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Microbes in the Endoscopy Environment

Microbes in the Endoscopy Environment. What You Need To Know Marcia Hardick, RN,BS,CSPDT Clinical/Education Specialist STERIS CORPORATION.

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Microbes in the Endoscopy Environment

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  1. Microbes in the Endoscopy Environment What You Need To Know Marcia Hardick, RN,BS,CSPDT Clinical/Education Specialist STERIS CORPORATION

  2. 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.

  3. Objectives • Identify the various microorganisms encountered in the endoscopy environment • Discuss the infection prevention behaviors necessary to decrease the risk of infections in healthcare

  4. 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

  5. Healthcare 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 disease CDC, National Nosocomial Infections Surveillance System (NNIS) data

  6. 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

  7. 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”

  8. ECRI Institute’s White Paper • Top Health Technology Hazards for 2011: • Prioritizing patient safety efforts • Increase awareness, prevent risks • #3 “Cross contamination from flexible endoscopes” • Failure to perform proper steps • Compromises integrity of the process • Creates inconvenience and anxiety to patients • Potential life threatening infections • Consistent adherence to instructions

  9. 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

  10. 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

  11. Microbes Encountered in the Endoscopy Environment

  12. Resistance of Microorganisms PRIONS(Creutzfeld-Jakob Disease) Prion processing Sterilization BACTERIAL SPORES Clostridium difficile Clostridium perfringensCryptosporidium MYCOBACTERIUM Mycobacterium tuberculosis Mycobacterium chelonae High Level Disinfection NONLIPID VIRUSES poliovirus -- polio rhinovirus – common cold Intermediate Level Disinfection FUNGI Candida albincans – thrush Aspergillus Trichophyton fungus – Athlete’s Foot Low Level Disinfection VEGETATIVE BACTERIA Pseudomanas,sp. Salmonella, sp. Staphylococcus,sp. Escherichia coli – E coli MRSA LIPID VIRUSES Hepatitis A, B Herpes Simplex HIV

  13. Pseudomonas aeruginosa Staphylococcus aureus Salmonella, Shigella Enterobacter, E-coli Klebsiella Camphylobacter H.pylori Serratia marcesens Clostridium difficile Mycobacterium Glut-resistant M. chelonae Giardia, amoebiasis HBV, HCV, CMV Herpes simplex Candida Cryptosporidium Microorganisms

  14. Multi-Drug Resistant Organisms“Superbugs” in 2010 • 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

  15. Microorganisms • Most common pathogens associated with gastrointestinal endoscopy: • Pseudomonas aeruginosa • Salmonella sp. • Most common pathogens associated with bronchoscopy: • Pseudomonas aeruginosa • Mycobacterium tuberculosis • Candida albicans

  16. 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

  17. Pseudomonas aeruginosa • Ability to grow in • Water • Moist environments • Some disinfectants • Sinks • Water bottles • Found in biofilms • Sequelae: • Patient bacteremia • Patient deaths

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. MRSA – Decreasing Infection Rates • Transmission-based infection control policies • Surveillance cultures • Strict barrier precautions • Hand hygiene measures • Disinfect devices/surfaces/environment

  25. Enterococci • 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

  26. 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

  27. VRE Prevention • Education • Prevent transmission • Isolation • Dedicated equipment • Hand hygiene • Thorough environmental cleaning • Antibiotic management • Surveillance cultures

  28. Enterobacteriaceae • 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

  29. Enterobacteriaceae • Family includes: • Escherichia - (E-coli) - UTIs, diarrheal diseases, wound infections • 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

  30. 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

  31. 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

  32. Protozoa • 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

  33. Hepatitis • 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

  34. Hepatitis • 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

  35. 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 drugs

  36. 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

  37. 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

  38. 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

  39. Delays in Cleaning Lead to Biofilms • Structured community of cells • Formed as continuous layers • Four functional states • Attachment • Micro-colonization • Biofilm formation • Detachment

  40. Biofilms • 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

  41. Biofilm Control 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

  42. Preventing Infection in Endoscopy

  43. 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

  44. Reprocessing Environment • Many standards/recommended practices in place • AAMI ST79 • AAMI ST 58 • FDA • OSHA • CDC • SGNA • AORN • APIC • Maintaining safe environment • Limit cross contamination • Prevent transmission of infection

  45. 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

  46. 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

  47. 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

  48. Preventing InfectionAutomated 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

  49. Preventing InfectionAutomated 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

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