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Special Pathogens

Any medical procedure that results in contact with body fluids and secretions has associated risks and endoscopic (colonoscopy, EGD, ERCP) procedures are no exception. There are extensive guidelines and recommendations for the use of Personal Protective Equipment (PPE) for healthcare providers, instructions for thorough sanitization of the scopes, and protocols for cleaning carts and equipment between patients. These standards recognize the risks that can be present from contact or transmission of enteric secretions, which can most notably include C.diff, VRE, MRSA, and E. coli, in addition to blood borne pathogens, GI borne viruses, and other pathogens that, when present, are often colonized or have reservoirs in the GI tract.



C. difficile:

Clostridium difficile (C. difficile/C. diff) is a spore forming, gram-positive bacillus that produces exotoxins that are pathogenic to humans. C. difficile-associated disease (CDAD) can range in severity from mild diarrhea to fulminant colitis and death. Risk factors attributed to acquiring C. difficile associated disease (CDAD or infection include gastrointestinal procedures and surgery, advanced age, and prior exposure to antibiotics and proton pump inhibitors (PPI's). The CDC reports that up to 30% of patients who develop a health are associated diarrhea are positive for C. difficile, and most patients will remain asymptomatic, though colonized patients may serve as a source of contamination. Recent research indicates a significant increase in frequency and severity of health care-associated CDAD, with increased rates of CDAD as a discharge diagnosis increasing 26% from 2000-2001 and three fold increases in CDAD over a 10 year period. Environmental contamination by C. difficile is well known, especially in place where fecal contamination may occur, and contaminated high touch surfaces and patient care items have been implicated as sources of infection. Though a majority of patients remain asymptomatic after infection, the organism continues to be shed in their stools. The costs associated with treating C. diff or CDAD can be significant, with current research reporting that a single case of CDAD can increase hospitalization costs by 54% when compared with patients not complicated by C. diff during their hospitalization. This can equate to additional costs in excess of $15,000 due to extended hospitalization, requirements for isolation, and treatment.

VRE:

Enterococci are bacteria that are commonly found in the GI tract of 95% of the population. As these are generally normal flora, these bacteria rarely cause illness in healthy people. Vancomycin in an antibiotic used to treat very serious infections. It is often used to treat enterococci as they are resistant to many other types of antibiotics. VRE (Vancomycin Resistant Enterococcus)is a strain of enterococci that is resistant to antibiotic therapy, including vancomycin.

VRE is associated with increased mortality, length of hospital stay, admission to the ICU, surgical procedures and costs. In hospitalized patients, the prevalence VRE in enterococcal isolates has been found to be as high as 28.5%, with a 26 fold increase in nosocomial enterococcal infections from 1989-1993 in one study. If a patient is colonized with VRE, high concentrations of this pathogen can been found in their stool and can rapidly and extensively contaminate an environment. VRE can be transmitted by contaminated environmental surfaces and patient care equipment and the results of enterococcal outbreak investigations suggest a role for the environmental surfaces in the transmission of enterococci.

MRSA:

MRSA (methicillin-resistant Staphylococcus aureus) is a type of bacteria that is resistant to multiple types of antibiotics and is included in the CDC Recommendations for the management of Multi-Drug Resistant Organisms (MDRO's). Facilities continue to struggle with an increase in prevalence of MRSA, with MRSA accounting for almost 60% of S. aureus isolates in 2003. Recent research suggests that a significant number of patients may carry previously undetected gastrointestinal colonization of MRSA which can serve as a reservoir for MRSA transmission that may occur in health care facilities.




E. coli:

E. coli (Escherichia coli) is a type of bacteria commonly found in the digestive tract, primarily inhabiting the large intestine. E. coli is spread through contact with fecal contamination, and causes 3 primary types of infection, including urinary tract infections (UTI's), intestinal disease (e.g. gastroenteritis), and neonatal meningitis. E. coli is a leading cause of both community-acquired and nosocomial urinary tract infections, accounting for 90% of all UTI's and up to 50% of nosocomial infections. E. coli is also a frequent cause of other bacterial infections including cholecystitis, bacteremia, cholangitis, travelers diarrhea, prostatitis, and pneumonia.