DUODENOSCOPE-RELATED INFECTIONS: AN ITALIAN PICK IN 2019

Endoscopic retrograde cholangiopancreatography (ERCP) is typically performed with reusable duodenoscopes after manual and automated reprocessing. As regards cross-patient-infection risk, the reusable duodenoscope is identified as a semi-critical device. Recently, multiple drug-resistant infection outbreaks associated with infected duodenoscopes have been reported, despite rigorous reprocessing procedures. Our aim was to investigate the current Italian experience with duodenoscope-related infections and assess the criticality of the risk. Sixty-one Italian centers who are known to perform ERCP were invited to complete a structured questionnaire about various aspects of duodenoscope-associated infection over the past 3 years. Most centers (52, 85.2%) responded, mainly in Northern Italy (39, 75.0%). Nineteen (19, 36.6%) responders were academic centers. The median number of duodenoscopes in use was 3.7/center with 39 (75.0%) centers using Olympus, 11 (21.2%) Pentax, 10 (19.2%) Fujifilm and 1 Storz (1.9%). Twenty-four (24, 46.2%) centers affirmed adopting reusable accessories, mainly Dormia baskets. The median number of ERCP/year was 300, with 38 (73.1%) reporting<5% rate of ERCP-related complications mostly pancreatitis (post-ERCP pancreatitis<2% in 16 and<5% in 45 centers). Thirty-six (69.2%) centers reported at least one episode of duodenoscope-related infection experienced with a variable number of patients per center contaminated during ERCP (from 1 to 25 patients/center). Isolated pathogens were Klebsiella pneumoniae (KP) (18, 50%), Pseudomonas aeruginosa (10, 27.7%) and Escherichia coli (8, 22.3%). Six cases of KP infection were due to carbapenemase-producing strain, while only one patient was infected with ESBL E. coli. In all cases but six the infective episode prolonged hospitalization. Only 1 center reported 1 death due to duodenoscope-related infection. Major problems reported by the centers in reviewing duodenoscopes and local policies after the evidence of ERCP-related infections were mostly a damaged working channel and non-compliance with reprocessing procedures according to local and international guidelines. Forty-one (41, 78.9%) participants responded that duodenoscope-related infections are relevant for their daily practice and 49 (94.2%) stated that their center would agree to participate in a study on duodenoscope-related infections. These data represent the first Italian report pertaining to duodenoscope-associated infection with majority of Italian centers having experienced at least one case of ERCP-related infection. The rising number of cases reported worldwide makes it urgent to find a solution. Gaining awareness on infection aspects and technical pitfalls could be the first step toward reducing cross-patient infection risk in ERCP. Larger and well-designed studies are needed to confirm our results.