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Microbes in the
Endoscopy Environment
What You Need To Know
Marcia Hardick, RN,BS,CSPDT
Clinical/Education Specialist
STERIS CORPORATION
Participants must complete the entire presentation/seminar to
achieve successful completion and receive contact hour credit.
Partial credit will not be given.
All of the presenters are employees of STERIS Corporation and
receive no direct compensation other than their normal salaries
for participation in this activity.
This program has been approved by IAHCSMM and CBSPD.
Provider approved by the California Board of Registered
Nursing. Provider Number CEP 11681 for 1 contact hour.
STERIS Corporation is providing the speakers and contact hours
for this activity. However, products referred to or seen during
this presentation do not constitute a commercial support by the
speakers.
Objectives

Identify the various microorganisms
encountered in the endoscopy environment

Discuss the infection prevention behaviors
necessary to decrease the risk of infections in
healthcare
Trends in Infections
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Changing epidemiology of infectious agents
Poor personal/hand hygiene
Contaminated environmental surfaces
Increase in community-acquired
Social and demographic changes
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Population in community more vulnerable
Shorter hospital stays
More procedures performed in out-patient facilities
Home health care
‘at-risk’ groups in the home
Healthcare
Associated Infections (HAI)
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4.5/100 hospitalized patients acquire HAI
1.7 million infections, 99,000 deaths
Average 19 days longer in hospital
Up to $30.5 billion in costs
Death and LOS increased for IBD patients
Most frequent in patients with severe liver
disease
CDC, National Nosocomial Infections Surveillance System (NNIS) data
Healthcare Associated Infections
● Contributing factors
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Receiving intensive care
Increasing rates of antimicrobial resistance
Complex medical procedures
Invasive medical therapy
Increasing elderly population
Immune compromised population
Direct/indirect contact
Exogenous sources
– Environmental surfaces
– Medical equipment/devices
Healthcare Associated
Infections
 Misconceptions
● HAI incidence is insignificant
● Cost of HAI offset by reimbursement
● HAI expected outcome
 Survey responses
● 2/3 worried about contracting HAI
● l/3 experienced HAI or have friend/relative who has had
one
● “being admitted to hospital makes you sicker”
ECRI Institute’s White Paper
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Top Health Technology Hazards for 2011:
● Prioritizing patient safety efforts
● Increase awareness, prevent risks
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#3 “Cross contamination from flexible
endoscopes”
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Failure to perform proper steps
● Compromises integrity of the process
● Creates inconvenience and anxiety to patients
● Potential life threatening infections
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Consistent adherence to instructions
Centers for Disease Control
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“More HAI outbreaks linked to contaminated
endoscopes than any other medical device”
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“Clean vs. sterile” procedure mentality
Flexible endoscopes acquire high levels of
microbial contamination
Environment is a “mixing pot” of microbes
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● Patients, family, visitors, staff
Devices and Instrumentation
• Pathway for introduction of pathogenic microbes
• Not following manufacturer’s instructions
• Unable to identify specific model types
• Unsure of intended use
• Critical, semi-critical, non-critical
• Untrained personnel
• Responsible personnel
• Receive proper training
• Undergo initial / annual competency testing
Microbes Encountered in
the Endoscopy
Environment
Resistance of Microorganisms
PRIONS (Creutzfeld-Jakob Disease)
BACTERIAL SPORES
Clostridium difficile
Clostridium perfringens
Cryptosporidium
MYCOBACTERIUM
Mycobacterium tuberculosis
Mycobacterium chelonae
NONLIPID VIRUSES
poliovirus -- polio
rhinovirus – common cold
FUNGI
Candida albincans – thrush
Aspergillus
Trichophyton fungus – Athlete’s Foot
VEGETATIVE BACTERIA
Pseudomanas,sp.
Salmonella, sp.
Staphylococcus,sp.
