Key Point

A consensus statement on the prevention of flexible bronchoscopy–associated infection has been jointly released by the American College of Chest Physicians and the American Association of Bronchoscopy.

CLEVELAND—About half a million flexible bronchoscopies are performed in the United States each year, so one can safely assume that clinicians here are thoroughly versed in ways of preventing infections associated with the procedure, right? Unfortunately, this is not the case.

Survey data suggest that nearly two thirds of US bronchoscopists, including medical directors of bronchoscopy suites, are unfamiliar with national recommendations for reprocessing bronchoscopes after use. Nearly four in 10 are unfamiliar with the reprocessing approaches at their own institutions. The American College of Chest Physicians and the American Association for Bronchology have therefore released a joint statement on the prevention of flexible bronchoscopy–associated infection.¹

“Because of the relative absence of prospective investigations in this area, most of these recommendations are based on clinical experience and consensus opinion, rather than the higher grades of evidence generally required for true clinical practice guidelines,” the authors of the statement cautioned. “We would also like to highlight that these recommendations are not intended to ensure the inactivation or removal of causative agents of transmissible spongiform encephalopathies (prion proteins).”

PERIPROCEDURAL AND POSTPROCEDURAL PRECAUTIONS

The literature suggests that all flexible bronchoscopy–associated infections are preventable, stated the authors. They advised that standard infection control precautions be mandated for every procedure and that full barrier—gown, gloves, mask, and eye shields—and needle precautions be required for the bronchoscopist.

In addition, the bronchoscopist should at least use a fit-tested N95 particulate respirator when mycobacterial infection is suspected. A power air-purifying respirator hood is recommended when highly contagious organisms such as the SARS coronavirus are thought to be present.

“There must be compelling indications for bronchoscopy in patients suspected of having highly contagious infections,” the authors emphasized. “When bronchoscopy is to be performed in such patients, it should be performed in a negative pressure-ventilated room, if one is available. These patients should also be required to wear a surgical mask so that the risk of dissemination of airborne infection can be minimized.”

The bronchoscope should be cleaned immediately after use to minimize the potential for infected organic material to either dry or harden on it. “Meticulous cleaning alone achieves a 3.5- to 4-log reduction in the organism load,” the authors pointed out.

Because the flexible bronchoscope comes into contact with mucous membranes but does not normally penetrate sterile tissue, it requires high-level disinfection—the destruction of all vegetative microorganisms, mycobacteria, viruses, and fungal spores but only some bacterial spores—before reuse. Complete sterilization is not necessary.

DRYING AND STORAGE

Proper drying and storage of the flexible bronchoscope is imperative to prevent recontamination of the device after disinfection. “Ideally, the instrument is dried by purging the channel with 70% alcohol and compressed air,” the authors related.

When stored, the bronchoscope should be hung vertically without the valves in a spacious, well-ventilated cabinet to prevent moisture accumulation; placing a desiccant in the cabinet is an additional measure to avoid moisture buildup. The bronchoscope should not be stored in its carrying case because the case cannot be disinfected. The carrying case is for long-distance transportation only, and the bronchoscope should be disinfected both before it is put into the case and after it is removed.

NOTIFICATION IN THE EVENT OF INFECTION

If a bronchoscopy–associated infection occurs, the bronchoscopy team must inform their institution’s infection control officer, the bronchoscope manufacturer, the state health department, the FDA Med-Watch program, the CDC, the patient, and the referring physicians. If contamination of the bronchoscope is suspected, the device must immediately be removed from service and the problem must be investigated by culturing the bronchoscope parts, the institution’s tap water, and the disinfection equipment.

“On the basis of this initial assessment, the infection control team and bronchoscopy personnel should proceed as needed to assess and ameliorate any breach in infection control practices,” said the authors. They asserted that the prevention of bronchoscopy–associated infection requires increased vigilance by physicians, assiduous implementation of disinfection protocols, and closer collaboration between bronchoscopy personnel, infection control practitioners, microbiology laboratories, and manufacturers.

—Timothy Begany

Reference
1. Mehta AC, Prakash UBS, Garland R, et al. American College of Chest Physicians and American Association for Bronchoscopy consensus statement: prevention of flexible bronchoscopy-associated infection. Chest. 2005;128:1742-1755.

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