title: Hygiene: The Looming Achilles Heel in Endoscopy.
abstract: BACKGROUND
  Since the late 1970s there have been sporadic reports of nosocomial infections linked to endoscopic procedures. Infections by multidrug-resistant organisms (MDRO) have an increasing impact on healthcare systems worldwide. Since 2010 outbreaks involving MDRO have been reported as a result of endoscopic retrograde cholangiopancreatography (ERCP) from the USA, France, Germany and the Netherlands.
  
  
  METHODS
  This article evaluates the recent outbreaks and developments and demonstrates a structural approach to how to prevent future infections. Current national and international guidelines were used as a basis for discussions.
  
  
  RESULTS
  In some cases insufficient cleaning or drying supported the outbreak. In the majority of cases, outbreaks occurred despite the apparently appropriate reprocessing protocols being in use. Microlesions were identified on a number of endoscopes, which supported the growth of bacteria and represented a vehicle for the transmission of infectious material. National official bodies responded with warnings. Manufacturers informed their customers accordingly. Separate, purpose-designed reprocessing rooms and a sufficient number of competent staff provide the structural quality for a safe reprocessing. The process quality includes a thorough cleaning of all endoscope channels and crucial instrument components, followed by an automated and validated reprocessing procedure. Strict adherence to manufacturers' recommendations is essential. The outcome quality should be evaluated by regular audits, validation of reprocessing procedures and microbiological surveillance. If outbreaks occur, a close co-operation with official bodies and manufacturers is essential.
  
  
  CONCLUSIONS
  Health care professionals and manufacturers should be aware of their responsibility to ensure patient safety. A structural approach is key in prevention of endoscopy-associated infections.
authors: Klinik für Innere Medizin 2 (Gastroenterologie, Diabetologie, Onkologie), Katholisches Klinikum Mainz, Mainz, Germany.
authors: Michael
authors: M
authors: Jung
authors: Ulm, Germany.
authors: Ulrike
authors: U
authors: Beilenhoff
keywords: Duodenoscope design; Endoscopy; Infection control; Multidrug-resistant organisms (MDRO); Reprocessing