Clin Endosc.  2024 Nov;57(6):821-831. 10.5946/ce.2024.030.

Microbiological surveillance result of endoscopes after INTERCEPT Foam Spray: a quasi-experimental pilot study in Singapore

• Wang C
• Zhang R
• Fan R
• Low J
• Du R
• Ma X
• Cai C

• KMID: 2561167
• DOI: http://doi.org/10.5946/ce.2024.030

Abstract

Background/Aims
This study aimed to assess the impact of INTERCEPT Foam Spray (IFS) application on delayed endoscope reprocessing through microbiological surveillance culture (MSC).
Methods
A quasi-experimental, matched-comparison pilot study was conducted using gastrointestinal endoscopy. IFS was applied to the endoscopes after precleaning and before reprocessing the next day. An equal number of endoscopes, matched by endoscope type, were subjected to routine reprocessing. The MSC were subjected to high-level disinfection to detect any contamination. Data were analyzed using the chi-square test or Fisher exact test (categorical data) and Student t-test (continuous data).
Results
In total, 150 MSCs were collected from 42 endoscopes. Positive MSCs were observed in 4.0% (4/75) of the sprayed group and 1.3% (1/75) of the control group (95% confidence interval, 30.34–0.31; p>0.05), all of which were contributed by colonoscopes. Colonoscope were more prone to positive MSC (mean difference in percentage, p<0.05). Mean spraying hours were not associated with detected growth (11.7% vs. 13.6%; 95% confidence interval, 1.43 to –5.27; p>0.05), with environmental and skin flora being the primary contaminants.
Conclusions
IFS may be applied when delayed endoscope processing is necessary, but with caution when applied to colonoscopes. However, further research is warranted to verify the result.

Keyword

Disinfection; Environmental monitoring; Gastrointestinal endoscopes; Pilots

Figure

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  Fig. 1. Boxplot of sprayed hours for samples with growth and without growth.

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  Fig. 2. Frequency of detection of microorganisms among gastroscopes and colonoscopes between study groups.

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Reference

1. Centers for Disease Control and Prevention (CDC). Infection control: disinfection and sterilization [Internet]. CDC;2019. [cited 2023 Mar 18]. Available from: https://www.cdc.gov/infection-control/hcp/disinfection-and-sterilization/index.html.

2. Beilenhoff U, Biering H, Blum R, et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA): update 2018. Endoscopy. 2018; 50:1205–1234.

3. Reprocessing Guideline Task Force, Petersen BT, Cohen J, et al. Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update. Gastrointest Endosc. 2017; 85:282–294.

4. Devereaux B, Jones D, Wardle E. Clinical update: infection prevention and control in endoscopy 2021. Gastroenterological Society of Australia;2021. Avilable from: https://www.genca.org/public/5/files/Nurses%20info/IPCE%202021_Feb2022update.pdf.

5. Shenoy ES, Pierce VM, Walters MS, et al. Transmission of mobile colistin resistance (mcr-1) by duodenoscope. Clin Infect Dis. 2019; 68:1327–1334.

6. Grein JD, Murthy RK. New developments in the prevention of gastrointestinal scope-related infections. Infect Dis Clin North Am. 2018; 32:899–913.

7. Humphries RM, Yang S, Kim S, et al. Duodenoscope-related outbreak of a carbapenem-resistant Klebsiella pneumoniae identified using advanced molecular diagnostics. Clin Infect Dis. 2017; 65:1159–1166.

8. Marsh JW, Krauland MG, Nelson JS, et al. Genomic epidemiology of an endoscope-associated outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae. PLoS One. 2015; 10:e0144310.

9. Wendorf KA, Kay M, Baliga C, et al. Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol. 2015; 36:634–642.

10. McCafferty CE, Aghajani MJ, Abi-Hanna D, et al. An update on gastrointestinal endoscopy-associated infections and their contributing factors. Ann Clin Microbiol Antimicrob. 2018; 17:36.

11. Alfa MJ, Singh H, Nugent Z, et al. Simulated-use polytetrafluorethylene biofilm model: repeated rounds of complete reprocessing lead to accumulation of organic debris and viable bacteria. Infect Control Hosp Epidemiol. 2017; 38:1284–1290.

12. Akinbobola AB, Sherry L, Mckay WG, et al. Tolerance of Pseudomonas aeruginosa in in-vitro biofilms to high-level peracetic acid disinfection. J Hosp Infect. 2017; 97:162–168.

13. Loyola M, Babb E, Bocian S, et al. Standards of infection prevention in reprocessing flexible gastrointestinal endoscopes. Gastroenterol Nurs. 2020; 43:E142–E158.

14. Roberts CG. The role of biofilms in reprocessing medical devices. Am J Infect Control. 2013; 41(5 Suppl):S77–S80.

15. Alfa MJ, Singh H. Contaminated flexible endoscopes: review of impact of channel sampling methods on culture results and recommendations for root-cause analysis. Infect Control Hosp Epidemiol. 2022; 43:623–638.

