Endoscopes, including bronchoscopes, are the medical devices most frequently associated with outbreaks of nosocomial infections. We investigated a pseudo-outbreak of Stenotrophomonas maltophila after bronchoscopic procedures.
Microbiologic results were reviewed to determine the rates of recovery of S. maltophila from bronchoalveolar-lavage (BAL) specimens. Environmental samples from endoscopes, bronchoscopy towers and travel ventilators were cultured. Medical records were reviewed to identify cases in the 14 days after a bronchoscopy and those who died. Chi-square test was used to compare the S. maltophila incidence in bronchoscopyduring pseudo-outbreak and after it has been controlled.
Conclusion: This pseudo-outbreak of S. maltophila infections related to bronchoscopy was apparently caused by structural damage to bronchoscopes that did not result in a failure of leak test. Instrument safety for bronchoscopy must be improved to include periodic inspection of bronchoscopes to detect structural damage instead of just relying on leak tests.
R. Newman, None
P. Gildenblatt, None
T. Wilson, None