Escherichia coli – E coli
LIPID VIRUSES
Hepatitis A, B
Herpes Simplex
HIV
MRSA
Prion processing
Sterilization
High Level Disinfection
Intermediate Level
Disinfection
Low Level Disinfection
Microorganisms
● Pseudomonas aeruginosa
● Mycobacterium
● Staphylococcus aureus
● Glut-resistant M. chelonae
● Salmonella, Shigella
● Giardia, amoebiasis
● Enterobacter, E-coli
● HBV, HCV, CMV
● Klebsiella
● Herpes simplex
● Camphylobacter
● Candida
● H.pylori
● Cryptosporidium
● Serratia marcesens
● Clostridium difficile
Multi-Drug Resistant Organisms
“Superbugs” in 2010
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MRSA, VISA, VRSA
VRE
Extended Spectrum Beta Lactamases (ESBLs)
Acinetobacter baumanni
Klebsiella pneumonia
C.difficile
Vancomycin is standard of care but losing
effectiveness
● Many MDROs now endemic in hospitals
Microorganisms
● Most common pathogens associated with
gastrointestinal endoscopy:
– Pseudomonas aeruginosa
– Salmonella sp.
● Most common pathogens associated with
bronchoscopy:
– Pseudomonas aeruginosa
– Mycobacterium tuberculosis
– Candida albicans
Pseudomonas aeruginosa
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Gram negative bacilli
Ultimate opportunistic vegetative bacteria
4th leading healthcare associated infection
Infects tissue when host defenses compromised
– Respiratory
– Urinary tract
– GI tract
● Patients with
– AIDS
– Burns
– Cancer
Pseudomonas aeruginosa
● Ability to grow in
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Water
Moist environments
Some disinfectants
Sinks
Water bottles
● Found in biofilms
● Sequelae:
– Patient bacteremia
– Patient deaths
Pseudomonas aeruginosa
● Factors contributing to infections
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Inadequate disinfectant
Contamination of inner channel
Inadequate drying of channels
Sinks/drains not disinfected
Water bottle not sterile
Sterile water not used in water bottle
Biofilms
Mycobacterium
● Acid-fast bacilli
● Grows slowly, colonies appear after 1-12 weeks
● Survives for long periods in environment
● Can withstand drying
● Species
– M. tuberculosis
– M. avium-intracellulare
– M. gordonae
– M. chelonae
Mycobacterium tuberculosis
 M. tuberculosis transmission:
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Immune suppressed
Airborne droplets
Coughing, speaking, laughing
Bronchoscopes, medical equipment
 Caused by:
• Inadequate cleaning
• Incorrect disinfection procedures
• Not following instructions from AER manufacturer
Mycobacterium chelonae
● Rapidly growing Mycobacterium (nonTb)
• Found in natural / treated water, hemodialysis fluids
• Infections associated with skin markers, wound site
infections, catheters
• Very difficult to treat
• Disinfectant solutions
• Resistant to glutaraldehyde
● AERs – reservoirs
• Biofilms develop
Mycobacterium chelonae
● Pseudo-outbreaks found
● Contaminated endoscopes
● Monitor MEC of HLD
● Dry channels prior to storage
● Disinfect all fluid pathways in AER
● Include rinse water pathway
● Change sterile/bacteria-free filters as
necessary
Methicillin-Resistant
Staphylococcus aureus
● Mild skin infection
toxic shock syndrome
● Community acquired (CA-MRSA)
● 2 million colonized
● Identify at admission
● Infection prevention and surveillance programs
● Decreased from 2005-2008
MRSA –
Decreasing Infection Rates
● Transmission-based infection control policies
● Surveillance cultures
● Strict barrier precautions
● Hand hygiene measures
● Disinfect devices/surfaces/environment
Enterococci
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Gram+ bacteria
Found in soil, water, mammals
Normal flora in lower GI tract
Cause of serious infections
● Endocarditis
● Wounds, abscesses
● Urinary tract
● Found in biofilms
Vancomycin Resistant
enterococcus (VRE)
● Anerobic gram positive cocci
● VRE mutant strain of enterococcus
● More than a dozen strains identified
● Prevalence continues to rise
● Inhabits GI tract of human hosts
● Colonized patients
● At risk:
– Immune suppressed
– Young, elderly, very ill
VRE Prevention
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Education
Prevent transmission
● Isolation
● Dedicated equipment
