A Commentary on “Outbreak of Cystoscopy-Related Urinary Tract Infections With Pseudomonas aeruginosa in South Korea, 2022: A Case Series”

Article information

Urogenit Tract Infect. 2025;20(1):52-54

Publication date (electronic) : 2025 April 30

doi : https://doi.org/10.14777/uti.2550010005

Byoungkyu Han

Director of Urological Endoscopy Certification Committee, The Korean Urological Association Perfect Urology Clinic, Seoul, Korea

Corresponding author: Byoungkyu Han Director of Urological Endoscopy Certification Committee, The Korean Urological Association, Perfect Urology Clinic, 626 Gangnam-daero, Gangnam-gu, Seoul 06035, Korea Email: bkurol@gmail.com

Received 2025 February 3; Revised 2025 March 10; Accepted 2025 March 13.

To the editor,

Pseudomonas aeruginosa, a Gram-negative bacterium commonly found in healthcare environments, is a major pathogen responsible for healthcare-associated infections (HAIs) and is recognized as a significant global public health concern. P. aeruginosa accounts for approximately 7%–10% of HAIs, causing a variety of infections, particularly ventilator-associated pneumonia, urinary tract infections (UTIs), and bloodstream infections [1-3].

Infections caused by P. aeruginosa lengthen hospitalization, increase medical costs, and, in some cases, are associated with high mortality rates [4]. A major concern is the bacterium’s strong association with antibiotic resistance. Recent studies have reported multidrug resistance rates of up to 80.5% in clinical isolates, complicating treatment and posing significant challenges to infection control [5].

Hospital environments, especially moist areas such as sinks and faucets, serve as key reservoirs for P. aeruginosa [6]. However, recent studies suggest that direct transmission from these environments may be lower than previously assumed, with some findings indicating that only 15% of bloodstream infections caused by P. aeruginosa are directly linked to environmental sources [4]. Therefore, a multifaceted approach—including rigorous environmental management, proper hand hygiene, antimicrobial stewardship, and continuous surveillance systems—is essential for the effective prevention and management of HAIs caused by this pathogen.

This study investigating P. aeruginosa infections following cystoscopy makes an important contribution to the field. The investigation involved 353 patients who underwent cystoscopy, of whom 6 developed febrile UTIs requiring hospitalization. P. aeruginosa was detected in 4 of these 6 patients, and environmental surveillance cultures identified the bacterium in a diluted solution sample of a dual-enzymatic detergent (EmPower, Metrex Research Corp., Orange, CA, USA). The authors reported that after changing the disinfectant and en-hancing the cleaning protocol, no further bacterial growth was observed, suggesting that the contaminated detergent was the likely source of the cystoscopy room associated infections [7].

Infection control in cystoscopy suites is critically important, particularly given the growing number of cystoscopic procedures. Beyond the limitations acknowledged by the authors, several key aspects require further discussion. Although P. aeruginosa was identified in the detergent, the precise route of contamination remains unclear. As this bacterium is a common opportunistic pathogen in healthcare settings, cross-transmission via healthcare workers’ hands cannot be ruled out. Transmission of P. aeruginosa is known to occur more frequently in intensive care units (ICUs), and multiple outbreaks in neonatal ICUs have been reported. One study found that exposure to specific healthcare personnel was a significant risk factor for P. aeruginosa infection [8,9].

P. aeruginosa is a major cause of HAIs, particularly in moist environments where it forms biofilms that enable prolonged survival [10]. Preventing biofilm formation is crucial because biofilm-associated P. aeruginosa can persist under low-oxygen conditions and in extreme environments, making eradication difficult [11]. In healthcare settings, this bacterium is predominantly found on moist surfaces—including sinks, showerheads, and faucets— which serve as critical sources of HAIs [12].

Thus, stringent environmental management is essential for preventing P. aeruginosa-related HAIs. Key measures include:

(1) Hand hygiene and personal protective equipment (PPE) compliance – strengthen adherence to alcohol-based hand sanitizers, ensure the availability of proper handwashing facilities, and enforce mandatory PPE use in high-risk areas.

(2) Healthcare worker education – provide continuous training on disinfectant use, proper sterilization protocols, and infection control measures to prevent cross-contamination.

(3) Environmental cleaning and disinfection – implement routine cleaning and disinfection protocols, with particular attention to moist environments such as sinks, faucets, and showers, which serve as reservoirs for P. aeruginosa.

(4) Medical device reprocessing and sterilization – ensure strict adherence to proper cleaning, drying, and sterilization protocols for reusable medical devices, including cystoscopes, to prevent biofilm formation and bacterial persistence; rapid drying after cleaning is particularly important.

(5) Surveillance and monitoring systems – establish continuous environmental surveillance cultures and infection monitoring for early detection and intervention, particularly in high-risk areas such as hospital sinks, drains, and medical equipment storage units [10-13].

P. aeruginosa is generally susceptible to alcohol-based disinfectants, making alcohol-based hand sanitizers a crucial component of infection prevention. Notably, increased use of these sanitizers has been significantly correlated with a reduction in carbapenem-resistant P. aeruginosa infections [14]. However, some limitations exist; for instance, certain commercial alcohol wipes do not demonstrate sufficient bactericidal activity within 1–15 minutes of contact [15].

A critical survival mechanism of P. aeruginosa in hostile environments, including those with antibiotic exposure, is biofilm formation [10]. Therefore, preventing HAIs caused by this pathogen requires a dual approach— strict environmental management coupled with proper disinfection. Through these strategies, healthcare institutions can effectively inhibit biofilm formation and limit bacterial persistence and transmission. I would like to express our gratitude to the authors for conducting this pioneering study on cystoscopy-related P. aeruginosa infections in Korea. This research underscores the importance of infection control in endoscopic procedures and provides valuable insights for preventing similar outbreaks in the future.