Outbreak Column 9: Endoscopy-related outbreaks

Alrabaa SF Nguyen P Sanderson R Baluch A Sandin RL Kelker D Karlapalem C Thompson P Sams K Martin S Montero J Greene JN . (2012) Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment. American Journal of Infection Control Available at: http://www.ncbi.nlm.nih.gov/pubmed/?term=alrabaa+nguyen- (accessed April 2013).

Anderson DJ Shimpi RA McDonald JR Branch MS Kanafani ZA Harger J Ely TM Sexton DJ Kaye KS . (2008) Infectious complications following endoscopic retrograde cholangiopancreatography: an automated surveillance system for detecting postprocedure bacteremia. American Journal of Infection Control 36(8): 592–4.

Aumeran C Poincloux L Souweine B Robin F Laurichesse H Baud O Bommelaer G Traore O. (2010) Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 42(11): 895–9.

Bisset L Cossart YE Selby W West R Catterson D O’Hara K Vickery K . (2006) A prospective study of the efficacy of routine decontamination for gastrointestinal endoscopes and the risk factors for failure. American Journal of Infection Control 34(5): 274–80.

Bou R Aguilar A Perpinan J Ramos P Peris M Lorente L Zuniga A . (2006) Nosocomial outbreak of Pseudomonas aeruginosa infections related to a flexible bronchoscope. Journal of Hospital Infection 64(2): 129–35.

Cetre JC Nicolle MC Salord H Perol M Tigaud S David G Bourjault M Vanhems P . (2005) Outbreaks of contaminated broncho-alveolar lavage related to intrinsically defective bronchoscopes. Journal of Hospital Infection 61(1): 39–45.

Cosgrove SE Ristaino P Caston-Gaa A Fellerman DP Nowakowski EF Carroll KC Perl TM Maragakis LL . (2012) Caveat emptor: the role of suboptimal bronchoscope repair practices by a third-party vendor in a pseudo-outbreak of pseudomonas in bronchoalveolar lavage specimens. Infection Control and Hospital Epidemiology 33(3): 224–9.

Curran E Wilson J . (2008) Using data effectively to prevent and control infection. British Journal of Infection Control 9(2): 26–33.

Curran ET . (2013a) Outbreak Column 7: Pseudo-outbreaks (part 1). Journal of Infection Prevention 14(2): 69–73.

Curran ET . (2013b) Outbreak Column 8: Pseudo-outbreaks and no-infection outbreaks (part 2). Journal of Infection Prevention 14(3 ): 108–113.

Curran ET Coia JE . (2010) Is ORION missing rich information on outbreak error causation? Journal of Hospital Infection 74(4): 410–11.

Gonzalez-Candelas F Guiral S Carbo R Valero A Vanaclocha H Gonzalez F Bracho MA . (2010) Patient-to-patient transmission of hepatitis C virus (HCV) during colonoscopy diagnosis. Virology Journal 7: 217.

Grant E Leavenworth R (1996) Models for quality management and problem solving. In Statistical quality control (international edn). McGraw Hill: New York: 669–89.

GRS Endoscope Decontamination Working Party. (2009) National endoscopy programme: decontamination standards for flexible endoscopes. Available at: http://www.thejag.org.uk/downloads%5CUnit%20Resources%5CDecontamination%20Standards%20for%20Flexible%20Endoscopy.pdf (accessed 29 May 2013).

Gutelius B Perz JF Parker MM Hallack R Stricof R Clement EJ Lin Y Xia GL Punsalang A Eramo A Layton M Balter S . (2010) Multiple clusters of hepatitis virus infections associated with anesthesia for outpatient endoscopy procedures. Gastroenterology 139(1): 163–70.

Health Protection Scotland. (2012) HPS hospital outbreak algorithm/checklist. Health Protection Scotland 25 July 2012. Available at: http://www.hps.scot.nhs.uk/haiic/ic/toolkits.aspx#outbreak (accessed march 2013).

Herve R Keevil CW . (2013) Current limitations about the cleaning of luminal endoscopes. Journal of Hospital Infection 83(1): 22–9.

