Disinfection Research Articles

Microbiological surveillance result of endoscopes after INTERCEPT Foam Spray: a quasi-experimental pilot study in Singapore.

This study aimed to assess the impact of INTERCEPT Foam Spray (IFS) application on delayed endoscope reprocessing through microbiological surveillance culture (MSC). A quasi-experimental, matched-comparison pilot study was conducted using gastrointestinal endoscopy. IFS was applied to the endoscopes after precleaning and before reprocessing the next day. An equal number of endoscopes, matched by endoscope type, were subjected to routine reprocessing. The MSC were subjected to high-level disinfection to detect any contamination. Data were analyzed using the chi-square test or Fisher exact test (categorical data) and Student t-test (continuous data). In total, 150 MSCs were collected from 42 endoscopes. Positive MSCs were observed in 4.0% (4/75) of the sprayed group and 1.3% (1/75) of the control group (95% confidence interval [CI], 30.34-0.31; p>0.05), all of which were contributed by colonoscopes. Colonoscope were more prone to positive MSC (mean difference in percentage, p<0.05). Mean spraying hours were not associated with detected growth (11.7% vs. 13.6; 95% CI, 1.43 to -5.27; p>0.05), with environmental and skin flora being the primary contaminants. IFS may be applied when delayed endoscope processing is necessary, but with caution when applied to colonoscopes. However, further research is warranted to verify the result.

Impact of COVID-19 Pandemic on Reusable Device Pre-Cleaning Training for Front-line Staff

High-level disinfection and sterilization are complex processes, requiring initial and ongoing training of frontline staff.1 A key component of appropriate disinfection and sterilization is point-of-use pre-cleaning performed by front-line staff. Our facility implemented an annual hospital-wide education and competency program for staff that perform pre-cleaning of reusable medical devices.

Effect of simethicone on the bactericidal efficacy of a high-level disinfectant.

Introduction. Simethicone is an over-the-counter product that is frequently used by clinicians during endoscopic procedures to reduce foaming and improve visualization. Published studies have found simethicone residue on endoscopes after cleaning and disinfecting the devices as per the manufacturer's instructions. Some literature suggests that simethicone residue may reduce disinfection efficacy and increase the risk of patient infections.Gap Statement. However, there appears to be a lack of direct evidence in the literature to either disprove this or correlate simethicone presence with an increased microbial risk.Aim: Research was conducted to evaluate the in vitro impact of simethicone on disinfection efficacy.Methodology. Bacteria were grown in a microtitre plate assay in the presence of a range of simethicone concentrations and then treated with a disinfectant. Bacterial growth was assessed by spotting each microtitre well onto an agar plate.Results. The results demonstrated that, under the conditions tested, simethicone did not reduce the efficacy of Cidex ortho-phthalaldehyde disinfectant, which demonstrated at least a 6-log unit reduction in bacterial viability. Additional experiments showed that direct exposure to 66 mg ml-1 of simethicone reduced bacterial viability.Conclusion. These results indicate that simethicone may not reduce the bactericidal efficacy of disinfectant during reprocessing, under certain conditions.

Ultrasound transducer disinfection for percutaneous procedures: A review of the evidence supporting guideline recommendations

AbstractIntroduction/PurposeThere are varying international recommendations regarding the minimum level of disinfection required for ultrasound transducers used in percutaneous procedures. While some guidelines recommend high‐level disinfection (HLD), others question the additional benefit this delivers over low‐level disinfection (LLD).MethodsThis narrative review identifies current guidelines and evaluates the evidence used to support disinfection recommendations for ultrasound transducers used in percutaneous procedures. Thirteen guidelines were identified using a search encompassing PubMed, Embase, Scopus and Google from 1st January 2013 to 31st January 2024.ResultsNo guidelines were supported by high‐quality evidence, instead, guidelines relied upon: expert opinion through the application of national standards and infection control principles; consideration of recommendations from other published guidelines; and the incidence of infection from retrospective studies. Guidelines were uniformly supportive of using ultrasound transducer covers and sterile ultrasound gel during ultrasound‐guided percutaneous procedures. However, the minimum recommended disinfection level was varied with seven guidelines recommending HLD, four LLD and two not specifying a level. Spaulding's classification was commonly used to support disinfection recommendations, however, the resultant wide variation in classification and subsequent recommendations suggest that its utility in accurately determining the minimum level of disinfection in this specific context is low.ConclusionWithout high‐level evidence, using a risk‐based assessment will likely remain fundamental to future guideline recommendations in determining the minimum disinfection level for an ultrasound transducer used in percutaneous procedures. This risk assessment must include the highest level of evidence available in addition to acknowledging the contribution of all steps taken to prevent infection during ultrasound‐guided percutaneous procedures.

