WATER QUALITY IN ENDOSCOPE REPROCESSING

1 HIRL BirminghamHIRL BirminghamHIRL BirminghamWATER QUALITY IN ENDOSCOPE REPROCESSINGC hristina BradleyHospital Infection Research LaboratoryCity HospitalBirmingham, UKHIRL BirminghamHIRL BirminghamHIRL BirminghamCONTROLS ASSURANCE IN CONTROLS ASSURANCE IN INFECTION CONTROLINFECTION CONTROLD econtamination of medical devicesDecontamination of medical devicesValidate washer disinfectors using HTM Validate washer disinfectors using HTM 2030, with particular emphasis on 2030, with particular emphasis on ensuring that the cleaning process is ensuring that the cleaning process is effectiveeffectiveHSC 1999/179 HSC 1999/179 HIRL BirminghamHIRL BirminghamHIRL BirminghamENDOSCOPE WASHER ENDOSCOPE WASHER DISINFECTORS : DISINFECTORS : PROBLEMSPROBLEMSzDisinfectant concentrationzMachine contaminationzWater qualityzMaintenancezValidationHIRL BirminghamHIRL BirminghamHIRL BirminghamWater is used forzPreparation of detergentzPreparation of disinfectantzFinal rinsingHIRL BirminghamHIRL BirminghamHIRL BirminghamHIRL BirminghamHIRL BirminghamHIRL BirminghamWater : potential problemszChemical residueszParticulateszMicro-organismszEn dotoxinsHIRL BirminghamHIRL BirminghamHIRL BirminghamThe Importance of WATER QualityzWater will effect Cleaning performance Rinsing Device compatibility Device/procedure safety Microbial contamination levelsHIRL BirminghamHIRL BirminghamHIRL BirminghamWaterzTap WATER is not sterilezRising main WATER rarely used Holding tanks become contaminated Mycobacterium spp.

2 , Pseudomonas spp.,fungi, etczContaminated scopes False positive microbiologyzInfectionHIRL BirminghamHIRL BirminghamHIRL BirminghamSource of contaminationzIncoming WATER inadequately treatedzWater treatment systemzEndoscope washer disinfector formation of biofilmHIRL BirminghamHIRL BirminghamHIRL BirminghamWater treatment methodszFiltration mzReverse OsmosiszAddition of biocideszUltraviolet lightzCombination of methodsHIRL BirminghamHIRL BirminghamHIRL BirminghamMachine contaminationMachine contaminationDue to:-zInadequate cleaning, disinfection and maintenance of machinezStatic WATER remaining in tanks and pipeworkzPoor QUALITY WATER supplyzBiofilm within the machineHIRL BirminghamHIRL BirminghamHIRL BirminghamProblemszPseudomonas species machine contamination, WATER treatmentzAtypical mycobacteria misdiagnosis of infection, resistant strainsHIRL BirminghamHIRL BirminghamHIRL BirminghamPseudomonaszBronchoscopes 30% of specimens taken with scopes yielded PseudomonaszLoose biopsy port capz3 deaths probably due to outbreakzInstruments removed from servicezWas Pseudomonas in the WATER ?

3 Rinse WATER negative on cultureSrinivasan NEJM 2003; 348: 221-7 HIRL BirminghamHIRL BirminghamHIRL BirminghamM chelonaez7 patientszM chelonae from BAL fluidzSame organism isolated from WD Detergent dispenserzPreviously rinsed with tap waterzEO and discontinuation of use of tap WATER ended problemNye et al JHI 1990 16; 257-261 HIRL BirminghamHIRL BirminghamHIRL BirminghamFungizAFOS washer disinfectorzFlexible cystoscopeszMains WATER via PVC pipeszDaily decontamination 1% hydrogen peroxidezCulture pigmented fungi, Ps aeruginosa,zPiping changed Biofilm, bacteria free rinse WATER not usedPhillips et al JHI 1998; 40: 250-1 HIRL BirminghamHIRL BirminghamHIRL BirminghamM. M. xenopixenopizSpinal infections post disc operations 58 cases of M xenopi spinal infectionz No infection control procedure existed at the time of investigation zPercutaneous nucleotomy Nucleotome cleaned in tap WATER Disinfected in glutaraldehyde 10 mins Rinsed in tap waterAstagneau et al Lancet: 2001.

