope’s elevator wire channel (see: Alrabaa et al., 2010), in particular.
In older duodenoscope models, the elevator wire channel is ‘exposed,’ requiring that staff reprocess it to prevent disease transmission. In newer models, however, this channel may have been ‘sealed’ during its manufacturing using an o-ring* (so that staff would not have to reprocess this channel any longer). It remains to be determined, however, whether biofilms of infectious bacteria can become embedded and retained either inside this otherwise ‘sealed’ channel while still passing the “leak test” or in an inaccessible area around the duodenoscope’s plastic distal hood (or casing, which may be removed by the manufacturer during service of the endoscope and then re-sealed). If so, then this channel (or plastic hood) could unknowingly become a reservoir of bacteria that could infect patients during ERCP. The possibility that this elevator wire channel (or plastic hood) could have become a source of a confirmed bacterial outbreak may be determined by exposing and microbiologically sampling all of the internal surfaces with a swab. — Lawrence F Muscarella, PhD
Update (May 12, 2015): The “o-ring” to which Dr. Muscarella refers in this quote is a rubber ring, or disk, that encircles the axis of the wire that controls the endoscope’s forceps elevator mechanism (Verfaillie et al., 2015; refer to this paper’s Figure 4).
For the older models of ERCP endoscopes, the channel that houses this wire is exposed requiring reprocessing.
For the newer models of ERCP endoscopes, however, this o-ring is designed to “seal” this portion of the endoscope and to act as a barrier between the inside of the elevator wire channel, which is inaccessible and cannot be reprocessed, and the outside of the endoscope, which, in contrast, can be cleaned and disinfected.
After dismantling ERCP endoscopes (model: Olympus TJF-Q180V) suspected of being the cause of an outbreak of carbapenem-resistant P. aeruginosa in the Netherlands in 2012, Verfaillie et al. (2015) report that this o-ring may have become worn and fail, with both sides, including the side of the o-ring that is inaccessible during reprocessing, becoming contaminated with a “brown layer.”
According to Verfaillie et al.’s (2015) report, the o-ring can become worn and torn and therefore, from the perspective of disease transmission, “is an important area of concern.”
These authors add that:
- “adequate sealing of the elevator wire channel (as is necessarily required to prevent its contamination and possible cross-infection of subsequent patients undergoing ERCP) cannot be guaranteed;”
- “it is likely that (potentially infectious) debris had been transported in both directions (contaminating the otherwise “sealed” and inaccessible elevator wire channel and, too, patients) during movement of the forceps elevator”;
- as part of its routinely scheduled preventive maintenance procedure, the endoscope’s manufacturer (Olympus) provides “no recommendations on the periodic replacement” of this o-ring ostensibly prone to wear and tear; and
- “the validation data regarding the effectiveness of … the construction of the o-ring and judgment of the integrity of the construction this sealing ring could not be provided by (Olympus, the endoscope’s manufacturer).”
Indeed, failure of this o-ring can allow bacteria to enter and colonize in the ERCP endoscope’s otherwise “sealed” elevator wire channel, which may pose an infection risk during subsequently performed ERCP because reprocessing this channel, according to the manufacturer (Olympus), would be superfluous and therefore is precluded by the endoscope’s design.
Moreover, wear to this o-ring and the un-sealing of the elevator wire channel is not likely to be detected during a leak test.
Whether another contributor to the recent spate of outbreaks of CRE or a related superbug may be a shortcoming in the design or labeling of the model of the automated endoscope reprocessor (AER) used to disinfect the ERCP endoscope is currently unclear.
For every deviation or error that is identified in a healthcare setting, it is necessary to investigate and determine each contributing factor and/or root cause.
In addition, as part of a quality system, it is imperative that the healthcare facility develop and implement effective corrective and preventive actions, or “CAPAs,” based on the error’s identified root causes, to prevent the recurrence of the associated adverse event, which, in these instances, are bacterial outbreaks likely due to contaminated GI endoscopes.
The following recommendations (which are not all inclusive) are therefore provided to prevent HAIs following ERCP.
This hospital’s outbreak of CRE in 2013 (along with several others reported herein, including a few in 2014) links contaminated GI endoscopes used during ERCP not only to patient infection or colonization, but to patient mortality. I recommend that healthcare staffers consider contacting their GI endoscope’s manufacturer for specific instructions for thorough reprocessing of those endoscopes in inventory with a forceps elevator, such that are used during ERCP. — Lawrence F Muscarella, PhD
A review of the healthcare facility’s policies and procedures for inclusion of these recommendations is suggested:
1. Develop and implement a written procedure that includes step-by-step instructions for properly reprocessing, after each of its uses, every model of GI endoscope in inventory.
- Ensure all reprocessing steps are performed in strict accordance with the endoscope manufacturer’s reprocessing instructions (as provided in its operator’s manual) and as required by published endoscope reprocessing guidelines.
