ASGE guideline for infection control during GI endoscopy

Abstract

The Quality Assurance in Endoscopy Committee of the American Society for Gastrointestinal Endoscopy (ASGE) updated and revised this document, which was originally prepared by The Standards of Practice Committee of the ASGE and was published in 2008.1Banerjee S. Shen B. Nelson D.B. et al.ASGE Standards of Practice CommitteeInfection control during GI endoscopy.Gastrointest Endosc. 2008; 67 ([abstract]): 781-790Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar In preparing this guideline, a search of the medical literature was performed by using PubMed, supplemented by accessing the related-articles feature of PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data existed from well-designed prospective trials, emphasis was given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This guideline is intended to be an educational tool to provide information that may assist endoscopists in delivering care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. Millions of GI endoscopies are performed annually throughout the United States, and it is reassuring that documented instances of infectious adverse events remain rare.2Kimmey M.B. Burnett D.A. Carr-Locke D.L. et al.Transmission of infection by gastrointestinal endoscopy.Gastrointest Endosc. 1993; 36: 885-888Abstract Full Text PDF Google Scholar Several recent reports of infections with multidrug-resistant organisms (MDRO) associated with duodenoscope use suggest that prior assumptions regarding endoscopy-related infection rates may be an underestimate, particularly for ERCP. These outbreaks of infection have led to a reassessment of current infection control practices. Endoscopy-related transmission of infections may occur if microorganisms are spread from patient to patient by contaminated equipment or if microorganisms are spread from the gut lumen during endoscopy through the bloodstream to susceptible organs, adjacent tissues, or prostheses. Non-endoscopic transmission of infections within endoscopy units also can occur if microorganisms are transmitted from patients to endoscopy personnel. The purpose of this document is to disseminate information and promote understanding of endoscopy-related transmission of infection in order to minimize its risk of occurrence. Circumstances in which an endoscopy-related infection might occur are discussed, as are measures to prevent such infection, including endoscope reprocessing and reprocessing failure, general infection control, protection of endoscopy personnel, and the importance of leadership. Over the course of an endoscopic examination, the external surface and internal channels of flexible endoscopes are exposed to body fluids and contaminants. Disinfection of these reusable instruments pose special challenges. Flexible endoscopes are heat labile devices and as such are not suitable for steam sterilization. Therefore, reprocessing is achieved by mechanical and detergent cleaning, followed by high-level disinfection (HLD), rinsing, and drying. Stringent guidelines for the reprocessing of flexible endoscopes were developed by the ASGE and the Society for Healthcare Epidemiology of America, who convened with representatives from physician, nursing, and infection control organizations, industry leaders, and federal and state agencies. This conference resulted in the 2003 publication of the Multisociety Guideline for Reprocessing of Flexible GI Endoscopes,3American Society for Gastrointestinal EndoscopyMulti-society guideline for reprocessing flexible gastrointestinal endoscopes.Gastrointest Endosc. 2003; 58: 1-8Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar which was updated in 20114Petersen B.T. Chennat J. Cohen J. et al.ASGE Quality Assurance in Endoscopy CommitteeMultisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011.Gastrointest Endosc. 2011; 73 ([abstract]): 1075-1084Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar and in 2016.5Petersen B.T. Cohen J. Hambrick 3rd, R.D. et al.Reprocessing Guideline Task ForceMultisociety guideline on reprocessing flexible GI endoscopes: 2016 update.Gastrointest Endosc. 