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harbored high-concern organisms or actionable levels of
microbial growth (>100 CFU). Mold and Gram-negative
bacteria were detected, including S. maltophilia, Sphin-
gomonas phyllosphaerae, and Escherichia coli/Shigella. At
one hospital, high protein levels were detected in seven
of eight bronchoscopes, indicating manual cleaning failed
to remove soil. Visual inspections using magnification and
borescopes identified residue or defects in 100 percent of
bronchoscopes.”
Ofstead and her team found that audits evaluating per-
sonal protective equipment use and reprocessing guideline
adherence (e.g., point-of-care pre-cleaning; leak testing;
manual cleaning; visual inspection; cleaning verification;
high-level disinfection; rinsing; drying; storage; transport
and handling) identified breaches in all five hospitals. They
explain, “Technicians in two hospitals (Sites 1, 5) performed
most reprocessing steps correctly, but bronchoscopes at both
sites harbored S. maltophilia due to contaminated rinse
water. In three hospitals (Sites 2-4), nearly all steps were
performed incorrectly or skipped entirely. In light of these
breaches and observations that most bronchoscopes were
damaged and contaminated, a recommendation was made
that procedures in two hospitals be halted until strict protocols
could be implemented and personnel retrained. In addition,
it was recommended that badly damaged bronchoscopes be
removed from service and replaced with single-use, sterile
bronchoscopes or new reusable bronchoscopes constructed
with sterilizable materials.”
“It is possible that contaminated bronchoscopes could
infect COVID-19 patients with other infectious diseases,” says
Cori L. Ofstead, MSPH. “It’s also possible that contaminated
devices could expose healthcare workers to the virus when
they are cleaning and disinfecting them between patients.
Given what we’ve learned about the overall level of
bronchoscope contamination, we urgently need to know
whether healthcare personnel are getting exposed to the
virus or other pathogens on bronchoscopes due to the lack
of PPE and other supplies.”
The authors note that sterile, disposable bronchoscopes
would “substantially reduce the risks” to patients and
hospital staff, and also point out that disposable devices are
recommended by the American Association for Bronchology
and Interventional Pulmonology. In addition, many tests for
COVID-19 result in false negatives, while a bronchoscopy
is the most accurate way to confirm that a patient has the
virus, Ofstead notes.
As Ofstead and Hopkins, et al. (2020) observe, “There is
currently an urgent need to reduce the number of patients
requiring hospitalization or intensive care, in part because of
shortages of ventilators and personal protective equipment.
Given the high bronchoscope contamination rates found
during routine use in previous studies, we must now consider
the possibility of bronchoscopy-associated transmission of
COVID-19 or other pathogens that could cause secondary
infections. Theoretically, high-level disinfection should elim-
inate these risks when bronchoscopes are well-maintained
and reprocessed according to manufacturer instructions
and professional guidelines. However, even during normal
patient loads, practices are frequently substandard, and
pathogens are commonly present on patient-ready endo-
scopes. The presence of gastrointestinal pathogens found in
bronchoscopes and BAL samples suggests the possibility of
cross-contamination caused by intermingling bronchoscopes
and gastrointestinal endoscopes during reprocessing. This
hypothesis is supported by findings at one hospital where
protein and bioburden levels on brand-new bronchoscopes
increased significantly following manual cleaning prior to
any clinical use.”
The researchers add, “Reprocessing effectiveness has
not been evaluated in epidemic settings and research is
needed to confirm that COVID-19, influenza viruses, and
other pathogens are eliminated in these settings. The use of
sterile, disposable bronchoscopes would substantially reduce
the risks for patients and reprocessing
personnel, and this approach has
been recommended by the American
Association for Bronchology and “It is
Interventional Pulmonology. However,
possible that
single-use bronchoscopes are not
contaminated
universally available and may not be
sufficient for advanced bronchoscopy. bronchoscopes
When reusable bronchoscopes must
could infect
be used, they should be segregated
from gastrointestinal endoscopes COVID-19
and sterilized rather than relying on
patients
high-level disinfection. We urgently
recommend further research assessing with other
potential contamination of reusable
infectious
bronchoscopes with viral, bacterial, and
diseases.”
fungal pathogens. Laboratory methods
should include bacterial/fungal cultures — Cori L.
and molecular assays (e.g., real-time Ofstead, MSPH
PCR) for respiratory viruses, including
COVID-19. To optimize the accuracy of results, samples should
be taken from multiple components using a friction-based
technique (e.g., flush-brush-flush for sampling ports and
channels). Laboratories should utilize methods that foster
growth of microbes that are viable but not easily culturable
(e.g., using neutralizers to counteract residual reprocessing
chemicals that could suppress growth, concentrating
samples, and incubating for at least five to seven days or
six to eight weeks when culturing for Mycobacteria). Due
to the relative insensitivity of viral culture and potential
safety concerns related to cultivating COVID-19, molecular
testing (i.e., targeted real-time PCR and multiplex respiratory
panels) could be considered to assess for contamination
with viral pathogens.”
“No patient should suffer from preventable nosocomial
infections due to bronchoscopy,” Ofstead says. “Using
bronchoscopes that have physical defects and harbor
viruses, bacteria, or fungi puts vulnerable patients at risk
and could have adverse effects on public health. Institutions
are obligated to protect both patients and reprocessing
personnel and ensure bronchoscope reprocessing practices
adhere to guidelines and manufacturer instructions.”
Reference:
Ofstead CL, Hopkins KM and Binnicker MJ. Potential impact of contam-
inated bronchoscopes on novel coronavirus disease (COVID-19) patients.
Infect Control Hosp Epidemiol. 2020 Apr 2:1-10.
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