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

• 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

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

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 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

● 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

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 Environment

Resistance of Microorganisms

Low Level Disinfection

LIPID VIRUSESHepatitis A, BHerpes SimplexHIV

High Level Disinfection

Intermediate Level Disinfection

BACTERIAL SPORES Clostridium difficile Clostridium perfringensCryptosporidium

MYCOBACTERIUMMycobacterium tuberculosisMycobacterium chelonae

NONLIPID VIRUSES

poliovirus -- poliorhinovirus – common cold

FUNGICandida albincans – thrush

AspergillusTrichophyton fungus – Athlete’s Foot

VEGETATIVE BACTERIA Pseudomanas,sp. Salmonella, sp.

Staphylococcus,sp. Escherichia coli – E coli

MRSA

Sterilization

PRIONS (Creutzfeld-Jakob Disease) Prion processing

Microorganisms

● 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

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

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● 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

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:

• 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

● 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

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

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

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

● 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

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

• 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

Hepatitis

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

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

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

Biofilm Control

-10123456789

10

Product Exposure

OPA

Glutaraldehyde

Na Hypochlorite

PA

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 InfectionEndoscope 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

place ● AAMI ST79● AAMI ST 58● FDA● OSHA● CDC● SGNA● AORN● APIC

● Maintaining safe environment● Limit cross contamination● Prevent transmission of infection

Preventing InfectionResponsible 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 sterilizationMicrobicidal 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 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

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

● 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 InfectionDrying

Preventing InfectionStorage

● 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 InfectionAwareness 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– NEVER THE SWIPE AND THE WIPE!

Liquid Waste Management● 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 InfectionCompliance 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

Questions● 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