Over-prescribing antibiotics – about 47 million unnecessary prescriptions annually – has contributed greatly to the growth of antimicrobial resistance (AMR).

To help curb the spread of AMR, the U.S. Centers for Disease Control and Prevention recommends hospitals and clinics adopt antimicrobial stewardship programs. These programs are meant to help reduce the overuse of antibiotics in clinical settings.

In addition to prescribing antibiotics for infection, antibiotics are often administered to patients prior to surgical procedures to prevent subsequent infection. But, for endoscopic procedures, the protocols are less clear.

That’s because there is no current precedent for prophylactic antibiotic treatment prior to a bronchoscopy to help prevent infection. This is a common practice for many hospital procedures where there may be an infection risk, according to Dr. Atul Mehta, a pulmonologist at the Cleveland Clinic.

Mehta said physicians “have to weigh the risks and benefits” of using prophylactic antibiotic treatment prior to a bronchoscopy. Physicians should not use antibiotics unnecessarily, but they also need to mitigate infection risk.

It is important for physicians to consistently collect blood cultures for hundreds of patients to see if any have tested positive for certain illnesses or bacteria. This should help determine if a prophylactic antibiotic is necessary for future patients based on the track record of the flexible bronchoscopes on hand, he said.

Because of a general lack of monitoring and testing, “nobody knows how frequently they are spreading infection,” Mehta said. “Nobody is doing blood cultures consecutively to see if they are helping to spread infection.”

Nurses Vital to Stewardship in ICU

Physician awareness of antimicrobial stewardship as it relates to bronchoscopy is just one piece of the puzzle.

In the intensive care unit, antimicrobial-resistant bacteria can grow, foster, and ultimately infect a patient in several ways, including via a contaminated flexible endoscope. Curbing the spread of AMR in the ICU needs to move beyond simply reducing the use of antibiotics to treat those patients.

Bedside nurses need to play a greater role in antimicrobial stewardship, according to the American Journal of Nursing special feature, “Good Nursing is Good Antibiotic Stewardship.”

As the article noted:

Rather than viewing antimicrobial stewardship as yet another job to be saddled on the backs of nurses already burdened with other interdisciplinary efforts, nurses should view antimicrobial stewardship as a way to better understand the proper use of antibiotics. Nurses are already recognized as the primary bedside advocates and monitors of patient safety and progress. The nursing role also positions nurses to be at the center of – and facilitators of – communications among all the participants in antimicrobial stewardship programs.

What’s not explored in the feature, however, is how bedside nurses may be instrumental in preventing the spread of AMR with the proper handling of medical devices such as flexible endoscopes.

Biofilm – which has been known to harbor antimicrobial-resistant bacteria on endoscopes after cleaning and disinfection – can form on the inside of a channel of an endoscope in 24 hours. Once there, biofilm is almost impossible to remove.

If bronchoscopes are not washed immediately after use, there is an increased risk of biofilm forming on the inside of the long, narrow channels of the scope. In fact, many experts agree the most important step in flexible endoscope reprocessing to prevent biofilm formation is the immediate pre-cleaning at the point of use.

Bedside nurses can ensure reprocessing starts immediately after a flexible endoscope is used bedside.

There’s an even more critical need to address antimicrobial stewardship in the ICU, especially for those undergoing a bronchoscopy. The CDC Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 noted that risks of contracting infections from antibiotic-resistant bacteria like Vancomycin-resistant Enterococci (VRE) or Methicillin-resistant Staphylococcus aureus (MRSA) can be very high in the ICU and increases significantly the more time a patient spends in the unit.

Reaching All Corners

The risk of antimicrobial growth inside the flexible channels of endoscopes, and risk of infection transmission, raises the question of whether the proper cleaning of endoscopes needs to be a part of a hospital system’s antimicrobial stewardship strategy.

While rare, cases of cross-contamination do happen. And it’s likely these cases are often underreported. With the global threat of AMR estimated to take millions of lives in the next few decades, is it time for the antimicrobial stewardship discussion to reach all corners of the healthcare space? Effective infection prevention, as well as curbing of antibiotic use, are both needed to prevent the continued rapid spread of global AMR.

This article concludes our series on the role reprocessing endoscopes plays in antimicrobial stewardship. As noted in previous postings, new innovative technology such as single-use bronchoscopes can help curb the spread of antimicrobial-resistant bacteria.

To read more of the series, click on the topics below.

The Impact: Antimicrobial resistance is one of the most significant challenges facing health care providers today.

The Causes: The continued misuse and overuse of antimicrobials only accelerates the spread of antimicrobial resistance.

Stewardship: The CDC, SHEA, and APIC all provide suggested best practices for antimicrobial stewardship, but their recommendations do not go far enough to address the risk from medical devices.

The Role of Infection Prevention: Infection prevention, as it relates to medical devices, typically does not fall under the umbrella of antimicrobial stewardship.

Challenges and Innovations: There are a number of factors that contribute to inadequate endoscope reprocessing and ultimately could increase AMR. New technologies provide ways to eliminate risks of patient cross-contamination.