Accepted Manuscript Surveillance of guideline practices for duodenoscope and linear echoendoscope reprocessing in a large health system Jack J. Brandabur, M.D, James E. Leggett, M.D, Lian Wang, MS, Rebecca L. Bartles, MPH, CIC, Lynda Baxter, MPH, MBA, George A. Diaz, M.D, Gary L. Grunkemeier, PhD, Shannan Hove, RN, Margret Oethinger, M.D.s, PhDs PII: S0016-5107(16)01774-0 DOI: 10.1016/j.gie.2016.03.1480 Reference: YMGE 9927 To appear in: Gastrointestinal Endoscopy Received Date: 13 November 2015 Accepted Date: 17 March 2016 Please cite this article as: Brandabur JJ, Leggett JE, Wang L, Bartles RL, Baxter L, Diaz GA, Grunkemeier GL, Hove S, Oethinger M, Surveillance of guideline practices for duodenoscope and linear echoendoscope reprocessing in a large health system, Gastrointestinal Endoscopy (2016), doi: 10.1016/ j.gie.2016.03.1480. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT February 26, 2016 Surveillance of guideline practices for duodenoscope and linear SC Jack J. Brandabur, M.D. RI PT echoendoscope reprocessing in a large health system James E. Leggett, M.D. M AN U Lian Wang, MS Rebecca L. Bartles, MPH, CIC Lynda Baxter, MPH, MBA George A. Diaz, M.D. TE D Gary L. Grunkemeier, PhD Shannan Hove, RN EP Margret Oethinger, M.D., PhD AC C Providence Health & Services, Renton, Washington Abbreviated title: Duodenoscope and linear echoendoscope surveillance cultures Key words: Endoscope surveillance; Endoscope reprocessing; duodenoscope; linear echoendoscope Word count: 3065 There are no conflicts of interest or financial support 1 ACCEPTED MANUSCRIPT February 26, 2016 Corresponding author: Jack Brandabur, MD, 1221 Madison St., Suite 1220 RI PT Seattle, WA 98104 Phone: (206)-215-4250 AC C EP TE D M AN U SC Jack.Brandabur@swedish.org 2 ACCEPTED MANUSCRIPT February 26, 2016 ABSTRACT Background and Aims: In order to assess the adequacy of currently recommended duodenoscope and linear echoendoscope (DLE) automatic endoscope reprocessing RI PT (AER) and high-level disinfection (HLD), we collected daily post-reprocessing surveillance cultures of 106 DLEs in 21 Providence and Affiliate Hospitals. SC Methods: Daily qualitative surveillance of dried, post-HLD DLE was conducted for a M AN U minimal of 30 days at each facility. Positivity rates of any microbial growth and growth of high-concern pathogens were reported. Potential effects of DLE manufacturer and age, and AER processor on culture-positivity rate were assessed. TE D Results: Microbial growth was recovered from 201 of 4032 (5%) specimens or 189 of 2238 (8.4%) encounters, including 23 (0.6%) specimens or 21 (0.9%) encounters for a high-concern pathogen. Wide variations in culture-positivity rate were observed across EP facilities. No striking difference in culture-positivity rate was seen among 8 DLE models, 3 DLE manufacturers, DLE age, manual or bedside cleanser, or automatic flushing AC C system use. However, there was suggestive evidence that Custom Ultrasonics AER had lower culture-positivity rate than Medivators AER regarding high-concern pathogen growth (0/1079 vs 21/2735 specimens, or 0/547 vs 20/1582 encounters). Two endoscopes grew intestinal flora on several occasions despite multiple HLD. No multidrug-resistant organism was detected. 3 ACCEPTED MANUSCRIPT February 26, 2016 Conclusions: In this multicenter DLE surveillance study, microbial growth was recovered in 5.0% of specimens (8.4% of encounters), with the majority being environmental microbes. Enteric bacterial flora was recovered in 0.6% of specimens RI PT (0.9% of encounters), despite adherence to 2014 U.S. guidelines and manufacturer’s recommendations for cleaning and HLD process. The observed better performance of M AN U INTRODUCTION SC Custom Ultrasonics AER deserves further investigation. Despite over 500,000 ERCP procedures using duodenoscopes having been performed annually in the United States1 since 2011, when new guidelines on reprocessing GI endoscopes were published2, only 146 infection associated medical TE D device adverse event reports involving duodenoscopes have been received by the Food and Drug Administration (FDA). An additional 152 reports involving automatic endoscope reprocessing (AER) systems have been filed for patient infection, patient EP exposures, or device contaminations related problems3. Before 2013, most ERCPassociated infections were attributed to breaches in end-user adherence to AC C manufacturer’s reprocessing instructions; since then, transmission of infections has been documented despite meticulous adherence to such instructions4-6. GI endoscopes, including duodenoscopes and linear echoendoscopes (DLE), are semi-critical devices that present challenges for cleaning and high-level disinfection (HLD)2, 7, prompting the FDA to issue a safety communication listing supplemental duodenoscope reprocessing measures8. 4 ACCEPTED MANUSCRIPT February 26, 2016 International guidelines recommend routine surveillance for bacterial contamination after reprocessing, using a variety of sampling methods at variable intervals9. Recent reports of ERCP-related carbapenem-resistant Enterobacteriaceae RI PT infections raised serious questions regarding the adequacy of existing guidelines for DLE reprocessing and HLD4, 5. In response to these reports, Providence Health & Services (PHS) and its SC affiliates, Swedish Health Services and Kadlec Medical, investigated the adequacy of M AN U current endoscope cleaning and reprocessing practices used in its facilities. METHODS Setting TE D This assessment was conducted within 21 facilities in which over 4500 ERCP procedures are performed each year, with individual facility volumes ranging from less than 1 ERCP procedure per week to an average of 10 per day. Twenty-three EUS and EP 61 ERCP endoscopes were in service during the study period, all from Olympus except 3 Pentax ERCP endoscopes (used in 1 facility), and 22 trial Fuji endoscopes (15 ERCP and AC C 7 EUS) at 5 facilities. Most Olympus ERCP endoscopes were of models 160 (n=38) and 