Becker's Clinical Quality & Infection Control

6 YEAR IN REVIEW Endoscope reprocessing risks Earlier this year, news broke that patients at multiple hospitals had been falling ill with superbug infections linked to improperly reprocessed duodenoscopes, a specific type of scope which one expert even called "almost impossible" to clean correctly. In fact, a study published in the American Journal of Infection Control in August found that aer manual cleaning, 92 percent of studied endoscopes had microbial residue that exceeded benchmarks. e U.S. Department of Justice responded to the issue by taking legal action against scope manufacturers and having organizations like the CDC issue updated protocol on how to safely reprocess duodenoscopes. Some hospitals even moved away from reprocessing and toward full sterilization instead. Since this summer, more stories have come out about different endoscopes being improperly cleaned. For instance, a hospital in California discovered an endoscope used for colonoscopies had been cleaned improperly during a seven-year period, putting about 5,000 patients at increased risk of infection. en, in November, the U.S. Food and Drug Administration issued a recall of all automated endoscope reprocessing machines manufactured by Custom Ultrasonics, totaling about 2,800 machines. e FDA cited continued violations by Custom Ultrasonics that could put patients at increased risk of infection, including the company's inability to verify the machines could properly wash and disinfect endoscopes. To top things off, the ECRI Institute listed "inadequate cleaning of flexible endoscopes before disinfection" and the risk it poses to spread harmful pathogens at the top of its "2016 Top 10 Health Technology Hazards" list issued in November. Legionnaires' disease outbreaks abound Legionella, a bacterium occurring naturally in the environment, usually in warm water, has wreaked havoc on cities and healthcare organizations alike this year. e bacterium causes Legionnaires' disease, or legionellosis, which people can acquire when they breathe in a mist or vapor contaminated with the bacteria. Elderly people, current and former smokers, people with weak immune systems and those with chronic lung diseases are at increased risk of being infected. is year, New York City experienced a Legionnaires' disease outbreak tied to contaminated water-cooling towers in the Bronx. e outbreak killed 12 people and sickened hundreds. Hospitals also reported the presence of Legionella in their water systems or isolated instances of the illness within their facility this year — for instance, a Veterans Affairs hospital in Phoenix relocated 20 of its patients aer discovering the bacteria in its water system in August. According to the CDC, anywhere from 8,000 to 18,000 people in the U.S. are hospitalized annually due to Legionnaires' disease, but that number has been steadily increasing, according to a study published this year in the Journal of Public Health Management and Practice. e study found the number of reported cases of Legionnaires' disease in the U.S. more than tripled between 2001 and 2012. "Legionellosis deserves a higher public health priority for research and policy development," the study concludes. "We recommend a formal and comprehensive review of national public health guidelines for prevention of legionellosis." NTM infections emerge as risk of open-heart surgery Heater-cooler devices used during open- heart surgeries have recently been identified as a potential patient safety hazard by both the FDA and the CDC because the devices have been linked to nontuberculous mycobacterium infections. NTM are slow-growing bacteria naturally found in water and soil. Water in the heater-cooler devices can become contaminated with NTM bacteria and then become airborne through a vent on the device, thus potentially transmitting it to patients. e infections can take multiple years to manifest in patients, and they can be deadly. Two hospitals — WellSpan York (Pa.) Hospital and Penn State Hershey (Pa.) Medical Center — contacted thousands of open-heart surgery patients in October and November to inform them of the infection risk. Five open-heart surgery WellSpan York Hospital patients have died, and experts consider the NTM infections a "contributing factor" to their death. e FDA has issued a safety communication,

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