Transcript No Slide Title - Disinfection and Sterilization

Reprocessing Flexible Endoscopes:
What’s New
William A. Rutala, Ph.D., M.P.H.
Director, Hospital Epidemiology, Occupational Health and Safety Program, UNC Health
Care; Professor of Medicine, Director, Statewide Program for Infection Control and
Epidemiology, University of North Carolina (UNC) at Chapel Hill, NC, USA
DISCLOSURES




Consultation and Honoraria
 ASP (Advanced Sterilization Products), Clorox
Honoraria
 3M
Grants
 CDC, CMS
No funds from Medivator, session sponsor
Reprocessing Flexible Endoscopes
Objectives
Risks associated with reprocessing flexible endoscopes
 Causes of contamination and infection
 Gaps in current reprocessing standards
 Establish scientific rationale and evidence requirements
for enhancing safe practices

Reprocessing Flexible Endoscopes
Topics













Risks associated with reprocessing flexible endoscopes
Audits-cleaning (ATP) and microbiological sampling
Outbreaks when no reprocessing deficiencies identified
Patient notification after failure to follow guidelines
Endoscopes reprocessed if unused at 5 days
Human papilloma virus
C. difficile spores
Biofilms
Unsafe injection practices
Reprocessing steps performed in compliance with guidelines
AERs
Newer high-level disinfectants
Fecal transplants
Reprocessing Flexible Endoscopes
Objectives

Risks associated with reprocessing flexible endoscopes

Margin of safety and evidence of transmission, patient
notification
Causes of contamination and infection
 Gaps in current reprocessing standards
 Establish scientific rationale and evidence requirements
for enhancing safe practices

ENDOSCOPE REPROCESSING
Disinfection and Sterilization
EH Spaulding believed that how an object will be disinfected
depended on the object’s intended use.
CRITICAL - objects which enter normally sterile tissue or the
vascular system or through which blood flows should be
sterile.
SEMICRITICAL - objects that touch mucous membranes or
skin that is not intact require a disinfection process (highlevel disinfection [HLD]) that kills all microorganisms but
high numbers of bacterial spores.
NONCRITICAL -objects that touch only intact skin require lowlevel disinfection .
ENDOSCOPES





Widely used diagnostic and therapeutic procedure (11-22 million
GI procedures annually in the US)
GI endoscope contamination during use (109 in/105 out)
Semicritical items require high-level disinfection minimally
Inappropriate cleaning and disinfection has lead to crosstransmission
In the inanimate environment, although the incidence remains very
low, endoscopes represent a significant risk of disease
transmission
Endoscope Reprocessing:
Current Status of Cleaning and Disinfection

Guidelines
 Multi-Society Guideline, 12 professional organizations, 2011
 Centers for Disease Control and Prevention, 2008
 Society of Gastroenterology Nurses and Associates, 2010
 AAMI Technical Information Report, Endoscope Reprocessing, In
preparation
 Food and Drug Administration, 2009
 Endoscope Reprocessing, Health Canada, 2010
 Association for Professional in Infection Control and Epidemiology,
2000
MULTISOCIETY GUIDELINE ON REPROCESSING GI
ENDOSCOPES, 2011
Petersen et al. ICHE. 2011;32:527
ENDOSCOPE REPROCESSING
Multi-Society Guideline on Endoscope Reprocessing, 2011






