Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastrointestinal endoscopy

Table 3 Recommended practices for the effective reprocessing of gastrointestinal endoscopes

1 Reprocess the GI endoscope promptly after the endoscopic procedure in accordance with its manufacturer’s step-by-step set of instructions

(1) As required, supplement these instructions with the recommendations of published infection-control guidelines

(2) Always reprocess the GI endoscope’s air/water channels (Also, always reprocess the GI endoscope’s suction and air/water valves and other accessories)

(3) Before its reprocessing, visually examine the GI endoscope, especially its distal sheath, for excessive wear and tear, having it servicing when required

(4) Practice Standard Precautions when reprocessing GI endoscopes (As required, also employ Contact Precautions to prevent CRE transmission)

(5) Confirm that the high-level disinfectant is contacting all of the GI endoscope's potentially contaminated surfaces

(6) The use of ethylene oxide (EtO) gas to sterilize ERCP endoscopes, in lieu of high-level disinfection, may be considered. (No matter, thorough cleaning of the endoscope is required)

2 Place emphasis on cleaning and brushing (prior to high-level disinfection) the area near, around and behind the ERCP endoscope’s forceps elevator (Figure 1B)

(1) Ensure that, if it is exposed, the ERCP endoscope’s elevator wire channel, which houses the cable that controls and angulates this forceps elevator, is thoroughly flushed with a detergent solution. The complete manual reprocessing (i.e., cleaning, high-level disinfection, and drying) of this (exposed) channel may be necessary for some ERCP endoscope models, to prevent disease transmission

(2) Routinely train and evaluate the knowledge of reprocessing staffers

(3) Periodically audit reprocessing staffers’ practices to verify the proper cleaning and brushing of all models of GI endoscopes, especially the ERCP endoscopes[61]

(4) Use cleaning brushes and detergents that have been validated, recommended, and/or “approved” for use by the GI endoscope’s manufacturer[31,62,63]

(5) Manually “leak test” the GI endoscope prior to its cleaning in accordance with its manufacturer’s instructions (unless otherwise instructed by the automated endoscope reprocessor’s [or, AER’s] manufacturer, if the AER is equipped with an automated leak tester)

3 Routinely monitor (i.e., at least once a day, if not more often) the concentration of the high-level disinfectant to ensure its effectiveness. Record the results in a log book or use an electronic format that permits archiving and documentation retreival

(1) In addition to its concentration, verify and record for each processed GI endoscope that the high-level disinfectant’s immersion time and temperature are appropriate

4 Use bacteria-free (or sterile) water to rinse the GI endoscope following its high-level disinfection

(1) Compliance with this instruction may require: (A) proper maintenance and replacement of a water filtration system, if one is used; and (B) routine monitoring of the rinse water to confirm its lack of bacteria[64]

5 Consider using sterile water in the water bottle for lens cleaning and irrigation during GI endoscopy, especially during ERCP[15,65]

6 Terminally dry all of the GI endoscope’s internal channels (including the ERCP elevator wire channel, if it is exposed) using 70% alcohol and forced air[5,66]

7 Store the GI endoscope with its insertion tube hanging freely and vertically in a clean, dry, and well-ventilated area or cabinet[66,67]

(1) Consider reprocessing the GI endoscope again before its reuse if it has been stored for more than 5 d[68]. Reprocessing ERCP endoscopes before each use may be advisable

8 If using an AER, ensure that it is performing properly; has been validated for the effective reprocessing of each GI endoscope in inventory; has been serviced and maintained as required; and that its internal surfaces and components are being routinely self-disinfected as instructed by its manufacturer

9 Manufacturers may consider enhanced design controls and validation measures to ensure the adequate reprocessing of ERCP endoscopes and other complex reusable instrumentation, to further minimize the risk of disease transmission during GI endoscopy

CRE: Carbapenem-resistant Enterobacteriaceae; GI: Gastrointestinal.