2017; 85 ([abstract]): 282-294.e1Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Historically, in the absence of defective equipment, reported cases of transmission of infection have resulted from failure to adhere to these guidelines. Since 2012, multiple U.S. and international medical centers have reported patient-to-patient transmission of MDROs such as carbapenem-resistant Enterobacteriaceae (CRE), without identifiable, overt breaches of reprocessing protocol.6Murray P. Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients. Minority staff report. January 13, 2016. Available at: https://www.help.senate.gov/imo/media/doc/Duodenoscope Investigation FINAL Report.pdf.Google Scholar Transmission of these organisms has been linked to the elevator channel endoscopes (duodenoscopes, linear array EUS scopes) and primarily attributed to persistent contamination of the elevator mechanism, the elevator cable, and the cable channel itself. When clinically significant bacterial infections are transmitted endoscopically, they are often recognized because their incubation periods are often short, and patients usually develop overt clinical symptoms. However, cases of transmission may be missed if the illness is subclinical or if symptoms are attributed to other factors associated with the procedure (issues related to the interventions performed or to sedation) or to other patient-specific conditions or events. Overall, although accurate data on infection transmission rates are difficult to obtain because of the lack of a proper mechanism for reporting and calculation of transmission rates, a summary of the available data, in the context of these reporting limitations, is provided below. A total of 84 cases of endoscopy-related transmission of Salmonella species between patients were reported between 1974 and 1987,7Holmberg S.D. Osterholm M.T. Senger K.A. et al.Drug-resistant Salmonella from animals fed antimicrobials.N Engl J Med. 1984; 311: 617-622Crossref PubMed Google Scholar, 8Chmel H. Armstrong D. Salmonella oslo: a focal outbreak in a hospital.Am J Med. 1976; 60: 203-208Abstract Full Text PDF PubMed Scopus (49) Google Scholar, 9Dean A.G. Transmission of Salmonella typhi by fiberoptic endoscopy.Lancet. 1977; 2: 134Abstract PubMed Google Scholar, 10Beecham 3rd, H.J. Cohen M.L. Parkin W.E. Salmonella typhimurium: transmission by fiberoptic upper gastrointestinal endoscopy.JAMA. 1979; 241: 1013-1015Crossref PubMed Google Scholar, 11Schliessler K.H. Rozendaal B. Taal C. et al.Outbreak of Salmonella agona infection after upper intestinal fibreoptic endoscopy.Lancet. 1980; 2: 1246Abstract PubMed Google Scholar, 12Hawkey P.M. Davies A.J. Viant A.C. et al.Contamination of endoscopes by Salmonella species.J Hosp Infect. 1981; 2: 373-376Abstract Full Text PDF PubMed Google Scholar, 13O'Connor B.H. Bennett J.R. Alexander J.G. et al.Salmonellosis infection transmitted by fibreoptic endoscopes.Lancet. 1982; 2: 864-866Abstract PubMed Scopus (41) Google Scholar, 14Dwyer D.M. Klein E.G. Istre G.R. et al.Salmonella newport infections transmitted by fiberoptic colonoscopy.Gastrointest Endosc. 1987; 33: 84-87Abstract Full Text PDF PubMed Scopus (69) Google Scholar, 15Tuffnell P.G. Salmonella infections transmitted by a gastroscope.Can J Public Health. 1976; 67: 141-142Google Scholar but none have been reported since that time. Overall, there have been rare reports of endoscopic transmission of Pseudomonas species.16Greene W.H. Moody M. Hartley R. et al.Esophagoscopy as a source of Pseudomonas aeruginosa sepsis in patients with acute leukemia: the need for sterilization of endoscopes.Gastroenterology. 1974; 67: 912-919Abstract Full Text PDF PubMed Google Scholar, 17Elson C.O. Hattori K. Blackstone M.O. Polymicrobial sepsis following endoscopic retrograde cholangiopancreatography.Gastroenterology. 