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- Original Article Outbreak of Cystoscopy-Related Urinary Tract Infections With Pseudomonas aeruginosa in South Korea, 2022: A Case Series
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Beomsoo Kim1
, Young-Sin Choi2, Jun-Koo Kang3, Yun-Sok Ha1,4, Seock Hwan Choi3,4, Bum Soo Kim1,4, Hyun Tae Kim1,4, Eun Sang Yoo1,4, Tae Gyun Kwon3,4, Jae-Wook Chung3,4, Tae-Hwan Kim3,4 -
Urogenital Tract Infection 2024;19(3):97-103.
DOI: https://doi.org/10.14777/uti.2448028014
Published online: December 31, 2024
1Department of Urology, Kyungpook National University Hospital, Daegu, Korea
2Department of Infection Control, Chilgok Kyungpook National University Hospital, Daegu, Korea
3Department of Urology, Chilgok Kyungpook National University Hospital, Daegu, Korea
4Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
- Corresponding author: Jae-Wook Chung, Department of Urology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hoguk-ro, Buk-gu, Daegu 41404, Korea, Email: jeus119@hanmail.net
- Co-corresponding author: Tae-Hwan Kim, Department of Urology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hoguk-ro, Buk-gu, Daegu 41404, Korea, Email: doctork@knu.ac.kr
• Received: October 4, 2024 • Revised: November 25, 2024 • Accepted: November 29, 2024
Copyright © Korean Association of Urogenital Tract Infection and Inflammation
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
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Purpose This study conducted an epidemiological investigation of Pseudomonas aeruginosa urinary tract infections (UTIs) following cystoscopy at Chilgok Kyungpook National University Hospital.
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Materials and Methods From May 16 to July 15, 2022, among 353 patients who underwent cystoscopy, 6 patients reported febrile UTIs following cystoscopy. They were admitted to the urology department of the hospital after visiting the Emergency Department. P. aeruginosa was found in the urine cultures of 4 of the 6 hospitalized patients. During the epidemiological investigation, no changes were observed in factors such as the reprocessing procedures for endoscopic equipment. Therefore, microbiological tests were performed using environmental samples derived from the endoscopic equipment and cleaning process.
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Results P. aeruginosa was identified in a dual-enzymatic detergent (EmPower) used during the endoscope cleaning process. After changing the disinfectant and cleaning process, no further bacterial growth was observed in subsequent microbiological tests.
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Conclusions This study highlights the potential of cystoscopes to serve as reservoirs for bacteria due to inadequate cleaning during the disinfection process. To minimize the risk of infections following cystoscopy, it is important to pay close attention to the reprocessing and cleaning of cystoscopes.
HIGHLIGHTS
Over 2 months in 2022, 6 patients undergoing cystoscopy at our hospital complained of febrile urinary tract infections, with Pseudomonas aeruginosa found in 4 cases. Contamination was identified in a dual-enzymatic detergent (EmPower) used for cystoscope cleaning. Revising the cleaning process and disinfectant prevented further infections.
INTRODUCTION
Pseudomonas aeruginosa, a gram-negative bacterium commonly encountered in hospital-acquired infections, often exhibits antibiotic resistance [1]. Notably, it forms biofilms, adhering to the surfaces of medical devices or structures, which hinders effective removal during the cleaning process [2]. Biofilms, which serve as protective barriers for bacteria, can reduce the effectiveness of antibiotics or detergents and are particularly common on medical equipment such as endoscopes. Previous studies have reported outbreaks of infections associated with contaminated endoscopes and inadequate disinfection [3–9]. Therefore, P. aeruginosa infections warrant special attention, and it is essential to implement appropriate disinfection and infection control procedures [10].
Cystoscopy, one of the most common procedures in urology, requires the careful cleaning of cystoscopes before use on the next patient to prevent infections; accordingly, considerable attention has been directed towards cystoscopy in ongoing research [11–14]. The incidence rate of urinary tract infections (UTIs) after cystoscopy has been reported to range from 2% to 21.2% [11,15]. The most common microorganisms are Escherichia coli, enterococci, and staphylococci [16], and P. aeruginosa accounts for only 1%–2% of UTIs [17,18]. In this study, we investigated P. aeruginosa-related
UTIs occurring after cystoscopy at Chilgok Kyungpook National University (Hospital 1) in July 2022.
