As hospitals seek to implement coordinated strategies to help mitigate the spread of antimicrobial-resistant bacteria, flexible endoscopes present a unique challenge.

The same long, flexible channels that allow for greater ease of access and navigation around the hollow cavities of the body make flexible endoscopes notoriously difficult to clean. Reprocessing can take up to two hours and includes more than 100 steps, from bedside pre-cleaning to drying and storage.

Still, all of this is necessary to prevent microbial growth on parts of the instrument and ultimately infection transmission to patients. Bronchoscopy patients are at an increased risk of infection if the patient has a hemorrhage, ulcers, or lesions.

In a world where antimicrobial resistance (AMR) is becoming a greater threat, there is reason to believe that antibiotic-resistant bacteria will become more prevalent among hospital-acquired infections. And these types of bacteria have already shown an ability to be transmitted via contaminated endoscopes.

The Challenges of Reprocessing

In a recent experiment, viable but nonculturable P. aeruginosa accumulated over eight days of cyclic biofilm formation on an endoscope channel. And the resistant bacteria was recovered during a dry storage period, proving the bacteria’s ability to thrive in endoscopic channels.

Complicating matters is the reality that even if all proper cleaning protocols are followed, there is still a risk of cross-contamination on flexible endoscopes. A 2018 study conducted by Cori Ofstead found that reprocessing was not always enough to remove all contaminants from flexible bronchoscopes.

Ofstead is an epidemiologist and the president and CEO of Ofstead and Associates in St. Paul, Minnesota. She specializes in validating healthcare guidelines, treatments, and product claims. Ofstead’s 2018 report points to a need for staff guidance and accountability. Reprocessing technicians need to be properly trained and more surveillance is needed to ensure adequate reprocessing.

Ofstead also concluded facilities should stop using lubricants that cannot be removed and ensure proper water quality for cleaning procedures. She encouraged adequate bedside cleaning, immediate reprocessing, and putting a reprocessing protocol in place for the evening and weekends.

Single-Use Offers Unique Solution

The only way to eliminate any risk of cross-contamination is by using a single-use endoscope, according to Ofstead. Further studies have indicated that single-use bronchoscopes are also more cost-effective as they do not require the regular repair and maintenance that reusable scopes do.

The U.S. Food and Drug Administration has recommended switching from high-level disinfection to low-temperature sterilization to help further prevent the transmission of multidrug-resistant bacteria via flexible endoscope. Research has shown that high-level disinfection does not fully mitigate the risk of transmission of CRE via flexible endoscopes, and sterilization can be more effective in preventing patient outbreaks.

Recently, the FDA also recommended a switch to disposable duodenoscopes – a type of flexible gastrointestinal endoscope – when available. This recommendation came in response to multiple duodenoscope-associated patient infections from antimicrobial-resistant bacteria.

Leading the Charge Against AMR

The U.S. Centers for Disease Control and Prevention does not include flexible endoscope disinfection in its recommendations for addressing AMR. Antimicrobial stewardship typically focuses antibiotic prescription practices – it is estimated 47 million antibiotics are unnecessarily prescribed annually from the outpatient setting.

Throughout this series, we’ve raised the question of whether antimicrobial stewardship should include mitigating the spread of infection via medical devices. After all, it’s more difficult and expensive to cure infections caused by antimicrobial-resistant organisms than every before. AMR has made once powerful antibiotics ineffective in treating infections caused by resistant bacteria, fungi, or parasites.

We will close out our series on AMR discussing the role hospital leadership plays in antimicrobial stewardship programs. We’ll also examine how important leadership is in bringing medical device decontamination into the antimicrobial stewardship discussion.

To read more in the series, you can visit previous 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.