180 (n=15). Because no human subjects were involved in this surveillance study, no IRB approval was required by PHS. All facilities across 5 western states used minimum specifications consistent with American Society for Gastrointestinal Endoscopy (ASGE) guidelines2 and manufacturers’ reprocessing recommendations for leak testing, cleaning, disinfection, drying, and 5 ACCEPTED MANUSCRIPT February 26, 2016 storage. Significant variation existed within the individual process steps, workflow, and facility design. At the end of an endoscopic procedure, each facility conducted a bedside clean with an enzymatic cleaner while still inside the endoscopy suite, followed by a RI PT thorough manual clean in a designated decontamination area, before placing each DLE in an AER for HLD. The manual cleaning consisted of wiping of all external surfaces, brushing of all internal channels and components, and flushing of the internal channels SC (manually in 3 facilities, using an automatic flushing aid in 18 facilities). Across the M AN U system, 7 brands of bedside cleaner, 8 brands of manual cleaners, 4 AER systems and five brands of high level disinfectants were used, although each facility used only one cleaning method during the time of microbiological surveillance in accordance with the manufacturer’s instructions. All necessary quality control parameters were reviewed TE D before each cycle. Sampling EP Collection: Between March and July 2015, daily cultures (Monday through Friday) from each AC C DLE were collected for a minimal of 30 days at each facility. Culturing occurred each morning on stored DLEs that had previously undergone HLD and complete drying. Some facilities opted to not culture DLEs that had not been reprocessed since their last culturing encounter. Sixteen of 21 facilities followed the protocol described in Appendix 1. In brief, one sample was collected using a sterile swab for swabbing the auxiliary port (if 6 ACCEPTED MANUSCRIPT February 26, 2016 available) and the elevator mechanism of the endoscope. A second specimen was collected using a sterilized, disposable channel cleaning brush for sampling the inside of the suction channels and working channel. Swab and brush tips were cut off and RI PT dropped into 2 separate vials containing 5 mL of tryptic soy broth. Three facilities collected cultures from the same sites but only using 1 or 2 swabs and no brush. Two facilities followed the flush method described by the Centers for Disease Control and SC Prevention (CDC)10 and collected only a single sample from each endoscope. Four M AN U brands of brushes and 5 brands of swabs were used to collect culture specimens. Among the 4 culture collection methods used, no significant differences were detected (Supplementary Table 1). TE D Laboratory Testing: Detailed instructions for processing the collected samples were provided to each facility’s laboratory (see Appendix 2). Broth cultures were incubated at 37°C in ambient EP air and read at 24 h and 48 h. Positive cultures were worked up to genus or species level using routine microbiology methods. High-concern pathogens included enteric AC C Gram-negative bacilli, Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus, Enterococcus spp. and Stenotrophomonas maltophilia. Coagulase-negative staphylococci, Bacillus spp., coryneform Gram-positive bacilli and other Gram-negative glucose-nonfermenters were considered environmental colonizers. In one laboratory, the recently published CDC protocol10 for quantitative cultures was followed. Variation existed in lab reporting format. 7 ACCEPTED MANUSCRIPT February 26, 2016 Reporting and Follow-up: Culture results were documented in a shared electronic record. Endoscopy and RI PT infection prevention were alerted to the growth of any high concern pathogens. If positive for microbial growth, the DLE was re-processed, re-cultured and quarantined before it was returned to use. The 2 endoscopes with multiple positive results were sent M AN U SC back to the manufacturer for additional investigation and repair. Statistical Analysis Because either one or two specimens were collected at each culturing encounter, both specimen-based and encounter-based culture-positivity rates were reported. TE D Culture-positivity rates, for any microbial growth and for high-concern pathogen growth, were summarized with exact 95% confidence interval (CI) for binomial probability. Stratification of the culture-positivity rates by various categorical factors EP were used for assessing difference among each factor, relying on the 95% CIs. Because no significant differences in the culture-positivity rates were observed among the 4 AC C culture collection methods (see supplementary Table 1 for details), they were not distinguished in subsequent analyses. DLE manufacturer, AER system, and endoscope usage (endoscope age used as a proxy) were the factors of primary interest. Poisson regression, which accounts for the varying numbers of cultures collected for each endoscope, was used for evaluating the effect of endoscope age on culture-positivity rates. Because an older-age endoscope in a low-volume facility might have less usage 8 ACCEPTED MANUSCRIPT February 26, 2016 than a newer endoscope in a high-volume facility, the regression evaluation was limited to the subgroup of endoscopes from the 3 high-volume facilities (possessing 10 or more endoscopes). The regression analysis was repeated for evaluating the collective effects RI PT of these 3 factors. Other potential factors available in the data were also investigated. Statistical Computing, Vienna, Austria). RESULTS SC The analyses were performed using R 3.1.0 statistical program (R Foundation for M AN U Altogether, 4032 surveillance culture specimens were obtained from 2238 encounters for the 106 DLE in clinical use. Of those, 201 (5.0%; 95% CI, 4.3%-5.7%) specimens or 189 (8.4%; 95% CI, 7.3%-9.7%) encounters showed microbial contamination after routine recommended bedside and manual cleaning, AER, and TE