Infection Control & Hospital Epidemiology (2019), 40, 106–108 doi:10.1017/ice.2018.298
Concise Communication
Mycobacterium avium pseudo-outbreak associated with an outpatient bronchoscopy clinic: Lessons for reprocessing
Jessica L. Seidelman MD1,2, Richard J. Wallace, Jr MD3, Elena Iakhiaeva3, Ravikiran Vasireddy3, Barbara A. Brown-Elliott MS3, Celeste McKnight4, Luke F. Chen MBBS, MPH, CIC, FRACP1, Terry Smith MS3 and
Sarah S. Lewis MD, MPH1,2 1Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, 2Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, 3Department of Microbiology, the University of Texas Health Science Center at Tyler, Tyler, Texas and 4Duke Clinical Microbiology Laboratory, Duke University Medical Center, Durham, North Carolina (Present affiliation: Merck & Co, Philadelphia, PA [L.F.C].)
Abstract
We identified a pseudo-outbreak of Mycobacterium avium in an outpatient bronchoscopy clinic following an increase in clinic procedure volume. We terminated the pseudo-outbreak by increasing the frequency of automated endoscope reprocessors (AER) filter changes from quarterly to monthly. Filter changing schedules should depend on use rather than fixed time intervals.
(Received 9 July 2018; accepted 11 September 2018; electronically published 26 November 2018)
Inadequate high-level disinfection or sterilization of broncho- scopes can result in contaminated bronchoalveolar lavage (BAL) fluids or transmission of opportunistic pathogens that cause colonization or infection of susceptible patients. Nontuberculous mycobacteria (NTM) are ubiquitous in the environment, prone to form biofilms, and resistant to most disinfectants including chlorine, which make them well suited to cause outbreaks.1–3 Bronchoscope-related NTM outbreaks have been attributed to contaminated automated endoscope reprocessors (AERs).2 We identified an increase in positive Mycobacterium avium
complex (MAC) BAL samples from an outpatient bronchoscopy suite in the fall of 2015. This report describes our investigation of what proved to be a pseudo-outbreak and the measures taken to mediate it.
Methods
The pseudo-outbreak took place at the Duke Clinic, an outpatient clinic operated by Duke University Hospital, a 957-bed tertiary- care hospital in Durham, North Carolina. Duke is a high-volume lung transplant center, and frequent routine post-transplant surveillance bronchoscopies are performed in this clinic. Prior to the outbreak, in October 2014, 2 endoscopy procedural areas were consolidated into a single area. Following the clinic merge, the monthly average volume of bronchoscopies performed in this single clinic increased from 105 to 143. The reprocessing area of the clinic houses 3 AERs; the water source and number of AERs were constant during the study.
Author for correspondence: Jessica L. Seidelman, 310 Trent Drive, Hanes House Room 181, Durham, NC 27710. E-mail:
jessica.seidelman@
duke.edu
Cite this article: Seidelman JL, et al. (2019). Mycobacterium avium pseudo-outbreak
associated with an outpatient bronchoscopy clinic: Lessons for reprocessing. Infection Control & Hospital Epidemiology 2019, 40, 106–108. doi: 10.1017/ice.2018.298
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
Our epidemiologic investigation included (1) review of mycobacterial culture data, (2) inspection of the bronchoscopy clinical and reprocessing areas, and (3) environmental sampling in the bronchoscope reprocessing area. We determined the per- centage of positive MAC BAL isolates from the outpatient bronchoscopy clinic from January 2014 through June 2017 and defined the baseline (January 1, 2014, through June 30, 2015), outbreak (July 1, 2015, through February 28, 2016), and post- outbreak (March 1, 2016, through June 30, 2017) periods. The prevalences of MAC-positive cultures were compared between periods using 2-sample t tests. Infection preventionists reviewed reprocessing, endoscope
handling and storage, and general cleanliness of the bronchoscopy reprocessing area and clinic environment. As part of the investi- gation, cultures of biofilm were obtained at the time of routine (quarterly) filter change from tubing distal to the 1-µm, 0.4-µm, and 0.1-µm filters serving one of the AERs. These swab samples were decontaminated with cetylpyridine chloride,4 and streaked onto Mitchison and Middlebrook 7H11 agar plates.5 MAC isolates were identified using standard methods, including a commercial molecular probe (AccuProbe, Hologic, Marlborough, MA). As part of the investigation, a subset of 8 clinical MAC isolates
suspected to be related to the pseudo-outbreak, 2 clinical MAC isolates from a different clinical area not suspected to be related to the pseudo-outbreak, and 2 MAC isolates recovered from the AER tubing were submitted for species identification using partial 16S r-RNA gene sequencing and molecular relatedness testing using variable-number tandem repeats (VNTR) typing6 and pulsed-field gel electrophoresis (PFGE).7 Subsequently, VNTR was performed on a convenience sample of archived MAC iso- lates from BAL specimens obtained in the clinic during the baseline (n=6), outbreak (n=4), and postoutbreak (n=4) periods.
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