1975; 69: 507-510PubMed Google Scholar As recently as 2011, 4 patients who underwent upper endoscopy were found to be infected with multidrug-resistant Pseudomonas. Several potential causes for the transmission were identified, including insufficient initial cleaning, shortening of immersion and brushing times, insufficient channel flushing, and inadequate drying before storage.18Bajolet O. Ciocan D. Vallet C. et al.Gastroscopy-associated transmission of extended-spectrum beta-lactamase-producing Pseudomonas aeruginosa.J Hosp Infect. 2013; 83: 341-343Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar In addition to inadequate reprocessing of the endoscope itself, the propensity for organism growth in moisture-rich environments is a common factor in facilitating transmission. In some instances, an unsterilized irrigation water bottle attached to the endoscope was identified as a source of infection.19Doherty D.E. Falko J.M. Lefkovitz N. et al.Pseudomonas aeruginosa sepsis following retrograde cholangiopancreatography (ERCP).Dig Dis Sci. 1982; 27: 169-170Crossref PubMed Scopus (0) Google Scholar, 20Bass D.H. Oliver S. Bornman P.C. Pseudomonas septicaemia after endoscopic retrograde cholangiopancreatography—an unresolved problem.S Afr Med J. 1990; 77: 509-511PubMed Google Scholar A lack of cleaning and drying of the air-water and/or the elevator channels of duodenoscopes also was implicated in some cases of transmission of Pseudomonas infection.21Cryan E.M. Falkiner F.R. Mulvihill T.E. et al.Pseudomonas aeruginosa cross-infection following endoscopic retrograde cholangiopancreatography.J Hosp Infect. 1984; 5: 371-376Abstract Full Text PDF PubMed Google Scholar, 22Struelens M.J. Rost F. Deplano A. et al.Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.Am J Med. 1993; 95: 489-498Abstract Full Text PDF PubMed Scopus (126) Google Scholar, 23Qiu L. Zhou Z. Liu Q. et al.Investigating the failure of repeated standard cleaning and disinfection of a Pseudomonas aeruginosa-infected pancreatic and biliary endoscope.Am J Infect Control. 2015; 43: e43-e46Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 24Verfaillie C.J. Bruno M.J. Voor in 't Holt A.F. et al.Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa.Endoscopy. 2015; 47: 493-502Crossref PubMed Scopus (30) Google Scholar Failure of automated endoscope washer-dryers has been implicated in several cases.22Struelens M.J. Rost F. Deplano A. et al.Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.Am J Med. 1993; 95: 489-498Abstract Full Text PDF PubMed Scopus (126) Google Scholar, 25Alvarado C.J. Stolz S.M. Maki D.G. Nosocomial infections from contaminated endoscopes: a flawed automated endoscope washer: an investigation using molecular epidemiology.Am J Med. 1991; 91: 272S-280SAbstract Full Text PDF PubMed Google Scholar, 26Kressel A.B. Kidd F. Pseudo-outbreak of Mycobacterium chelonae and Methylobacterium mesophilicum caused by contamination of an automated endoscopy washer.Infect Control Hosp Epidemiol. 2001; 22: 414-418Crossref PubMed Google Scholar Recently, a strain of Pseudomonas with reduced susceptibility to glutaraldehyde was reported.27Tschudin-Sutter S. Frei R. Kampf G. et al.Emergence of glutaraldehyde-resistant Pseudomonas aeruginosa.Infect Control Hosp Epidemiol. 2011; 32: 1173-1178Crossref PubMed Scopus (0) Google Scholar A few reports of endoscopic transmission of Helicobacter pylori were attributed to inadequate reprocessing of endoscopes and biopsy forceps.28Graham D.Y. Alpert L.C. Smith J.L. et al.Iatrogenic Campylobacter pylori infection is a cause of epidemic achlorhydria.Am J Gastroenterol. 1988; 83: 974-980PubMed Google Scholar, 29Langenberg W. Rauws E.A. Oudbier J.H. et al.Patient-to-patient transmission of Campylobacter pylori infection by fiberoptic gastroduodenoscopy and biopsy.J Infect Dis. 1990; 161: 507-511Crossref PubMed Google Scholar Up to 61% of endoscopes became contaminated after use in patients infected with H pylori,30Fantry G.T. Zheng Q.X. James S.P. Conventional cleaning and disinfection techniques eliminate the risk of endoscopic transmission of Helicobacter pylori.Am J Gastroenterol. 