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Communications to the Editor |

The Importance of Bronchoscope Reprocessing Guidelines : Raising the Standard of Care FREE TO VIEW

Lawrence F. Muscarella, PhD
Author and Funding Information

Affiliations: Custom Ultrasonics, Inc, Ivyland, PA,  Johns Hopkins Medical Institutions, Baltimore, MD

Correspondence to: Lawrence F. Muscarella, PhD, Custom Ultrasonics, Inc., 144 Railroad Dr, Ivyland, PA 18974; e-mail: lfm@myendosite.com



Chest. 2004;126(3):1001-1003. doi:10.1378/chest.126.3.1001
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Published online

To the Editor:

As expressed by Srinivasan et al (January 2004),1I agree that bronchoscope-specific reprocessing guidelines that provide step-by-step instructions similar to those developed for GI endoscopes are needed.2 By familiarizing the pulmonary community with important infection control and reprocessing policies and details, the development and publication of bronchoscope-reprocessing guidelines would contribute to the establishment of a more consistent standard of care and to a reduction of the risk of disease transmission via contaminated bronchoscopes. Because specific reprocessing guidelines for bronchoscopes have not been published, some health-care practitioners may be unaware of the current minimum bronchoscope-reprocessing requirements, failing to practice important infection control principles that are crucial to the prevention of nosocomial infection. Others may “borrow” published reprocessing guidelines for GI endoscopes and apply them to bronchoscopes. Even though several of the reprocessing instructions and steps for GI endoscopes are similar to those for bronchoscopes, the application of reprocessing guidelines for one type of instrument to another can be confusing, can result in noncompliance, and can establish an unnecessary precedent.

In addition to agreeing with the recommendation of Srinivasan et al that bronchoscope-reprocessing guidelines be developed and published, I would like to express my concern that the current standard of care, which condones, if not encourages, the clinical use of “just-reprocessed-and-wet-with-rinse-water” endoscopes including bronchoscopes, is potentially unsafe.3Several organizations recommend drying bronchoscopes, GI endoscopes, arthroscopes, and other types of flexible and rigid endoscopes after high-level disinfection at the end of the day—that is, before storage of the endoscope—but not between patient procedures during the course of the day.4 Moreover, for automated endoscope reprocessors (AERs) that are labeled with instructions to “sterilize” endoscopes using a liquid chemical sterilant (LCS) and “sterile” rinse water, most organizations do not recommend drying the endoscope after reprocessing (and water rinsing) at any time, either between patient procedures or at the end of the day.4To be clear, especially for a bronchoscope that may be reused several times in 1 day, the failure to dry the endoscope, including its external surfaces, suction channel, and biopsy port, immediately after reprocessing and before reuse all but ensures that the bronchoscope will be wet with rinse water when introduced into the patient’s lungs. Such a practice, while common, is dubious, because it can result in the transmission of waterborne bacteria during bronchoscopy and nosocomial infection, especially if the patient is critically ill and immunosuppressed. Several published reports59 have documented outbreaks (and pseudo-outbreaks) due to the transmission of waterborne bacteria via wet or improperly dried bronchoscopes (and GI endoscopes). As discussed in these reports, each bacterial outbreak was abruptly terminated once the bronchoscope was dried after manual or automated reprocessing (and water rinsing).

Therefore, I suggest, for the sake of clarity, completeness, and the elevation of patient care, that future bronchoscope reprocessing guidelines, as well as documents published by the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), recommend that, irrespective of the claim of the LCS or AER (ie, “high-level disinfection” or “liquid sterilization”), or the quality of the water used for rinsing (eg, tap water, “bacteria-free” water, or water labeled as “sterile”), the endoscope be dried after reprocessing both between patient procedures and prior to storage.3It is unclear why some professional organizations do not recommend drying the endoscope immediately after the completion of each reprocessing cycle,4 especially since drying, which can be achieved by flushing the suction channel and biopsy port of the bronchoscope with 70% alcohol followed by forced (or compressed) air, is an inexpensive and a relatively simple and rapid process that does not require complex equipment. It is also unclear why the CDC does not recommend drying the endoscope between patient procedures, or why the FDA does not require that the labeling of endoscopic equipment underscore the importance of drying the endoscope after manual and automated reprocessing (and water rinsing).1011

Finally, I recommend that future bronchoscope (and current GI endoscope) reprocessing guidelines address the importance of microbiologically monitoring the rinse water used during endoscope reprocessing. Currently, save for a few investigators including this letter’s author, the CDC does not recommend the monitoring of rinse water as required to determine its microbial quality.12 As a result, the microbial quality and content of the rinse water is generally unknown (unless the health-care facility is, for example, investigating a bacterial outbreak or pseudo-outbreak linked to contaminated bronchoscopes). Although it is surprisingly often overlooked in reprocessing guidelines, the failure to monitor the rinse water and to determine its microbial quality renders meaningless any advertised claim that the endoscope was successfully “high-level disinfected” or “sterilized,” because the possibility exists that the endoscope was recontaminated with waterborne bacteria during the water-rinsing phase that follows high-level disinfection or “liquid sterilization.” To be sure, contaminated rinse water yields contaminated endoscopes, irrespective of the potency, strength, claims, or effectiveness of the LCS.

