CRE: stowaways travelling with your endoscope

Infections with carbapenem resistant enterobacteriaceae (CRE) are beyond doubt among the most dreadful infection control threats currently. In The Netherlands, a setting well known for its low incidence of highly resistant pathogens, such as MRSA, the 2011 outbreak of Oxa-48 producing CRE had a unprecedented impact. More recently, a small outbreak of KPC producing Klebsiella pneumoniae in a long-term healthcare facility in The Netherlands again emphasized the hideous threat these CRE entail. Until then, only a few isolated cases of CRE, mostly imported from high incidence areas around the world, were reported in The Netherlands. None of these mounted an outbreak, thanks to timely and appropriate infection control measures. All in all, the infection control system in Dutch health care facilities is seemingly doing fairly well until now, when it comes to the CRE threat. However, unanticipated routes of transmission may infringe save infection control programs.

In January 2014 the CDC reported on such an unanticipated transmission mode. Contaminated endoscopes used in ERCP procedures were responsible for an NDM-producing E. coli outbreak. It was found that manual cleaning and high-level disinfection of these endoscopes may not reliably prevent transmission of multidrug-resistant bacteria by these exam tools ( These high-tech medical tools are undisputed vehicles of transmission for microorganisms and are notoriously difficult to disinfect. The outbreak was curbed by switching to a new sterilization procedure using gas sterilization with ethylene oxide. In The Netherlands, ethylene oxide is not available for use in healthcare facilities. In our setting, high level disinfection is used for flexible scopes and rigid endoscopes are sterilized using steam.

Another problem with gas sterilization using ethylene oxide (besides the fact that ethylene oxide is a toxic compound and a carcinogen) is that it cannot be used in between patients due to the lengthy cycle and aeration time. But then again, Infection preventionists all over the world will unanimously agree that lack of time is not your infection control programs’ best friend.

Category : Blog

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