1995; 90: 227-232PubMed Google Scholar but conventional cleaning and disinfection of the instruments are highly effective in eliminating H pylori. Before widespread application of standardized reprocessing guidelines, there were isolated reports of endoscopic transmission of other enteric bacteria, including Klebsiella,31Parker H.W. Geenen J.E. Bjork J.T. et al.A prospective analysis of fever and bacteremia following ERCP.Gastrointest Endosc. 1979; 25: 102-103Abstract Full Text PDF PubMed Google Scholar Enterobacter,17Elson C.O. Hattori K. Blackstone M.O. Polymicrobial sepsis following endoscopic retrograde cholangiopancreatography.Gastroenterology. 1975; 69: 507-510PubMed Google Scholar Serratia,32Gorse G.J. Messner R.L. Infection control practices in gastrointestinal endoscopy in the United States: a national survey.Infect Control Hosp Epidemiol. 1991; 12: 289-296Crossref PubMed Google Scholar and Staphylococcus.31Parker H.W. Geenen J.E. Bjork J.T. et al.A prospective analysis of fever and bacteremia following ERCP.Gastrointest Endosc. 1979; 25: 102-103Abstract Full Text PDF PubMed Google Scholar There have been no reports of transmission of mycobacteria by GI endoscopy. Current reprocessing guidelines were shown to be adequate in eradicating mycobacteria, and to date there are no reports of transmission of mycobacteria by GI endoscopy.33Muscarella L.F. Automatic flexible endoscope reprocessors.Gastrointest Endosc Clin N Am. 2000; 10: 245-257PubMed Google Scholar Similarly, reprocessing under the current guidelines was shown to inactivate biofilm and the spores of Clostridium difficile and other bacteria,34Rutala W.A. Gergen M.F. Weber D.J. Inactivation of Clostridium difficile spores by disinfectants.Infect Control Hosp Epidemiol. 1993; 14: 36-39Crossref PubMed Google Scholar, 35Muscarella L.F. Evaluation of the risk of transmission of bacterial biofilms and Clostridium difficile during gastrointestinal endoscopy.Gastroenterol Nurs. 2010; 33: 28-35Crossref PubMed Scopus (0) Google Scholar and no cases of transmission of C difficile have been reported. As mentioned previously, transmission of MDROs, including CRE, via duodenoscopes, has been reported.24Verfaillie C.J. Bruno M.J. Voor in 't Holt A.F. et al.Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa.Endoscopy. 2015; 47: 493-502Crossref PubMed Scopus (30) Google Scholar, 36Carbonne A. Thiolet J.M. Fournier S. et al.Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009.Euro surveill. 2010; 15 (pii:19734)Crossref Google Scholar, 37Alrabaa S.F. Nguyen P. Sanderson R. et al.Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment.Am J Infect Control. 2013; 41: 562-564Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 38Epstein L. Hunter J.C. Arwady M.A. et al.New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes.JAMA. 2014; 312: 1447-1455Crossref PubMed Scopus (126) Google Scholar Unlike prior outbreaks of endoscope-transmitted infections, no recognized breaches of standard reprocessing protocol have been identified in outbreaks of duodenoscope-associated CRE to date. These transmissions seem to be related to difficult-to-clean or even sealed portions of these specific endoscopes, particularly the areas around the elevator regions of duodenoscopes. Documentation of transmission of viral infections by endoscopy is more challenging, because these infections have a longer incubation period, and patients may be asymptomatic or minimally symptomatic. Thus, linking transmission of these infections to a previously performed procedure may be difficult. Still, existing data suggest that risk of viral transmission via endoscopy is extremely low to non-existent. There are rare reports of transmission of hepatitis C in situations where lapses in HLD of endoscopes occurred. Older case reports and epidemiologic studies suggested an association between endoscopy and hepatitis C virus (HCV) seropositivity. However, interpretation of these reports is difficult because of a reliance on self-reporting of risk