The author is employed by Custom Ultrasonics, Inc., a manufacturer of automated devices used to reprocess (eg, cleaning and high-level disinfection) flexible endoscopes. Custom Ultrasonics funded the research and writing of this article. The article does not endorse a product or promote a proprietary technology.

Srinivasan, A, Wolfenden, LL, Song, X, et al (2004) Bronchoscope reprocessing and infection prevention and control: bronchoscopy-specific guidelines are needed.”Chest125,307-314. [CrossRef] [PubMed]
 
Society of Gastroenterology Nurses and Associates. Standards of infection control in reprocessing of flexible gastrointestinal endoscopes.Gastroenterol Nurs2000;23,172-179. [CrossRef] [PubMed]
 
Muscarella LF. Bronchoscope reprocessing: are changes needed? Available at: http://www.chestjournal.org/cgi/eletters/ 125/1/307. Accessed August 19, 2004.
 
Association of Perioperative Registered Nurses. Recommended practices for cleaning and processing endoscopes and endoscope accessories.AORN J2003;77,434-438, 441–442. [CrossRef] [PubMed]
 
Alvarado, C, Stolz, SM, Maki, DG Nosocomial infections from contaminated endoscopes: a flawed automated endoscope washer; an investigation using molecular epidemiology.Am J Med1991;91(suppl),272S-280S
 
Allen, JI, Allen, MO, Olson, MM, et al Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope.Gastroenterology1987;92,759-763. [PubMed]
 
Kolmos, HJ, Lerche, A, Kristoffersen, K, et al Pseudo-outbreak ofPseudomonas aeruginosain HIV-infected patients undergoing fiberoptic bronchoscopy.Scand J Infect Dis1994;26,653-657. [CrossRef] [PubMed]
 
Fraser, VJ, Jones, M, Murray, PR, et al Contamination of flexible fiberoptic bronchoscopes withMycobacterium chelonaelinked to an automated bronchoscope disinfection machine.Am Rev Respir Dis1992;145,853-855. [PubMed]
 
Struelens, MJ, Rost, F, Deplano, A, et al Pseudomonas aeruginosaand Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.Am J Med1993;95,489-498. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention. Bronchoscopy-related infections and pseudoinfections: New York, 1996 and 1998.MMWR Morb Mortal Wkly Rep1999;48,557-560. [PubMed]
 
Muscarella, LF Deja vu … all over again? The importance of drying.Infect Control Hosp Epidemiol2000;21,628-629. [CrossRef] [PubMed]
 
Muscarella, LF Application of environmental sampling to flexible endoscope reprocessing: the importance of monitoring the rinse water.Infect Control Hosp Epidemiol2002;23,285-289. [CrossRef] [PubMed]
 
To the Editor:

We greatly appreciate the recent thoughtful communication from Dr. Muscarella regarding our report that was recently published in CHEST (January 2004).1

We strongly agree with the importance of a terminal alcohol rinse and the air-drying of bronchoscopes prior to their use. We found this to be a particular area of uncertainty among the bronchoscopists whom we surveyed, with over half being unaware of the institutional approaches to such aspects of reprocessing. This issue represents an important practical dilemma, as busy bronchoscopists might feel pressured to abbreviate this important component of instrument reprocessing. Although we are not aware of any instance in which the use of wet endoscopes is “encouraged,” this practice may well occur in busy endoscopy suites. The practice of drying the inner lumen of endoscopes with alcohol and compressed air impedes the growth of microorganisms, and helps to reduce the risk of bacterial contamination. Given that this step is inexpensive, universally available, adds very little time to the reprocessing procedure, and may enhance safety, we agree that expanding this practice to every reprocessing cycle, and not just those at the end of the day or in instances in which nonsterile rinse water is used, is reasonable.

In contrast, routine microbiological sampling of endoscope rinse water, while intuitively potentially worthwhile, would be much more expensive and time-consuming, and would require equipment and systems that are not available at all endoscopy sites. As noted in our report, the optimum approaches to surveillance measures (eg, periodic instrument/equipment/environmental cultures and computerized analyses of culture isolates from bronchoscopy procedures) require further definition, and the impact of such approaches on patient outcomes requires investigation. Before making such a recommendation, we believe that studies should be performed to define the utility of this practice and to clarify optimum approaches. Rather than proposing such a practice in the absence of data, we believe that a current focus for the bronchoscopy community should be the development, dissemination, and implementation of bronchoscope-specific reprocessing guidelines, including personal reappraisal of the bronchoscopy infection control programs at one’s own institution14.

