title: Risk of infections associated with improperly reprocessed transrectal ultrasound-guided prostate biopsy equipment.
abstract: OBJECTIVE
  A hospital discovered a lapse in the reprocessing procedures for transrectal ultrasound-guided prostate biopsy equipment. An investigation was initiated to assess the risks of transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and bacteria during prostate biopsies.
  
  
  METHODS
  We offered testing for HBV, HCV, and HIV infection to patients who had undergone prostate biopsies from January 30, 2003, through January 27, 2006. We reviewed their medical records and obtained information on the reprocessing procedures that were in use at the time for the prostate biopsy equipment.
  
  
  METHODS
  A healthcare facility in Maine.
  
  
  RESULTS
  Of the 528 patients exposed to improperly reprocessed prostate biopsy equipment, none tested positive for HIV or HCV. Sixteen patients (3%) tested positive for past HBV infection but had no prebiopsy HBV serologic test results available (ie, transmission from improperly reprocessed biopsy equipment was possible), and 11 (2%) had evidence of postbiopsy bacterial infections. The number of cases of HBV and bacterial infections were within reported ranges for this population and were not clustered in time. Review of the reprocessing procedures in use at the time revealed that the manufacturer-recommended brushes for cleaning the reusable biopsy needle guide were never used. Brushes did not come with the equipment and had to be ordered separately.
  
  
  CONCLUSIONS
  Despite the lack of evidence of pathogen transmission in this investigation, it is critical to review the manufacturer's reprocessing recommendations and to establish appropriate procedures to avert potential pathogen transmission and subsequent patient concerns. This investigation provides a better understanding of the risks associated with improperly reprocessed transrectal ultrasound prostate biopsy equipment and serves as a methodologic tool for future investigations.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia 30333, USA. flessa@cdc.gov
authors.forename: Fernanda
authors.initials: F
authors.lastname: Lessa
authors.forename: Sangwoo
authors.initials: S
authors.lastname: Tak
authors.forename: Shannon R
authors.initials: SR
authors.lastname: Devader
authors.forename: Rekha
authors.initials: R
authors.lastname: Goswami
authors.forename: Mary
authors.initials: M
authors.lastname: Anderson
authors.forename: Ian
authors.initials: I
authors.lastname: Williams
authors.forename: Kathleen F
authors.initials: KF
authors.lastname: Gensheimer
authors.forename: Arjun
authors.initials: A
authors.lastname: Srinivasan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001424:Bacterial Infections / Q000097:blood / Q000453:epidemiology / Q000635:transmission; D001707:Biopsy, Needle / Q000295:instrumentation / Q000379:methods; D003428:Cross Infection / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission*; D004866:Equipment Contamination / Q000517:prevention & control; D015658:HIV Infections / Q000097:blood / Q000453:epidemiology; D006509:Hepatitis B / Q000097:blood / Q000453:epidemiology / Q000635:transmission; D006526:Hepatitis C / Q000097:blood / Q000453:epidemiology / Q000635:transmission; D006801:Humans; D017053:Infection Control / Q000379:methods* / Q000592:standards; D007407:Interviews as Topic; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D011467:Prostate / Q000000981:diagnostic imaging / Q000473:pathology; D012307:Risk Factors; D013242:Sterilization / Q000379:methods* / Q000592:standards; D014463:Ultrasonography; D036761:Ultrasound, High-Intensity Focused, Transrectal / Q000295:instrumentation*