- Different endoscope models can feature unique channels—such as the ERCP endoscope’s (i.e., the duodenoscope’s) elevator-wire channel, or the colonoscope’s water jet channel—and these channels will most likely require specialized or additional reprocessing steps. It is therefore important to review the reprocessing instructions, diagrams and schematics of every endoscope model in inventory to ensure each channel is being properly reprocessed, even if the channel was not used during the clinical procedure.
- Note #1: Even if sealed, it is unclear whether the duodenoscope’s elevator wire channel may still become contaminated with, and retain, bacteria (e.g., CRE) and infectious biofilms. The dismantling and sampling of this endoscope’s internal channel may be required, as part of an outbreak’s investigation, to determine the cause of the infections.
- Note #2: In addition to the duodenoscope’s long and narrow elevator-wire channel (if it is exposed and designed to be reprocessed), it is imperative that healthcare staff manually clean and high-level disinfect, in accordance with the endoscope manufacturer’s written instructions, the area around and behind the elevator-wire forceps, which is at the duodenoscope’s distal tip.
2. Reprocess the GI endoscope immediately after the clinical exam, not several minutes later.
- Reprocess duodenoscopes again before their reuse if they have been stored and unused for more than two days. (Refer to Dr. Muscarella’s related article: “The Safe Storage of Gastrointestinal (GI) Endoscopes” – click here.
3. Receive written verification from the manufacturers of the GI endoscope (e.g., the duodenoscope used during ERCP) and of the automated endoscope reprocessor (AER) that:
- the endoscope’s manufacturer assures that, if the healthcare facility’s reprocessing staff member reprocesses the GI endoscope manually in accordance with the endoscope’s operating instructions, there is virtually no risk of disease transmission; and that
- the AER’s manufacturer assures that, if the healthcare facility’s reprocessing staff member reprocesses a specific brand, type, and model of GI endoscope in accordance with the AER’s operating instructions, there is virtually no risk of disease transmission.
- Note: Consider not using the GI endoscope or the AER model if the respective manufacturer does not comply with this instruction.
4. Ensure endoscope reprocessing staff are well-trained and knowledgeable in endoscope design, the principles of infection control, and standard precautions.
- Periodically conduct competency tests to evaluate the staff’s knowledge of the specific reprocessing instructions and channel adapters required for every endoscope model in inventory. Additional reprocessing training and testing may be required whenever a new endoscope model is introduced into use.
5. Develop and implement a quality assurance (QA) program that monitors all of the steps of endoscope reprocessing and ensures staff are provided with and properly using all of the required reprocessing equipment (e.g., channel adapters, luer fittings, detergents, liquid chemical sterilants, cleaning brushes).
- Periodically (at least once a year) perform internal or external audits to confirm that proper procedures are not just written in the medical facility’s infection-control and endoscope-reprocessing policies, but are actually being performed in clinical practice (e.g., that there are no gaps between the medical facility’s written policies and its actual reprocessing of duodenoscopes).
- It is further recommended that this QA program include not only a surveillance procedure designed to detect and report infections (and pseudo-infections) that could be a result of inadequate endoscope reprocessing, but also an instrument tracking system that permits quick identification of patients on whom a potentially contaminated endoscope was used.
6. If a bacterial outbreak linked to a contaminated duodenoscope is confirmed — several examples of which are provided, above — consider dismantling (i.e., destroying) the GI endoscope and microbiologically sampling its internal surfaces, including the duodenoscope’s elevator wire channel and distal hood (or case), which may otherwise be sealed or glued (or otherwise affixed) in place.
- Note #1: This step is important to identifying not only the source and the cause of a bacterial outbreak following GI endoscopy, but also the mode of the bacterium’s transmission (e.g., via a contaminated ERCP endoscope).
- Note #2: Transmission of waterborne bacteria, whether a strain resistant or susceptible to antibiotics, may suggest, among other shortcomings, inadequate drying of the endoscope.
7. If the duodenoscope is dismantled as part of an outbreak investigation, and its “sealed’ distal hood (or case) is removed, cultured and found to harbor bacteria (e.g., CRE), possibly being a reservoir of an outbreak, then manufacturers of duodensocopes may consider designing this sealed hood instead as a disposable component that is removed by the healthcare facility during the duodenoscope’s reprocessing, to ensure that this area of the endoscope, where the forceps is featured, comes into direct contact with the disinfectant.
8. Dr. Muscarella recommends that (at least until the cause of the recently publicized outbreaks of CRE are definitely published) the ERCP’s elevator wire channel, if exposed, be manually reprocessed – not reprocessed using an AER, at least not until the manufacturer of the AER provides written verification to the medical facility that its AER model has been both validated and cleared by the FDA for reprocessing all of the specific model numbers and types of the duodenoscopes (e.g., FujiFilm, Olympus, and Pentax) in the medical facility’s inventory. (Refer to Recommendation #2, above.)
