title: Gastrointestinal endoscopes cleaned without detergent substance following an automated endoscope washer/disinfector dysfunction.
abstract: OBJECTIVE
  To report cases of gastrointestinal endoscopies performed with endoscopes that were reprocessed without detergent substance during a period of dysfunction of the automated endoscope reprocessor (AER).
  
  
  METHODS
  A dysfunction of the AER for the cycles requiring detergent substance was reported at the Grenoble University Hospital on March 2005. During this period, 72 patients had potentially been exposed to a contaminated endoscope. A recall procedure was organized and serologic tests (HIV, HCV, HBV) were performed 3 and 6 months after the AER incident.
  
  
  RESULTS
  Within the 72 patients convened, 56 (77.8%) were seen in consultation and accepted the serologic screening. Finally, serologic screening was done for 59 patients (81.9%) and no seroconversion for HIV, HCV, or HBV was observed. The final attrition rate was 13 patients (18.1%).
  
  
  CONCLUSIONS
  No viral infection was transmitted during the AER dysfunction. After this AER incident, the monitoring of the endoscopic procedures and the traceability of the cleaning process were both improved to prevent further incidents.
authors.affiliation: Unité d'hygiène hospitalière, Centre Hospitalier Universitaire de Grenoble, Grenoble.
authors.forename: Marie
authors.initials: M
authors.lastname: Méan
authors.forename: Marie Reine
authors.initials: MR
authors.lastname: Mallaret
authors.forename: Philippe
authors.initials: P
authors.lastname: Bichard
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Shum
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Zarski
mesh_terms: D003428:Cross Infection / Q000517:prevention & control; D003902:Detergents; D004203:Disinfection / Q000295:instrumentation*; D020776:Endoscopes, Gastrointestinal; D004866:Equipment Contamination / Q000517:prevention & control; D004868:Equipment Failure; D017743:Equipment Reuse; D006801:Humans
chemical_list: D003902:Detergents