PRECLEAN-point-of-use (bedside) remove debris by wiping
exterior and aspiration of detergent through air/water and
biopsy channels; leak test
CLEAN-mechanically cleaned with water and enzymatic
cleaner
HLD/STERILIZE-immerse scope and perfuse HLD/sterilant
through all channels for exposure time (>2% glut at 20m at
20oC). If AER used, review model-specific reprocessing
protocols from both the endoscope and AER manufacturer
RINSE-scope and channels rinsed with sterile water, filtered
water, or tap water. Flush channels with alcohol and dry
DRY-use forced air to dry insertion tube and channels
STORE-hang in vertical position to facilitate drying; stored in a
manner to protect from contamination
Disinfection and Sterilization
EH Spaulding believed that how an object will be disinfected
depended on the object’s intended use.
CRITICAL - objects which enter normally sterile tissue or the
vascular system or through which blood flows should be
sterile.
SEMICRITICAL - objects that touch mucous membranes or
skin that is not intact require a disinfection process (highlevel disinfection [HLD]) that kills all microorganisms but
high numbers of bacterial spores.
NONCRITICAL -objects that touch only intact skin require lowlevel disinfection .
Critical Items
Sterilization-Huge Margin of Safety





Huge margin of safety associated with sterilization of
critical items
Surgical instrument contaminated with <100
microorganisms
Decontamination by washer-disinfector eliminates >5 logs
(or 100,000 fold reduction)
Sterilization processes inactivate 12 logs of spores (or
1,000,000,000,000 spores)
Unlikely sterilized instrument will transmit infection when
compliant with recommendations
FEATURES OF ENDOSCOPES THAT PREDISPOSE
TO DISINFECTION FAILURES






Require low temperature
disinfection
Long narrow lumens
Right angle turns
Blind lumens
May be heavily contaminated
with pathogens, 109
Cleaning (4-6 log10 reduction)
and HLD (4-6 log10 reduction)
essential for patient safe
instrument
GI Endoscopes
HLD-Narrow Margin of Safety





Narrow margin of safety associated with high-level
disinfection of semicritical items
Instrument contaminated with 1,000,000,000
microorganisms
Cleaning eliminates ~5 logs (or 100,000 fold reduction)
High-level disinfection process inactivates ~ 5 logs of
microbes (100,000 fold)
Likely exposed to previous patient’s pathogens if
reprocessing protocol is not followed precisely
Transmission of Infection by Endoscopy
Kovaleva et al. Clin Microbiol Rev 2013. 26:231-254
Scope
Outbreaks
Micro (primary)
Pts
Contaminated
Pts Infected
Cause
(primary)
Upper GI
19
Pa, H. pylori,
Salmonella
169
56
Cleaning/Disinfection (C/D)
Sigmoid/Colon 5
oscopy
Salmonella, HCV 14
6
Cleaning/Disinfection
ERCP
23
Pa
152
89
C/D, water
bottle, AER
Bronchoscopy
51
Pa, Mtb,
Mycobacteria
778
98
C/D, AER,
water
Totals
98
1113
249
Based on outbreak data, if eliminated deficiencies associated with cleaning, disinfection, AER , contaminated water and
drying would eliminate about 85% of the outbreaks.
TRANSMISSION OF INFECTION

Gastrointestinal endoscopy




Bronchoscopy



>150 infections transmitted
Salmonella sp. and P. aeruginosa
Clinical spectrum ranged from colonization to death (~4%)
~100 infections transmitted
M. tuberculosis, atypical Mycobacteria, P. aeruginosa
Endemic transmission may go unrecognized (e.g., inadequate
surveillance, low frequency, asymptomatic infections)
Kovaleva et al. Clin Microbiol Rev 2013. 26:231-254
Endoscope Reprocessing, Worldwide

Worldwide, endoscopy reprocessing varies greatly
India, of 133 endoscopy centers, only 1/3 performed even a
minimum disinfection (1% glut for 2 min)
 Brazil, “a high standard …occur only exceptionally”
 Western Europe, >30% did not adequately disinfect
 Japan, found “exceedingly poor” disinfection protocols
 US, 25% of endoscopes revealed >100,000 bacteria

Schembre DB. Gastroint Endoscopy 2000;10:215
Nosocomial Infections via GI Endoscopes

