Background: Endoscopes represent the medical devices most commonly linked to health care-associated outbreaks and pseudo-outbreaks. Most of the recent outbreaks and pseudo-outbreaks have resulted from contaminated automated endoscope reprocessors (AER) or the use of damaged or malfunctioning bronchoscopes or contaminated equipment. Objectives: We investigated a pseudo-outbreak of Pseudomonas putida and Stenotrophomonas maltophilia recovered from bronchial washing (BW) specimens obtained during bronchoscopy in a bronchoscopy unit. Methods: Samples were obtained from environmental surfaces in the endoscopy suite, bronchoscopes, and bronchoscopic dispensable material, and specimens of cleaning solutions, cleaning brushes, the AER, and the ultrasound system were sent for bacterial culture. Medical records were reviewed to identify possible infections after a bronchoscopy. Results:P. putida and S. maltophilia were isolated from BW samples of 39 patients. The bronchoscopy models Olympus BF-1T160 and BF-160 were contaminated. Both bronchoscopes and other contaminated material (cleaning brushes, diluted cleaning solutions, and the sink) were isolated, but new cases continued to appear. The AER was recently installed, and new connections were used for the water lines and new tubes were connected to the AER. Initially, specimens were obtained from the external circuits and the internal walls of the AER. Finally, cultures were made from the filters on the water lines, and growth of P. putida and S. maltophilia was found. The investigation revealed that the BW specimens were contaminated because sterile saline was injected by means of the biopsy port of the bronchoscope and was recovered through the same channel by means of the proximal suction port. No patients developed clinical signs or symptoms of infection, but the positive cultures did lead to treatment of 21 patients. Conclusions: We described a pseudo-outbreak related to a contaminated bronchoscope because of inadequate installation of the AER for used new water lines and because the new tubes were connected to the AER. The antibacterial filters of the AER used tap water, and this may have contained low levels of microorganisms. No serious clinical complications derived from this pseudo-outbreak.

Keywords:
Bronchoscope, Pseudo-outbreak, Automated endoscope reprocessor, Pseudomonas putida, Stenotrophomonas maltophilia
1.
Du Rand IA, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, Mandal S, Martin J, Mils J, Navani N, Rahman NM, Wrightson JM, Munawar M; British Thoracic Society Bronchoscopy Guideline Group: British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax 2013;68(suppl 1):i1-i44.
2.
Casal RF, Ost DE, Eapen GA: Flexible bronchoscopy. Clin Chest Med 2013;34:341-352.
3.
Peaper DR, Havill NL, Aniskiewicz M, Callan D, Pop O, Towle D, Boyce JM: Pseudo-outbreak of Actinomyces graevenitzii associated with bronchoscopy. J Clin Microbiol 2015;53:113-117.
4.
Cosgrove SE, Ristaino P, Caston-Gaa A, Fellerman DP, Nowakowski EF, Carroll KC, Orens JB, Perl MT, Maragakis LL: Caveat emptor: the role of suboptimal bronchoscope repair practices by a third-party vendor in a pseudo-outbreak of Pseudomonas in bronchoalveolar lavage specimens. Infect Control Hosp Epidemiol 2012;33:224-229.
5.
Kenters N, Huijskens EGW, Meier C, Voss A: Infectious diseases linked to cross-contamination of flexible endoscopes. Endosc Int Open 2015;3:E259-E265.
6.
Weber DJ, Rutala WA: Lessons learned from outbreaks and pseudo-outbreaks associated with bronchoscopy. Infect Control Hosp Epidemiol 2012;33:230-234.
7.
Metha AC, Prakash UBS, Garland R, Haponik E, Moses L, Schaffner W, Silvestri G: American College of Chest Physicians and American Association for Bronchology consensus statement: prevention of flexible bronchoscopy-associated infection. Chest 2005;128:1742-1755.
8.