4 747-51 HIRL BirminghamHIRL BirminghamHIRL BirminghamHIRL BirminghamHIRL BirminghamHIRL BirminghamHTM 2030zStates levels for Total Viable Count (TVC) Environmental mycobacteria Bacterial endotoxinHIRL BirminghamHIRL BirminghamHIRL BirminghamHTM 2030 - WATER treatmentzFiltration ( m)zHeat disinfectionzReverse osmosiszUltraviolet lightzAddition of biocidesHIRL BirminghamHIRL BirminghamHIRL BirminghamHTM 2030 WATER qualityzReverse osmosis Disinfectant diluent, final rinse m filtered, heat or UV Post disinfection/sterilization rinsing for critical applicationszSterile purified Post disinfection/sterilization rinsing for critical applicationsHIRL BirminghamHIRL BirminghamHIRL BirminghamHTM 2030 WATER QUALITY - TVCFor WDs in which the product is rinsed after disinfection there should be no organisms per 100 mlAll other WATER services supplied to WDs should have <100 cfu/100ml(Weekly test)

5 HIRL BirminghamHIRL BirminghamHIRL BirminghamHTM 2030 HTM 2030 WATER QUALITY WATER QUALITY environmental mycobacteriaenvironmental mycobacteriaFor ENDOSCOPE WDs in which the product is rinsed after the disinfection stage there should be no mycobacteria detected(Yearly test)HIRL BirminghamHIRL BirminghamHIRL BirminghamHTM 2030 WATER QUALITY - endotoxins When the intended use of the WD is for products that will be used invasively surgical instruments the WATER used for the final rinse should be tested for bacterial endotoxins (LAL test) (Yearly test)HIRL BirminghamHIRL BirminghamHIRL BirminghamEN ISO 15883 Washer DisinfectorszPart 1 General requirementszPart 2 Thermal washer disinfectors for surgical instruments, anaesthetic equipment, holloware etczPart 3 Thermal washer disinfectors for human waste containerszPart 4 Chemical washer dsinfectorsfor thermo-labile equipmentzPart 5 Test soils for demonstrating cleansing efficacyHIRL BirminghamHIRL BirminghamHIRL BirminghamEN ISO 15883 (Part 1)zFinal rinse WATER should contain <10 cfu/100ml sample and shall be free from legionellae, Pseudomonas aeruginosa and mycobacteriazRecommended weekly testHIRL BirminghamHIRL BirminghamHIRL BirminghamEN ISO 15883 (Part 1)

6 ZIf a requirement for the level of bacterial endotoxins is stated in other parts of EN 15883 then the LAL test with a sensitivity of EU/ml should be usedzEndotoxins are not mentioned in EN 15883-4 HIRL BirminghamHIRL BirminghamHIRL BirminghamValidation of decontaminationValidation of decontaminationNumerous tests are described in HTM 2030 but at the minimum, the user must ensurezAll channel irrigation occurszDisinfectant is within minimum effective concentrationzQuality of WATER is adequateHIRL BirminghamHIRL BirminghamHIRL BirminghamWater testingWater testingzWho will carry out the testing?zHow are the samples transported to the laboratory?zWho receives the results?zAre the results presented in an understandable formatzWho will take action dependant on the results?zWhat action will be taken in the event of contamination being detected?

7 HIRL BirminghamHIRL BirminghamHIRL BirminghamIs there a problem?HIRL BirminghamHIRL BirminghamHIRL BirminghamAction if WATER is contaminatedzLow counts Alcohol flush. ? Antibiotic prophylaxiszHigh counts Suspend high risk procedures (ERCP etc) Double strength disinfectzContinued problem Change filters Disinfect machine/ WATER treatment system Get manufacturer to strip down machineHIS Working Party (2000) J. Hosp. InfHIRL BirminghamHIRL BirminghamHIRL BirminghamRisk assessmentRisk assessmentHIRL BirminghamHIRL BirminghamHIRL BirminghamType of procedurezHigher risk ERCP Bronchoscopy CystoscopyzLower risk Upper and lower GIHIRL BirminghamHIRL BirminghamHIRL BirminghamWater SamplingWater SamplingWillis (2006) Epidemiol. Infect. 134279-284020406080100120123456789 10 11 12 13 14 15 16 17 18 19 20 Endoscopy Unit% Unacceptable SamplesHIRL BirminghamHIRL BirminghamHIRL BirminghamSuggested Action LevelsWillis (2006) Epidemiol.

8 Infect. 134279-284 Unacceptable take WD out of action>100 Unsatisfactory investigate and super chlorinate10-100 Acceptable counts under reasonable control1-9 (achieved on a regular basis)Satisfactory0 Interpretation/actionAerobic cfu/100 mlHIRL BirminghamHIRL BirminghamHIRL BirminghamThings to consider?zShould we be carrying out weekly TVC s on final rinse waterzIs the presence of >10 cfu/ml TVC in rinse WATER significant?zAre endotoxins an issue?zWhat level of endotoxin can cause harm to a patient?zWhat level of endotoxin remains on the instrument?zShould we risk assess depending on use of device? zIs there a departmental action plan summarising action to be taken?zAre the methods for collecting samples and interpreting results clearly defined?HIRL BirminghamHIRL BirminghamHIRL BirminghamSummaryzInferior WATER QUALITY can potentially cause problemszWasher disinfectors and WATER treatment systems should be well maintainedzWasher disinfectors should be tested in accordance with National GuidelineszAll staff should receive adequate trainingHIRL BirminghamHIRL BirminghamHIRL BirminghamThank you for listening