D drying procedures. Pathogenic organisms as described above were found in 0.6% (n=23) of specimens (95% CI, 0.4%-0.9%) or 0.9% (n=21) of encounters (95% CI, 0.6%-1.4%), none of which were multi-drug resistant organisms (MDRO) (see Table 1), EP cultured from 14 different endoscopes. Wide variations in the culture-positivity rates were noted among facilities (Figure 1), as well as cleaning and culturing processes AC C (Table 2). One facility (4 endoscopes, 176 cultures) detected no organisms at all during the surveillance period. Pathogenic organisms occurred in 1 to 5 occasions from 9/21 facilities. Pathogenic organisms were recovered in endoscopes from all 3 manufacturers, as well as from 5 of 8 endoscope models and 2 of 4 AER types. No trends were identified with cleaners or HLD solutions. Two endoscopes from different facilities had 9 ACCEPTED MANUSCRIPT February 26, 2016 multiple repeat positive results. One duodenoscope grew E coli on 4 occasions/specimens and one linear echoendoscope grew enteric flora on 3 occasions/specimens, including E coli, E gergoviae, E faecalis,and A calcoaceticus- RI PT baumannii complex (with multiple organisms isolated within two of the culture specimens). Both endoscopes were returned to the manufacturers for overhaul. The linear echoendoscope was noted to have significant deep grooves inside the working SC channel. Neither endoscope grew significant bacteria after service overhaul by M AN U manufacturer. Of the 21 encounters positive for high-concern pathogens, 12 had a clearly defined culture source. Notably, the elevator was implicated in all 12 encounters. The working channel specimen was implicated in only 2 out of 12 encounters. Table 3 shows the culture-positivity rates stratified by manufacturer or AER TE D system. Olympus endoscopes accounted for 85% of all culturing encounters (84% of all specimens). No manufacturer stood out as better or worse based on the 95% confidence intervals. Among the 4 AERs in use (Medivators accounting for 70% of the EP encounters or 68% of all specimens), culture-positivity rates were similar for any microbial growth, either encounter-based or specimen-based. Further stratification by AC C both manufacturer and AER system again showed no difference in the overall culturepositivity rates either, with broad overlap of 95% confidence intervals (Tables 4 and 5). However, the number of high-concern pathogens recovered was significantly lower for Custom Ultrasonics compared to Medivators AER (0/547 vs 20/1582 encounters or 0/1079 vs 21/2735 specimens, Table 3). Custom Ultrasonics AER has since been removed from the market for unrelated reasons11. When stratified by manufacturer, a 10 ACCEPTED MANUSCRIPT February 26, 2016 similar AER-influence was observed among Olympus DLE (0/912 Custom Ultrasonics vs 19/2394 Medivators specimens or 0/463 vs 19/1392 encounters, Tables 4 and 5). Because the 2 endoscopes with multiple positive encounters might skew the data, RI PT stratification of the high-concern positivity-rates, by AER, was repeated with those 2 cases removed and the same observation remained (data not shown). Because we were unable to determine the actual usage accrued by each SC individual DLE, we used individual DLE age from the time of purchase as a proxy for M AN U usage. Forty-three percent of DLE were >72 months of age (median 58 months, range 1-192 months). Regression analysis revealed no age effect on the culture-positivity rates among the 3 high-volume facilities (all p-values >0.05). Of note, the single duodenoscope that had both a high culture-positivity rate and persistent E coli growth TE D had been used for 77 months, and the single linear echoendoscope that showed persistent growth (3 occasions during the study period and 2 additional positive results outside the study period) had been used for 54 months. No other potential contributing EP factors examined, including endoscope model type, contributed significantly to culturepositivity (Supplementary Table 2). AC C Based on multivariable modeling for overall microbial growth, limited to DLEs from the 3 high-volume facilities, none of the factors of interest (DLE age, AER type, and manufacturer) was a significant independent determinant of culture-positivity on routine surveillance (all p values >0.1). Very low event counts, and hence several noevent sub-categories, rendered multivariable modeling unstable and unreliable for identifying contributing factors on the high-concern pathogen growth. 11 ACCEPTED MANUSCRIPT February 26, 2016 DISCUSSION Recent high profile MDRO outbreaks associated with DLE have presented RI PT endoscopists with an inconvenient truth: despite strict adherence to published guidelines bacteria may on occasion survive within our instruments12. We therefore collected surveillance microbiological cultures after routine cleaning, automatic SC reprocessing, and drying in a non-outbreak setting. Our average rates of any bacterial growth (5.0% of specimens or 8.4% of culturing encounters) and growth of high- M AN U concern pathogens (0.6% of specimens or 0.9% of encounters) were similar to other recent reports, including that from Virginia Mason Medical Center13. Most organisms recovered were low-concern environmental microbes and were likely due to postcleaning contamination during the storage period. No multidrug-resistant organism was TE D detected, nor was any patient transmission case, death, or significant patient morbidity related to DLE reprocessing was encountered during the study period. All endoscope models from 3 manufacturers, in clinical use during our month- EP long surveillance, demonstrated microbial contamination at similar rates. Indeed, AC C instruments from all 3 manufacturers and multiple models, including DLEs with similar elevator mechanisms, have been implicated in outbreaks3. No striking differences in bacterial recovery rates were noted among the various bedside or manual cleansers, or HLD solutions. However, significantly greater high-concern