The Effectiveness of Ultraviolet Smart D60 in Reducing Contamination of Flexible Fiberoptic Laryngoscopes.

OBJECTIVE: To compare the effectiveness of disinfection protocols utilizing a ultraviolet (UV) Smart D60 light system with Impelux™ technology with a standard Cidex ortho-phthalaldehyde (OPA) disinfection protocol for cleaning flexible fiberoptic laryngoscopes (FFLs). METHODS: Two hundred FFLs were tested for bacterial contamination after routine use, and another 200 FFLs were tested after disinfection with one of four methods: enzymatic detergent plus Cidex OPA (standard), enzymatic detergent plus UV Smart D60, microfiber cloth plus UV Smart D60, and nonsterile wipe plus UV Smart D60. Pre- and post-disinfection microbial burden levels and positive culture rates were compared using Kruskal-Wallis ANOVA and Fisher's two-sided exact, respectively. RESULTS: After routine use, approximately 56% (112/200) of FFLs were contaminated, with an average contamination level of 9,973.7 ± 70,136.3 CFU/mL. The standard reprocessing method showed no positive cultures. The enzymatic plus UV, microfiber plus UV, and nonsterile wipe plus UV methods yielded contamination rates of 4% (2/50), 6% (3/50), and 12% (6/50), respectively, with no significant differences among the treatment groups (p > 0.05). The pre-disinfection microbial burden levels decreased significantly after each disinfection technique (p < 0.001). The average microbial burden recovered after enzymatic plus UV, microfiber plus UV, and nonsterile wipe plus UV were 0.40 CFU/mL ± 2, 0.60 CFU/mL ± 2.4, and 12.2 CFU/mL ± 69.5, respectively, with no significant difference among the treatment groups (p > 0.05). Micrococcus species (53.8%) were most frequently isolated, and no high-concern organisms were recovered. CONCLUSION: Disinfection protocols utilizing UV Smart D60 were as effective as the standard chemical disinfection protocol using Cidex OPA. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3512-3519, 2023.

A Manufacturer and User Facility Device Experience Analysis of Upper Aerodigestive Endoscopy Contamination: Is Flexible Laryngoscopy Different?

OBJECTIVES/HYPOTHESIS: Several recent studies have observed a high incidence of duodenoscope microbial contamination and an association of contamination with healthcare-acquired infections. This study sought to quantify nasopharyngoscope microbial contamination relative to that of other endoscope categories and characterize the manufacturers, outcomes, and microbial profiles associated with these cases. STUDY DESIGN: Retrospective, cross-sectional study. METHODS: A total of 3,865 adverse events were collected from 2013 to 2019 using the US Food and Drug Administration Manufacturer and User Facility Device Experience database. The fraction of total device failures associated with contamination was quantified for nasopharyngoscopes, bronchoscopes, duodenoscopes, and gastroscopes. Odds ratios of nasopharyngoscope contamination compared to that of bronchoscopes, duodenoscopes, or gastroscopes were calculated, and significance was assessed by χ2 analysis. The Kruskal-Wallis test was used for nonparametric testing of significance. RESULTS: Nasopharyngoscope device failures were reported at an incidence of 0.646 per month; 34.1% involved contamination, comparable to the frequency observed for bronchoscopes (23.4%, P = .118), duodenoscopes (29.2%, P = .493), and gastroscopes (45.3%, P = .178). The frequency of device contamination was observed to be significantly higher for a particular endoscope manufacturer regardless of endoscope category (Kruskal-Wallis P = .021). In instances of contamination, nasopharyngoscopes were significantly less associated with patient harm or death than bronchoscope (odds ratio [OR] = 10.2) and duodenoscope (OR = 4.81) cases. CONCLUSIONS: Although the rates of contamination were comparable across all endoscope categories, nasopharyngoscope contamination was less commonly associated with patient harm or death. In an era of rising healthcare costs, determining adequate disinfection standards for nasopharyngoscopes and their impact on patient safety is crucial. LEVEL OF EVIDENCE: NA Laryngoscope, 131:598-605, 2021.

