Duodenoscope-Acquired Infections: Risk Factors to Consider

In the wake of highly publicized duodenoscope-associated outbreaks caused by multidrug-resistant organisms (MDRO), a herculean effort was made to understand the conditions that led to these transmission events. Although there is now a clearer picture on how these outbreaks happened, there are still significant data gaps when it comes to understanding the rate of duodenoscope-acquired infections (DAIs), especially in nonoutbreak situations. Recent publications indicate that DAIs are still occurring and suggest that infection rates are higher than currently believed. Given this data gap, it is important to identify those patient populations that are most at risk of postprocedure infection, so that appropriate infection control measures may be implemented. Although those patients receiving antibiotic prophylaxis are most at risk for infection, there are additional risk factors that should be considered. For the purposes of this review, risk factors for infection were divided into three broad categories as follows: (1) those that increase patient susceptibility to infection, (2) those related to the endoscopic procedure, and (3) those factors that put reusable duodenoscope inventories at risk of contamination. Infection risk is a complex interaction between the immune status of the patient, the characteristics of the infectious agent (antibiotic sensitivity, virulence factors, and epidemiology), and the environment of care. Because of this complexity, any assessment of the risk of infection should be performed on a case-by-case basis. There is a dearth of information on infection risk for those patients undergoing endoscopic retrograde cholangiopancreatograpy (ERCP), especially in the context of the development and implementation of new device technology, and new endoscopic procedures that are increasing in complexity. This narrative review was developed using the Medical Subject Heading (MeSH) terms to perform an electronic search in PubMed with the goal of generating a summary of the patient, procedural, and duodenoscope-associated factors that increase the risk of infection in patients undergoing ERCP. This review provides practical information regarding the segmentation of ERCP patients by infection risk, so that endoscopists can make informed decisions about the risk benefits of using enhanced duodenoscope technologies in the care of their patients.