factors for HCV and other inherent biases. In fact, the documented cases of HCV were all related to non-endoscopic transmission rather than direct endoscopy-related transmission. Bronowicki et al39Bronowicki J.P. Venard V. Botte C. et al.Patient-to-patient transmission of hepatitis C virus during colonoscopy.N Engl J Med. 1997; 337: 237-240Crossref PubMed Scopus (358) Google Scholar documented transmission of hepatitis C from an infected patient to 2 subsequent patients who underwent colonoscopy with the same instrument. Transmission was originally attributed to 2 breaches in endoscope reprocessing: failure to clean the working channel of the endoscope manually before disinfection and failure to sterilize the biopsy forceps between patients. However, inadequate aseptic techniques practiced at this center also raise the possibility of transmission of the virus via contaminated intravenous tubing, syringes, or multi-dose vials rather than the endoscope itself.40Saludes V. Esteve M. Casas I. et al.Hepatitis C virus transmission during colonoscopy evidenced by phylogenetic analysis.J Clin Virol. 2013; 57: 263-266Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 41Gonzalez-Candelas F. Guiral S. Carbo R. et al.Patient-to-patient transmission of hepatitis C virus (HCV) during colonoscopy diagnosis.Virol J. 2010; 7: 217Crossref PubMed Scopus (0) Google Scholar In another example, a single-center report showed that 8 of 87 (9.2%) HCV-negative patients seroconverted after propofol vials designed for single use were reused on multiple patients undergoing endoscopic procedures.42Fischer G.E. Schaefer M.K. Labus B.J. et al.Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007-2008.Clin Infect Dis. 2010; 51: 267-273Crossref PubMed Scopus (61) Google Scholar There is evidence, however, that when currently accepted reprocessing guidelines are followed, transmission of HCV is extremely rare to non-existent. A multicenter prospective cohort study followed 8260 HCV-seronegative patients undergoing endoscopy.43Ciancio A. Manzini P. Castagno F. et al.Digestive endoscopy is not a major risk factor for transmitting hepatitis C virus.Ann Intern Med. 2005; 142: 903-909Crossref PubMed Google Scholar All centers reported compliance with internationally accepted guidelines for cleaning and disinfection of endoscopes. All 8260 patients, including 912 patients who underwent an endoscopy with an instrument previously used on HCV carriers, remained seronegative at follow-up testing performed 6 months after their endoscopic procedures. Four seroconversions occurred over the study period in a control group of 38,280 blood donors, which indicated a background seroconversion rate of 0.042 per 1000 patient-years. Similar results were reported in a prospective cohort study of 859 patients, with a high prevalence of hepatitis C of 71%.44Mikhail N.N. Lewis D.L. Omar N. et al.Prospective study of cross-infection from upper-GI endoscopy in a hepatitis C-prevalent population.Gastrointest Endosc. 2007; 65: 584-588Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Endoscopes were cleaned and disinfected in accordance with guidelines published by the ASGE and the Society of Gastroenterology Nurses and Associates. Of the 149 patients who were seronegative and for whom follow-up serology could be obtained, 4 subsequently developed antibodies to HCV. Two were found to have had HCV RNA in blood samples obtained before an endoscopy, which indicated that they were infected before undergoing endoscopy. Of the remaining 2 patients who developed anti-HCV antibodies after an endoscopy, neither had HCV RNA detected on follow-up testing at 3 and 6 months after the procedure, which suggested false-positive serologic tests. Thus, endoscopy did not result in transmission of hepatitis C in any of these patients, despite the extremely high exposure risk in this cohort. A handful of isolated case reports suggest that transmission of hepatitis B via endoscopy is possible.45Morris I.M. Cattle D.S. Smits B.J. Endoscopy and transmission of hepatitis B.Lancet. 