Infections traced to deficient practices
 Inadequate cleaning (clean all channels)
 Inappropriate/ineffective disinfection (time exposure, perfuse
channels, test concentration, ineffective disinfectant,
inappropriate disinfectant)
 Failure to follow recommended disinfection practices (tapwater
rinse)
 Flaws and complexity in design of endoscopes or AERs
Reprocessing Flexible Endoscopes
Objectives
Risks associated with reprocessing flexible endoscopes
 Causes of contamination and infection


Complex device/complex reprocessing
Gaps in current reprocessing standards
 Establish scientific rationale and evidence requirements
for enhancing safe practices

FEATURES OF ENDOSCOPES THAT PREDISPOSE
TO DISINFECTION FAILURES






Require low temperature
disinfection
Long narrow lumens
Right angle turns
Blind lumens
May be heavily contaminated
with pathogens, 109
Cleaning (4-6 log10 reduction)
and HLD (4-6 log10 reduction)
essential for patient safe
instrument
Multi-Society Guideline for Reprocessing Flexible
Gastrointestinal Endoscopes, 2011

Transmission categorized as:
 Non-endoscopic and related to care of intravenous lines and
administration of anesthesia or other medications
Multidose vials
Reuse of needles and syringes
Intravenous sedation tubing
 Endoscopic and related to endoscope and accessories
Failure to sterilize biopsy forceps between patients
Lapses in reprocessing tubing used in channel irrigation
HCV from Unsafe Injection Practices at an Endoscopy
Clinic in Las Vegas, 2007-2008
Fischer et al. Clin Infect Dis. 2010;51; 267




Background-in January 2008, 3 persons with acute HCV underwent
endoscopy at a single facility in Nevada.
Method-reviewed clinical and laboratory data
Results- 5 additional cases of HCV were identified and quasispecies analysis
identified two clusters. 7/38 (17%) who followed source patient were HCV
infected. Reuse of syringes on single patients with use of single-use
propofol vials for multiple patients was observed.
Conclusion- patient-to-patient transmission of HCV resulted from
contamination of single-use medication vials that were used for multiple
patients during anesthesia administration. The resulting notification of
>50,000 persons was the largest of its kind in US health care.
Unsafe Injection Practices
HCV patient-new needle, same syringe, contaminated vial propofol
SAFE INJECTION PRACTICES
Endoscope Reprocessing Methods
Ofstead , Wetzler, Snyder, Horton, Gastro Nursing 2010; 33:204
Endoscope Reprocessing Methods
Ofstead , Wetzler, Snyder, Horton, Gastro Nursing 2010; 33:204
Performed all 12 steps with only 1.4% of endoscopes using manual versus 75.4% of those processed
using AER
Automated Endoscope Reprocessors
Automated Endoscope Reprocessors (AER)





Manual cleaning of endoscopes is prone to error. AERs can enhance
efficiency and reliability of HLD by replacing some manual reprocessing
steps
AER Advantages: automate and standardize reprocessing steps, reduce
personnel exposure to chemicals, filtered tap water, reduce likelihood that
essential steps will be skipped
AER Disadvantages: failure of AERs linked to outbreaks, may not eliminate
precleaning BMC Infect Dis 2010;10:200
Problems: incompatible AER (side-viewing duodenoscope); biofilm buildup;
contaminated AER; inadequate channel connectors; used wrong set-up or
connector MMWR 1999;48:557
Must ensure exposure of internal surfaces with HLD/sterilant
Automated Endoscope Reprocessors
Gastro Endoscopy 2010;72:675





