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									    Microbes in the
Endoscopy Environment

What You Need To Know

    Marcia Hardick, RN,BS,CSPDT
     Clinical/Education Specialist
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
   Identify the various microorganisms
    encountered in the endoscopy environment
   Discuss the infection prevention behaviors
    necessary to decrease the risk of infections in
          Trends in Infections
•   Changing epidemiology of infectious agents
•   Poor personal/hand hygiene
•   Contaminated environmental surfaces
•   Increase in community-acquired
•   Social and demographic changes
    •   Population in community more vulnerable
    •   Shorter hospital stays
    •   More procedures performed in out-patient facilities
    •   Home health care
    •   ‘at-risk’ groups in the home
    Associated Infections (HAI)
●   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

         CDC, National Nosocomial Infections Surveillance System (NNIS) data
Healthcare Associated Infections
 ● Contributing factors
   ●   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
 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
 ● “being admitted to hospital makes you sicker”
ECRI Institute’s White Paper

●   Top Health Technology Hazards for 2011:
    ● Prioritizing patient safety efforts
    ● Increase awareness, prevent risks
●   #3 “Cross contamination from flexible
●   Failure to perform proper steps
    ● Compromises integrity of the process
    ● Creates inconvenience and anxiety to patients
    ● Potential life threatening infections
●   Consistent adherence to instructions
Centers for Disease Control
●   “More HAI outbreaks linked to contaminated
    endoscopes than any other medical device”

●   “Clean vs. sterile” procedure mentality
●   Flexible endoscopes acquire high levels of
    microbial contamination
●   Environment is a “mixing pot” of microbes
    ● 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
Resistance of Microorganisms
  PRIONS (Creutzfeld-Jakob Disease)        Prion processing
    Clostridium difficile
    Clostridium perfringens

     Mycobacterium tuberculosis                 High Level Disinfection
     Mycobacterium chelonae

    poliovirus -- polio
                                                     Intermediate Level
    rhinovirus – common cold                         Disinfection
    Candida albincans – thrush
    Trichophyton fungus – Athlete’s Foot

                                                            Low Level Disinfection
     Salmonella, sp.
     Escherichia coli – E coli
     Hepatitis A, B
     Herpes Simplex
● 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
● Extended Spectrum Beta Lactamases (ESBLs)
● Acinetobacter baumanni
● Klebsiella pneumonia
● C.difficile
● Vancomycin is standard of care but losing
● Many MDROs now endemic in hospitals
● Most common pathogens associated with
  gastrointestinal endoscopy:
  – Pseudomonas aeruginosa
  – Salmonella sp.
● Most common pathogens associated with
  – Pseudomonas aeruginosa
  – Mycobacterium tuberculosis
  – Candida albicans
     Pseudomonas aeruginosa
●   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
  –   Water
  –   Moist environments
  –   Some disinfectants
  –   Sinks
  –   Water bottles
● Found in biofilms
● Sequelae:
  – Patient bacteremia
  – Patient deaths
       Pseudomonas aeruginosa

● Factors contributing to infections

   •   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
● 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:
  •   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
      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

●   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
●   Education
●   Prevent transmission
    ● Isolation
    ● Dedicated equipment
●   Hand hygiene
●   Thorough environmental cleaning
●   Antibiotic management
●   Surveillance cultures

●   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
● Family includes:
  – Escherichia -   (E-coli) - UTIs, diarrheal diseases, wound
  – Salmonella -    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
●   Giardia (Flagellate)
    ● Causes Giardiasis including dysentery
    ● Can survive water chlorination
●   Entamoeba histolytica (Ameba)
    ● Causes Amebiasis including dysentery
    ● Transferred in contaminated water and food
    ● Survives up to 5 weeks
●   Cryptosporidium (Sporozoa)
    ● Causes severe diarrhea
    ● Resistant to biocides
• 100,000 patients notified since 1998
  • Potential exposure to HBV, HCV, and/or HIV
• HBV and HCV hidden epidemics
  •   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
•   HBV
    •   10 times more infective than HCV
    •   Carriers no symptoms
    •   Survives in dried blood up to 7 days
•   HBC
    •   85% of new cases become chronic
    •   Leading cause of more severe liver disease
    •   Survives on environmental surfaces at least
        16 hours
        Helicobacter pylori

● 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
           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
• 76 million illnesses in U.S.
• Infants, elderly, immune compromised
• Various bacteria, viruses, parasites
• New pathogens continue to emerge
• Symptoms vary widely
    •   Diarrhea and vomiting most common
•   Sequelae
    •   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
●   Reservoir for bacterial growth
●   Biofilms difficult/impossible to treat
●   Implicated in HAIs/medical devices, AERs
    ● Contaminated medical devices
    ● Contaminated washer-disinfectors
●   Ineffective disinfectants contribute to growth
            Biofilm Control
 6                                                                                            Glutaraldehyde
 4                                                                                            Na Hypochlorite
 3                                                                                            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
     Blood borne pathogens
     Emerging pathogens
     Bioterrorism agents

 Exception:
   Prions
        Reprocessing Environment
●   Many standards/recommended practices in
    ●   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
 Temporary staff should NOT reprocess equipment
 Cleaning always precedes HLD and/or sterilization
 Microbicidal method depends on intended use
       Preventing Infection
 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
 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
●   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

●   Dry exterior
●   Dry all removable parts
            Preventing Infection
●   Closed cabinet with air circulation
●   Surface nonporous
    ● Clean/disinfect surfaces
●   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
●   Surface material withstands frequent disinfection
    ● Floors, surfaces, patient equipment
●   Contaminated with blood/infectious materials
    ● Focus on cleaning, then disinfection
●   Vigorous environmental hygiene
    ● Hospital grade germicides
●   Use germicide correctly
    ● Cleaners, sanitizers, disinfectants
    ● Mops/buckets, sprays, wipes disinfection products
    ● Wet surface contact time
    Liquid Waste Management
●   Leak proof containers prevent exposure
●   Discard disposable liner and tubing after each
●   Liquid waste disposed according to state
    ● Solidifer
    ● Liquid waste disposal system
    ● Pouring down sanitary sewer
    Preventing Infection
Compliance with Hand Hygiene
●   Reduces incidence of infection
●   Apply hand hygiene procedures
    ● Correctly
    ● At correct time
●   Hands-free equipment
    ● Sink
    ● Towels
    ● Soap dispensers
●   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
●   Do you have a staff member identified as IP/QI
●   Do you conduct regular IP rounds?
●   Have you identified areas of risk for infection?
●   Are you able to identify/report breaches without
●   Do you have a committee to address issues for
●   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?

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