Augmenting the Guidelines: Screening Patients for CRE Carriage Prior to Endoscopic Retrograde Cholangiopancreatography (ERCP) as Surveillance and Risk Mitigation Strategy

Abstract

Introduction: Outbreaks of Carbapenem Resistant Enterobacteriaceae (CRE) due to contaminated duodenoscopes continue to be reported despite adherence to optimal reprocessing practices. Frequent culturing of devices can be labor intensive and adds challenges in maintaining workflow. Our study hypothesizes that reliable and timely detection of CRE colonization among patients can help inform surveillance practices, such that a duodenoscope is assessed for microbial contamination only after use on CRE colonized persons. Methods: In a prospective observational study, screening for CRE via dual rectal swab occurred immediately prior to ERCP. All swabs were tested for CRE using PCR and culture methods. Bacterial culture swabs were plated on Hardy Chrome CRE media. Subsequent positive growth was cultured to a Mac-Conkey plate. Duodenoscope reprocessing occurred per the manufacturer's instructions. Results: During the six-month study period, 111 samples were collected from 97 patients. Median age of the study cohort was 65 years (range 37-91); 57 % were women. The most common underlying diagnoses were pancreatic (58%) and colon cancer (10%) [Table 1]. 24 (25%) patients had undergone ERCP at another institution in the past and 19 patients previously had ERCP at our institution. Three (3%) patients had detectable MDR colonization on screening, one each with CRE (KPC; detected by PCR only) and ESBL producing organism, a third patient was co-colonized with ESBL and CRE (OXA-48). Three patients (3%) developed bloodstream infection within 30 days following the ERCP procedure, none were CRE. The blood isolates included Streptococus species and Enterobacter, none were MDR. No patient to patient transmission of CRE was detected during the study period. Conclusion: In a large tertiary care referral cancer center, we found a low prevalence of CRE colonization in our patient population. This is despite the diverse referral pattern of our patient population, high rate of previous device exposure, and geographic location in a CRE endemic area. These findings support a potential approach to screen patients for CRE thus limiting the number of duodenoscopes that need to be screened for potential CRE contamination. This strategy may serve as a useful adjunct to the recent new multisociety duodenoscope surveillance sampling and culturing protocol and may streamline workflow practices at large volume endoscopy centers.1065 Figure 1 No Caption available.