Recommendations from the U.S. Centers for Disease Control and Prevention for curbing the spread of antimicrobial resistant organisms expand slightly beyond the responsible use of antibiotics. They include proper handwashing regimens and removing temporary medical devices, such as catheters and ventilators, as soon as they are no longer needed.

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

“When we are talking about endoscope reprocessing, that typically is managed by a different set of staff members,” said Lawrence Muscarella, president and founder of LFM Healthcare Solutions LLC.

Muscarella has researched and authored more than 200 articles on the topics of disinfection, sterilization, instrument reprocessing, risk management, and infection control. Do infection prevention practices like cleaning endoscopes tend to belong in the same conversation as antimicrobial stewardship?

“I would say not really,” Muscarella said.

Dr. Mohammad Ashraf, an infectious disease specialist and associate director of antimicrobial stewardship at the University of Nebraska Medical Center, agreed. Medical device decontamination is not usually under the umbrella of antimicrobial stewardship, he said.

“It would be hard to correlate these two. If you don’t follow all the procedures, there’s a chance you can transmit [multidgrug-resistant bacteria],” Ashraf said of reprocessing endoscopes. “Other organisms can also be transferred. … Either way, it’s not desirable.”

A Sense of Complacency?

Flexible endoscopes are long, delicate instruments that allow physicians to view hollow organs or body cavities without performing surgery. Endoscopes can also administer treatments or collect tissue or secretions for diagnostic reasons.

Given the vast number of endoscopic procedures performed annually in the U.S. – an estimated 500,000 bronchoscopies alone – the number of reported infections from cross-contamination of those instruments is quite low. But the actual number of endoscopy-related infections may be underreported due to of poor tracking, limited surveillance, or an absence of clinical symptoms while the patient is still in the endoscopy suite.

As awareness around the potential for infection transmission from contaminated endoscopes grows, so does the number of reported cases of infection or device contamination to the U.S. Food and Drug Administration. There were more than 200 more reports of infection or device contamination associated with reprocessed flexible bronchoscopes reported in 2017 than in 2006.

Contaminated bronchoscopes caused more than 300 patient infections in the U.S. from 2016 to 2017, according to the FDA.

Prior to many of these bronchoscope-related infections coming to light, a 2002 study in the American Journal of Respiratory and Critical Care Medicine noted that most bronchoscopists are familiar with a 1 percent to 3 percent rate of immediate procedure-related complications due to bronchoscopy.

“In contrast, reports of bronchoscopic pathogen transmission have been scattered and largely anecdotal,” according to the study. “Under-recognition and under-reporting of such episodes have contributed to a sense of complacency regarding infection control in the bronchoscopy suite.”

Understanding Infection-Control Risks

Dr. Atul Mehta, a pulmonologist at the Cleveland Clinic, said physicians tend to fall into two groups when it comes to understanding the infection-transmission risks posed by reusable flexible bronchoscopes: those who are oblivious of the problem and those who overlook the problem.

Typically, physicians who fall into the first category are novices and can be easily persuaded of the risks once they are educated on how bacteria can survive and grow on bronchoscopes, he said. The latter group – those aware of the problem but choose not to act on it – are “basically hiding their heads in the ground,” Mehta said.

Bronchoscopes are also increasingly hard to clean and disinfect as they become more intricate and complicated in nature, he added. Unfortunately, there is not enough time to sterilize the equipment in between procedures.

Inadequately reprocessed flexible endoscopes have caused many multidrug-resistant patient infections in the last 10 years. Of note are carbapenem-resistant Enterobacteriaceae (CRE) outbreaks connected to contaminated duodenoscopes. CRE is highly resistant to antibiotics, and has limited treatment options. As a May 2016 review of endoscopy-related CRE cases stated: “Considering high morbidity and mortality associated with CRE bacteria, prevention of these healthcare associated infections should be considered a priority for patient safety and quality of care.”

‘Newly Identified Safety Concern’

In their co-authored 2019 CHEST article, “Bronchoscope-Related ‘Superbug’ Infections,” Mehta and Muscarella found the first reported case of bronchoscopy-related CRE transmission in the U.S. to be in 2014.

“While their transmission of multidrug-resistant bacteria is not a new public health risk, bronchoscopes remaining persistently contaminated and infecting patients, specifically CRE, despite being reprocessed according to the manufacturer’s instructions, is a relatively newly identified safety concern,” the authors write.

Other multidrug-resistant organisms that have been known to be transferred during a bronchoscopy include P. aeruginosa, and M. tuberculosis, leading to patients contracting sepsis, pneumonia, bronchitis, lung tuberculosis, and pulmonary infections. Studies link these infections back to inappropriate cleaning, drying and storing of bronchoscopes, contaminated automated endoscope reprocessors (AER), and broken bronchoscopes.

P. aeruginosa accounts for 9 percent of all hospital-acquired infections in the U.S and is the second most common cause for nosocomial pneumonia, health care-associated pneumonia, and ventilator-associated pneumonia. This waterborne organism is also one of the most common organisms found in contaminated endoscopes.

Curbing Contamination with Innovation

Reprocessing a flexible endoscope is a long and arduous process, prone to errors. There are, however, some innovations that help curb contamination risk. We’ll explore this and other questions around antimicrobial stewardship strategies as we wrap our series in the coming weeks with these stories:

  • Leadership: Typically, physicians who prescribe antibiotics spearhead antimicrobial stewardship efforts, 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.

Previous topics in this series include:

  • 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.