Patient Safety Tip
of the Week
June 26, 2018 Infection Related to Colonoscopy
Several years ago we were trying to help a hospital find benchmarks for
colonoscopy complications. We were amazed that such benchmarks were not readily
available. We discussed complications of colonoscopy in our November 15, 2011
Patient Safety Tip of the Week “Rethinking
Colonoscopy” and noted that the few studies done did not separate out
screening colonoscopies from diagnostic or therapeutic ones. Rates also
depend on whether polypectomy was done, and also
relate to the age of the population and associated comorbidities (Warren 2009). All these factors make it extremely difficult
to compare rates of colonoscopy complications across facilities. Some of the
same factors likely explain why rates at free standing ambulatory sites tend to
be lower than at hospital-based endoscopy units.
Then, in our March
1, 2016 Patient Safety Tip of the Week “Colonoscopy
Complications”, we noted a
study from researchers at the Yale-New Haven Center for Outcomes Research and
Evaluation (CORE) (Ranasinghe
2016) which found outpatient colonoscopies
were followed by unplanned hospital visits within 7 days at an overall rate of
16.3/1000 colonoscopies, or a rate of about 1.6%. Hemorrhage, abdominal pain,
and perforation were the most common causes of unplanned hospital visits.
In those columns, infections related to colonoscopies never
were a significant part of our discussions. So we were quite taken aback at a
recent study by researchers at Johns Hopkins (Wang 2018)
that showed unexpectedly high rates of infection following colonoscopy (and
also endoscopy) at ambulatory surgery centers (ASC’s).
The rates of postendoscopic
infection per 1000 procedures within 7 days were 1.1 for screening colonoscopy,
and 1.6 for non-screening colonoscopy (and 3.0 for esophagogastroduodenoscopies).
Predictors of postendoscopic
infection included recent history of hospitalization or endoscopic procedure;
concurrence with another endoscopic procedure; low procedure volume or
non-freestanding ASC; younger or older age; black or Native American race and
male sex. Rates of 7-day postendoscopic infections
varied widely by ASC, ranging from 0 to 115 per 1000 procedures for screening
colonoscopy, 0 to 132 for non-screening colonoscopy.
The most common organisms associated
with infections were E. coli, Klebsiella, Clostridium difficile, and Staphylococcus
species. And among those unplanned postprocedure visits, over 60% required hospitalization.
Infection as a complication of colonoscopy has caught most
of us by surprise. Even the recently updated American Cancer Society guidelines
(Wolf
2018) on screening for colorectal cancer don’t discuss infection. Those
guidelines state “The principal recognized harms of CRC screening, which are
rare, are those associated with colonoscopy (bleeding, perforation,
cardiorespiratory complications of sedation) as a primary screening test or as
a follow‐up of other positive noncolonoscopy
tests.”
The variation in infection rates across ASC’s was striking,
with rates at some ASCs more than 100 times higher than expected.
So what does this mean for you? It
obviously depends on whether you are a provider or a consumer. If you are an
ASC performing endoscopies, you better find out what your rates of
complications, including infections, really are (and stratify them by screening
vs. nonscreening colonoscopy and whether polypectomy
was performed). If you have no way of getting data from area hospitals
regarding ED visits or hospitalizations of your patients after colonoscopy, you
need to routinely contact your patients to find out whether complications occurred.
Many ASC’s already make a phone call to patients 24-48 hours after a procedure,
but the Hopkins study would suggest you need to also contact them later
(perhaps at 30 days) to ensure you are identifying all complications.
And if you are a consumer, you’ll want to know the ASC’s
rate for complications, infectious or otherwise, for colonoscopies (or EGD’s).
If you can’t get that data, consider using a different ASC.
Colonoscopy is still a very valuable tool in the prevention
and management of colorectal cancer. And guidelines for screening are expanding
to begin screening earlier. The most recent American Cancer Society guidelines (Wolf 2018)
recommend that adults aged 45 years and older with an average risk of CRC
undergo regular screening with either a high‐sensitivity stool‐based
test or a structural (visual) examination, depending on patient preference and
test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with
timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified
recommendation. The recommendation for regular screening in adults aged 50
years and older is a strong recommendation.
The lack of accurate data on the complications of
colonoscopy has made it difficult to assess the risk:benefit equations for colonoscopy as a screening
tool for colorectal cancer. In fact, in our
March 1, 2016 Patient Safety Tip of the Week “Colonoscopy
Complications” we noted that
the jump to colonoscopy as the most recommended tool was based upon the
assumption that colonoscopy was more comprehensive than sigmoidoscopy (which
had been shown to reduce colorectal cancer mortality) but that untoward consequences
of colonoscopy had not really been factored into decisions.
It's incumbent upon all facilities performing colonoscopies
to have accurate data on complications of these procedures. This obviously should
apply not only to ASC’s but also to hospital-based colonoscopies. Many
facilities may be surprised they are not doing quite as well as they thought
they were.
References:
Warren J.L., Klabunde
C.N., Mariotto A.B., et al: Adverse
events after outpatient colonoscopy in the Medicare population. Ann
Intern Med 2009; 150: 849-857
http://www.annals.org/content/150/12/849.full
Ranasinghe I, Parzynski CS, Searfoss R, et al. Differences in Colonoscopy Quality Among
Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of
Unplanned Hospital Visits. Gastroenterology 2016; 150(1): 103-113
http://www.gastrojournal.org/article/S0016-5085%2815%2901353-0/abstract
Wang P, Xu T, Ngamruengphong S, Makary MA, et al. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut 2018; Published Online First: 10
Apr 2018
http://gut.bmj.com/content/early/2018/05/18/gutjnl-2017-315308
Wolf AMD, Fontham ETH, Church TR,
et al. Colorectal cancer screening for average‐risk adults: 2018
guideline update from the American Cancer Society. CA: A Cancer Journal for
Clinicians 2018; First published: 30 May 2018
https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457
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