MATERIALS AND METHODS
At Hospital 1, cystoscopy was performed on an outpatient basis in the cystoscopy room using 2 reusable flexible cystoscopes. In July 2022, with an increase in cases of UTIs following cystoscopy, which led to hospitalizations, the cystoscopy department at Hospital 1 implemented additional passive measures. Previously, only betadine disinfection was conducted before cystoscopy; subsequently, 0.5% hexachlorophene (disinfectant) was added to the betadine disinfection process [19]. However, as the occurrence of UTIs remained an issue, an epidemiological investigation was conducted on July 18, 2022.
From May 16 to July 15, 2022, a total of 353 patients underwent cystoscopy at Hospital 1. Among them, 6 patients developed UTIs with accompanying fever after cystoscopy, leading to hospitalization in the urology department after visiting the Emergency Department (ED) of Hospital 1. Among the 6 hospitalized patients, P. aeruginosa was identified in the urine cultures of 4 individuals. The demographic and clinical data of the 6 patients are presented in Table 1.
All 6 patients were male, and they visited the ED within 8 days after undergoing cystoscopy. All patients underwent microbiological tests on the day of their ED visit and were admitted for antibiotic treatment of the infections. After confirmation of negative results in follow-up urine cultures, they were discharged. All 6 patients tested negative for bacteria in blood cultures, with P. aeruginosa confirmed in the urine cultures of only 4 of them. However, in the case of patient 2, who showed a negative urine culture result, he had been experiencing fever for 2 days before his ED visit and had been taking oral antibiotics prescribed by a local hospital. As a result, it cannot be ruled out that the negative urine culture result at the time of the ED visit may be attributed to the prescribed oral antibiotics. In the case of patient 6, he underwent cystoscopy the day before visiting the ED. Given the short interval between the procedure and the ED visit, a false-negative result could not be ruled out. Among the 6 patients, only 1 of them (patient 5) was a paraplegic patient requiring cystostomy, and only patient 6 had been hospitalized within 30 days. Patient 6 underwent pelvic mass excision surgery on June 16, 2022 and was hospitalized for postoperative management until June 24. During the surgery, a prophylactic right ureteral stent was inserted. On July 14, 2022, cystoscopy was performed to remove the ureteral stent. However, on the next day, the patient developed right-sided pyelonephritis and was hospitalized for infection treatment.
It was found that since May 2022, the cystoscopy room has been relocated from a distant area (endoscopy room 7) in the endoscopy cleaning room to an adjacent area. Other than the relocation, there were no changes observed in other factors, including the reprocessing procedures for endoscopic equipment.
Before proceeding with further environmental cultures and investigations, we strengthened the disinfection and cleaning protocols for the cystoscopy room and endoscopic equipment on July 18, 2022. First, to address concerns regarding residual organic matter during the cleaning of the cystoscopy room, ethanol (disinfectant) was incorporated into the cleaning process [20]. Additionally, considering the possibility of urine leakage due to the nature of cystoscopy, we implemented cleaning methods with diluted sodium hypochlorite solution [21]. To address concerns such as biofilm formation on the surface of the sink, caused by pouring sterilized water used for rinsing endoscopic equipment into the sink, we recommended surface disinfection using a combination of an enzymatic cleaner and a disinfectant [22]. The cleaning process after cystoscopy at Hospital 1 is presented in Table 2.
On July 18, 2022, the same day of the report, the first round of environmental microbiological tests was conducted on 2 reusable cystoscopes (Table 3). Samples were collected following the protocol described in a previous study [23]. After collecting a total of 29 samples, microbiological tests were performed.
RESULTS
On July 20, 2022, microbiological tests of 29 samples detected the presence of P. aeruginosa in one of the enzymatic detergent samples. Additionally, bacteria were detected in cultures from the cleaning brush (Lactococcus lactis) and sink surface (Lactobacillus spp. and Candida krusei). However, no bacteria were detected in the remaining 26 samples. On the same day the test results were confirmed, the cleaning solution and cleaning method were promptly altered. Previously, cystoscopes were cleaned with a dual-enzymatic detergent (EmPower, Metrex Research Corp., Orange, CA, USA), followed by rinsing with water. This procedure was changed to immerse the cystoscopes in a quad-enzymatic detergent (SaniZyme, Ultra Clean Systems Inc., Oldsmar, FL, USA). Additionally, the cleaning brush was replaced with a single-use brush. Given the issues discovered during the cleaning process, all environmental samples were subjected to a second round of tests on July 20, 2022 (Table 4).