pathogen recovery from non-ultrasonic AER suggests that further investigation be undertaken to confirm our results. Our findings confirm the potential for transmission of bacteria between patients despite seemingly appropriate and optimal reprocessing techniques, as noted in the 12 ACCEPTED MANUSCRIPT February 26, 2016 concluding remarks of panel members at the May 14 to 15, 2015 FDA advisory panel meeting3. The elevator mechanism was implicated in all our positive high-concern culturing encounters with clearly reported culture site. This lends evidence that the RI PT elevator, with its complex and difficult to clean design, might be the culprit underlying recent outbreaks14. A small sample size could explain our finding of no significant differences among SC our culture collection methods, but the variations that we observed among these M AN U methods were much smaller than the variations among the 16 facilities using the same collection method, so we felt that it was reasonable to not distinguish the culture collection methods in analyzing our data. To our knowledge, no direct comparative culture methodological studies have been published involving DLE, whose elevator TE D mechanism is particularly difficult to clean14, 15. The CDC acknowledges that their advised method for obtaining endoscope cultures, designed for outbreak investigations, has not been validated for ensuring sterility in routine settings10. Moreover, the EP American Society for Microbiology has advised against the routine performance of endoscope cultures by clinical diagnostic laboratories16. Our use of disparate culture AC C collection methods reflects “real-life” data; we are planning a randomized study using a standardized culture collection method to further investigate enhanced processing methods of DLE going forward. It remains unclear how often surveillance should be done. The low prevalence of enteric pathogens makes it difficult to imagine that the use of current routine surveillance methods would be sufficient to avert an outbreak if done any less frequently than daily with quarantining of endoscopes until results are known. 13 ACCEPTED MANUSCRIPT February 26, 2016 Real-time, non-culture monitoring methods show promise, but are not yet validated for this purpose7. Persistent bacterial growth noted on some endoscopes in our study replicates the RI PT findings of other recent investigations17, and suggests the presence of a biofilm that renders microorganisms more resistant to repeated single cycles of HLD and/or small defects in instruments not otherwise compromising their functionality18. Indeed, the use SC of repeated washing and HLD at Virginia Mason Medical Center eradicated most M AN U persistent infections13, and has been advocated as an enhanced safety measure7. It is unknown what impact routine repeated HLD will have on the effective clinical use lifespan of these delicate instruments. Interestingly, endoscope age had no impact on our bacterial growth rates. DLE TE D age is an inexact proxy for endoscope usage over its lifetime. Although we attempted to indirectly assess the number of times that a DLE was used over its lifetime by performing subset analyses of high-volume facilities and by determining the frequencies EP of cultures obtained from older versus newer endoscopes, future studies should seek to directly measure the lifetime number of individual endoscope uses. Tracking of each AC C use of every endoscope are now in place and being used. The large variability observed across the 21 facilities included in this study highlights the importance of multi-center studies in examining the multistep, operatordependent, complex cleaning and reprocessing of DLE. Operator-dependent variability could also have contributed to the observed variability. Coordinated efforts may play an increasingly important role in assisting agencies such as the CDC or FDA to quickly 14 ACCEPTED MANUSCRIPT February 26, 2016 gather sufficient, generalizable data with which to provide timely evidence-based advice. We are planning a prospective evaluation with standardized culture methods in order to determine whether an already available, enhanced reprocessing method such ACKNOWLEDGEMENTS SC CRE Clinical Focus Group RI PT as double HLD will enhance the margin of safety for our patients. Alaska: Amy Myers, Lisa Lannet • California: Gisho Tatsutani, Ruth Arevalo • Montana: Claude Tonnerre, MD • Oregon: Ron Dworkin, MD, Ken Flora MD, Justin Jin, MD, Mike Philips MD, Nancy M AN U • Wilmoth RN • TE D O’Connor, Paul Sehdev, MD, Bill Sherer, Kim Heath, Thomas Rowe RN, Katie Washington: David Carlson, Judith Miller, Michael Myint, MD, Mike Oswald, John • EP Pauk MD, Martha Raymond, Casilde Sesti, Preston Smith System Office: Randy Axelrod, MD, David Carlson, Mike Oswald, Joanne Roberts, AC C MD, Casilde Sesti PhD. Antimicrobial Resistance and Emerging Pathogens Team, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention • Judith Noble Wang, PhD, Alexander J. Kallen, MD, MPH, FACP, Maroya Walters, PhD, Angela Coulliette-Salmond, PhD, Debra Taylor, MPH REFERENCES 15 ACCEPTED MANUSCRIPT February 26, 2016 5. 6. 7. 8. 9. 10. 11. 12. RI PT SC M AN U 4. TE D 3. EP 2. Puig, I., X. Calvet, M. Baylina, et al. How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis. PLoS One 2014;9:e92922. Petersen, B.T., J. Chennat, J. Cohen, et al. Multisociety guideline on reprocessing flexible GI endoscopes: 2011. Infect Control Hosp Epidemiol 2011;32:527-37. Meeting of the Gastroenterology and Urology Devices Panel of the Medical Devices Advisory Committee: Effective Reprocessing of Endoscopes Used in Endoscopic retrograde cholangiopancratography (ERCP) Procedures, May 14-15, 2015. Available from: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterial s/MedicalDevices/MedicalDevicesAdvisoryCommittee/GastroenterologyUrologyDevicesPanel/UCM446924.pdf. Epstein, L., J.C. Hunter, M.A. Arwady, et al., New Delhi metallo-beta-lactamaseproducing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA, 2014. 