title: Multidrug-resistant NDM-1 Klebsiella outbreak and infection control in endoscopic urology.
abstract: What's known on the subject? and What does the study add? Since the first case of multidrug-resistant New Delhi metallo-β-lactamase (NDM-1) Klebsiella and Escherichia coli UTI in January 2008, there have been more reports of cases worldwide. Urology is a specialty uniquely vulnerable to these organisms because the NDM-1 carriers tend to be the common UTI-causing organisms. Further, the nature of the procedures involved in endoscopy in the urinary tract confers the potential for direct exposure and transmission of the organisms that commonly cause UTI. Although decontamination by sterilization of urological endoscopes and surgical instruments is well established in the operating theatre suite, there were no national standardized guidelines for infection control measures with respect to the video camera head in endoscopic urology in the UK. This paper reports the first UK outbreak of NDM-1 Klebsiella UTI, for which the common source of infection was rapidly traced to the endoscopic camera head in the urology theatre, where single-use sterile disposable plastic camera sheaths were not routinely used and the camera head was regularly cleaned with detergent wipes. We found that infection control practices vary across UK urology units. In the context of infection control, we highlight a need for standardized practice in the use of camera sheaths and in the decontamination process for endoscopic video camera heads. Either sterilization or use of single-use sterile disposable plastic camera sheaths with regular cleaning of the camera head using approved disinfectant for all endoscopy work is recommended.
  
  
  OBJECTIVE
  • To report the first UK outbreak of NDM-1 Klebsiella, for which the common source of infection was rapidly traced to the endoscopic camera head in the urology theatre, where camera sheathing was not routinely used and the camera head was regularly cleaned with detergent wipes. • To survey the use of camera sheath and infection control practices in endoscopy in urology in the UK.
  
  
  METHODS
  • A structured questionnaire was conducted via telephone interview with urological theatre sisters/charge nurses from all urological units across the UK. • Data on the use of camera sheath, cleaning practices, type of disinfectant used and choice of prophylactic antibiotics were obtained.
  
  
  RESULTS
  • Out of 206 NHS urology units, 158 (77%) units across the UK were surveyed. Forty-one (25.9%) do not use camera sheaths, 16 (10.1%) were used dependent on the consultant's preference, and the remaining 101 (63.9%) routinely used camera sheath. • Twenty-one (13.3%) units clean the camera head only at the end of the operating list and the remainder clean after every case. • The choice of cleaning agent/disinfectant used varied considerably. They are broadly categorised as alcoholic wipes 90 (57%), detergent wipes 46 (29.1%) and soapy water 21 (13.3%). • The choice of prophylactic antibiotic includes gentamicin alone (96.3%), augmentin alone (1.4%), gentamicin/amoxicillin (0.7%) and cefuroxime alone (0.7%).
  
  
  CONCLUSIONS
  • In the context of infection control, we highlight the need for a standardized practice in the use of camera sheaths and the process of decontamination of the endoscopic camera head. • Either sterilization or use of single-use sterile disposable plastic camera sheath with regular cleaning of the camera head using approved disinfectant for all endoscopy work is recommended.
authors.affiliation: Department of Urology, Shrewsbury and Telford Hospital Trust, Shrewsbury, West Midlands, UK. vkoo76@gmail.com
authors.forename: Vincent S W
authors.initials: VS
authors.lastname: Koo
authors.forename: Patricia
authors.initials: P
authors.lastname: O'Neill
authors.forename: Andrew
authors.initials: A
authors.lastname: Elves
mesh_terms: D004196:Disease Outbreaks; D004203:Disinfection / Q000379:methods; D018432:Drug Resistance, Multiple; D019723:Endoscopes / Q000382:microbiology*; D004724:Endoscopy / Q000009:adverse effects; D006801:Humans; D017053:Infection Control / Q000379:methods*; D007709:Klebsiella / Q000187:drug effects / Q000302:isolation & purification*; D013242:Sterilization / Q000379:methods; D006113:United Kingdom / Q000453:epidemiology; D014552:Urinary Tract Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D001618:beta-Lactamases / Q000494:pharmacology*
chemical_list: D001618:beta-Lactamases; C552864:beta-lactamase NDM-1