Hinckley CM . (2001) Make no mistake (1st edn). Productivity Press: New York: 29.

Hubner NO Assadian O Poldrack R Duty O Schwarzer H Moller H Kober P Rather M Schroder LW Sinha J Lerch MM Kramer A . (2011) Endowashers: an overlooked risk for possible post-endoscopic infections. GMS Krankenhhyg Interdiszip 6(1): Doc13.

Infection Prevention Society. (2012) Infection prevention quality improvement tools: endoscopy – decontamination. Infection Prevention Society http://www.ips.uk.net/uploads/ResourceInfo/QIT/endoscopydecontaminationPIT.pdf (accessed March 2013): 1–19

Koo VS O’Neill P Elves A . (2012) Multidrug-resistant NDM-1 Klebsiella outbreak and infection control in endoscopic urology. BJU International 110(11 Pt C): E922-E926.

Kovaleva J Meessen NE Peters FT Been MH Arends JP Borgers RP Degener JE . (2009) Is bacteriologic surveillance in endoscope reprocessing stringent enough? Endoscopy 41(10): 913–16.

MHRA Microbiology Advisory Committee (The MAC Manual). (2005) Sterilization, disinfection and cleaning of medical equipment: guidance on decontamination: Part 2 Protocols. 1–37.

Muscarella LF . (2006) Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying. American Journal of Gastroenterology 101(9): 2147–54.

Petersen BT Chennat J Cohen J Cotton PB Greenwald DA Kowalski TE Krinsky ML Park WG Pike IM Romagnuolo J Rutala WA . (2011) Multisociety guideline on reprocessing flexible GI endoscopes: 2011. Infection Control and Hospital Epidemiology 32(6): 527–37.

Reason J . (2008) Perceptions of unsafe acts. In The human contribution: unsafe acts, accidents and heroic recoveries. Ashgate: Farnham, Surrey: 69–103.

Rosengarten D Block C Hidalgo-Grass C Temper V Gross I Budin-Mizrahi A Berkman N Benenson S . (2010) Cluster of pseudoinfections with Burkholderia cepacia associated with a contaminated washer-disinfector in a bronchoscopy unit. Infection Control and Hospital Epidemiology 31(7): 769–71.

Rutala WA Weber DJ , HICPACH. (2008) Guideline for disinfection and sterilization in healthcare facilities. Department of Health and Human Services: USA: 1–158.

Schuetz AN Hughes RL Howard RM Williams TC Nolte FS Jackson D Ribner BS . (2009) Pseudo-outbreak of Legionella pneumophila serogroup 8 infection associated with a contaminated ice machine in a bronchoscopy suite. Infection Control and Hospital Epidemiology 30(5): 461–6.

Seoane-Vazquez E Rodriguez-Monguio R . (2008) Endoscopy-related infection: relic of the past? Current Opinion on Infectious Diseases 21(4): 362–6.

Silva CV Magalhaes VD Pereira CR Kawagoe JY Ikura C Ganc AJ . (2003) Pseudo-outbreak of Pseudomonas aeruginosa and Serratia marcescens related to bronchoscopes. Infection Control and Hospital Epidemiology 24(3): 195–7.

Spach DH Silverstein FE Stamm WE . (1993) Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Annals of Internal Medicine 118(2): 117–28.

Vergis AS Thomson D Pieroni P Dhalla S . (2007) Reprocessing flexible gastrointestinal endoscopes after a period of disuse: is it necessary? Endoscopy 39(8): 737–9.

Weber DJ Rutala WA . (2001) Lessons from outbreaks associated with bronchoscopy. Infection Control and Hospital Epidemiology 22(7): 403–8.

Weber DJ Rutala WA . (2012) Lessons learned from outbreaks and pseudo-outbreaks associated with bronchoscopy. Infection Control and Hospital Epidemiology 33(3): 230–4.

Wilson SJ Everts RJ Kirkland KB Sexton DJ . (2000) A pseudo-outbreak of Aureobasidium species lower respiratory tract infections caused by reuse of single-use stopcocks during bronchoscopy. Infection Control and Hospital Epidemiology 21(7): 470–2.