312(14): p. 1447-55. Kovaleva, J., F.T. Peters, H.C. van der Mei, et al., Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev, 2013. 26(2): p. 231-54. Wendorf, K.A., M. Kay, C. Baliga, et al., Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol, 2015. 36(6): p. 634-42. Rutala, W.A. and D.J. Weber, ERCP scopes: what can we do to prevent infections? Infect Control Hosp Epidemiol, 2015. 36(6): p. 643-8. Supplemental Measures to Enhance Duodenoscope Reprocessing: FDA Safety Communication. [Accessed 9/2/2015]; Available from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm454766. Gillespie, E.E., D. Kotsanas, and R.L. Stuart, Microbiological monitoring of endoscopes: 5-year review. J Gastroenterol Hepatol, 2008. 23(7 Pt 1): p. 106974. Interim protocol for healthcare facilities regarding surveillance for bacterial contamination of duodenoscopes after reprocessing. [Accessed 9/2/2015]; Available from: http://www.cdc.gov/hai/organisms/cre/cre-duodenoscopesurveillance-protocol.html. FDA Recommends Health Care Facilities Transition from Custom Ultrasonics Endoscope Washer/Disinfectors to Alternate Reprocessing Methods: FDA Safety Communication. [Accessed 2/26/2016]; Available from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm472462.htm?so urce=govdelivery&utm_medium=email&utm_source=govdelivery. Saviuc, P., R. Picot-Gueraud, J. Shum Cheong Sing, et al., Evaluation of the Quality of Reprocessing of Gastrointestinal Endoscopes. Infect Control Hosp Epidemiol, 2015. 36(9): p. 1017-23. AC C 1. 16 ACCEPTED MANUSCRIPT February 26, 2016 16. 17. 18. RI PT 15. SC 14. Ross, A.S., C. Baliga, P. Verma, et al., A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli. Gastrointest Endosc, 2015. 82(3): p. 477-83. 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Appendix 1 – ERCP endocope culturing process Appendix 2 – Endoscope surveillance culture lab processing instructions TE D FIGURE LEGENDS Facility variation in culturing results: Overall culture-positivity – specimen-based (A) and encounter-based (C); High-concern culture-positivity – specimen-based (B) and encounter-based (D). Each circle represents one endoscope, with the area proportional to the number of cultures collected. The black bars are the average rate for each facility. AC C EP Figure 1. 17 ACCEPTED MANUSCRIPT February 26, 2016 Table 1. Bacteria of high concern cultured from duodenoscopes and linear ultrasound endoscopes Number of Number of specimens encounters Single pathogen 1 E coli 5 SC S aureus RI PT Bacteria of high concern Enterococcus spp 1 5 5 3 1 1 1 1 1 1 1 1 1 1 1 1 Enterococcus spp, GNB 1 1 Enterococcus spp, yeast 1 1 E coli, E gergoviae, Enterococcus spp 1 1 S aureus, CoNS, Strep Viridans 2 2 Eikanella, apathogen Neisseria, Strep Viridans 1 1 M AN U Pseudomonas aeruginosa Klebsiella pneumoniae Enterobacter gergoviae Chryseobacterium TE D Leclercia adecarboxylata Two Pathogens AC C EP Stenotrophomonas, Chryseobacterium Three Pathogens 18 ACCEPTED MANUSCRIPT February 26, 2016 Sum: 23 21 19 ACCEPTED MANUSCRIPT February 26, 2016 Table 2. Cleaning and culturing processes among facilities Scope Manufacturer AER Manual Cleaner HLD Bedside cleaner Automated Flushing System Culture method Brush type Swab type Monthly EUS Volume Monthly ERCP Volume Olympus Puritan - 15 Olympus FLOQ 12 36 Pentax BBL 23 30 1 Flush None None - 6 RI PT # of endosc opes #1 3 Olympus Medivators Rapicide Endozime AW Endochoice Compliance Kit Yes #2 4 Olympus Medivators Rapicide Intercept Ep-4 Yes #3 3 Pentax Steris Reliance Reliance DG Endozime AW #4 2 Olympus Medivators Metricide Enzol Endozime SLR Kit Endochoice Compliance Kit SC Facility #5 1 Olympus Steris System 1 Gultaraldehyde Megazyme Endozime AW Yes 2 Swabs None FLOQ 4 2 #6 6 Olympus Medivators Rapicide First Step Kit Yes 2 Swabs None FLOQ 4 13 #7 3 Olympus KC Puritan - 6 #8 2 Olympus KC BBL - 3 #9 10 Olympus / Fuji KC BBL 34 32 #10 5 Olympus Olympus Dacron 27 23 #11 15 Olympus / Fuji Medivators Cidex OPA #12 4 Olympus / Fuji Custom Ultrasonics Cidex OPA #13 3 Olympus Medivators Rapicide #14 2 Olympus Steris Reliance Reliance DG #15 4 Olympus Medivators Rapicide #16 8 Olympus / Fuji Medivators Rapicide Cidex OPA Metricide Yes M AN U Endochoice Compliance Kit Endochoice Compliance Kit Endochoice Compliance Kit Endochoice Compliance Kit Endochoice Compliance Kit TE D Cidex OPA EP Cidex OPA AC C Custom Ultrasonics Custom Ultrasonics Custom Ultrasonics Custom Ultrasonics Endozime AW Ecolab Enzymatic Ecolab Enzymatic Ecolab Enzymatic Endozime AW Endozime AW Ecolab Enzymatic Tripower Enzymatic Endozime AW Intercept soap Ecolab Enzymatic No Metrisponge Tripower Enzymatic Endozime SLR Kit No Yes Yes Yes Providence Protocol Providence Protocol Providence Protocol Providence Protocol Yes 1 Flush None None 97 106 Yes 1 Swab None FLOQ 7 11 KC FLOQ 5 20 KC BBL - 2 US Endo Medlin e 12 14 KC BBL 37 24 Yes No First Step Kit Yes Endochoice Compliance Kit Yes 20 Providence Protocol Providence Protocol Providence Protocol Providence Protocol Providence Protocol Providence Protocol Providence Protocol ACCEPTED MANUSCRIPT February 26, 2016 Medivators Rapicide #18 2 Olympus Medivators Rapicide #19 19 Olympus / Fuji Medivators Rapicide #20 3 Olympus Medivators Rapicide #21 5 Olympus Custom Ultrasonics Metricide Cidex SPD Mediclean Ezymatic Mediclean Ezymatic Mediclean Ezymatic Ecolab Enzymatic Endozime SLR Kit No First Step Kit Yes First Step Kit Yes First Step Kit Yes Endochoice Compliance Kit Yes TE D EP AC C 21 Providence Protocol Providence Protocol Providence Protocol Providence Protocol Providence Protocol RI PT Olympus SC 2 M AN U #17 KC FLOQ - 8 KC FLOQ - 5 KC FLOQ 73 90 KC FLOQ 9 10 KC FLOQ 7 9 ACCEPTED MANUSCRIPT February 26, 2016 Culture positivity stratified by endocope manufacturer or AER system Specimen-based Encounter-based % Positive [n] % Positive [n] Categories (95% CI) RI PT Table 3: (95% CI) High-Concern Any Growth High-Concern Any Growth Organism SC Organism Fuji N= 508 specimens/ 274 encounters (23 scopes) Olympus M AN U Scope Manufacturer 5.9% [30] 0.4% [2] 9.5% [26] 0.4% [1] (4.0-8.3%) (0.0-1.4%) (6.3-13.6%) (0.0-2.0%) 4.8% [163] 0.6% [19] 8.2% [157] 1.0% [19] (4.1-5.6%) (0.3-0.9%) (7.0-9.6%) (0.6-1.6%) 6.7% [8] 1.7% [2] 10.0% [6] 1.7% [1] (2.9-12.7%) (0.2-5.9%) (3.8-20.5%) (0.0-8.9%) 5.6% [60] 0.0% [0] 10.1% [55] 0.0% [0] (4.2-7.1%) (0.0-0.3%) (7.7-12.9%) (0.0-0.7%) 4.6% [126] 0.8% [21] 7.6% [121] 1.3% [20] Pentax EP (80 scopes) TE D N= 3404 specimens/ 1904 encounters N= 120 specimens/ 60 encounters AC C (3 scopes) AER System Custom Ultrasonics N= 1079 specimens/ 547 encounters (29 scopes) Medivators 22 ACCEPTED MANUSCRIPT February 26, 2016 N= 2735 specimens/ 1582 encounters (3.9-5.5%) (0.5-1.2%) (6.4-9.1%) (0.8-1.9%) 6.9% [14] 1.0% [2] 11.8% [12] 1.0% [1] (3.8-11.2%) (0.1-3.5%) (6.2-19.6%) (0.0-5.3%) 7.1% [1] 0.0% [0] 14.3% [1] 0.0% [0] (0.2-33.9%) (0.0-23.2%) (0.4-57.9%) (0.0-41.0%) (71 scopes) N= 204 specimens/ 102 encounters (5 scopes) N= 14 specimens/ 7 encounters AC C EP TE D M AN U (1 scope) SC Steris System 1 RI PT Steris Reliance 23 ACCEPTED MANUSCRIPT February 26, 2016 Table 4: Culture positivity stratified by both AER system and endoscope manufacturer, specimen-based % Positive [n] AER system manufacture RI PT # of specimens Endoscope (95% CI) (# of endoscopes) High-concern Any growth 912 6.1% [56] 0.0% [0] (24) (4.7-7.9%) (0.0-0.4%) Olympus 2394 4.2% [100] 0.8% [19] (53) (3.4-5.1%) (0.5-1.2%) 84 7.1% [6] 0.0% [0] (2) (2.7-14.9%) (0.0-4.3%) 14 7.1% [1] 0.0% [0] (1) (0.2-33.9%) (0.0-23.2%) 167 2.4% [4] 0.0% [0] (5) (0.7-6.0%) (0.0-2.2%) 341 7.6% [26] 0.6% [2] (18) (5.0-11.0%) (0.1-2.1%) 120 6.7% [8] 1.7% [2] (3) (2.9-12.7%) (0.2-5.9%) TE D Steris Reliance M AN U Custom Ultrasonics Medivators SC organism EP Steris System 1 Fuji AC C Custom Ultrasonics Medivators Pentax Steris Reliance 24 ACCEPTED MANUSCRIPT February 26, 2016 Table 5: Culture positivity stratified by both AER system and endoscope manufacturer, encounter-based # of encounters Endoscope AER system manufacture (# of endoscopes) RI PT % Positive [n] (95% CI) High-concern Any growth 463 11.0% [51] 0.0% [0] (24) (8.3-14.2%) (0.0-0.8%) Olympus 1392 7.1% [99] 1.4% [19] (53) (5.8-8.6%) (0.8-2.1%) 42 14.3% [6] 0.0% [0] (2) (5.4-28.5%) (0.0-8.4%) 7 14.3% [1] 0.0% [0] (1) (0.4-57.9%) (0.0-41.0%) 84 4.8% [4] 0.0% [0] (5) (1.3-11.7%) (0.0-4.3%) 190 11.6% [22] 0.5% [1] (18) (7.4-17.0%) (0.0-2.9%) 60 10.0% [6] 1.7% [1] (3) (3.8-20.5%) (0.0-8.9%) TE D Steris Reliance M AN U Custom Ultrasonics Medivators SC organism EP Steris System 1 Fuji AC C Custom Ultrasonics Medivators Pentax Steris Reliance 25 ACCEPTED MANUSCRIPT February 26, 2016 Supplementary Table 1. Culture positivity stratified by culture collection methods Encounter-based % Positive [n] % Positive [n] (95% CI) (95% CI) Culture Collection Method High-Concern Any Growth (17 scopes) 1 Swab (4 scopes) 2 Swabs SC Organism 7.7% [33] 0.9% [4] (5.4-10.6%) (0.3-2.4%) (5.4-10.6%) (0.3-2.4%) 7.7% [1] 0.0% [0] 7.7% [1] 0.0% [0] (0.2-36.0%) (0.0-24.7%) (0.2-36.0%) (0.0-24.7%) 2.8% [5] 1.7% [3] 5.7% [5] 3.4% [3] (0.9-6.5%) (0.4-4.9%) (1.9-12.8%) (0.7-9.6%) 4.7% [162] 0.5% [16] 8.8% [150] 0.8% [14] (4.1-5.5%) (0.3-0.8%) (7.5-10.2%) (0.4-1.4%) TE D N= 13 specimens/ 13 encounters 0.9% [4] M AN U 7.7% [33] N= 429 specimens/ 429 encounters High-Concern Any Growth Organism 1 Flush RI PT Specimen-based (7 scopes) AC C Providence Protocol EP N= 176 specimens/ 88 encounters N= 3414 specimens/ 1708 encounters (78 scopes) 26 ACCEPTED MANUSCRIPT February 26, 2016 Supplementary Table 2:Culture positivity stratified by other potential factors (* trial endoscopes were excluded since not applicable). % Positive [n] (95% CI) % Positive [n] (95% CI) Categories High-Concern High-Concern Any Growth SC Any Growth Encounter-based RI PT Specimen-based Organism M AN U Endocope Type ERCP 4.9% [145] 0.5% [16] 8.5% [137] 0.9% [14] (4.2-5.8%) (0.3-0.9%) (7.2-9.9%) (0.5-1.4%) 5.1% [56] 0.6% [7] 8.4% [52] 1.1% [7] (3.9-6.6%) (0.3-1.3%) (6.3-10.9%) (0.5-2.3%) 5.0% [2] 0.0% [0] 10.0% [2] 0.0% [0] (0.6-16.9%) (0.0-8.8%) (1.2-31.7%) (0.0-16.8%) 2.4% [4] 0.0% [0] 4.9% [4] 0.0% [0] (0.7-6.1%) (0.0-2.2%) (1.3-12.0%) (0.0-4.4%) N= 2932 specimens/ 1619 encounters TE D (76 scopes) LEUS Organism N= 1100 specimens/ 619 encounters EP (30 scopes) Scope model among Olympus ERCP scopes AC C 130 N= 40 specimens/ 20 encounters (1 scope) 140 N= 164 specimens/ 82 encounters (3 scopes) 27 ACCEPTED MANUSCRIPT February 26, 2016 160 4.7% [66] 0.8% [11] 8.0% [64] 1.4% [11] (3.6-5.9%) (0.4-1.4%) (6.2-10.2%) (0.7-2.5%) 5.1% [41] 0.1% [1] (3.7-6.8%) (0.0-0.7%) N= 1418 specimens/ 796 encounters 180 N= 810 specimens/ 459 encounters HLD Solution N=972 specimens/ 676 encounters (34 scopes) Glutaraldehyde Metricide 0.2% [1] (6.3-11.7%) (0.0-1.2%) 5.6% [54] 0.1% [1] 8.0% [54] 0.1% [1] (4.2-7.2%) (0.0-0.6%) (6.1-10.3%) (0.0-0.8%) 7.1% [1] 0.0% [0] 14.3% [1] 0.0% [0] (0.2-33.9%) (0.0-23.2%) (0.4-57.9%) (0.0-41.0%) 7.3% [39] 0.6% [3] 11.3% [34] 1.0% [3] (5.2-9.8%) (0.1-1.6%) (8.0-15.5%) (0.2-2.9%) 4.0% [93] 0.7% [17] 7.6% [88] 1.4% [16] (3.3-4.9%) (0.4-1.2%) (3.2-9.3%) (0.8-2.2%) 6.9% [14] 1.0% [2] 11.8% [12] 1.0% [1] (3.8-11.2%) (0.1-3.5%) (6.2-19.6%) (0.0-5.3%) TE D N=14 specimens/ 7 encounters M AN U Cidex OPA (1 scope) 8.7% [40] SC (15 scopes) RI PT (38 scopes) AC C (12 scopes) EP N=536 specimens/ 300 encounters Rapicide N=2306 specimens/ 1153 encounters (54 scopes) Reliance DG N=204 specimens/ 102 encounters 28 ACCEPTED MANUSCRIPT February 26, 2016 (5 scopes) Bedside Cleaner Endochoice Compliance 0.3% [5] 8.1% [98] 0.4% [5] (4.3-6.3%) (0.1-0.6%) (6.6-9.8%) (0.1-1.0%) 7.1% [1] 0.0% [0] 14.3% [1] 0.0% [0] (0.2-33.9%) (0.0-23.2%) (0.4-57.9%) (0.0-41.0%) (53 scopes) N=14 specimens/ 7 encounters Endozime SLR N=236 specimens/ 118 encounters Ep-4 6.8% [16] 0.8% [2] 11.9% [14] 0.8% [1] (3.9-10.8%) (0.1-3.0%) (6.6-9.1%) (0.0-4.6%) 0.0% [0] 0.0% [0] 0.0% [0] 0.0% [0] (0.0-2.1%) (0.0-2.1%) (0.0-4.1%) (0.0-4.1%) 5.0% [74] 0.7% [11] 9.3% [69] 1.4% [10] (4.0-6.3%) (0.4-1.3%) (7.3-11.7%) (0.7-2.5%) 