Kirschke DL, Jones TF, Craig AS, Chu PS, Mayernick GG, Patel JA, Schaffner W: Pseudomonas aeruginosa and Serratia marcescens contamination associated with a manufacturing defect in bronchoscopes. N Engl J Med 2003;348:214-220.
9.
Ece G, Erac B, Limoncu MH, Baysak A, Oz AT, Ceylan KC: Stenotrophomonas maltophilia pseudo-outbreak at a university hospital bronchoscopy unit in Turkey. West Indian Med J 2014;63:59-61.
10.
Silva CV, Magalhães VD, Pereira CR, Kawagoe JY, Ikura C, Ganc AJ: Pseudo-outbreak of Pseudomonas aeruginosa and Serratia marcescens related to bronchoscopes. Infect Control Hosp Epidemiol 2003;24:195-197.
11.
Schuetz AN, Hughes RL, Howard RM, Williams TC, Nolte FS, Jackson D, Ribner BS: Pseudo-outbreak of Legionella pneumophila serogroup 8 infection associated with a contaminated ice machine in a bronchoscopy suite. Infect Control Hosp Epidemiol 2009;30:461-466.
12.
Srinivasan A, Wolfenden LL, Song X, Mackie K, Hartsell TL, Jones HD, Diette GB, Orens JB, Yung RC, Ross TL, Merz W, Scheel PJ, Haponik EF, Perl TM: An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes. N Engl J Med 2003;348:221-227
13.
Rosengarten D, Block C, Hidalgo-Grass C, Temper V, Gross I, Budin-Mizrahi A, Berkman N, Benenson S: Cluster of pseudoinfections with Burkholderia cepacia associated with a contaminated washer-disinfector in a bronchoscopy unit. Infect Control Hosp Epidemiol 2010;31:769-771.
14.
Chroneou A, Zimmerman SK, Cook S, Willey S, Eyre-Kelly J, Zias N, Shapiro DS, Beamis JF Jr, Craven DE: Molecular typing of Mycobacterium chelonae isolates from a pseudo-outbreak involving an automated bronchoscope washer. Infect Control Hosp Epidemiol 2008;29:1088-1090.
15.
Sorin M, Segal-Maurer S, Mariano N, Urban C, Combest A, Rahal JJ: Nosocomial transmission of imipenem-resistant Pseudomonas aeruginosa following bronchoscopy associated with improper connection to the Steris System 1 processor. Infect Control Hosp Epidemiol 2001;22:409-413.
16.
Vanhems P, Gayet-Ageron A, Ponchon T, Bernet C, Chayvialle JA, Chemorin C, Morandat L, Bibollet MA, Chevallier P, Ritter J, Fabry J: Follow-up and management of patients exposed to a flawed automated endoscope washer-disinfector in a digestive diseases unit. Infect Control Hosp Epidemiol 2006;27:89-92.
17.
Mean M, Mallaret MR, Bichard P, Shum J, Zarski JP: Gastrointestinal endoscopes cleaned without detergent substance following an automated endoscope washer/disinfector dysfunction. Gastroenterol Clin Biol 2006;30:665-668.
18.
Stigt JA, Wolfhagen MJ, Smulders P, Lammers V: The identification of Stenotrophomonas maltophilia contamination in ultrasound endoscopes and reproduction of decontamination failure by deliberate soiling tests. Respiration 2015;89:565-571.
19.
Waite TD, Georgiou A, Abrishami M, Beck CR: Pseudo-outbreaks of Stenotrophomonas maltophilia on an intensive care unit in England. J Hosp Infect 2016;92:392-396.
20.
Scorzolini L, Mengoni F, Mastroianni CM, Baldan R, Cirillo DM, De Giusti M, Marinelli L, Cottarelli A, Fattorini L, Vullo V: Pseudo-outbreak of Mycobacterium gordonae in a teaching hospital: importance of strictly following decontamination procedures and emerging issues concerning sterilization. New Microbiol 2016;39:25-34.
© 2016 S. Karger AG, Basel
2016
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.