A New Drying Method of Thermolabile Flexible Endoscope Channels by Laminar and Turbulent Airflow: A Prospective, Randomized-Controlled, Single-Center, Proof-of-Concept Trial.

International guidelines suggest different possibilities for drying of endoscopes during reprocessing. Clinical results of these available drying methods are not satisfactory. The aim of this study was to compare the drying cycle of a standard endoscope washer-disinfector (EWD) (standard drying method [SD]) with a shortened mandatory drying by the EWD followed by a special drying device using laminar and turbulent air flow (novel drying method [ND]). Sixty endoscopes (duodenoscopes, colonoscocopes, and gastroscopes) from 3 different manufacturers underwent high-level disinfection and drying depending on the randomization group. Operational time of drying was measured for both groups. Residual fluid in the channels was measured using a laboratory scale. After a 14-day storage period, a sample of the endoscope channels was obtained to determine bacterial contamination. ND had significantly fewer residual water in endoscope channels (SD: 90% vs ND: 0%; P < 0.001) after high-level disinfection and drying and less bacterial contamination after storage for 14 days (SD: 47% vs ND: 20%; P = 0.028). Time consumed for drying in ND was also significantly shorter (SD: 16 minutes 4 seconds vs ND: 5 minutes 59 seconds; P < 0.001). Drying with a special automatic drying device was superior compared with an EWD's drying program as evidenced by no measurable residual water, reduced microbiological contamination, and a more than 2-fold decrease in operational time. Thus, drying by laminar and turbulent airflow may represent an attractive alternative to the currently used standard approach in the reprocessing process of flexible endoscopes.

Peatland wetness as an indicator of fire occurrence in forest and land fires (FLFs)

Background: Peatland ecosystems play an important role in the hydrological cycle and carbon cycling. In Indonesia, peatlands store about 28.6 gigatonnes of carbon which is equivalent to 10 years of global fossil fuel emissions. Peatlands act as a water storage during wet seasons and slowly release water during dry seasons to maintain river discharges and hydrological balance. However, climate change induced prolong drought has increased peatland dryness in recent decades which elevate the risks of unwanted peatland fires. During El Nino-induced drought in 2015, over 2.6 million hectares of forest and land burned, emitting 0.81–1.4 gigatonnes of greenhouse gases. The extreme fires damaged biodiversity, degraded water quality and displaced thousands of locals. This study aimed to analyze peatland wetness as an indicator of fire occurrences in forest and land fires (FLFs) in Riau, Indonesia by examining the relationship between degree of peatland wetness derived from satellite imagery and hotspots data. Methods: Peatland wetness was estimated from microwave backscattering coefficients at several RadarSat synthetic aperture radar (SAR) wavelengths and cross validated with water table depth measurements from 120 monitoring wells. Hotspots data between 2015-2020 were obtained from NASA's MODIS active fire product. Finding: Preliminary results showed significant negative correlations between peatland wetness and numbers of hotspots in peatlands, with more hotspots occurring in drier peatlands compared to wetter ones. This implies that maintaining peatland hydrological functions through continuoussaturation is pivotal to prevent severe peatland wildfires under future climate change. Conclusion: Conservation efforts to restore hydrological balance in degraded peatlands through re-wetting strategies are recommended. Further research utilizing machine learning algorithms to produce high-resolution peatland wetness maps can improve fire risk monitoring in peatlands. Novelty/Originality of this Study: This study introduces the novel concept of utilizing peatland wetness as a key indicator for predicting and mitigating forest and land fires in Indonesia, particularly in Riau Province. By combining peatland moisture and temperature data, the research establishes threshold values to better predict fire risks and guide timely mitigation efforts, thereby enhancing the efficiency and effectiveness of FLF response activities.