On July 22, 2022, a total of 9 samples were tested for microorganisms. Among them, P. aeruginosa was identified in samples from the EmPower diluted solution, interior of the EmPower diluted can #1, and sink handle. Additionally, Citrobacter freundii was detected in samples from the interior of the EmPower diluted can #2 and sink surface. No bacteria were detected in the remaining 4 samples. Accordingly, all remaining EmPower solution and diluted cans were discarded, and the cleaning frequency in the cleaning room was increased from once daily to twice daily. Additionally, new sink handles were installed, and cystoscopes were promptly cleaned after each procedure to prevent organic residues from solidifying inside the equipment. Furthermore, cystoscopes were not simply stored after cleaning; instead, they were stored in the equipment storage area only after completing the cleaning process. After cleaning and organizing the cleaning room and sink area, a third round of environmental microbiological tests was conducted on July 22, 2022 (Table 5).
On July 25, 2022, a total of 11 samples were cultured, and no bacteria were detected in any of them, effectively ending the outbreak and resolving the issue.
DISCUSSION
From May 16 to July 15, 2022, a total of 353 patients underwent cystoscopy at Hospital 1. Subsequently, 14 patients visited the ED, with 6 of them admitted to the urology department for the treatment of UTIs with fever. During the study, P. aeruginosa was identified in the dual-enzymatic detergent (EmPower) during endoscope reprocessing. Therefore, the disinfectant and disinfection methods were changed to resolve the issue.
In previous studies, outbreaks of P. aeruginosa infections following cystoscopy have been reported [17,23]. In these studies, the authors identified contaminated cystoscopes and improper equipment reprocessing methods as the causes of the outbreaks [17,23]. They resolved the outbreaks by implementing proper endoscope reprocessing methods [17,23]. Like previous studies, this study also reports an outbreak of P. aeruginosa infections following cystoscopy. However, in the previous studies, the contamination was caused by endoscopic equipment that was contaminated due to improper cleaning methods, whereas in this study, the source of contamination was the cleaning solution used during the endoscope cleaning process. In another study, cystoscopy-related outbreaks were caused by Carbapenem-resistant Enterobacteriaceae, and issues were identified in the disinfection and reprocessing processes [24].
This study has some limitations. First, only patients admitted to the ED of Hospital 1 were included in this study. Patients with symptoms of UTIs in outpatient settings or those admitted to other hospitals for UTIs were excluded. For example, 4 patients admitted to rural hospitals for UTIs following cystoscopy during the study period were excluded from this investigation. Second, precystoscopy urine cultures were not conducted for all patients undergoing cystoscopy. In other words, prior to cystoscopy, it was not confirmed that all patients had a negative urine culture result. Therefore, the detection of P. aeruginosa in urine cultures performed upon admission to the ED could not definitively confirm whether it was associated with cystoscopy. Third, after cystoscopy, patients typically visit the outpatient department 1–2 weeks later to receive the results of cystoscopy. However, urine cultures were not performed for all patients at their next outpatient visit. As a result, asymptomatic bacteriuria patients were excluded, and patients who did not complain of fever due to UTIs but presented with other symptoms were also excluded. This raises the possibility of underestimating the patient population.
Following the study, Hospital 1 established and implemented a cleaning process for cystoscopes and a cleaning room management manual (Tables 6 and 7). When the aforementioned manual and revised cleaning process for cystoscopes were used, there were no further cases of hospitalized patients developing UTIs after cystoscopy.
CONCLUSIONS
Following the occurrence of UTIs in several patients after cystoscopy, an epidemiological investigation was conducted, which revealed that improper cleaning during endoscope sterilization led to the cystoscopes acting as potential reservoirs for bacteria. Therefore, modifications were made to the cleaning process, and a cleaning room management manual was established. This could allow interventions and proactive prevention measures to be taken to prevent similar infection outbreaks from occurring in the future. Close attention must be given to reprocessing and disinfection procedures for endoscopic equipment in order to minimize the risk of infections following cystoscopy.