All AERs have disinfection and rinsing cycles; some detergent cleaning;
alcohol flush and/or forced-air drying
Additional features may include: variable cycle times; printed
documentation; HLD vapor recovery systems; heating; automated leak
testing; automated detection of channel obstruction, MEC
Not all AERs compatible with all HLDs or endoscopes; some models
designed with specific HLDs
Some AERs consume and dispose of HLD and other reuse HLD
Some AERs have an FDA-cleared cleaning claim (eliminates soil and
microbes equivalent to optimal manual cleaning-<6.4µg/cm2 protein)
Automated Endoscope Reprocessors
with Cleaning Claim
(requires procedure room pre-cleaning)
Medivator Advantage Plus
Endoscope Reprocessing System
Evo-Tech (eliminates soil and microbes
equivalent to optimal manual cleaning.
BMC ID 2010;10:200)
ENDOSCOPE REPROCESSING: CHALLENGES
NDM-Producing E. coli Associated ERCP
MMWR 2014;62:1051
NDM-producing E.coli recovered from elevator channel
ENDOSCOPE REPROCESSING: CHALLENGES
NDM-Producing E. coli Associated ERCP
MMWR 2014;62:1051






March-July 2013, 9 patients with cultures for New Delhi Metallo-ßLactamase producing E. coli associated with ERCP
History of undergoing ERCP strongly associated with cases
NDM-producing E.coli recovered from elevator channel
No lapses in endoscope reprocessing identified
Hospital changed from automated HLD to ETO sterilization
Due to either failure of personnel to complete required process every
time or intrinsic problems with these scopes (not altered reprocessing)
ENDOSCOPE REPROCESSING: CHALLENGES
NDM-Producing E. coli Associated ERCP
MMWR 2014;62:1051

Recommendations




Education/adherence monitoring
Certification/competency testing of reprocessing staff
Enforcement of best practices-preventive maintenance schedule
Improved definition of the scope of the issue and contributing factors
Development of innovative approaches to improve and assess the
process
Systematic assessment of the ability of AERs/technicians to
clean/disinfect scopes
Disinfection evaluation testing that relates to risk of pathogen
transmission
DECREASING ORDER OF RESISTANCE OF MICROORGANISMS
TO DISINFECTANTS/STERILANTS
Most Resistant
Prions
Spores (C. difficile)
Mycobacteria
Non-Enveloped Viruses (norovirus, polio, HPV, parvo)
Fungi
Bacteria (MRSA, VRE, Acinetobacter)
Enveloped Viruses
Most Susceptible
ENDOSCOPE REPROCESSING: CHALLENGES
Susceptibility of Human Papillomavirus
J Meyers et al. J Antimicrob Chemother, Epub Feb 2014




High-level disinfectants no effect on
HPV
Finding inconsistent with other
small, non-enveloped viruses such
as polio and parvovirus
Further investigation warranted: test
methods unclear; organic matter;
comparison virus
Use HLD consistent with FDAcleared instructions (not altered
reprocessing)
Monitoring Endoscope Cleaning
Endoscope Cleaning
Endoscope must be cleaned using water with detergents
or enzymatic cleaners before processing.
 Cleaning reduces the bioburden and removes foreign
material (organic residue and inorganic salts) that
interferes with the HLD or sterilization process.
 Cleaning and decontamination should be done as soon as
possible after the items have been used as soiled
materials become dried onto the endoscopes.

Bacterial Bioburden Associated with Endoscopes
Gastroscope, log10
CFU
After procedure
6.7
Colonoscope, log10
CFU
8.5 Gastro Nursing 1998;22:63
6.8
8.5 Am J Inf Cont 1999;27:392
9.8 Gastro Endosc 1997;48:137
After cleaning
2.0
2.3
4.8
4.3
5.1
Viral Bioburden from Endoscopes Used with AIDS Patients
Hanson et al. Lancet 1989;2:86; Hanson et al. Thorax 1991;46:410
Dirty
Cleaned
Disinfected
7/20
1/20
0/20
0/20
0/20
0/7
Bronchoscopes
HIV (cDNA) 7/7
HBsAg
1/10
0/7
0/10
0/7
0/10
Gastroscopes
HIV (PCR)
HBsAg
IS THERE A STANDARD TO DEFINE WHEN A
DEVICE IS CLEAN?