Contamination and Disinfection of Rigid Laryngoscopes: A Literature Review.

This article reviews current literature about the contamination of laryngoscope blades and handles, disinfection practices for laryngoscope blades and handles, and environmental effects and costs of reusable and single-use laryngoscopes. This review shows that inadequately processed rigid laryngoscopes may have the ability to transmit infections to patients and health care personnel. Although the laryngoscope handle has been considered a noncritical item that contacts only intact skin, health care team members should consider both the laryngoscope blade and handle as semicritical items and process them by high-level disinfection (HLD) or steam sterilization according to manufacturer's instructions. The fewest environmental effects occur when a reusable stainless-steel laryngoscope is processed by HLD. Laryngoscope costs are lower for processing reusable laryngoscope handles and blades by HLD and highest for single-use laryngoscopes. Evidence-based guidelines are needed to specify and standardize best practices for processing rigid laryngoscopes.

Bacterial Contamination and Disinfection Status of Laryngoscopes Stored in Emergency Crash Carts.

OBJECTIVES: To identify bacterial contamination rates of laryngoscope blades and handles stored in emergency crash carts by hospital and area according to the frequency of intubation attempts. METHODS: One hundred forty-eight handles and 71 blades deemed ready for patient use from two tertiary hospitals were sampled with sterile swabs using a standardized rolling technique. Samples were considered negative (not contaminated) if no colonies were present on the blood agar plate after an 18-hour incubation period. Samples were stratified by hospital and according to the frequency of intubation attempts (10 attempts per year) using the χ2-test and Fisher exact test. RESULTS: One or more species of bacteria were isolated from 4 (5.6%) handle tops, 20 (28.2%) handles with knurled surfaces, and 27 (18.2%) blades. No significant differences were found in microbial contamination levels on the handle tops and blades between the two hospitals and two areas according to the frequency of intubation attempts. However, significant differences were found between the two hospitals and two areas in the level of microbial contamination on the handles with knurled surfaces (p<0.05). CONCLUSIONS: Protocols and policies must be reviewed to standardize procedures to clean and disinfect laryngoscope blades and handles; handles should be re-designed to eliminate points of contact with the blade; and single-use, one-piece laryngoscopes should be introduced.

Laryngoscopes: Evaluation of microbial load of blades.

BACKGROUND: Laryngoscope blades were analyzed, and the presence of blood, bodily fluids, and microorganisms was verified, indicating their potential as a source of cross contamination during clinical usage. The way in which the blades are cleaned and disinfected in daily practice may place the patient and health care team at risk. The aim of this study was to determine the bacterial and fungal load on this equipment. METHODS: Descriptive cross-sectional study. A total of 83 laryngoscope blades, ready for use, were analyzed for their bacterial and fungal load at 2 university hospitals. RESULTS: The microbiologic analysis revealed the presence of microorganisms in 76.2% of cases at institution 1 and 92.7% of cases at institution 2, with microbial loads >10(1) colony forming units in 31.2% and 44.7% of cases, respectively. At both institutions, potentially pathogenic microorganisms were found, including Candida sp, Staphylococcus aureus, Enterococcus faecalis, Streptococcus agalactiae, extended-spectrum ß-lactamase-producing Klebsiella pneumoniae, multiresistant Acinetobacter baumannii, Pantoea sp, Enterobacter gergoviae, Escherichia coli, and Proteus mirabilis. CONCLUSIONS: These results indicate that the use of laryngoscope blades at these 2 institutions present a potential risk. Based on these findings, action needs to be taken so a higher level of safety can be offered to patients and health care professionals who have direct contact with this equipment.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation.

BACKGROUND: Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. METHODS: Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. RESULTS: Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. CONCLUSIONS: The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

Microbiological sampling of the forgotten components of a flexible fiberoptic laryngoscope: what lessons can we learn?

