SBAR regarding Duodenoscopes


Submitted by Mark Ingerman, MD, System Division Chief, Infectious Diseases; Bob Etemad, MD, Medical Director of Endoscopy; and Connie Cutler, RN, MS, CIC, FSHEA, Director, Infection Prevention and Control


Situation:  Prevention of Infection from Duodenoscopes


Background:  In 2013, a Chicago-area hospital reported the first case of carbapenem-resistant Enterobacteriaceae (CRE) transmitted from duodenoscopes to patients, which was investigated by the Centers for Disease Control and Prevention1.  Since then, hospitals in Seattle, Philadelphia, and Los Angeles have also reported similar issues.  CRE are gastrointestinal organisms such as E. coli and Klebsiella species that produce enzymes that break down carbapenem antibiotics, making them ineffective.  These antibiotics (e.g. Imipenem, Meropenem, Ertapenem, and Doripenem) have the broadest antibacterial spectrum.  Therefore when resistance develops, treatment of serious and potentially life-threatening infections is difficult.  Duodenoscopes are used to diagnose and treat problems of the bile and pancreatic ducts.  The inherent design of these scopes with an elevator channel makes them difficult to reprocess.


Assessment:  At MLH, there have been no infections related to performance of a procedure with a duodenoscope.  Our current process consists of manual cleaning, use of an automated endoscopic reprocessor, and high level disinfection.  Competency with reprocessing of these scopes is evaluated on an ongoing basis.  Infection Preventionists at the acute care hospitals have visited areas performing reprocessing on several occasions to assure compliance with manufacturers’ instructions.  Communications between the Medical Directors of Endoscopy and Infectious Diseases and Director of Infection Prevention have occurred.  Surveys of practices in area hospitals indicate that the majority are not changing from high level disinfection to ethylene oxide sterilization.



  • Follow all manufacturers’ instructions for cleaning and reprocessing.
  • Continue ongoing surveillance for healthcare-associated infections related to duodenoscopes.
  • Report problems with reprocessing to the manufacturer and the FDA.
  • Inform patients of the benefits and risks associated with this procedure through informed consent.
  • Review FDA Safety Communications as they are updated and reevaluate our process as warranted.


1CDC. MMWR / January 3, 2014 / Vol. 62 / Nos. 51 & 52


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