Risk Factors for Transmission of Carbapenem Resistant Enterobacteriaceae (CRE) Infection During Endoscopic Retrograde Cholangiopancreatography (ERCP)

Abstract Background Reusable duodenoscopes utilized for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures are challenging to clean thoroughly. Outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) have been associated with the use of duodenoscopes even when no clear breaches in manufacturer-recommended manual cleaning and high-level disinfection have been found. We evaluate the impact of implementation of ethylene oxide (ETO) sterilization on rates of ERCP-associated CRE. Methods The charts of all patients who developed CRE colonization or infection between 2012 and 2018 in a large tertiary care teaching hospital were reviewed to determine whether the patient had an ERCP in the 90 days prior to the CRE culture date. Rates of CRE acquisition per 100 ERCPs performed were calculated and compared pre (ERCP performed January 2012 through February 2015) and post-implementation (ERCP performed March 2015 thru December 2018) of routine ETO sterilization of duodenoscope following high-level disinfection (HLD) with an automatic endoscope reprocessor (AER) rather than HLD alone. Results Between 2012 and 2018, 44 patients had first clinical culture with CRE within 90 days of ERCP (36% blood, 34% wound/surgical, 25% urinary and 7% respiratory sources). ETO sterilization of duodenoscopes following manufacturer recommended HLD was implemented March 2015. Rates of first CRE clinical culture within 90 days of ERCP decreased from 0.80 with HLD alone to 0.25 per 100 ERCP procedures with HLD plus ETO (unadjusted IRR 0.31 ETO vs. HLD alone, 95% CI 0.16–0.57, p-value < 0.001). This decrease occurred despite implementation of updated CLSI carbapenem breakpoints in July 2016. Figure 1 shows post ERCP CRE clinical culture trends over time Conclusion Implementation of ETO sterilization for duodenoscopes following HLD reduced our rates of post ERCP CRE in clinical cultures within 90 days of the procedure. Disclosures All authors: No reported disclosures.

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Prevalence of, and risk factors for, carriage of carbapenem-resistant Enterobacteriaceae among hospitalized patients in Japan

Journal of Hospital Infection ◽

10.1016/j.jhin.2017.07.015 ◽

2017 ◽

Vol 97 (3) ◽

pp. 212-217 ◽

Cited By ~ 30

Author(s):

N. Yamamoto ◽

R. Asada ◽

R. Kawahara ◽

H. Hagiya ◽

Y. Akeda ◽

...

Keyword(s):

Risk Factors ◽

Hospitalized Patients ◽

Carbapenem Resistant ◽

Carbapenem Resistant Enterobacteriaceae

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Duodenoscope-Associated Outbreak of a Carbapenem Resistant Enterobacteriaceae

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.738 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s197-s197

Author(s):

Sung Ran Kim ◽

Joon Young Song ◽

Min Hee Cho ◽

Ji Yeon Song

Keyword(s):

Gel Electrophoresis ◽

Case Control ◽

Pulsed Field Gel Electrophoresis ◽

Control Analysis ◽

Endoscopic Retrograde ◽

Carbapenem Resistant ◽

Case Control Analysis ◽

Record Review ◽

Carbapenem Resistant Enterobacteriaceae ◽

Cleaning Protocol

Background: We describe and evaluate our outbreak of carbapenem-resistant K. pneumoniae transmitted by contaminated duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedures. Methods: An outbreak investigation was performed when Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) were identified from bile specimens of 4 patients. The investigation included medical record review, practice audits, and surveillance cultures of duodenoscopes and environmental sites. If available, clinical specimens were obtained from patients who had undergone ERCP in the previous 3 months. Carbapenem-resistant Enterobacteriaceae (CRE) screening cultures were performed to identify additional patients until no CRE cases were detected during 2 consecutive weeks. Pulsed-field gel electrophoresis (PFGE) of KPC-KP isolates was implemented. Results: In total, 12 cases were identified with exposure to duodenoscope from February 2019 through April 2019, including 6 cases with infections and 6 asymptomatic carriers. Case-control analysis showed that 2 specific duodenoscopes would be associated with the KPC-KP outbreak. Duodenoscope reprocessing procedures did not deviate from manufacturer recommendations for reprocessing. After ethylene oxide (EO) gas sterilization, the outbreak was terminated. Conclusions: Meticulous cleaning protocol and enhanced surveillance are necessary to prevent outbreaks of CRE. Notably, enhanced cleaning measures, such as sterilization for duodenoscopes, would be required after procedures with KPC-KP carriers.Funding: NoneDisclosures: None

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An Outbreak of Carbapenem-resistant Klebsiella pneumoniae Infections Associated With Endoscopic Retrograde Cholangiopancreatography (ERCP) Procedures at a Hospital

American Journal of Infection Control ◽

10.1016/j.ajic.2010.04.191 ◽

2010 ◽

Vol 38 (5) ◽

pp. e141 ◽

Cited By ~ 10

Keyword(s):

Klebsiella Pneumoniae ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Endoscopic Retrograde ◽

Carbapenem Resistant

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Risk factors for adverse events associated with endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a retrospective study

BMC Gastroenterology ◽

10.1186/s12876-021-02031-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Xiaojia Chen ◽

Fan Wang ◽

Jing Liu ◽

Wenhui Tao ◽

Zhang Zhang ◽

...

Keyword(s):

Risk Factors ◽

Bile Duct ◽

Adverse Events ◽

Endoscopic Retrograde Cholangiopancreatography ◽

Univariate Analysis ◽

Balloon Dilation ◽

Endoscopic Papillary Balloon Dilation ◽

Endoscopic Retrograde ◽

Therapeutic Success ◽

Surgically Altered Anatomy

Abstract Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be a challenge in patients with surgically altered anatomy. We aimed to identify the risk factors of ERCP-related adverse events in patients with surgically altered anatomy in our center. Methods We included patients with surgically altered anatomy who underwent ERCP between April 2017 and December 2020 at our center. Clinical characteristics and outcomes were analyzed in univariate and multivariate methods to identify the risk factors for adverse events. Results A total of 121 ERCP procedures were performed in 93 patients. The papilla or surgical anastomosis was successfully reached in 113 cases (93.4%). Diagnostic success was achieved in 106 cases (93.8%) and subsequent therapeutic success was achieved in 102 cases (96.2%). ERCP-related adverse events occurred in 31 cases (25.6%). In univariate analysis, not first time ERCP attempt, a CBD stone diameter ≥ 15 mm, multiple cannulation attempts, endoscopic papillary balloon dilation, endoscopic papillary large balloon dilation, endoscopic retrograde biliary drainage, biopsy in the bile duct or papilla, mechanical lithotripsy use, and stone retrieval basket were associated with ERCP-related adverse events. In multivariate analysis, multiple cannulation attempts (OR 5.283; 95% CI 1.088–25.659; p = 0.039), endoscopic papillary balloon dilation (OR 4.381; 95% CI 1.191–16.114; p = 0.026), and biopsy in the bile duct or papilla (OR 35.432; 95% CI 2.693–466.104; p = 0.007) were independently associated with ERCP-related adverse events. Conclusions ERCP in patients with surgically altered anatomy was feasible and safe. Interventions including multiple cannulation attempts, endoscopic papillary balloon dilation, and biopsy in the bile duct or papilla were independent risk factors for ERCP-related adverse events.

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