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Risk of Infections Associated with Improperly Reprocessed Transrectal Ultrasound–Guided Prostate Biopsy Equipment

Published online by Cambridge University Press:  02 January 2015

Fernanda Lessa ,
Sangwoo Tak ,
Shannon R. DeVader ,
Rekha Goswami ,
Mary Anderson ,
Ian Williams ,
Kathleen F. Gensheimer  and
Arjun Srinivasan
Fernanda Lessa*
Affiliation:
Division of Healthcare Quality Promotion, Atlanta, Georgia Epidemic Intelligence Service, Office of Workforce and Career Development, Atlanta, Georgia
Sangwoo Tak
Affiliation:
Epidemic Intelligence Service, Office of Workforce and Career Development, Atlanta, Georgia
Shannon R. DeVader
Affiliation:
Centers for Disease Control and Prevention (CDC), and the CDC/Council of State and Territorial Epidemiologists Applied Epidemiology Fellowship Program, Atlanta, Georgia Maine Department of Human Services, Augusta, Maine
Rekha Goswami
Affiliation:
Togus Veterans Affairs Medical Center, Augusta, Maine
Mary Anderson
Affiliation:
Togus Veterans Affairs Medical Center, Augusta, Maine
Ian Williams
Affiliation:
Division of Viral Hepatitis, Atlanta, Georgia
Kathleen F. Gensheimer
Affiliation:
Maine Department of Human Services, Augusta, Maine
Arjun Srinivasan
Affiliation:
Division of Healthcare Quality Promotion, Atlanta, Georgia
*
Centers for Disease Control and Prevention, 1600 Clifton Road, MS A-24, Atlanta, GA 30333 (flessa@cdc.gov)
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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.

Setting.

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.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 29 , Issue 4 , April 2008 , pp. 289 - 293
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2008

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