The effectiveness of a Cidex-based decontamination protocol was analyzed for its effectiveness in cleaning various components of a flexible fiberoptic laryngoscope (FFL), including the handle, eyepiece, and detachable light cable. A random microbiological sampling and aerobic bacterial culture analysis of 6 FFL eyepieces, 6 FFL driver handles, and 5 light cables prior to patient use was performed. Of 17 samples collected, 7 (41%) were contaminated with bacterial organisms. Organisms recovered represented both environmental organisms from skin and oral flora origin. This study demonstrates that potential contaminants may be present on FFL eyepieces and light cables, which are commonly overlooked in the cleaning protocols of a standard otolaryngology clinic.

High level disinfection of flexible nasopharyngoscopes, videolaryngoscopes, and rigid nasal endoscopes: an evidence-based approach.

In 2008, the Center for Disease Control (CDC) issued new guidelines for the cleaning of nasopharyngoscope (flexible fiberoptic), videolaryngoscopes, and rigid nasal endoscopes (Rutala et al., 2008). The guidelines outlined the basic process steps and requirements including staff training, competency testing, approved products, personal protective equipment, and appropriate storage. To date, published occurrences of pathogen transmission related to procedures requiring the use of a scope have been associated with failure to follow established cleaning and disinfection guidelines or use of defective equipment (Rutala, 2011). The University of Iowa Hospitals and Clinics (UIHC) established a multi-disciplinary team to review and revise the current policy and to generate implementation recommendations. The team used a systematic evidence-based approach to initiate the changes in practice. The initial project focus was in the Otolaryngology Department due to high scope usage in that patient care area.

Bacterial contamination of re-usable laryngoscope blades during the course of daily anaesthetic practice.

BACKGROUND AND OBJECTIVES: Hospital-acquired infections (HAIs) are largely preventable through risk analysis and modification of practice. Anaesthetic practice plays a limited role in the prevention of HAIs, although laryngoscope use and decontamination is an area of concern. We aimed to assess the level of microbial contamination of re-usable laryngoscope blades at a public hospital in South Africa. SETTING: The theatre complex of a secondary-level public hospital in Johannesburg. METHODS: Blades from two different theatres were sampled twice daily, using a standardised technique, over a 2-week period. Samples were quantitatively assessed for microbial contamination, and stratified by area on blade, theatre and time using Fisher's exact test. RESULTS: A contamination rate of 57.3% (63/110) was found, with high-level contamination accounting for 22.2% of these. Common commensals were the most frequently isolated micro-organisms (79.1%), but important hospital pathogens such as Enterobacter species and Acinetobacter baumannii were isolated from blades with high-level contamination. No significant difference in the level of microbial contamination by area on blade, theatre or time was found (p<0.05). CONCLUSIONS: A combination of sub-optimal decontamination and improper handling of laryngoscopes after decontamination results in significant microbial contamination of re-usable laryngoscope blades. There is an urgent need to review protocols and policies surrounding the use of these blades.

Laryngoscope blades and handles as sources of cross-infection: an integrative review.

The lack of standardization of efficient procedures to clean and disinfect laryngoscope blades and handles, which may be important sources of infection during their clinical use, has been reported previously, revealing contamination with blood, body fluids and micro-organisms. This paper aimed to evaluate the evidence available in the literature regarding the risk of laryngoscope blades and handles as a source of patient contamination. An integrative review of the literature was performed using databases such as Medline, LILACS, SciELO, Cochrane Library, BDENF and PubMed, and keywords in Medical Subject Headings (MeSH). The sample comprised 20 articles published between 1994 and 2012. The studies demonstrated risk of cross-infection and no consensus in current guidelines regarding cleaning and disinfection of this equipment. It was concluded that there are important gaps to be filled and urgent investigations required in order to facilitate standardization of efficient procedures to clean and disinfect laryngoscope blades and handles, and in turn to reduce the potential risk to which the patient and/or health team is exposed.

