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Follow-up and Management of Patients Exposed to a Flawed Automated Endoscope Washer-Disinfector in a Digestive Diseases Unit

Published online by Cambridge University Press:  21 June 2016

Philippe Vanhems*
Affiliation:
Unite d'Epidémiologie et d'Hygiène Hospitalière, Hôpital Edouard Herriot, Lyon, France
Angèle Gayet-Ageron
Affiliation:
Unite d'Epidémiologie et d'Hygiène Hospitalière, Hôpital Edouard Herriot, Lyon, France
Thierry Ponchon
Affiliation:
Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
Claude Bernet
Affiliation:
Unite d'Epidémiologie et d'Hygiène Hospitalière, Hôpital Edouard Herriot, Lyon, France
Jean-Alain Chayvialle
Affiliation:
Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
Christine Chemorin
Affiliation:
Unite d'Epidémiologie et d'Hygiène Hospitalière, Hôpital Edouard Herriot, Lyon, France
Léone Morandat
Affiliation:
Unite d'Epidémiologie et d'Hygiène Hospitalière, Hôpital Edouard Herriot, Lyon, France
Marie-Ange Bibollet
Affiliation:
Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
Philippe Chevallier
Affiliation:
Laboratoire de Virologie, Hôpital Edouard Herriot, Lyon, France
Jacques Ritter
Affiliation:
Laboratoire de Virologie, Hôpital Edouard Herriot, Lyon, France
Jacques Fabry
Affiliation:
Unite d'Epidémiologie et d'Hygiène Hospitalière, Hôpital Edouard Herriot, Lyon, France
*
Unite d'Epidémiologie et d'Hygiene Hospitalière, Hôpital Edouard Herriot, Place d'Arsonval, 69437 Lyon cedex 03, France ([email protected])

Abstract

The possible transmission of pathogens to 236 persons exposed to an endoscope processed in a flawed automated endoscope washer-disinfector in a gastrointestinal endoscopy unit was investigated. During 6 months, 197 patients (83.5%) were followed up, and no cases of acute human immunodeficiency virus, hepatitis C virus, or hepatitis B virus infection were observed. This event created the conditions for improvements in safety procedures.

Type
Concise Communications
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2006

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References

1.Spach, DH, Silverstein, FE, Stamm, WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993; 118:117128.Google Scholar
2.Schembre, DB. Infectious complications associated with gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 2000; 10:215232.Google Scholar
3.Dwyer, DM, Klein, EG, Istre, GR, Robinson, MG, Neumann, DA, McCoy, GA. Salmonella newport infections transmitted by fiberoptic colonoscopy. Gastrointest Endosc 1987; 33:8487.Google Scholar
4.Rohr, MR, Castro, R, Morais, M, Brant, CQ, Castelo Filho, A, Ferrari Junior, AP. Risk of Helicobacter pylori transmission by upper gastrointestinal endoscopy. Am J Infect Control 1998; 26:1215.Google Scholar
5.Srinivasan, A, Wolfenden, LL, Song, X, et al. An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes. N Engl J Med 2003; 348:221227.Google Scholar
6.Bronowicki, JP, Venard, V, Botte, C, et al. Patient to patient transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997; 337:237240.Google Scholar
7.Kozarek, RA. Transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997; 337:18481849.Google Scholar
8.Birnie, GG, Quigley, EM, Clements, GB, Follet, EA, Watkinson, G. Endoscopic transmission of hepatitis B virus. Gut 1983; 24:171174.Google Scholar
9.Leape, LL. Reporting of adverse events. N Engl J Med 2002; 347:16331638.Google Scholar
10.Vincent, C. Understanding and responding to adverse events. N Engl J Med 2003; 348:10511056.Google Scholar
11.Amoore, J, Ingram, P. Learning from adverse incidents involving medical devices. BMJ 2002; 325:272275.Google Scholar
12.Lawton, R, Parker, D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002; 11:1518.Google Scholar
13.Alvarado, CJ, Stolz, S, Maki, DG. Nosocomial infections from contaminated endoscopes: a flawed automated endoscope washer: an investigation using molecular epidemiology. Am J Med 1991; 91(Suppl 3B): 272S280S.Google Scholar
14.Schelenz, S, French, G. An outbreak of multidrug-resistant Pseudomonas aeruginosa infection associated with contamination of bronchoscopes and an endoscope washer-disinfector. J Hosp Infect 2000; 46:2330.Google Scholar
15.Fournet, J, Dhumeaux, D. Le livre blanc de l'hépato-gastro-entérologie: les maladies de l'appareil digestif et du foie: les enjeux. Tours, Italy: Société Nationale Française de Gastroentérologie, 2001.Google Scholar