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Hand hygiene
Thorough environmental cleaning
Antibiotic management
Surveillance cultures
Enterobacteriaceae
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Gram negative bacilli
Can grow in presence or absence of oxygen
Found in intestinal tract
Emerging E-coli resistant strain ST131
● High level of virulence
● Resistant to fluoroquinolones and cephalosporins
Enterobacteriaceae
● Family includes:
– Escherichia -
– Salmonella -
(E-coli) - UTIs, diarrheal diseases, wound
infections
leading cause of gastroenteritis from food
and water
– Enterobacter – Klebsiella pneumonia, UTIs
– Haemophilus – Found in upper respiratory tract
Causes meningitis in children
– Serratia Wound infections, biofilms
– Shigella Enteritis
– Yersinia Enterocolitica, enteritis, pestis, plague,
pseudo tuberculosis, mesenteric adenitis
Clostridium difficile
● Now out-numbers MRSA
● Gram-positive, spore-forming bacillus
• Found in both vegetative and spore forms
• Spore form resistant to being killed
• Can survive on surfaces for months
• Fecal – Oral transmission route
• Major complication of antibiotic therapy
• Alters and disrupts normal colon flora
• Allows C. difficile to flourish and produce toxins
• New More Virulent strain
• Causes more severe disease
Clostridium difficile
• Prevent transmission and cross contamination
• Strict contact precaution guidelines
• Barrier precautions
• Isolate patients ASAP
• Personal protective equipment (PPE)
• Awareness of “clean” and “dirty”
• Hand hygiene with soap and water
• Environmental disinfection with bleach
• Alcohol hand rubs not effective
• Appropriate processing of medical devices
• Mandatory reporting to NYSDOH
Protozoa
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Giardia (Flagellate)
● Causes Giardiasis including dysentery
● Can survive water chlorination
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Entamoeba histolytica (Ameba)
● Causes Amebiasis including dysentery
● Transferred in contaminated water and food
● Survives up to 5 weeks
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Cryptosporidium (Sporozoa)
● Causes severe diarrhea
● Resistant to biocides
Hepatitis
• 100,000 patients notified since 1998
• Potential exposure to HBV, HCV, and/or HIV
• HBV and HCV hidden epidemics
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Up to 75% (5 million) do not know they have it
2/3 baby boomers
Triple HCV death rate in next 10-20 years
Up to $80 billion extra costs
Hepatitis
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HBV
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10 times more infective than HCV
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Carriers no symptoms
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Survives in dried blood up to 7 days
HBC
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85% of new cases become chronic
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Leading cause of more severe liver disease
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Survives on environmental surfaces at least
16 hours
Helicobacter pylori
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Spiral shaped gram - bacterium
Discovered in 1983 in rural Australia
Adapts to harsh acidic gastric environment
Plays a role in chronic infection, gastritis and
Peptic Ulcer Disease
● Treated with antibiotics and acid-suppressing
drugs
Helicobacter pylori
● Incidence
● Up to 90% of global populations affected
● Up to 50% U.S. citizens affected
● Developing world, lower socioeconomic groups
● Transmission unknown
● Humans only known reservoir
● Can survive
● Manual cleaning
● Disinfection with 2% glutaraldehyde for 15-30 min
● Follow strict guidelines for processing
Water-borne Diseases
● Risk groups
● 2 billion people living in poverty in developing world
● US citizens with poor water treatment systems
● Surveillance
● Sporadic cases under-reported
● Outbreaks abroad often missed
● Prevention
● Chlorination and safe water handling
● Improvements in infrastructure
Food-borne Illnesses
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76 million illnesses in U.S.