There is currently no standard to define when a device is
“clean”, cleanliness controlled by visual
Potential methods: level of detectable bacteria; protein
(6µg/cm2); endotoxin; ATP; lipid
This is due in part to the fact that no universally accepted test
soils to evaluate cleaning efficiency and no standard
procedure for measuring cleaning efficiency
Audit Manual Cleaning of Endoscopes
Establishing Benchmarks
Alfa et al. Am J Infect Control 2012;40:860. Rapid Use Scope
Test detects organic residuals: protein (<6.4µg/cm2);
hemoglobin (<2.2.µg/cm2); and carbohydrate (<1.2µg/cm2)
 Alfa et al. Am J Infect Control 2013;41:245-248. If <200 RLUs
of ATP, the protein, hemoglobin and bioburden (<4-log10
CFU/cm2 [>106 per scope]) were achieved.
 Alfa et al. Am J Infect Control 2014;42:e1-e5. 200 RLU
adequate for ATP.

Audit Manual Cleaning of Endoscopes

Issues for consideration
 What is the clinical importance of <6.4µg/cm2 for protein and <4 log10
CFU/cm2 bioburden: that is, has it been related epidemiologically or
clinically to decrease or increase risk of infection?
 ATP may be related to markers (e.g., protein) but markers may have no
relationship to microbes/disease and providing patient safe instrument.
 Ideally, validation of benchmarks should include correlation with
patients’ clinical outcome. The CDC has suggested that sampling be
done when there are epidemiological data that demonstrate risk (e.g.,
endotoxin testing and microbial testing of water used in dialysis
correlated to increased risk of pyrogenic reactions in patient).
ATP and Microbial Contamination
Rutala, Gergen, Weber. Unpublished 2014
ATP no correlation to microbes
Pathogen
Microbial Load
ATP
C. difficile
106
<100
Acinetobacter baumannii
~104
<100
MRSA
~104
<100
C. difficile: A GROWING THREAT
C. difficile spores
DECREASING ORDER OF RESISTANCE OF MICROORGANISMS
TO DISINFECTANTS/STERILANTS
Most Resistant
Prions
Spores (C. difficile)
Mycobacteria
Non-Enveloped Viruses (norovirus)
Fungi
Bacteria (MRSA, VRE, Acinetobacter)
Enveloped Viruses
Most Susceptible
C. difficile:
MICROBIOLOGY AND EPIDEMIOLOGY









Gram-positive bacillus: Strict anaerobe, spore-former
Colonizes human GI tract
Increasing prevalence and incidence
New epidemic strain that hyper-produces toxins A and B
Causes virtually all cases of antibiotic-associated pseudomembranous
colitis.
Introduction of CDI from the community into hospitals
High morbidity and mortality in elderly
Inability to effectively treat fulminant CDI
Absence of a treatment that will prevent recurrence of CDI
Disinfectants and Antiseptics
C. difficile spores at 10 and 20 min, Rutala et al, 2006

~4 log10 reduction (3 C. difficile strains including BI-9)
Chlorine, 1:10, ~6,000 ppm chlorine (but not 1:50, ~1,200 ppm)
 Chlorine, ~1,910 ppm chlorine
 Chlorine, ~25,000 ppm chlorine
 0.20% peracetic acid
 2.4% glutaraldehyde
 2.65% glutaraldehyde
 3.4% glutaraldehyde and 26% alcohol

Control Measures
C. difficile


No reports document the transmission of C. difficile by a GI
endoscope.
Current guidelines should be effective in preventing transmission
via GI endoscope (i.e., HLD such as glutaraldehyde and
peracetic acid reliably kills C. difficile spores using normal
exposure times)
BIOFILMS
Pajkos, Vickery, Cossart. J Hosp Infect 2004;58:224
BIOFILMS
(Multi-Layered Bacteria Plus Exopolysaccharides That Cement Cell to Surface;
Develop in Wet Environments)
BIOFILMS
(Multi-Layered Bacteria Plus Exopolysaccharides That Cement Cell to Surface;
Develop in Wet Environments)
BIOFILMS