1975; 2 ([letter]): 1152Abstract PubMed Google Scholar, 46Seefeld U. Bansky G. Jaeger M. et al.Prevention of hepatitis B virus transmission by the gastrointestinal fibrescope. Successful disinfection with an aldehyde liquid.Endoscopy. 1981; 13: 238-239Crossref PubMed Google Scholar, 47Birnie G.G. Quigley E.M. Clements G.B. et al.Endoscopic transmission of hepatitis B virus.Gut. 1983; 24: 171-174Crossref PubMed Scopus (171) Google Scholar However, transmission of hepatitis B appears to be very rare, even when inadequate cleaning and disinfection occurs, and there are no reported cases of transmission when currently accepted guidelines are followed. In 5 prospective studies, 120 patients who had undergone endoscopy with an instrument previously used in a patient infected with hepatitis B were followed.48McDonald G.B. Silverstein F.E. Can gastrointestinal endoscopy transmit hepatitis B to patients?.Gastrointest Endosc. 1976; 22: 168-170Abstract Full Text PDF PubMed Google Scholar, 49McClelland D.B. Burrell C.J. Tonkin R.W. et al.Hepatitis B: absence of transmission by gastrointestinal endoscopy.Br Med J. 1978; 1: 23-24Crossref PubMed Google Scholar, 50Morgan A.G. McAdam W.A. Walker B.E. Hepatitis B and endoscopy.Br Med J. 1978; 1: 369Crossref PubMed Google Scholar, 51Moncada R.E. Denes A.E. Berquist K.R. et al.Inadvertent exposure of endoscopy patients to viral hepatitis B.Gastrointest Endosc. 1978; 24: 231-232Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 52Chiaramonte M. Farini R. Truscia D. et al.Risk of hepatitis B virus infection following upper gastrointestinal endoscopy: a prospective study in an endemic area.Hepato-gastroenterology. 1983; 30: 189-191PubMed Google Scholar No hepatitis B virus (HBV)-seronegative patients developed clinical or serologic evidence of hepatitis B over a 6-month follow-up. In 4 additional prospective studies, a total of 722 patients who were HBV seronegative were observed for up to 12 months after an endoscopy.53Hoofnagle J.H. Blake J. Buskell-Bales Z. et al.Lack of transmission of type B hepatitis by fiberoptic upper endoscopy.J Clin Gastroenterol. 1980; 2: 65-69Crossref PubMed Google Scholar, 54Ayoola E.A. The risk of type B hepatitis infection in flexible fiberoptic endoscopy.Gastrointest Endosc. 1981; 27: 60-62Abstract Full Text PDF PubMed Google Scholar, 55Villa E. Pasquinelli C. Rigo G. et al.Gastrointestinal endoscopy and HBV infection: no evidence for a causal relationship. A prospective controlled study.Gastrointest Endosc. 1984; 30: 15-17Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 56Lok A. Lai C. Hui W. et al.Absence of transmission of hepatitis B by fibreoptic upper gastrointestinal endoscopy.J Gastroenterol Hepatol. 1987; 2: 175-190Crossref Google Scholar The background prevalence rates of hepatitis B surface antigen positivity in these populations were up to 9.6%. In total, only 3 of the 722 patients seroconverted. None of the seroconversions were attributed to the endoscopy because none of these patients had undergone an endoscopy with an instrument previously used on a patient who was infected. In addition, the seroconversion rate was lower than that for a control population not undergoing endoscopy. In a recent prospective cohort study from a center in which ASGE reprocessing guidelines were followed, none of 30 seronegative patients undergoing endoscopy with instruments previously used in patients who were hepatitis B surface antigen–positive subsequently seroconverted.44Mikhail N.N. Lewis D.L. Omar N. et al.Prospective study of cross-infection from upper-GI endoscopy in a hepatitis C-prevalent population.Gastrointest Endosc. 2007; 65: 584-588Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Finally, a recent Canadian study of patients who underwent endoscopy in a unit with identified infection control lapses over a 9-year period confirmed the negligible risk of HBV infection after endoscopy. In this study, 5042 of 6728 (75%) living patients completed blood-borne pathogen testing after endoscopy, and there was no increased risk for infection among those who underwent a procedure within 7 days of a known HBV or HCV case.57Willmore J. Ellis E. Etches V. et al.Public health response to a large-scale endoscopy infection control lapse in a nonhospital clinic.Can J Infect Dis Med Microbiol. 