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Funding/Support
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) and funded by the Korean government (MSIT) (2021R1G1A1092985).
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Research Ethics
This study was approved by the Institutional Review Board (IRB) of Chilgok Kyungpook National University Hospital (IRB No. KNUCH 2024-09-015) and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The need for informed consent was waived by the aforementioned IRB due to the retrospective nature of this study.
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Conflict of Interest
The authors have nothing to disclose.
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Author Contribution
Conceptualization: BK, YSC, JWC, THK; Data curation: BK, YSC, JKK, YSH, SHC, BSK, HTK, ESY, TGK, JWC, THK; Formal analysis: BK, YSC, JWC, THK; Funding acquisition: JWC, THK; Methodology: BK, YSC, JKK, YSH, SHC, BSK, HTK, ESY, TGK, JWC, THK; Project administration: JWC, THK; Visualization: BK, YSC; Writing - original draft: BK, YSC, JKK, YSH, SHC, BSK, HTK, ESY, TGK, JWC, THK; Writing - review & editing: JWC, THK.
NOTES
Table 1
Characteristics of patients with P. aeruginosa urinary tract infections
Table 2
Cleaning process after cystoscopy
Table 3
First round of environmental microbiological tests
| No.a) | Specimenb) | Culture |
|---|---|---|
| After washing with EmPower | ||
| 1, 2 | Suction tip area | NG |
| 3, 4 | Distal end area | NG |
| 5, 6 | Liquid passed from the suction tip to distal end | NG |
| After immersion in Perasafe | ||
| 7, 8 | Suction tip area | NG |
| 9, 10 | Distal end area | NG |
| 11, 12 | Liquid passed from the suction tip to distal end | NG |
| After immersion in sterilized water | ||
| 13, 14 | Suction tip area | NG |
| 15, 16 | Distal end area | NG |
| 17, 18 | Liquid passed from the suction | NG |
| tip to distal end | ||
| 19, 20 | Water used for rinsing cystoscopes | NG |
| 21 | EmPower diluted solution | P. aeruginosac) |
| 22 | Perasafe diluted solution | NG |
| 23 | Cleaning brush | Lactococcus lactis |
| 24 | Sink | Lactobacillus spp. & Candida krusei |
| 25 | Sterilized tray | NG |
| Interior of cystoscope storage cabinet | ||
| 26 | #1 (wall side) | NG |
| 27 | #2 (door side) | NG |
| 28 | Handle of storage cabinet | NG |
| 29 | Treatment cart | NG |
NG, no growth; P. aeruginosa, Pseudomonas aeruginosa.
EmPower (Metrex Research Corp., Orange, CA, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA).
a)No. 1–20 are samples collected from each of the 2 flexible cystoscopes.
b)The cleaning process is outlined in Table 2.
c)P. aeruginosa shows susceptibility to all tested antibiotics, including amikacin, aztreonam, cefepime, ceftazidime, ceftazidime/ avibactam, ciprofloxacin, gentamicin, imipenem, levofloxacin, meropenem, and piperacillin/tazobactam.
Table 4
Second round of environmental microbiological tests
| Specimen | Culture |
|---|---|
| EmPower undiluted solution | NG |
| EmPower subdivided solutiona) | NG |
| EmPower diluted solutionb) | P. aeruginosac) |
| Interior of the EmPower diluted can | |
| #1 | P. aeruginosad) & Chryseobacterium indologenes |
| #2 | Citrobacter freundii |
| Nozzle of the EmPower diluted pump | NG |
| Sink | |
| #1 (Handle) | P. aeruginosae) |
| #2 (Faucet) | NG |
| #3 (Surface) | Citrobacter freundii |
NG, no growth; P. aeruginosa, Pseudomonas aeruginosa.