Bacteria residing within biofilms are many times more resistant
to chemical inactivation than bacteria is suspension
Does formation of biofilms within endoscopic channels contribute
to failure of decontamination process? Not known
Could be a reason for failure of adequate HLD processes but if
reprocessing performed promptly after use and endoscope dry
the opportunity for biofilm formation is minimal
Reprocessing Flexible Endoscopes
Objectives
Risks associated with reprocessing flexible endoscopes
 Causes of contamination and infection
 Gaps in current reprocessing standards
 Establish scientific rationale and evidence requirements
for enhancing safe practices


New HLDs, TJC, AERs, reprocessing if unused for 5-7 days,
microbiologic sampling, fecal transplants
High-Level Disinfection of
“Semicritical Objects”
Exposure Time > 8m-45m (US), 20oC
Germicide
Concentration_____
Glutaraldehyde
> 2.0%
Ortho-phthalaldehyde
0.55%
Hydrogen peroxide*
7.5%
Hydrogen peroxide and peracetic acid*
1.0%/0.08%
Hydrogen peroxide and peracetic acid*
7.5%/0.23%
Hypochlorite (free chlorine)*
650-675 ppm
Accelerated hydrogen peroxide
2.0%
Peracetic acid
0.2%
Glut and isopropanol
3.4%/26%
Glut and phenol/phenate**
1.21%/1.93%___
*May cause cosmetic and functional damage; **efficacy not verified
ResertTM HLD


High Level Disinfectant - Chemosterilant
2% hydrogen peroxide, in formulation




Efficacy (claims need verification)







pH stabilizers
Chelating agents
Corrosion inhibitors
Sporicidal, virucidal, bactericidal, tuberculocidal, fungicidal
HLD: 8 mins at 20oC
Odorless, non-staining, ready-to-use
No special shipping or venting requirements
Manual or automated applications
12-month shelf life, 21 days reuse
Material compatibility/organic material resistance (Fe, Cu)?
*The Accelerated Hydrogen Peroxide technology and logo are the property of Virox
Technologies, Inc. Modified from G MacDonald. AJIC 2006;34:571
ACCREDITING AGENCIES
The Joint Commission/CMS

Recommendations for Improvement must be based on
evidence-based guidelines



7-day endoscope reprocessing (challenged, removed from report)
Storage
Handling disinfected endoscopes with clean hands versus gloves
(challenged, removed from report)
MULTISOCIETY GUIDELINE ON REPROCESSING GI ENDOSCOPES, 2011
Petersen et al. ICHE. 2011;32:527
Multi-Society Guideline for Reprocessing Flexible
Gastrointestinal Endoscopes, 2011

Unresolved Issues
 Interval of storage after which endoscopes should be reprocessed
before use
Data suggest that contamination during storage for intervals of 714 days is negligible, unassociated with duration, occurs on
exterior of instruments and involves only common skin organisms
Data are insufficient to proffer a maximal outer duration for use of
appropriately cleaned, reprocessed, dried and stored endoscopes
Without full data reprocessing within this interval may be
advisable for certain situations (endoscope entry to otherwise
sterile regions such as biliary tree, pancreas)
Endoscopes Reprocessed If Unused 5 Days
AORN, 2010
Provided all channels thoroughly reprocessed and dried, reuse within 1014 appears safe. Data are insufficient to offer maximum duration for use.
Investigator
Shelf Life
Contamination Rate
Recommendation
Osborne,
Endoscopy 2007
18.8h
median
15.5% CONS, Micrococcus,
Bacillus
Environmental /process
contamination
Rejchrt, Gastro
Endosc 2004
5 days
3.0% (4/135), skin bacteria
(CONS, diphteroids)
Reprocessing before use not
necessary
Vergis, Endoscopy
2007
7 days
8.6% (6/70), all CONS
Reprocessing not necessary
for at least 7d
Riley, GI Nursing,
2002
24,168h
50% (5/10), <3 CFU CONS, S.
aureus, P. aeurginosa,
Micrococcus
Left for up to 1 week
Multi-Society Guideline for Reprocessing Flexible
Gastrointestinal Endoscopes, 2011