2015; 26: 77-84Crossref PubMed Scopus (0) Google Scholar Taken together, these data indicate that when currently accepted guidelines for cleaning and disinfection of endoscopes are followed, transmission of hepatitis B after endoscopic procedures does not occur or is very rare. There are no reports of transmission of HIV by endoscopy. Manual cleaning of the endoscope with detergent eradicates >99.0% of the virus from the instrument, and subsequent disinfection with glutaraldehyde has been shown to eliminate the virus from endoscopes.4Petersen B.T. Chennat J. Cohen J. et al.ASGE Quality Assurance in Endoscopy CommitteeMultisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011.Gastrointest Endosc. 2011; 73 ([abstract]): 1075-1084Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 58Hanson P.J. Gor D. Jeffries D.J. et al.Elimination of high titre HIV from fibreoptic endoscopes.Gut. 1990; 31: 657-659Crossref PubMed Google Scholar, 59Classen M. Dancygier H. Gurtler L. et al.Risk of transmitting HIV by endoscopes.Endoscopy. 1988; 20: 128Crossref PubMed Google Scholar, 60Hanson P.J. Gor D. Clarke J.R. et al.Contamination of endoscopes used in AIDS patients.Lancet. 1989; 2: 86-88Abstract PubMed Scopus (0) Google Scholar A single report documented transmission of Strongyloides to 4 patients from a contaminated instrument.61Mandelstam P. Sugawa C. Silvis S. et al.Complications associated with esophagogastroduodenoscopy and with esophageal dilation.Gastrointest Endosc. 1976; 23: 16-19Abstract Full Text PDF PubMed Scopus (152) Google Scholar There are no other reports of transmission of parasites by endoscopy. There are no documented cases of transmission of fungal infections by GI endoscopy. Creutzfeldt-Jacob disease (CJD) is a neurologic disease that is transmitted by proteinaceous agents called prions. GI endoscopy does not result in contact of the endoscope or accessories with prion-infected tissues, and, therefore, there is no theoretical need for any special processing of endoscopes used on patients with CJD.62Rutala W.A. Weber D.J. Creutzfeldt-Jakob disease: recommendations for disinfection and sterilization.Clinical Infect Dis. 2001; 32: 1348-1356Crossref PubMed Scopus (0) Google Scholar There are no reports of transmission of CJD by endoscopy. Variant CJD (vCJD) is a related condition caused by the consumption of beef contaminated by the bovine spongiform encephalopathy agent. Approximately 125 cases have been reported worldwide, with a single case reported in the United States. vCJD differs from CJD in that the mutated prion protein can be found in lymphoid tissue throughout the body, including the tonsils and the gut. The mutated prions are resistant to conventional disinfectants and sterilants. We, therefore, recommend that an endoscopy be avoided, if at all possible, in patients with known vCJD.63Axon A.T. Beilenhoff U. Bramble M.G. et al.Variant Creutzfeldt-Jakob disease (vCJD) and gastrointestinal endoscopy.Endoscopy. 2001; 33: 1070-1080Crossref PubMed Scopus (0) Google Scholar When an endoscopy must be performed in a patient with known vCJD, we recommend use of an instrument dedicated for patients with vCJD or one that is approaching the end of its life and that can be destroyed after use. Given the absence of any further reported cases of vCJD in the United States, no changes to general reprocessing guidelines are warranted at this time. There is a paucity of data regarding risk of transmission of infection via endoscopes used in animal models. The Centers for Disease Control and Prevention (CDC) recommends that “when medical or surgical instruments, especially those invasive instruments that are difficult to clean [eg, endoscopes], are used on animals, these instruments should be