7.7% [1] 0.0% [0] 7.7% [1] 0.0% [0] (0.2-36.0%) (0.0-24.7%) (0.2-36.0%) (0.0-24.7%) 4.4% [6] 3.7% [5] 8.8% [6] 7.4% [5] TE D (7 scopes) M AN U (1 scope) SC Endozime AW RI PT 5.2% [103] N=1981 specimens/ 1206 encounters (4 scopes) First Step EP N=176 specimens/ 88 encounters AC C N=1476 specimens/ 738 encounters (34 scopes) Metrisponge N=13 specimens/ 13 encounters (4 scopes) Tripower Enzymatic 29 ACCEPTED MANUSCRIPT February 26, 2016 N=136 specimens/ 68 encounters (1.6-9.4%) (1.2-8.4%) 6.3% [2] 0.0% [0] (0.8-20.8%) (0.0-10.9%) 4.6% [56] 0.1% [1] (3.3-18.2%) (2.4-16.3%) (3 scopes) Cidex SPD N=32 specimens/ 16 encounters Ecolab Enzymatic (32 scopes) Endozime AW N=1083 specimens/ 725 encounters Enzol 0.0% [0] (1.6-38.3%) (0.0-20.6%) 8.3% [51] 0.2% [1] (3.5-5.9%) (0.0-0.5%) (6.2-10.8%) (0.0-0.9%) 4.7% [62] 0.6% [6] 8.3% [60] 0.7% [5] (4.4-7.3%) (0.2-1.2%) (6.4-10.5%) (0.2-1.6%) 6.5% [4] 4.8% [3] 6.5% [4] 4.8% [3] (1.8-15.7%) (1.0-13.5%) (1.8-15.7%) (1.0-13.5%) 1.5% [5] 0.3% [1] 3.0% [5] 0.6% [1] (0.5-3.5%) (0.0-1.7%) (1.0-6.8%) (0.0-3.3%) 5.6% [65] 0.6% [7] 10.4% [60] 1.0% [6] (4.4-7.1%) (0.2-1.2%) (8.0-13.2%) (0.4-2.2%) TE D (34 scopes) M AN U N=1215 specimens/ 615 encounters 12.5% [2] SC (2 scopes) RI PT Manual Cleaner (2 scopes) AC C Intercept EP N=62 specimens/ 62 encounters N=334 specimens/ 167 encounters (8 scopes) Mediclean Enzymatic N=1156 specimens/ 578 encounters (24 scopes) 30 ACCEPTED MANUSCRIPT February 26, 2016 Megazyme 7.1% [1] 0.0% [0] 14.3% [1] 0.0% [0] (0.2-33.9%) (0.0-23.2%) (0.4-57.9%) (0.0-41.0%) 4.4% [6] 3.7% [5] (1.6-9.4%) (1.2-8.4%) N=14 specimens/ 7 encounters Tripower Enzymatic N=136 specimens/ 68 encounters Automatic Flushing Equipment (10 scopes) Yes (96 scopes) Manufacturer EP Maintenance Company* 7.4% [5] (3.3-18.2%) (2.4-16.3%) 5.4% [20] 0.5% [2] 9.7% [18] 0.5% [1] (3.3-8.2%) (0.1-1.9%) (5.8-14.9%) (0.0-3.0%) 4.9% [181] 0.6% [21] 8.3% [171] 1.0% [20] (4.3-5.7%) (0.4-0.9%) (7.2-9.6%) (0.5-1.5%) 5.4% [96] 0.6% [11] 8.6% [93] 0.9% [10] (4.4-6.6%) (0.3-1.1%) (7.0-10.4%) (0.4-1.7%) 4.0% [63] 0.3% [5] 7.6% [59] 0.6% [5] (3.1-5.1%) (0.1-0.7%) (5.8-9.6%) (0.2-1.5%) 4.4% [6] 3.7% [5] 8.8% [6] 7.4% [5] TE D N=3660 specimens / 2052 encounters M AN U No N=372 specimens/ 186 encounters 8.8% [6] SC (3 scopes) RI PT (1 scope) AC C N=1762 specimens/ 1082 encounters (40 scopes) 3rd party N=1561 specimens/ 781 encounters (38 scopes) Both 31 ACCEPTED MANUSCRIPT February 26, 2016 N=136 specimens/ 68 encounters (1.6-9.4%) (1.2-8.4%) 7.4% [68] 1.0% [9] (5.8-9.3%) (0.4-1.9%) 4.1% [52] 0.6% [8] (3.3-18.2%) (2.4-16.3%) (3 scopes) Annually N=919 specimens/ 655 encounters Biannually (25 scopes) Repairs only N=1276 specimens/ 644 encounters 1.4% [9] (7.6-12.3%) (0.6-2.6%) 8.1% [51] 1.3% [8] (3.1-5.4%) (0.3-1.2%) (6.1-10.5%) (0.5-2.5%) 3.5% [45] 0.3% [4] 6.7% [43] 0.5% [3] (2.6-4.7%) (0.1-0.8%) (4.9-8.9%) (0.1-1.4%) TE D (32 scopes) M AN U N=1264 specimens/ 632 encounters 9.8% [64] SC (24 scopes) RI PT Maintenance Frequency* AC C EP Culture-positivity was seemingly not affected by endoscope model type, HLD solution, use of automatic flushing system (used in all but 3 facilities), or maintenance frequency. For high-concern pathogen, there were some differences in the culture-positivity rate for some bedside cleansers, manual cleansers, and maintenance company. However, most the differences disappeared when the 2 scopes with multiple positive encounters were excluded (data not shown). The manual cleansing agent Enzol still showed higher positivity rate than Ecolab Enzymatic (3/62 vs. 1/1215 specimens or 3/62 vs. 1/615 encounters). Since Enzol was used in only one facility equipped with 2 DLEs and both the total number of positive events and sample size were small, this difference was not convincing. 32 ACCEPTED MANUSCRIPT positive specimens at each facility0:505pecimens =1005pecimens 40' 0 ll) 0 ?30320Facility ACCEPTED MANUSCRIPT positive specimens at each facilityspecimens 100 specimens _r 01 I I positive specimens Facility ACCEPTED MANUSCRIPT positive encounters at each facility: 0.0 0.8 3.0 4.3 4.9 5.9 6.3 8.0 8.6 8.8 9.0 93125 65100143143136 7.7 7.9152 50 0:10encounters 40o-m?e?e Facility ACCEPTED MANUSCRIPT positive encounters at each facilityencounters 50 encounters 20' 15- 10' positive encounters Facility ACCEPTED MANUSCRIPT Acronym list: DLE - Duodenoscope and Linear Echoendoscope AER - Automatic Endoscope Reprocessing /Reprocessor FDA - Food and Drug Administration EUS - Endoscopic Ultrasound ASGE - American Society of Gastrointestinal Endoscopy AC C EP TE D MDRO - Multi-drug Resistant Organisms M AN U CI – Confidence Interval SC ERCP - Endoscopic Retrograde Cholangiopancreatography RI PT HLD - High-Level Disinfection ACCEPTED MANUSCRIPT Version 3, March 31, 2015 ERCP Scope Culturing Process working copy as of 3/31/15 Scopes will be cultured each morning. Put on PPE: Mask, eye protection, gown and sterile gloves. Establish a sterile field using a sterile drape (table cover 50x90 ref DYNJP2319) RI PT 1)Put on mask, goggles and gown 2)Place Sterile drape on working surface, keeping drape sterile. 3) Put on sterile gloves 4) Grab scope and place on one far end of the sterile field 5) Once scope cultured, place scope back in tray 6) Fold utilized portion of drape over 7) Remove sterile gloves and then repeat steps 3 -6 *Note depending on number of scopes more than one drape may be required The following process requires 2 people. SC Equipment Needed for Scope Cultures M AN U 1. Cleaning Brush submitted to CSSD for packaging and processing in Sterad Kimberly-Clark CB-X II Dual Ended Cleaning Brush. REF # 60219 Lawson #114985. 