Petrucci, et al. (2025) report that over a 14-day period, four patients developed sepsis within hours of undergoing endoscopic procedures at a gastroenterology outpatient clinic in Geneva, Switzerland, triggering an urgent epidemiological investigation upon notification to authorities. The case clustering raised concerns about a iatrogenic source, prompting a coordinated public health response. This report outlines the investigation led by the Geneva Health Authorities in collaboration with the medical team, emergency care providers, infection prevention specialists, and the bacteriology laboratory at Geneva University Hospitals. A multidisciplinary team, including an epidemiologist, a pharmacist and an infection prevention specialist, conducted an on-site investigation the day after the outbreak was identified, highlighting a probable extrinsic contamination of propofol by Escherichia coli.

Following the identification of the epidemiological link between two cases of sepsis by emergency physicians, two additional cases were found through retrospective reviews of hospital records, patient interviews, and consultations with the clinic's medical team. All cases were classified as sepsis occurring within 24 hours post-endoscopy. Sepsis was defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, in accordance with the Sepsis-3 criteria. The four cases occurred on three different days over a two-week period (days 1, 12, and 13, with two cases on the last day). Among 28 patients who underwent an endoscopic procedure under propofol at the same clinic during the three days under investigation, four developed sepsis within 24 hours post-procedure. None of the remaining 24 patients, contacted by telephone, reported any symptoms. Days without new cases during the two-week period between events were not investigated, as the standard 24 to 48 hours post-procedure follow-up calls reported no symptomatic patients. The same team (one doctor and two nurses, alternating roles in assistance) performed all the endoscopies.

This outbreak highlights the risks associated with suboptimal aseptic practices in outpatient endoscopy settings. Implementing strict aseptic handling protocols can reduce contamination risks, the authors say. The following measures were implemented: immediate suspension of endoscopic procedures; sharing audit reports with the involved medical team to guide them in evaluating and improving hygiene practices, stock management, drug administration, and staff training to ensure compliance with standards. Following notification to the local gastroenterology association, a communication was sent to all affiliates to raise awareness and reinforce adherence to national quality and hygiene standards.

The outbreak was swiftly managed by a multidisciplinary team of epidemiologists, quality inspectors, pharmacists, and medical device experts, in collaboration with the clinic's medical team. Recommendations were promptly communicated, enabling the implementation of corrective measures without delay. Collaboration with the professional association turned the incident into an opportunity to promote best practices among outpatient endoscopy professionals and improve patient safety, the authors conclude.

Reference: Petrucci R, et al. Antimicrobial Resistance & Infection Control. Dec. 24, 2025. Volume 14, article number 151, (2025)