Infection control breach related to reprocessing of a transrectal ultrasound probe

 

To: Hospitals, Ambulatory Surgical Centers, and Free Standing Emergency Departments From: The Colorado Department of Public Health and Environment Healthcare-Associated Infections and Antimicrobial Resistance Program The Colorado Department of Public Health and Environment Healthcare-Associated Infections and Antimicrobial Resistance Program recently identified that a transrectal ultrasound probe was reprocessed using low-level disinfection (LLD) instead of high-level disinfection (HLD), which was contrary to the manufacturer’s instructions for use (MIFU). This is a semi-critical device for which HLD is necessary. Failure to reprocess this device by HLD according to the MIFU may create a low risk of bacterial, viral, and bloodborne pathogens. In this scenario, the transrectal ultrasound probe was being reprocessed and supplied by a hospital vendor. We are not aware of any infections related to this event. Infection preventionists and sterile processing departments (SPDs) should review the MIFU for endocavitary probes, including transrectal ultrasound probes and similar devices such as endovaginal probes that come into contact with mucous membranes, and ensure that they are reprocessed according to the MIFU. CDC guidelines recommend the use of a new probe cover and HLD between patients, CDC. Disinfection and Sterilization Guideline. Ensure proper reprocessing by internal SPD staff and by external vendors that supply the instrument. If patients are exposed to improperly reprocessed endocavitary probes, conduct a risk assessment for infection or other harm, and consider patient notification as appropriate. Contact the Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program at the Colorado Department of Public Health and Environment for assistance: email cdphe_hai_ar@state.co.us or call 303-692-2700.