EmPower (Metrex Research Corp., Orange, CA, USA).
a)EmPower undiluted solution dispensed into smaller bottles.
b)EmPower subdivided solution mixed with sterile water.
c)P. aeruginosa shows susceptibility to all tested antibiotics.
d)P. aeruginosa shows susceptibility to most tested antibiotics but exhibits resistance to gentamicin, imipenem, and meropenem, with intermediate susceptibility to ceftazidime.
e)P. aeruginosa shows susceptibility to most tested antibiotics but exhibits resistance to ceftazidime, imipenem, and meropenem.
Table 5
Third round of environmental microbiological tests
Table 6
Updated cleaning process after cystoscopy
Table 7
Environmental management of the cleaning room
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Outbreak of Cystoscopy-Related Urinary Tract Infections With Pseudomonas aeruginosa in South Korea, 2022: A Case Series
Characteristics of patients with P. aeruginosa urinary tract infections
| Patient | Age (yr) | Sex | Recent hospitalization (within 30 days) | Date of cystoscopy | Date of positive sampling | Delay between cystoscopy and positive sampling (day) | Hospitalization duration (day) | Urine culture | Blood culture |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 87 | Male | − | 2022.05.27 | 2022.06.04 | 8 | 7 | P. aeruginosa | NG |
| 2 | 67 | Male | − | 2022.05.30 | 2022.06.05 | 6 | 9 | NG | NG |
| 3 | 56 | Male | − | 2022.07.05 | 2022.07.13 | 8 | 10 | P. aeruginosa | NG |
| 4 | 64 | Male | − | 2022.07.06 | 2022.07.09 | 3 | 21 | P. aeruginosa | NG |
| 5 | 58 | Male | − | 2022.07.13 | 2022.07.15 | 2 | 11 | P. aeruginosa | NG |
| 6 | 64 | Male | + | 2022.07.14 | 2022.07.15 | 1 | 7 | NG | NG |
P. aeruginosa, Pseudomonas aeruginosa; NG, no growth.
Cleaning process after cystoscopy
| 1 After cystoscopy, wipe the endoscope with a gauze to remove organic material. |
| 2 Wash with a dual-enzymatic detergent (EmPower), and rinse with tap water in the sink. |
| 3 Immerse in 0.2% peracetic acid (Perasafe) for 10 min. |
| 4 Immerse in 2 L of sterile water in a sterilized tray, then rinse. |
EmPower (Metrex Research Corp., Orange, CA, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA).
First round of environmental microbiological tests
| No. |
Specimen |
Culture |
|---|---|---|
| After washing with EmPower | ||
| 1, 2 | Suction tip area | NG |
| 3, 4 | Distal end area | NG |
| 5, 6 | Liquid passed from the suction tip to distal end | NG |
| After immersion in Perasafe | ||
| 7, 8 | Suction tip area | NG |
| 9, 10 | Distal end area | NG |
| 11, 12 | Liquid passed from the suction tip to distal end | NG |
| After immersion in sterilized water | ||
| 13, 14 | Suction tip area | NG |
| 15, 16 | Distal end area | NG |
| 17, 18 | Liquid passed from the suction | NG |
| tip to distal end | ||
| 19, 20 | Water used for rinsing cystoscopes | NG |
| 21 | EmPower diluted solution | P. aeruginosa |
| 22 | Perasafe diluted solution | NG |
| 23 | Cleaning brush | Lactococcus lactis |
| 24 | Sink | Lactobacillus spp. & Candida krusei |
| 25 | Sterilized tray | NG |
| Interior of cystoscope storage cabinet | ||
| 26 | #1 (wall side) | NG |
| 27 | #2 (door side) | NG |
| 28 | Handle of storage cabinet | NG |
| 29 | Treatment cart | NG |
NG, no growth; P. aeruginosa, Pseudomonas aeruginosa.
EmPower (Metrex Research Corp., Orange, CA, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA).
a)No. 1–20 are samples collected from each of the 2 flexible cystoscopes.
b)The cleaning process is outlined in
c)P. aeruginosa shows susceptibility to all tested antibiotics, including amikacin, aztreonam, cefepime, ceftazidime, ceftazidime/ avibactam, ciprofloxacin, gentamicin, imipenem, levofloxacin, meropenem, and piperacillin/tazobactam.
