Getting to Zero: Reducing the Risk for Duodenoscope-Related Infections
Authors: Jeffrey L. Tokar, John I. Allen, Michael L. Kochman
Journal: Annals of Internal Medicine (2015)

Ideas and Opinions1 December 2015Getting to Zero: Reducing the Risk for Duodenoscope-Related InfectionsJeffrey L. Tokar, MD, John I. Allen, MD, and Michael L. Kochman, MDJeffrey L. Tokar, MDFrom Fox Chase Cancer Center and University of Pennsylvania Health System, Philadelphia, Pennsylvania, and Yale University School of Medicine, New Haven, Connecticut., John I. Allen, MDFrom Fox Chase Cancer Center and University of Pennsylvania Health System, Philadelphia, Pennsylvania, and Yale University School of Medicine, New Haven, Connecticut., and Michael L. Kochman, MDFrom Fox Chase Cancer Center and University of Pennsylvania Health System, Philadelphia, Pennsylvania, and Yale University School of Medicine, New Haven, Connecticut.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M15-1719 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In recent months, recognition of "superbug infections" from agents transmitted by duodenoscopes (specialized endoscopes used for endoscopic retrograde cholangiopancreatography [ERCP]) has prompted investigation and development of action plans by the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and such professional medical societies as the American Gastroenterological Association (AGA) and the American Society for Gastrointestinal Endoscopy. This commentary highlights the situation and the efforts under way to better understand the problem; develop creative solutions; and, above all, ensure patient safety.During gastrointestinal endoscopy, endoscopes are exposed to millions of bacteria that constitute the gut ...References1. Spaulding EH. The role of chemical disinfection in the prevention of nosocomial infections.. In: Brachman PS, Eickoff TC, eds. Proceedings of the International Conference on Nosocomial Infections, Atlanta, Georgia, 3–6 August 1970. Chicago: American Hospital Association; 1971:254-74. Google Scholar2. Epstein L, Hunter JC, Arwady MA, Tsai V, Stein L, Gribogiannis M, et al. New Delhi metallo-ß-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA. 2014;312:1447-55. [PMID: 25291580] doi:10.1001/jama.2014.12720 CrossrefMedlineGoogle Scholar3. Wendorf KA, Kay M, Baliga C, Weissman SJ, Gluck M, Verma P, et al. Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol. 2015;36:634-42. [PMID: 25817743] doi:10.1017/ice.2015.66 CrossrefMedlineGoogle Scholar4. Kola A, Piening B, Pape UF, Veltzke-Schlieker W, Kaase M, Geffers C, et al. An outbreak of carbapenem-resistant OXA-48–producing Klebsiella pneumonia associated to duodenoscopy. Antimicrob Resist Infect Control. 2015;4:8. doi:10.1186/s13756-015-0049-4 CrossrefMedlineGoogle Scholar5. Allen JI, Allen MO, Olson MM, Gerding DN, Shanholtzer CJ, Meier PB, et al. Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope. Gastroenterology. 1987;92:759-63. [PMID: 3817396] CrossrefMedlineGoogle Scholar6. U.S. Food and Drug Administration. Supplemental Measures to Enhance Duodenoscope Reprocessing: FDA Safety Communication. Silver Spring, MD: U.S. Food and Drug Administration; 2015. Accessed at www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm454766.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery&zbrandid=439&zidType=CH&zid=9819533&zsubscriberId=93270611&zbdom=http://www.informz.net on 25 August 2015. Google Scholar7. Centers for Disease Control and Prevention. Interim Duodenoscope Surveillance Protocol. Atlanta, GA: Centers for Disease Control and Prevention; 2015. Accessed at www.cdc.gov/hai/organisms/cre/cre-duodenoscope-surveillance-protocol.html on 25 August 2015. Google Scholar8. Ross AS, Baliga C, Verma P, Duchin J, Gluck M. A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli. Gastrointest Endosc. 2015;82:477-83. [PMID: 26092616] doi:10.1016/j.gie.2015.04.036 CrossrefMedlineGoogle Scholar9. Chandrasekhara V, Chathadi KV, Acosta RD, Decker GA, Early DS, Eloubeidi MA, et al; ASGE Standards of Practice Committee. The role of endoscopy in benign pancreatic disease. Gastrointest Endosc. 2015;82:203-14. [PMID: 26077456] doi:10.1016/j.gie.2015.04.022 CrossrefMedlineGoogle Scholar10. Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, et al; ASGE Standards of Practice Committee. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc. 2015;81:795-803. [PMID: 25665931] doi:10.1016/j.gie.2014.11.019 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Fox Chase Cancer Center and University of Pennsylvania Health System, Philadelphia, Pennsylvania, and Yale University School of Medicine, New Haven, Connecticut.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1719.Corresponding Author: Jeffrey L. Tokar, MD, Department of Medicine, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111; e-mail, Jeffrey.[email protected]edu.Current Author Addresses: Dr. Tokar: Department of Medicine, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111.Dr. Allen: Section of Digestive Disease, Yale University School of Medicine, 40 Temple Street, Suite 1A, New Haven, CT 06510.Dr. Kochman: University of Pennsylvania Health System, PCAM South, 7th Floor, GI, 3400 Civic Center Boulevard, Philadelphia, PA 19104.Author Contributions: Conception and design: J.L. Tokar, M.L. Kochman.Analysis and interpretation of the data: M.L. Kochman.Drafting of the article: J.L. Tokar, J.I. Allen, M.L. Kochman.Critical revision of the article for important intellectual content: J.I. Allen, M.L. Kochman.Final approval of the article: J.L. Tokar, J.I. Allen, M.L. Kochman.Collection and assembly of data: J.L. Tokar.This article was published online first at www.annals.org on 22 September 2015. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byA prospective, multicenter, clinical study of duodenoscope contamination after reprocessingHigh Prevalence Rate of Microbial Contamination in Patient-Ready Gastrointestinal Endoscopes in Tehran, Iran: an Alarming Sign for the Occurrence of Severe OutbreaksEnhanced reprocessing of duodenoscopes: A glass half full or half empty?Duodenoscope-associated infections: a reviewOther considerations: Perspective and obligations of our societies and governmental organizationsDuodenoscope-Associated Infections beyond the Elevator Channel: Alternative Causes for Difficult ReprocessingDuodenoscope ReprocessingOptimizing duodenoscope reprocessing: rigorous assessment of a culture and quarantine protocolRethinking Reprocessing: A Response to Snyder et alImplementation of a systematic culturing program to monitor the efficacy of endoscope reprocessing: outcomes and costsRisk of infection transmission in curvilinear array echoendoscopes: results of a prospective reprocessing and culture registryRisk factors associated with the transmission of carbapenem-resistant Enterobacteriaceae via contaminated duodenoscopes 1 December 2015Volume 163, Issue 11Page: 873-874KeywordsBacteriaEndoscopic retrograde cholangiopancreatographyEndoscopyEthyleneFood and Drug AdministrationGastroenterology and hepatologyHealth care facilitiesHealth care providersMultidrug resistanceSafety ePublished: 22 September 2015 Issue Published: 1 December 2015 Copyright & PermissionsCopyright © 2015 by American College of Physicians. 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