16. Kovaleva J, Peters FT, van der Mei HC, et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev. 2013; 26:231–254.

17. Bridier A, Sanchez-Vizuete Mdel P, Le Coq D, et al. Biofilms of a Bacillus subtilis hospital isolate protect Staphylococcus aureus from biocide action. PLoS One. 2012; 7:e44506.

18. Ofstead CL, Heymann OL, Quick MR, et al. Residual moisture and waterborne pathogens inside flexible endoscopes: evidence from a multisite study of endoscope drying effectiveness. Am J Infect Control. 2018; 46:689–696.

19. Naas T, Cuzon G, Babics A, et al. Endoscopy-associated transmission of carbapenem-resistant Klebsiella pneumoniae producing KPC-2 beta-lactamase. J Antimicrob Chemother. 2010; 65:1305–1306.

20. Benedict M. Delays in endoscope reprocessing … and the biofilms within [Internet]. Olympus America Inc.;2018. [cited 2023 Jan 2]. Available from: https://medical.olympusamerica.com/sites/default/files/us/files/pdf/Whitepaper---Delays-in-Endoscope-Reprocessing-FINAL-APPROVED-single-page-version.pdf.

21. Foliente RL, Kovacs BJ, Aprecio RM, et al. Efficacy of high-level disinfectants for reprocessing GI endoscopes in simulated-use testing. Gastrointest Endosc. 2001; 53:456–462.

22. Bromiley N. White paper: eliminating the need for Extended Endoscope Soak Times by the use of INTERCEPTTM Detergent and INTERCEPTTM Foam [Internet]. Medivators;2018. [cited 2022 Jan 15]. Available from: https://www.medivators.com/sites/default/files/minntech/documents/INTERCEPT%20Foam%20White%20Paper%20%28Rev.%20C%29%20edit.pdf.

23. Agrawal D, Muscarella LF. Delayed reprocessing of endoscopes. Gastrointest Endosc. 2011; 73:853–854.

24. Saverina EA, Frolov NA, Kamanina OA, et al. From antibacterial to antibiofilm targeting: an emerging paradigm shift in the development of quaternary ammonium compounds (QACs). ACS Infect Dis. 2023; 9:394–422.

25. Nadagouda MN, Vijayasarathy P, Sin A, et al. Antimicrobial activity of quaternary ammonium salts: structure-activity relationship. Med Chem Res. 2022; 31:1663–1678.

26. Ofstead CL, Wetzler HP, Doyle EM, et al. Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines. Am J Infect Control. 2015; 43:794–801.

27. da Costa Luciano C, Olson N, DeGagne P, et al. A new buildup biofilm model that mimics accumulation of material in flexible endoscope channels. J Microbiol Methods. 2016; 127:224–229.

28. Ma GK, Pegues DA, Kochman ML, et al. Implementation of a systematic culturing program to monitor the efficacy of endoscope reprocessing: outcomes and costs. Gastrointest Endosc. 2018; 87:104–109.

29. Chen SH, Liu T, Lai HW, et al. Monthly endoscopy surveillance culture facilitates detection of breaches in the scope reprocessing procedure: 5‐year experience in an endoscopy center. Adv Dig Med. 2022; 9:103–111.

30. Rex DK, Sieber M, Lehman GA, et al. A double-reprocessing high-level disinfection protocol does not eliminate positive cultures from the elevators of duodenoscopes. Endoscopy. 2018; 50:588–596.

31. Vickery K, Pajkos A, Cossart Y. Removal of biofilm from endoscopes: evaluation of detergent efficiency. Am J Infect Control. 2004; 32:170–176.

32. Bartles RL, Leggett JE, Hove S, et al. A randomized trial of single versus double high-level disinfection of duodenoscopes and linear echoendoscopes using standard automated reprocessing. Gastrointest Endosc. 2018; 88:306–313.

33. Snyder GM, Wright SB, Smithey A, et al. Randomized comparison of 3 high-level disinfection and sterilization procedures for duodenoscopes. Gastroenterology. 2017; 153:1018–1025.

34. Alfa MJ. Biofilms on instruments and environmental surfaces: do they interfere with instrument reprocessing and surface disinfection?: review of the literature. Am J Infect Control. 2019; 47S:A39–A45.

35. Alfa MJ, Howie R. Modeling microbial survival in buildup biofilm for complex medical devices. BMC Infect Dis. 2009; 9:56.

36. Akinbobola AB, Amaeze NJ, Mackay WG, et al. ‘Secondary biofilms’ could cause failure of peracetic acid high-level disinfection of endoscopes. J Hosp Infect. 2021; 107:67–75.