Second round of environmental microbiological tests
| Specimen | Culture |
|---|---|
| EmPower undiluted solution | NG |
| EmPower subdivided solution |
NG |
| EmPower diluted solution |
P. aeruginosa |
| Interior of the EmPower diluted can | |
| #1 | P. aeruginosa |
| #2 | Citrobacter freundii |
| Nozzle of the EmPower diluted pump | NG |
| Sink | |
| #1 (Handle) | P. aeruginosa |
| #2 (Faucet) | NG |
| #3 (Surface) | Citrobacter freundii |
NG, no growth; P. aeruginosa, Pseudomonas aeruginosa.
EmPower (Metrex Research Corp., Orange, CA, USA).
a)EmPower undiluted solution dispensed into smaller bottles.
b)EmPower subdivided solution mixed with sterile water.
c)P. aeruginosa shows susceptibility to all tested antibiotics.
d)P. aeruginosa shows susceptibility to most tested antibiotics but exhibits resistance to gentamicin, imipenem, and meropenem, with intermediate susceptibility to ceftazidime.
e)P. aeruginosa shows susceptibility to most tested antibiotics but exhibits resistance to ceftazidime, imipenem, and meropenem.
Third round of environmental microbiological tests
| Specimen | Culture |
|---|---|
| Quad-enzymatic detergent (SaniZyme) solution | NG |
| Sink handle | |
| #1 | NG |
| #2 | NG |
| Sink surface | |
| #1 | NG |
| #2 | NG |
| Barcode reader | NG |
| Computer mouse | NG |
| Keyboard | NG |
| Handle of the brush storage cart | NG |
| Scissors for cutting intravenous bags | NG |
| Handle for the sink drawer | NG |
NG, no growth.
SaniZyme (Ultra Clean Systems Inc., Oldsmar, FL, USA).
Updated cleaning process after cystoscopy
| 1 | Rinse with water after cystoscopy. |
| 2 | Immerse in SaniZyme for 5 min. |
| 3 | Pass SaniZyme through the biopsy channel entrance using a syringe, and scrub each channel entrance with a brush. |
| 4 | Wipe the endoscope with gauze and rinse with water. |
| 5 | Immerse in Perasafe for 10 min. |
| 6 | Immerse in 2 L of sterile water in a sterilized tray, then rinse. |
| 7 | If not used immediately, store in a storage cabinet for drying. |
SaniZyme (Ultra Clean Systems Inc., Oldsmar, FL, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA).
Environmental management of the cleaning room
| Diluted can | Every day after use, immerse in SaniZyme for 5 min, then rinse with water and dry on a drying rack. |
| Sink | Ethanol disinfection twice daily (before/after cystoscopy). |
| Brush | Exchange after each use. |
| SaniZyme | Exchange daily. |
SaniZyme (Ultra Clean Systems Inc., Oldsmar, FL, USA).
Cystoscopes are only stored in a storage cabinet after all cleaning steps are completed.
Twice a year, perform culture tests for cystoscopes including cleaning and disinfectant solutions.
Table 1
Characteristics of patients with P. aeruginosa urinary tract infections
Table 2
Cleaning process after cystoscopy
EmPower (Metrex Research Corp., Orange, CA, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA).
Table 3
First round of environmental microbiological tests
NG, no growth; EmPower (Metrex Research Corp., Orange, CA, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA). No. 1–20 are samples collected from each of the 2 flexible cystoscopes. The cleaning process is outlined in
Table 4
Second round of environmental microbiological tests
NG, no growth; EmPower (Metrex Research Corp., Orange, CA, USA). EmPower undiluted solution dispensed into smaller bottles. EmPower subdivided solution mixed with sterile water.
Table 5
Third round of environmental microbiological tests
NG, no growth. SaniZyme (Ultra Clean Systems Inc., Oldsmar, FL, USA).
Table 6
Updated cleaning process after cystoscopy
SaniZyme (Ultra Clean Systems Inc., Oldsmar, FL, USA), Perasafe (Ecolab Inc., St. Paul, MN, USA).
Table 7
Environmental management of the cleaning room
SaniZyme (Ultra Clean Systems Inc., Oldsmar, FL, USA). Cystoscopes are only stored in a storage cabinet after all cleaning steps are completed. Twice a year, perform culture tests for cystoscopes including cleaning and disinfectant solutions.