Infection control practices of laryngoscope blades: a review of the literature.

Current procedures for cleaning anesthesia airway equipment as assessed by the presence of visible and occult blood on laryngoscope blades and handles as labeled "ready for patient use" has been reported to be ineffective. Human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) are 2 commonly seen pathogens that frequently are found in the healthcare setting. It has been shown that HBV can survive on a dry surface for at least 7 days and both HIV and HBV are transmitted via blood. The potential for cross-contamination from airway equipment to patient has been shown in several studies. To prevent further potential infections, it should be ascertained why anesthesia providers are not all using disposable laryngoscope blades. The purpose of this literature review is to determine the use and infection control practices of disposable laryngoscope blades. Their frequency of use, their evaluation of ease of use, and any complications encountered when using the disposable blade are reviewed, as well as the perceptions of anesthesia providers regarding disposable laryngoscope blades.

Disinfection of flexible fiberoptic laryngoscopes after in vitro contamination with Staphylococcus aureus and Candida albicans.

OBJECTIVE: To determine the efficacy of various cleaning and disinfective methods in reducing bacterial and fungal load on flexible fiberoptic laryngoscopes (FFLs). DESIGN: In vitro model. SUBJECTS: Flexible fiberoptic laryngoscopes contaminated with Staphylococcus aureus and Candida albicans. INTERVENTIONS: Contamination with S aureus and C albicans was separately induced on FFLs, which were then disinfected with different protocols: 20-, 15-, 10-, and 5-minute soaks in ortho-phthalaldehyde (Cidex OPA; Johnson & Johnson) with or without presoaking in an enzymatic soap solution for 5 minutes; an isolated 5-minute soak in an enzymatic soap solution; a 30-second wipe with antibacterial soap and water; a 30-second wipe with isopropyl alcohol; a 30-second wipe with antibacterial soap, followed by a 30-second scrub with isopropyl alcohol; and a 30-second wipe with germicidal cloth, all accompanied by previous rinsing with 30 seconds of running tap water. RESULTS: All protocols except the isolated 5-minute soak in enzymatic soap solution were successful in completely disinfecting the FFLs after experimental contamination with S aureus or C albicans. CONCLUSION: Various different cleaning methods appeared to properly disinfect FFLs after inoculation with S aureus and C albicans in an in vitro model.

Contamination of laryngoscope handles.

Despite use of sterile or disposable laryngoscope blades for each patient, disinfection of laryngoscope handles does not routinely occur, and these devices present a potential route of transmission of pathogens between patients and staff. A total of 192 specimens from 64 laryngoscope handles deemed 'ready for patient use' in the anaesthetic rooms of 32 operating theatres were semiquantitatively assessed for bacterial contamination. A further 116 specimens from 58 of the handles were tested for occult blood contamination. One or more species of bacteria were isolated from 55 (86%) of the handles, and included organisms such as enterococci, meticillin-susceptible Staphylococcus aureus, Klebsiella and acinetobacter. Cultures did not yield any anaerobes, fungi, meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci or multiply-resistant Gram-negative bacilli. No occult blood contamination was demonstrated. Although the majority of organisms isolated were not pathogenic, their presence indicates the potential for transmission of pathogens from laryngoscope handles. Strategies to address contamination of handles include revision of procedures for disinfection and storage prior to use, introduction of disposable handles or sheaths, and re-design of handles to eliminate knurled surfaces and contact points.

Nosocomial contamination of laryngoscope handles: challenging current guidelines.