ISR 82 - Implementing an Innovative Tool for Rounding in Locations with High Level Disinfection

ISR 82 - Implementing an Innovative Tool for Rounding in Locations with High Level Disinfection

Two-year evaluation of Legionella in an aging residential building: Assessment of multiple potable water remediation approaches

Legionella is an opportunistic waterborne pathogen that is difficult to eradicate in colonized drinking water pipes. Legionella control is further challenged by aging water infrastructure and lack of evidence-based guidance for building treatment. This study assessed multiple premise water remediation approaches designed to reduce Legionella pneumophila within a residential building located in an aging, urban drinking water system over a two-year period. Samples (n = 745) were collected from hot and cold-water lines and quantified via most probable number culture. Building-level treatment approaches included three single heat shocks, three single chemical shocks, and continuous low-level chemical disinfection in the potable water system. The building was highly colonized with L. pneumophila with 71 % L. pneumophila positivity. Single heat shocks had a statistically significant L. pneumophila reduction one day post treatment but no significant L. pneumophila reduction at one week, two weeks, and four weeks post treatment. The first two chemical shocks resulted in statistically significant L. pneumophila reduction at two days and four weeks post treatment, but there was a significant L. pneumophila increase at four weeks following the third chemical shock. Continuous low-level chemical disinfection resulted in statistically significant L. pneumophila reduction at ten weeks post treatment implementation. This demonstrates that in a building highly colonized with L. pneumophila, sustained remediation is best achieved using continuous low-level chemical treatment.

AB048. SOH24AB_011. What is the impact high-level disinfection technology on microbial colonization in ultrasound/endocavity probes?

AB048. SOH24AB_011. What is the impact high-level disinfection technology on microbial colonization in ultrasound/endocavity probes?

PREVENTION COMPLIANCE FACTOR ANALYSIS AND CONTROL OF NOSOCOMIAL INFECTIONS IN HOSPITALS

Nosocomial infections were infections that occurred in the hospital environment. A person was said to have a nosocomial infection if the infection occurred while undergoing treatment in the hospital. Nosocomial infections could occur in patients, nurses, doctors, and hospital workers or visitors. To prevent nosocomial infections, namely stopping the transmission method by increasing staff compliance and equipment maintenance procedures, decontamination, cleaning, and sterilization of the tools used, or high-level disinfection had to be considered before the equipment was used to carry out maintenance actions. If a nosocomial infection occurred, it impacted the length of treatment days due to comorbidities during hospitalization. Nosocomial infections had to be avoided and prevented in patient care in hospitals with a target of zero cases, one of the efforts was through staff compliance. Considering the risk of nosocomial infections, a compliance review of care workers was carried out. This study aimed to analyze compliance with the prevention and control of nosocomial infections in one hospital in West Nusa Tenggara Province. The method in this research was quantitative survey research with a cross-sectional approach. The research population was all nurses who worked in inpatient treatment rooms. By using a simple random sampling technique, a large sample of 50 nurses was obtained in this study. Chi-Square and Logistic Regression analysis were conducted using SPSS. The research results showed that there was a significant relationship between the factors education, knowledge, supervision, infrastructure, and management support on officer compliance. The dominant factor was found in the availability of infrastructure.

Guidelines in Practice: Manual High-Level Disinfection.

There are several steps involved when performing high-level disinfection (HLD) of semicritical devices. The recently updated AORN "Guideline for manual high-level disinfection" provides perioperative nurses with evidence-based best practices for performing safe and effective HLD of reusable semicritical items. The guideline also addresses preventing injury to patients and health care workers associated with the handling of high-level disinfectants. This article provides an overview of the guideline and discusses recommendations for selection of a processing method, sterile processing areas, preparation of items for HLD, preparation of high-level disinfectants, manual HLD, drying and storage of items after HLD, and processing records. It also includes a scenario that illustrates specific concerns related to performing quality tests on high-level disinfectant solutions. Perioperative nurses should review the guideline in its entirety and apply the recommendations when performing manual HLD.

Predictive Analysis of Endoscope Demand in Otolaryngology Outpatient Settings

Background: There has been a trend to transit reprocessing of flexible endoscopes from a high-level disinfectant (HLD) centralized manner to sterilization performed by nursing staff in some Ear, Nose, and Throat (ENT) clinics. In doing so, the clinic nursing staff are responsible for predicting and managing clinical demand for flexible endoscopes. The HLD disinfection process is time-consuming and requires specialized training and competency to be performed safely. Solely depending on human expertise for predicting the flexible endoscope demands is unreliable and produced a concern of an inadequate supply of devices available for diagnostic purposes. Method: The demand for flexible endoscopes for future patient visits has not been well studied but can be modeled based on patients’ historical information, provider, and other visit-related factors. Such factors are available to the clinic before the visit. Binary classifiers can be used to help inform the sterile processing department of reprocessing needs days or weeks earlier for each patient. Results: Among all our trained models, Logistic Regression reports an average AUC ROC score of 89% and accuracy of 80%. Conclusion: The proposed framework not only significantly reduces the reprocessing efforts in terms of time spent on communication, cleaning, scheduling, and transferring scopes, but also helps to improve patient safety by reducing the exposure risk to potential infections.