Importantly, the American College of Chest Physicians has been attuned to this need for the prevention of bronchoscopy-associated infection and pseudoinfection, and, in collaboration with the American Association of Bronchology, has sponsored the development of a consensus statement through its Interventional Chest/Diagnostic Procedures Network. It is noteworthy that instrument drying is a component of these recommendations. We hope that this effort, coupled with the resolve to implement these procedures by bronchoscopists, will enhance the safety of this procedure, which is integral to patient care.

References
Srinivasan, A, Wolfenden, LL, Song, X, et al Bronchoscope reprocessing and infection prevention and control: bronchoscopy-specific guidelines are needed.Chest2004;125,307-314. [CrossRef] [PubMed]
 
Srinivasan, A, Wolfenden, LL, Song, X, et al An outbreak ofPseudomonas aeruginosainfections associated with flexible bronchoscopes.N Engl J Med2003;348,221-227. [CrossRef] [PubMed]
 
Culver, DA, Gordon, SM, Mehta, AC Infection control in the bronchoscopy suite.Am J Respir Crit Care Med2003;167,1050-1056. [CrossRef] [PubMed]
 
Prakash, UBS Does the bronchoscope propagate infection?Chest1993;104,552-559. [CrossRef] [PubMed]
 

Figures

Tables

References

Srinivasan, A, Wolfenden, LL, Song, X, et al (2004) Bronchoscope reprocessing and infection prevention and control: bronchoscopy-specific guidelines are needed.”Chest125,307-314. [CrossRef] [PubMed]
 
Society of Gastroenterology Nurses and Associates. Standards of infection control in reprocessing of flexible gastrointestinal endoscopes.Gastroenterol Nurs2000;23,172-179. [CrossRef] [PubMed]
 
Muscarella LF. Bronchoscope reprocessing: are changes needed? Available at: http://www.chestjournal.org/cgi/eletters/ 125/1/307. Accessed August 19, 2004.
 
Association of Perioperative Registered Nurses. Recommended practices for cleaning and processing endoscopes and endoscope accessories.AORN J2003;77,434-438, 441–442. [CrossRef] [PubMed]
 
Alvarado, C, Stolz, SM, Maki, DG Nosocomial infections from contaminated endoscopes: a flawed automated endoscope washer; an investigation using molecular epidemiology.Am J Med1991;91(suppl),272S-280S
 
Allen, JI, Allen, MO, Olson, MM, et al Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope.Gastroenterology1987;92,759-763. [PubMed]
 
Kolmos, HJ, Lerche, A, Kristoffersen, K, et al Pseudo-outbreak ofPseudomonas aeruginosain HIV-infected patients undergoing fiberoptic bronchoscopy.Scand J Infect Dis1994;26,653-657. [CrossRef] [PubMed]
 
Fraser, VJ, Jones, M, Murray, PR, et al Contamination of flexible fiberoptic bronchoscopes withMycobacterium chelonaelinked to an automated bronchoscope disinfection machine.Am Rev Respir Dis1992;145,853-855. [PubMed]
 
Struelens, MJ, Rost, F, Deplano, A, et al Pseudomonas aeruginosaand Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.Am J Med1993;95,489-498. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention. Bronchoscopy-related infections and pseudoinfections: New York, 1996 and 1998.MMWR Morb Mortal Wkly Rep1999;48,557-560. [PubMed]
 
Muscarella, LF Deja vu … all over again? The importance of drying.Infect Control Hosp Epidemiol2000;21,628-629. [CrossRef] [PubMed]
 
Muscarella, LF Application of environmental sampling to flexible endoscope reprocessing: the importance of monitoring the rinse water.Infect Control Hosp Epidemiol2002;23,285-289. [CrossRef] [PubMed]
 
Srinivasan, A, Wolfenden, LL, Song, X, et al Bronchoscope reprocessing and infection prevention and control: bronchoscopy-specific guidelines are needed.Chest2004;125,307-314. [CrossRef] [PubMed]
 
Srinivasan, A, Wolfenden, LL, Song, X, et al An outbreak ofPseudomonas aeruginosainfections associated with flexible bronchoscopes.N Engl J Med2003;348,221-227. [CrossRef] [PubMed]
 
Culver, DA, Gordon, SM, Mehta, AC Infection control in the bronchoscopy suite.Am J Respir Crit Care Med2003;167,1050-1056. [CrossRef] [PubMed]
 
Prakash, UBS Does the bronchoscope propagate infection?Chest1993;104,552-559. [CrossRef] [PubMed]
 
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