Unresolved Issues

Optimal frequencies for replacement of: clean water bottles
and tubing for insufflation of air and lens wash water, and
waste vacuum canisters and suction tubing
Concern related to potential for
backflow from a soiled endoscope
against the direction of forced fluid and air passage into clean
air/water source or from tubing/canister against a vacuum into
clean instruments

Microbiologic surveillance testing after reprocessing
Detection of non-environmental pathogens indicator of faulty
reprocessing equipment, inadequate solution, or failed human
process
Audit Manual Cleaning of Endoscopes
Establishing Benchmarks

Lack of consensus regarding the clinical value of routine
microbiological monitoring of endoscopes. We perform to assess
the efficacy of reprocessing.
 Alfa et al. Am J Infect Control 2012;40:233. Recommends a
bioburden residual of <100 CFU/ml.
 Beilenhoff et al. Endoscopy; 2007;39: 175. ESGE-ESGENA
allows bioburden count of <20 CFU/ channel.
 Heeg et al. J Hosp Infect; 2004;56:23. Contamination should
not exceed 1 CFU/ml. Certain organisms should not be
detected in any amount (e.g., P. aeruginosa, E. coli, S. aureus)
Fecal Transplants for Refractory
C. difficile Infection




Criteria for eligibility -failed standard therapy, no contraindication to
colonoscopy, confirmed C. difficile toxin positive, etc
Self-identified donor-donor will respond to eligibility questions: no GI
cancer, no metabolic disease, no prior use of illicit drugs, etc
Donor Testing-Stool-C. difficile toxin, O&P, bacterial pathogen panel
(Salmonella, Shigella, Giardia, norovirus, etc). Serum-RPR, HIV-1, HIV-2,
HCV Ab, CMV viral load, HAV IgM and IgG, HBsAg, liver tests, etc
Stool preparation-fresh sample into 1 liter sterile bottle, 500ml saline
added, vigorously shaking to liquefy, solid pieces removed with sterile
gauze so sample is liquid, liquid stool drawn up into 7 sterile 50ml syringes,
injected into terminal ileum, cecum, ascending colon, traverse colon,
descending colon, sigmoid colon. Colonoscope reprocessed by HLD.
Reprocessing Flexible Endoscopes
Objectives
Risks associated with reprocessing flexible endoscopes
 Causes of contamination and infection
 Gaps in current reprocessing standards
 Establish scientific rationale and evidence requirements
for enhancing safe practices

Conclusions





Endoscopes represent a nosocomial hazard. Narrow margin of safety
associated with high-level disinfection of semicritical items. Guidelines
must be strictly followed.
AERs can enhance efficiency and reliability of HLD of endoscopes by
replacing some manual reprocessing steps and reducing the likelihood that
essential steps are not skipped
Urgent need to better understand the gaps in endoscope reprocessingCRE, C. difficile spores, HPV, biofilms, etc. Industry must support research
to answer questions.
Data are insufficient to recommend ATP monitoring
Data suggest that contamination during storage for 7-14 days is negligible.
THANK YOU!
www.disinfectionandsterilization.org
Endoscopes: Delayed Reprocessing and Drying

Delayed Reprocessing (GI Endoscopy 2011;73;853)


Reprocess immediately after use; do not allow to sit idle and
soiled for hours before being processed. If precleaning not
initiated within an hour, soak in detergent before cleaning.
Endoscope Drying (J Hosp Infect 2008;68:59)

Microbial contamination lower when stored in drying and
storage cabinet.