For almost a decade, inadequate reprocessing and handling of flexible endoscopes has made an annual and closely watched top 10 health technology hazards list compiled by the ECRI Institute. The 2019 mention ranked number five. Back in 2010 and 2016, cross-contamination from and inadequate cleaning of flexible endoscopes topped their respective lists.

As antimicrobial resistance continues to spread at rapid rates around the globe, hospital-acquired infections caused by contaminated medical devices pose a greater risk to patients, as it is more difficult and expensive to cure infections caused by antimicrobial-resistant organisms than ever before.  Because of the spread of resistance, many once powerful antibiotics are no longer as effective in treating infections caused by resistant bacteria, fungi, or parasites.

More infections have been traced back to flexible endoscopes than any other medical device. Infectious agents in reported outbreaks from contaminated flexible endoscopes have included carbapenem-resistant Enterobacteriaceae (CRE) and Pseudomonas aeruginosa, both of which have demonstrated an ability to develop resistance to multiple classes of antibiotics. CRE has a 50 percent mortality rate and several recent outbreaks have been linked back to contaminated duodenoscopes, a type of flexible endoscope. P. aeruginosa, which has the ability to rapidly develop resistance, even during the course of a single treatment,  has been known to be transmitted via bronchoscopes, another type of flexible endoscope.

“Most of the time, those infections go unnoticed, go undiagnosed,” said Dr. Atul Mehta, a pulmonologist at the Cleveland Clinic, of superbug infections caused by bronchoscopes. “Nobody thinks the infection is a result of bronchoscopes.”

In a recently published study in CHEST, Mehta outlines 12 instances in which superbugs were traced back to bronchoscopes since 2013.

“If you look for it, the instances are much more,” Mehta said. “This is just the tip of the iceberg. Extra vigilance is definitely required.”

Traditionally, antimicrobial stewardship focuses primarily on antibiotic prescription practices – it is estimated 47 million antibiotics are unnecessarily prescribed annually from the outpatient setting. Should the battle against the rapid spread of antimicrobial resistant bacteria require an even more comprehensive approach?

In a series of posts, we’ll explore the question of whether effective antimicrobial stewardship should address all levels of infection prevention and control, including the proper handling of endoscopes. In the coming weeks we’ll talk to experts and probe a variety of angles:

  • 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: Should it should play a greater role in antimicrobial stewardship?
  • Challenges and innovations: Reprocessing a flexible endoscope is a long and arduous process, prone to errors. There are, however, some innovations that help curb contamination risk.
  • Leadership: Typically, antimicrobial stewardship is spearheaded by physicians who prescribe antibiotics, but bedside nurses are just as important to the strategy, especially in the OR and ICU.
  • Conclusions: Effective antimicrobial stewardship should address all levels of infection prevention and control, including the proper handling of bronchoscopes.