9. Ensure the reprocessing procedure includes terminal drying of the endoscope’s channels using 70% alcohol followed by forced air.
- Endoscope drying is necessary, particularly for side-viewing duodenoscopes (and bronchoscopes), whether the water used to rinse the endoscope is tap water, bacteria-free water, bottled sterile water, or “sterile” filtered water.
10. Consider using GI endoscopes manufactured by a single manufacturer, to avoid confusion, enhance familiarization with the endoscopes’ reprocessing requirements, and minimize the risk of using improper channel adapters or “irrigators,” connection kits, connectors, fittings, and caps during reprocessing. In general, endoscope manufacturers provide their own unique set of reprocessing instructions.
11. When using an automated endoscope reprocessor (AER), ensure its regulatory soundness and that reprocessing staff understand the AER’s operating instructions and proper use.
- Resolve any conflicts or discrepancies between the reprocessing instructions provided by the AER and endoscope manufacturers.
- Consider periodically (at least once a year) conducting internal or external audits to ensure that the staff’s knowledge of the proper operation of the AER and of the specific reprocessing instructions and channel adapters required to connect the AER properly to every endoscope model in inventory. Also, consider using AERs from a single company to minimize the risk of user error.
12. Leak-test the flexible endoscope in accordance with its manufacturer’s instructions.
13. Repair the flexible endoscope as required.
- Have the endoscope periodically serviced as recommended by its manufacturer. Failure to properly service and maintain an endoscope can result in disease transmission.
- Consider using only pristine, well-serviced ERCP endoscopes, not ones whose repair or service history is unknown or suspect.
14. To prevent transmission of CRE, it is necessary that staff members rigorously practice not only Standard Precautions, but also Contact Precautions as warranted.
- CRE is transmitted through direct and indirect contact.
15. Ensure aseptic technique is always practiced during the handling and administration of intravenous (IV) medications. Consider using single-dose IV medication vials. And, use a new sterile syringe and needle (and IV tubing line) for each patient.
16. Consider using single-use disposable biopsy forceps and other endoscopic accessories. Clean and steam sterilize all critical reusable instruments not damaged by heat. Maintain the sterility of these critical instruments prior to use. Steam sterilization is recommended because it is reported to be more reliable and effective than low-temperature sterilization processes.
Click here to read Dr. Muscarella’s article “Infection Risk at a Hospital in New Brunswick: Prevention of Disease Transmission during Colposcopy” about a health care facility’s improper sterilization of reusable biopsy forceps.
17. Appoint a staff member to remain in close contact with the manufacturer(s) of the endoscopes in inventory (and with the manufacturer of the AER, if used) to learn quickly of device recalls (or federal censures) and to resolve any confusing or conflicting endoscope reprocessing instructions.
18. Additional recommendations are provided in Dr. Muscarella’s articles:
- “Early Identification and Control of Carbapenemase-Producing Klebsiella pneumoniae Originating from a Contaminated GI Endoscope” — click here; and
- “Risk of transmission of carbapenem-resistant Enterobacteriaceae
and related ‘superbugs’ during gastrointestinal endoscopy” — click here., which is Dr. Muscarella’s peer-reviewed article that was published in October, 2014, in the World Journal of Gastrointestinal Endoscopy.
Aumeran C, et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010;42:895–99.
Carbonne A, et al. Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009. Euro Surveill. 2010 Dec 2;15(48).
Verfaillie CJ, et al. Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa. Endoscopy 2015;47:1-10.
Zweigner et al. A carbapenem-resistant Klebsiella pnemoniae outbreak following bronchoscopy. Am J Infect Control 2014;42:936-937.
It is also suggested that this blog’s abstract be read in conjunction with the following other blogs by Dr. Muscarella:
- “An Event-Related Paradigm Applied to the Storage of Flexible Endoscopes” – <Click here>;
- “Infections of Pseudomonas aeruginosa linked to Flexible Endoscopes” – <Click here>;
- “Risk of Disease Transmission following Cystoscopy: Discussion of a Specific Error in Maine (USA)” – <Click here>; and
- “Risk of Disease Transmission Associated with Gastrointestinal Endoscopy” – <Click here>.
Article by: Lawrence F Muscarella, PhD, president and owner of the think-tank quality and safety company “LFM Healthcare Solutions” — click here for a list of its services. Article posted on 5/11/2013; article updated 5/12/2015, Rev A.
One thought on “Investigation and Prevention of ‘Superbug’ Outbreaks Following Endoscopy”
ERCP may be useful in diagnosing and treating problems causing jaundice or pain in the abdomen. Problems that affect the pancreas and bile duct system can, in many cases, be diagnosed and corrected with ERCP.