• Infants, elderly, immune compromised
• Various bacteria, viruses, parasites
• New pathogens continue to emerge
• Symptoms vary widely
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Diarrhea and vomiting most common
Sequelae
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Septicemia, localized infections, arthritis, hemolytic
uremic syndrome, Guillaine-Barre Syndrome, death
Delays in Cleaning Lead to Biofilms
● Structured community of cells
● Formed as continuous layers
● Four functional states
● Attachment
● Micro-colonization
● Biofilm formation
● Detachment
Biofilms
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Reservoir for bacterial growth
Biofilms difficult/impossible to treat
Implicated in HAIs/medical devices, AERs
● Contaminated medical devices
● Contaminated washer-disinfectors
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Ineffective disinfectants contribute to growth
Biofilm Control
10
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1
0
-1
OPA
Glutaraldehyde
Na Hypochlorite
PA
Product Exposure
Bacterial Reduction
(log10 cfu/cm2 Pseudomonas aeruginosa)
Dr. Gerald MCDonnell
“Peroxygens and Other Forms of Oxygen, Their Use for Effective Cleaning, Disinfection and Sterilization”
PacifiChem 2005, Honolulu, HI, Dec, 2005, Symposium # 50
Preventing Infection
in Endoscopy
Preventing Infection
 Endoscope reprocessing shown to have
narrow margin of safety (Alfa, 2006)
 Standard sterilization/disinfection
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Blood borne pathogens
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Emerging pathogens
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Bioterrorism agents
 Exception:
 Prions
Reprocessing Environment
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Many standards/recommended practices in
place
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AAMI ST79
AAMI ST 58
FDA
OSHA
CDC
SGNA
AORN
APIC
Maintaining safe environment
Limit cross contamination
Prevent transmission of infection
Preventing Infection
 Responsible personnel
• Able to read, understand and implement instructions
• Receive proper training
• Cleaning, disinfection, sterilization
• Meet initial / annual competency testing
• Annual updates to ensure compliance with current
standards
 Temporary staff should NOT reprocess equipment
 Cleaning always precedes HLD and/or sterilization
 Microbicidal method depends on intended use
Preventing Infection
Cross-Contamination
 Cleaning
 Incompatible chemicals and processes
 Fluid invasion corrodes and harbors bacteria
 Reusing detergent solution and rinse water
 Proper enzymatic/detergent
 Appropriate size channel brushes
Preventing Infection
Cross-Contamination
 Processing
• Failure to reprocess all internal channels
• Reprocessing endoscope with sharp instruments
• Incorrect use of connectors during reprocessing
 Storage
• Storing in foam-padded shipping cases
• Storing with tubes looped
Preventing Infection
Automated Endoscope Reprocessors
 AER should possess these benefits:
 Automated and standardized
 Circulate fluids through all channels
 Staff not exposed to toxic vapors
 Parameters recorded for QA/documentation
 Filtered bacteria-free water
 Liquid germicide heated (if necessary)
 Alarms set to monitor phases of process
 Automated self-disinfection cycle
Preventing Infection
Automated Endoscope Reprocessors
• Prevent formation of biofilms
• Process for disinfection of AER
• Periodic preventive maintenance
• Maintain filtration systems
• Large and small micron
“Once biofilm forms, direct friction and/or
oxidizing chemicals are needed to remove it”
AAMI ST79, 2006: 6.3
Preventing Infection
Drying
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After each use and before reuse:
● Purge all channels with air (20 psi max)
● Flush with 70% isopropyl alcohol
– Drawn up fresh for each use
● Purge with air
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Dry exterior
Dry all removable parts
Preventing Infection
Storage
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Closed cabinet with air circulation
Surface nonporous
● Clean/disinfect surfaces
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Remove all caps and valves
Locks in free position
Hang vertically
Protect from damage/contamination
Preventing Infection
Awareness of Dirty/Clean
● Protective work practices
● Avoid cross contamination
Environmental Surfaces
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Surface material withstands frequent disinfection
● Floors, surfaces, patient equipment
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Contaminated with blood/infectious materials
● Focus on cleaning, then disinfection
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Vigorous environmental hygiene
● Hospital grade germicides
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Use germicide correctly
● Cleaners, sanitizers, disinfectants
● Mops/buckets, sprays, wipes disinfection products
● Wet surface contact time
– NEVER THE SWIPE AND THE WIPE!
Liquid Waste Management
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Leak proof containers prevent exposure
Discard disposable liner and tubing after each
use
Liquid waste disposed according to state
regulations
● Solidifer
● Liquid waste disposal system
● Pouring down sanitary sewer
Preventing Infection
Compliance with Hand Hygiene
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Reduces incidence of infection
Apply hand hygiene procedures
● Correctly
● At correct time
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Hands-free equipment
● Sink
● Towels
● Soap dispensers
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Alcohol sanitizers
Total Quality Management
● Written protocols
● Availability of trained personnel
● Good record keeping
● Equipment monitoring
● Periodic monitoring of healthcare environment
● Staff member identified as IP “champion”
● Facility design
● Accountability
Questions
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Do you have a staff member identified as IP/QI
“champion”?
Do you conduct regular IP rounds?
Have you identified areas of risk for infection?
Are you able to identify/report breaches without
retaliation?
Do you have a committee to address issues for
improvement?
Do you have a quality improvement program in
place to monitor IP practices?
Are we doing the best we can to follow-up with
patients for possible HAIs/sentinel events?
QUESTIONS