2. Dacron swabs – Copan 172C or equivalent such as BD swabs- Lawson Number 224140, PH&S Contract PLB0220, Mfr BD, Vendor (Distributor) Cardinal 3. Sterile Scissors (package # 56302) – From MSC TE D 4. Sterile water – (or equivalent would be sterile saline in Lawson # 313026, Sodium Chloride Inhalation Solution, USP, 15ml, REF R0159, Smiths Medical ASD, Inc., Vendor Tri-Anim, Contract: 14-000313-RP-GEN) 5. Tryptic soy broth vials 5ml (Remel Ref # R07224) 6. Lab requisition – supplied by Dynacare/LabCorp EP 7. Lab specimen bag with biohazard symbol Will need 1 brush, 1 Copan Swab, 2 sterile scissors, 2 tryptic vials per scope AC C Step 1: Label 2 vials ( A and E) with scope model, scope serial number, date cultured, staff initials Step 2: (use vial E)- Auxiliary and Elevator • Dip Copan Dacron swab in sterile water • Swab auxiliary port (if available) • Swab elevator on top, bottom, sides and the wire. • Cut end of swab off with sterile scissors into tryptic soy broth vial labelled E Step 3: (use vial A) – All other channels • Dip sterile brush into sterile water ACCEPTED MANUSCRIPT Version 3, March 31, 2015 • Run brush down both suction channels • Run brush down working channel • Cut end of brush off with sterile scissors into tryptic vial labelled A RI PT Step 4: Place both vials (E and A) in lab specimen bag with pre filled lab requisition • Log onto ERCP scope culturing log • Take all vials to C floor lab AC C EP TE D M AN U SC • ACCEPTED MANUSCRIPT Version 2, March 20, 2015 Endoscope Surveillance Cultures Sample ID _______________________ RI PT Ordering provider - 651 Epidemiology Test Code – EPIDC Purpose – SC Reprocessed endoscopes should be free of microbial pathogens except for small numbers of relatively avirulent microbes that represent exogenous environmental contamination (e.g., coagulase-negative Staphylococcus, Bacillus species, diphtheroids). Limited identification of pathogenic organisms will be performed. Additionally, all specimens will be screened for multi-drug resistant Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumanii including E. coli isolates exhibiting hyper-ampC phenotype (resistant to cefoxitin, ceftazidime and ceftriaxone). Specimen Processing – M AN U The endoscopy department will send two swabs to the First Hill lab for each accession. They will be labeled A and E and have an identifier for the scope that was tested. “A” stands for all other and will contain a small brush. “E” stands for elevator and will contain a swab. Hospital Labs (First Hill, Cherry Hill, Issaquah, Ballard Labs)— Microbiology— TE D Assure that the lids are on tightly and sent on the next available shipment to Microbiology. These should not be accessioned until arrival in microbiology. 1. Accession the test, using the provider 651 and the test code of EPIDC. 2. Incubate tubes at 35-37°C. Broth Culture Work-up— EP 1. Examine broths for turbidity. If all broths are clear at 24 hours, re-incubate at 35-37°C for an additional day. AC C 2. If a broth is turbid, subculture the broth to Blood Agar and MacConkey Agar plates. Do not issue a preliminary result. Note which broth is cloudy. a. Examine the MacConkey agar for Gram-negative rods. • Perform ID and susceptibility if enough isolated colonies are present. It may be necessary to subculture representative colonies of each morphology type to a non-selective media for isolation and for susceptibility testing. • If no GNRs on Mac, issue final report as described in the Reporting section. b. Examine the Blood Agar for Staph aureus and Enterococcus species. Rule out MRSA and/or VRE if either is present. • Report MRSA, MSSA, VRE, or “Enterococcus, not VRE” if present. c. Freeze ALL potentially pathogenic isolates. d. See reporting guidelines below. If any potentially pathogenic organisms are isolated, include the endoscope site (Elevator or Brushes, as noted in Specimen Processing above). Immediately call any culture positive for a Multidrug Resistant Gram-Negative Rod to Infection Control (206)386-2054. If unavailable, page Infection Control On-Call through the hospital operator (206)386-6000. Provide verbal result including: organism, collection date, model/serial number of scope. ACCEPTED MANUSCRIPT Endoscope Culture Workup Criteria Report Type Final Final (48 – 72 hrs) Report description No growth at 2 days Insignificant bacteria present. No Gram-negative rods isolated Sensi NA NA Biochemicals, Vitek ID/Susc Acceptable Vitek ID and meets MDRO criteria Prelim NA Acceptable Vitek ID and DOES NOT meets MDRO criteria Final (72-96 hrs) Unacceptable Vitek ID and meets MDRO criteria. Isolate presumptively ID as E. coli or Pseudomonas aeruginosa Final (72-96 hrs) Unacceptable Vitek ID and meets MDRO criteria Isolate is oxidase-negative and presumptive ID NOT E. coli Set up API 20E Unacceptable Vitek ID and meets MDRO criteria Isolate is oxidase-positive and presumptive ID NOT Pseudomonas aeruginosa Set up API 20NE Unacceptable Vitek ID and DOES NOT meet MDRO criteria Final (3- 5 days) “Growth of GNR detected. Identification to follow.” MULTI-DRUG RESISTANT GRAM-NEGATIVE RODS ISOLATED. MDRO Identified as: Organism Name Specific site: xxxx Organism Name isolated. Specific site: xxxx Organism does not meet multi-drug resistant Gram Negative Rod criteria. MULTI-DRUG RESISTANT GRAM-NEGATIVE RODS ISOLATED. MDRO Identified as: Presumptive Organism Name Specific site: xxxx MULTI-DRUG RESISTANT GRAM-NEGATIVE RODS ISOLATED. MDRO Identified as: Presumptive Organism Name Specific site: xxxx MULTI-DRUG RESISTANT GRAM-NEGATIVE RODS ISOLATED. Gram-negative rods isolated Specific site: xxxx No R/O MRSA using cefoxitin susceptibility Final (72-96 hrs) Vitek ID/Susc Final (72-96 hrs) Gram-negative rods isolated Specific site: xxxx No further workup Organism does not meet multi-drug resistant gram-negative rod criteria Methicillin-susceptible Staph aureus isolated OR Methicillin-resistant Staph aureus isolated Specific site: xxxx No GNR isolated Enterococcus species isolated. OR Vancomycin-resistant Enterococcus species isolated. Specific site: xxxx No GNR isolated EP Enterococcus AC C Staph aureus SC M AN U Final (72-96 hrs) RI PT Workup Negative Catalase, Staph latex, Pyr, Wet Mount/Gram stain if needed TE D Growth No growth Coag-neg Staph, diphtheroids, Bacillus, α-strep, Yeast Gram-negative rods Final (72-96 hrs) Final (72-96 hrs) Yes Yes Yes Yes Yes NA Yes