BACKGROUND: Laryngoscope blades are often cleaned between cases according to well-defined protocols. However, despite evidence that laryngoscope handles could be a source of nosocomial infection, neither our institution nor the American Society of Anesthesiologists has any specific guidelines for handle disinfection. We hypothesized that laryngoscope handles may be sufficiently contaminated with bacteria and viruses to justify the implementation of new handle-cleaning protocols. METHODS: Sixty laryngoscope handles from the adult operating rooms were sampled with premoistened sterile swabs. Collection was performed between cases, in operating rooms hosting a broad variety of subspecialty procedures, after the room and equipment had been thoroughly cleaned for the subsequent case. Samples from 40 handles were sent for aerobic bacterial culture, and antimicrobial susceptibility testing was performed for significant isolates. Samples from 20 handles were examined for viral contamination using a polymerase chain reaction assay that detects 17 respiratory viruses. RESULTS: Of the 40 samples sent for culture, 30 (75%) were positive for bacterial contamination. Of these positive cultures, 25 (62.5%) yielded coagulase-negative staphylococci, seven (17.5%) Bacillusspp. not anthracis, three (7.5%) alpha-hemolytic Streptococcusspp., and one each (2.5%) of Enterococcusspp., Staphylococcus aureus(S. aureus), and Corynebacteriumspp. No vancomycin-resistant enterococci, methicillin-resistant S. aureus, or Gram-negative rods were detected. All viral tests were negative. CONCLUSION: We found a high incidence of bacterial contamination of laryngoscope handles despite low-level disinfection. However, no vancomycin-resistant enterococci, methicillin-resistant S. aureus, Gram-negative rods, or respiratory viruses were detected. Our results support adoption of guidelines that include, at a minimum, mandatory low-level disinfection of laryngoscope handles after each patient use.

Profile of anesthetic infection control in Taiwan: a questionnaire report.

STUDY OBJECTIVE: To evaluate compliance of anesthesiologists and nurse anesthetists with personal hygiene and anesthetic equipment disinfection procedures in Taiwan. DESIGN: Survey instrument. SETTING: Anesthesiologists and nurse anesthetists working in medical and non-medical centers in Taiwan. PARTICIPANTS: 81 anesthesiologists and 181 nurse anesthetists working in medical and non-medical centers. MEASUREMENTS AND MAIN RESULTS: Questionnaires were sent to 500 anesthesiologists and nurse anesthetists in Taiwan. Two hundred sixty-two (52%) completed questionnaires (127 from medical centers and 135 from non-medical centers). Completed questionnaires were divided into two groups: those from medical centers (Group A) and those from non-medical centers (Group B). There was no significant difference in personal hygienic practices (wearing gloves and washing hands) between Groups A and B. There were significant differences between anesthesiologists and nurse anesthetists in wearing gloves (65.3% vs. 82%; P = 0.001) and hand washing (52.6% vs. 70.4%; P = 0.003). Medical center anesthesiologists and nurse anesthetists performed better than their non-medical-center counterparts when using disinfection procedures and disinfectants for laryngoscope blades and the cleaning of fiberscopes. CONCLUSIONS: Teaching programs should include anesthesia infection control in the curriculum for anesthesiologists and nurse anesthetists.

Reassessment of the risk of healthcare-acquired infection during rigid laryngoscopy.

Inadequate reprocessing of rigid laryngoscopes has been linked to nosocomial outbreaks with associated morbidity and mortality. Last year an outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit was responsible for multiple infections and colonisations, and at least two infant deaths. An investigation of this outbreak identified contaminated rigid laryngoscopes as its source, demonstrating that inadequate reprocessing of rigid laryngoscopes remains a current public health concern. This article revisits and reassesses the risk of healthcare-acquired infection during rigid laryngoscopy and establishes the minimum reprocessing requirements for blades and handles of rigid laryngoscopes. Several potential risk factors for microbial transmission are identified and discussed, including the publication of inconsistent reprocessing guidelines for rigid laryngoscopes. Concern about guidelines that recommend low-level or intermediate-level disinfection of rigid laryngoscopes is expressed. The use of a sterile disposable sheath to cover the rigid laryngoscope and minimise the risk of contamination is also discussed. Regardless of whether a sheath is used during the procedure, thorough cleaning followed by high-level disinfection and drying of the instrument is recommended to prevent microbial transmission.