37. Marion K, Freney J, James G, et al. Using an efficient biofilm detaching agent: an essential step for the improvement of endoscope reprocessing protocols. J Hosp Infect. 2006; 64:136–142.

38. Primo MG, Tipple AF, Costa DM, et al. Biofilm accumulation in new flexible gastroscope channels in clinical use. Infect Control Hosp Epidemiol. 2022; 43:174–180.

39. Qiu L, Zhou Z, Liu Q, et al. Investigating the failure of repeated standard cleaning and disinfection of a Pseudomonas aeruginosa-infected pancreatic and biliary endoscope. Am J Infect Control. 2015; 43:e43–e46.

40. Rutala WA, Weber DJ. Reprocessing semicritical items: an overview and an update on the shift from HLD to sterilization for endoscopes. Am J Infect Control. 2023; 51(11S):A96–A106.

41. Vickery K, Ngo QD, Zou J, et al. The effect of multiple cycles of contamination, detergent washing, and disinfection on the development of biofilm in endoscope tubing. Am J Infect Control. 2009; 37:470–475.

42. Ribeiro MM, Graziano KU, Olson N, et al. The polytetrafluoroethylene (PTFE) channel model of cyclic-buildup biofilm and traditional biofilm: the impact of friction, and detergent on cleaning and subsequent high-level disinfection. Infect Control Hosp Epidemiol. 2020; 41:172–180.

43. Gentle TM Jr, Kippenham RC Jr, Matta JJ. Improved endoscope cleaning performance with biofilm-removing detergents [Internet]. Medivators;2009. [cited 2024 Mar 20]. Available from: https://www.medivators.com/sites/default/files/minntech/documents/InterceptWhitePaper-October2009.pdf.

44. Fang Y, Shen Z, Li L, et al. A study of the efficacy of bacterial biofilm cleanout for gastrointestinal endoscopes. World J Gastroenterol. 2010; 16:1019–1024.

45. Murphy K, Sanow WR, Samantha Meuwissen MS, et al. Improved robustness of cleaning performance with non-enzymatic [Internet]. Medivators;2019. [cited 2024 Mar 20]. Available from: https://content.visionsfirst.com/Clients/Medivators/LIT-00049A.pdf.

46. Neves MS, da Silva MG, Ventura GM, et al. Effectiveness of current disinfection procedures against biofilm on contaminated GI endoscopes. Gastrointest Endosc. 2016; 83:944–953.

47. Ren-Pei W, Hui-Jun X, Ke Q, et al. Correlation between the growth of bacterial biofilm in flexible endoscopes and endoscope reprocessing methods. Am J Infect Control. 2014; 42:1203–1206.

48. Chiu KW, Tsai MC, Wu KL, et al. Surveillance cultures of samples obtained from biopsy channels and automated endoscope reprocessors after high-level disinfection of gastrointestinal endoscopes. BMC Gastroenterol. 2012; 12:120.

49. Decristoforo P, Kaltseis J, Fritz A, et al. High-quality endoscope reprocessing decreases endoscope contamination. Clin Microbiol Infect. 2018; 24:1101.

50. Cattoir L, Vanzieleghem T, Florin L, et al. Surveillance of endoscopes: comparison of different sampling techniques. Infect Control Hosp Epidemiol. 2017; 38:1062–1069.

51. Thornhill G, David M. Endoscope-associated infections: a microbiologist's perspective on current technologies. Tech Gastrointest Endosc. 2019; 21:150625.

52. Barakat MT, Girotra M, Huang RJ, et al. Scoping the scope: endoscopic evaluation of endoscope working channel damage/debris using a novel flexible inspection scope and assessment of the impact of automated drying and simethicone use on working channel fluid residue. Gastrointest Endosc. 2018; 87(6 Supplement):AB166–AB167.

53. Thaker AM, Kim S, Sedarat A, et al. Inspection of endoscope instrument channels after reprocessing using a prototype borescope. Gastrointest Endosc. 2018; 88:612–619.

54. Lineback CB, Nkemngong CA, Wu ST, et al. Hydrogen peroxide and sodium hypochlorite disinfectants are more effective against Staphylococcus aureus and Pseudomonas aeruginosa biofilms than quaternary ammonium compounds. Antimicrob Resist Infect Control. 2018; 7:154.

55. Ciocîrlan M. Low-cost disposable endoscope: pros and cons. Endosc Int Open. 2019; 7:E1184–E1186.

56. Rauwers AW, Kwakman JA, Vos MC, et al. Endoscope-associated infections: a brief summary of the current state and views toward the future. Tech Gastroint Endosc. 2019; 21:150608.

57. Rutala WA, Kanamori H, Sickbert-Bennett EE, et al. What’s new in reprocessing endoscopes: are we going to ensure “the needs of the patient come first” by shifting from disinfection to sterilization? Am J Infect Control. 2019; 47S:A62–A66.