Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
Gastrointest Endosc. 2019 Nov;90(5):793-804. doi: 10.1016/j.gie.2019.05.016. Epub 2019 May 15.
Worldwide, an increasing number of duodenoscope-associated outbreaks are reported. The high prevalence rate of contaminated duodenoscopes puts patients undergoing ERCP at risk of exogenous transmission of microorganisms. The contributing factors of the duodenoscope design to contamination are not well understood. This article reports on the investigation after the outbreak of a multidrug-resistant Klebsiella pneumoniae (MRKP) related to 2 Olympus TJF-Q180V duodenoscopes.
We conducted a contact patient screening and microbiologic laboratory database search. Reprocessing procedures were audited, and both duodenoscopes were fully dismantled to evaluate all potential contamination factors. Outcomes were reviewed by an experienced independent expert.
In total, 102 patients who had undergone an ERCP procedure from January to August 2015 were invited for screening. Cultures were available of 81 patients, yielding 27 MRKP-infected or -colonized patients. Ten patients developed an MRKP-related active infection. The 2 duodenoscopes had attack rates (the number of infected or colonized cases/number of exposed persons) of 35% (17/49) and 29% (7/24), respectively. Identical MRKP isolates were cultured from channel flushes of both duodenoscopes. The review revealed 4 major abnormalities: miscommunication about reprocessing, undetected damaged parts, inadequate repair of duodenoscope damage, and duodenoscope design abnormalities, including the forceps elevator, elevator lever, and instrumentation port sealing.
Outbreaks are associated with a combination of factors, including duodenoscope design issues, repair issues, improper cleaning, and systemic monitoring of contamination. To eliminate future duodenoscope-associated infections, a multipronged approach is required, including clear communication by all parties involved, a reliable servicing market, stringent surveillance measures, and eventually new duodenoscope designs and reprocessing procedures with a larger margin of safety.
全球范围内，越来越多的十二指肠镜相关感染暴发被报道。由于污染的十二指肠镜的高流行率，接受 ERCP 的患者面临着微生物外源性传播的风险。十二指肠镜设计导致污染的因素尚未得到很好的理解。本文报告了与 2 台奥林巴斯 TJF-Q180V 十二指肠镜相关的多重耐药肺炎克雷伯菌（MRKP）暴发的调查情况。
我们进行了接触患者筛查和微生物学实验室数据库搜索。审核了再处理程序，并对两台十二指肠镜进行了全面拆解，以评估所有潜在的污染因素。由一位有经验的独立专家对结果进行了审查。
共有 102 名在 2015 年 1 月至 8 月期间接受过 ERCP 手术的患者受邀进行筛查。81 名患者的培养物可用，其中 27 名患者为 MRKP 感染或定植。10 名患者发生了 MRKP 相关的活动性感染。这两台十二指肠镜的攻击率（感染或定植病例数/暴露人数）分别为 35%（17/49）和 29%（7/24）。从两台十二指肠镜的通道冲洗液中均培养出相同的 MRKP 分离株。审查发现了 4 个主要异常：再处理过程中的沟通失误、未检测到损坏部件、对十二指肠镜损坏的修复不充分，以及十二指肠镜设计异常，包括钳子提升器、提升杆和器械端口密封。
暴发与多种因素有关，包括十二指肠镜设计问题、维修问题、清洗不当以及对污染的系统监测。为了消除未来的十二指肠镜相关感染，需要采取多管齐下的方法，包括所有相关方之间的明确沟通、可靠的服务市场、严格的监测措施，最终采用具有更大安全裕度的新型十二指肠镜设计和再处理程序。
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