Lessons learned from outbreaks and pseudo-outbreaks associated with bronchoscopy.

Affiliation: 1. Department of Medicine, University of North Carolina Medical School, and Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, North Carolina. Received December 13, 2011; accepted December 15, 2011; electronically published January 19, 2012. 2012 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2012/3303-0004$15.00. DOI: 10.1086/664495 The bronchoscope has been an invaluable tool for the diagnosis and therapy of pulmonary diseases for more than a century. An estimated 497,000 bronchoscopies were performed in the United States in 1996, 305,000 in inpatients and 192,000 in ambulatory patients. More recent data from 2006 reported a slight decrease in the number of bronchoscopies: 282,000 in inpatients and 173,000 in ambulatory patients. Bronchoscopy is widely used for both diagnosis and therapy of pulmonary diseases. Current and new diagnostic methods include autofluorescence bronchoscopy, endobronchial ultrasonography, navigational bronchoscopy, and fibered confocal fluorescence microscopy. Advances in interventional bronchoscopy include argon plasma coagulation, electrocautery or laser ablation, airway stents, cryotherapy, brachytherapy, and photodynamic therapy. Flexible endoscopes are also widely used in other medical disciplines, especially to diagnose and treat disorders of the gastrointestinal tract. Endoscopes represent the medical devices most commonly linked to healthcare-associated outbreaks and pseudo-outbreaks. Flexible endoscopes present a challenge for low-temperature sterilization or high-level disinfection, because they have long, narrow lumens, cross-connections, mated surfaces, sharp angles, springs and valves, occluded dead ends, absorbent material, and rough or pitted surfaces. Failure to eradicate contamination that occurs during use may lead to person-to-person transmission of pathogens (eg, Mycobacterium tuberculosis), while failure to prevent contamination during disinfection or storage may lead to outbreaks or pseudo-outbreaks from environmental pathogens (eg, nontuberculous mycobacteria, Legionella sp.). In an excellent review of infections transmitted by flexible endoscopes, Spach and colleagues summarized 9 outbreaks or pseudo-outbreaks associated with bronchoscopy from 1975 to 1989. In 2001, Weber and Rutala reviewed the literature and summarized an additional 3 outbreaks and 22 pseudo-outbreaks associated with bronchoscopy between 1990 and 1999. Despite the publication of multiple authoritative guidelines by professional societies, outbreaks and pseudo-outbreaks continue to occur, with 24 reports published since 2000 (Table 1). In this issue, Cosgrove and colleagues report yet another pseudooutbreak associated with bronchoscopy. Outbreaks and pseudo-outbreaks associated with bronchoscopy continue to occur because of poor adherence to current disinfection guidelines, especially the failure of healthcare facilities to have policies and procedures consistent with the current guidelines. Training and periodic assessment of competency of persons performing cleaning and disinfection is an important component of preventing breaches in policy. It is crucial for infection control preventionists to continue to report outbreaks and pseudo-outbreaks, since these reports aid in improving the manufacture of endoscopes, methods of disinfection, and policies/procedures to prevent crosstransmission. The sources of contamination leading to outbreaks and pseudo-outbreaks of endoscopes have been reviewed. Contamination most commonly results from failure to adhere to the key steps in disinfection (see below): appropriate cleaning, disinfection, rinsing, drying, and/or storage (Table 2). Outbreaks and pseudo-outbreaks have also resulted from contamination of fluids that may be instilled during bronchoscopy, including topical anesthesia (eg, cocaine), the green dye added to the anesthetic, and the atomizer used to instill analgesia. Pseudo-outbreaks have also resulted from contamination of respiratory tract specimens in the microbiology laboratory. However, most recent outbreaks and pseudo-outbreaks have resulted from contaminated automatic endoscope reprocessors or the use of damaged or malfunctioning bronchoscopes. Outbreaks or pseudo-outbreaks have resulted from contaminated equipment, including rinsing tanks, tubing, antibacterial filters on water lines, cleaning brushes, and biofilms in the reprocessor. Outbreaks have led to the recall of poorly designed or poorly functioning bron-