DECONTAMINATION
Reprocessing scopes in the COVID era
Dr. Frank Bakker offers an insight in to best practice in endoscope reprocessing, in the wake of heightened concerns over the potential threat posed by COVID-19 – providing an overview of the latest evidence and guidance.
Endoscopy related infections pose a potential threat for healthcare systems worldwide. Infection outbreaks with highly resistant microorganisms have highlighted the problems of contaminated endoscopes.1 Outbreaks may increase morbidity and mortality, prolong hospital stays, and lead to secondary transmission to patients and staff.1
Although the exact number of
infections is unclear, contaminated flexible endoscopes have been reported as the vector for transmission of infections for many years.2 To date, there have been no confirmed
reports of SARS-CoV-2 (the virus that causes COVID-19) transmission through endoscopic procedures. However, many characteristics of the virus including its stability on various surfaces and modes of transmission, make gastrointestinal (GI) endoscopy a potentially high-risk procedure for COVID-19 transmission.3
There are a number of possible ways in which SARS-CoV-2 viral transmission could occur including person-to-person via direct contact with the virus, respiratory droplets, generation of infected aerosols during endoscopy, and through contact with contaminated endoscopic equipment, accessories and body fluids. Both upper and lower GI endoscopy procedures carry the risk of transmission of COVID-19.3 The additional risk of SARS-CoV-2 cross-infection is significant, as non- emergency endoscopies have only recently started taking place again. Data from the National Endoscopy Database indicate that total endoscopic activity fell to 5% of normal levels during the peak phase of the COVID-19 epidemic in the UK (down from approximately 35,000 reported procedures per week to 1,700 for the week ending 13 April 2020).4
As the number of procedures
increases, the need to ensure optimum infection prevention and control strategies will rise exponentially. Cleaning and reprocessing of flexible endoscopes to the
NOVEMBER 2020
highest standards will form a key component of these strategies.
Flexible endoscopes are reusable, highly complex devices which require considerable care during the essential decontamination process. Most flexible gastrointestinal endoscopes cannot withstand the conditions used in a steam sterilisation process. So, unlike rigid endoscopes, they cannot be autoclaved, yet still present a risk of infection if contaminated during use.5 Flexible endoscopes, which make contact with mucous membranes but do not penetrate sterile areas of the body, are generally reprocessed by high level disinfection rather than sterilisation. The term ‘high level disinfection’ is given to the process which is used to eliminate or kill all vegetative bacteria, mycobacteria, fungi and viruses (including coronaviruses). The BSG (British Society for Gastroenterology) recommends that a
guiding principle for decontamination is that ‘any patient must be considered a potential infection risk, and each endoscope and device must be reprocessed with the same rigour following every endoscopic procedure’.5
This advice is particularly
relevant today, when SARS-CoV-2 presents an ongoing risk.
Most flexible endoscopes are designed with multiple channels, which are difficult to clean and disinfect. The ability of microorganisms to form biofilms on the inner channel surfaces can therefore contribute to failure of the decontamination process.6 Natural bioburden levels detected on flexible GI endoscopes range from 105 CFU/ ml to 1010 CFU/ml after clinical use but effective cleaning reduces the number of microorganisms and organic debris by 4 logs, or 99.99%.6
It is now widely accepted that although COVID-19 is predominately spread by
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