The use of ultraviolet light generated from light-emitting diodes for the disinfection of transvaginal ultrasound probes.

Transvaginal ultrasound probes (TVUS) are used for several gynecological procedures. These need to be disinfected between patient use. In the current study we examine whether UVC delivered using light emitting diodes for 90 seconds can provide sufficient disinfection efficacy. A new UVC device that delivers UVC radiation at 265nm-275nm for 90 seconds was used. TVUS probes were swabbed before and after use in an in vitro fertilization clinic. Microbes on the swabs were cultured and identified. In addition, the ability of the UVC device to provided repeated high-level disinfection was analysed by deliberately contaminating probes with spores of Bacillus subtilis and then performing the UVC disinfection and bacterial culture. 50% of probes were contaminated with bacteria, most commonly Bacillus sp., directly after in vivo use. Whereas 97% were sterile after UVC disinfection for 90 seconds. The UVC treatment resulted in no growth of B. subtilis spores after each of five repeated contaminations with 5-9 x 107 spores on the probes. This study has found that UVC delivered via light emitting diodes for only 90 seconds can produce high level disinfection of transvaginal probes.

Use of Hydrogen Peroxide Vapour for Microbiological Disinfection in Hospital Environments: A Review.

Disinfection of nosocomial pathogens in hospitals is crucial to combat healthcare-acquired infections, which can be acquired by patients, visitors and healthcare workers. However, the presence of a wide range of pathogens and biofilms, combined with the indiscriminate use of antibiotics, presents infection control teams in healthcare facilities with ongoing challenges in the selection of biocides and application methods. This necessitates the development of biocides and innovative disinfection methods that overcome the shortcomings of conventional methods. This comprehensive review finds the use of hydrogen peroxide vapour to be a superior alternative to conventional methods. Motivated by observations in previous studies, herein, we provide a comprehensive overview on the utilisation of hydrogen peroxide vapour as a superior high-level disinfection alternative in hospital settings. This review finds hydrogen peroxide vapour to be very close to an ideal disinfectant due to its proven efficacy against a wide range of microorganisms, safety to use, lack of toxicity concerns and good material compatibility. The superiority of hydrogen peroxide vapour was recently demonstrated in the case of decontamination of N95/FFP2 masks for reuse to address the critical shortage caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the COVID-19 pandemic. Despite the significant number of studies demonstrating antimicrobial activity, there remains a need to critically understand the mechanism of action by performing studies that simultaneously measure damage to all bacterial cell components and assess the correlation of this damage with a reduction in viable cell count. This can lead to improvement in antimicrobial efficacy and foster the development of superior approaches.

Environmental Impact of a Direct Laryngoscopy: Opportunities for Pollution Mitigation.

To quantify the environmental impact of standard direct laryngoscopy surgery and model the environmental benefit of three feasible alternative scenarios that meet safe decontamination reprocessing requirements. This is a life cycle assessment (LCA) modeling study. Yale-New Haven Hospital (YNHH), a 1541-bed tertiary medical center in New Haven, Connecticut, USA. We performed cradle-to-grave LCA of DLS at Yale New Haven Hospital in 2022, including global warming potential (GWP), water consumption, and fine particulate matter formation. Three alternative scenarios were modeled: disinfecting surgical tools using high-level disinfection rather than steam sterilization, substituting non-sterile for sterile gloves and gowns; and reducing surgical towel and drape sizes by 30%. Changes in disinfection practices would decrease procedure GWP by 11% in each environmental impact category. Substituting non-sterile gowns and gloves reduced GWP by 15%, with nominal changes to water consumption. Linen size reduction resulted in 28% less procedure-related water consumption. Together, a nearly 30% reduction across all environmental impact categories could be achieved. Not exceeding minimum Center for Disease Control (CDC) decontamination standards for reusable devices and optimizing non-sterile consumable materials could dramatically reduce healthcare-associated emissions without compromising safety, thereby minimizing the negative consequences of hospital operations to environmental and human health. Findings extend to other non-sterile surgical procedures. NA Laryngoscope, 134:3206-3214, 2024.

Comparing contamination rates of sterile-covered and uncovered transducers for ultrasound-guided peripheral intravenous lines

IntroductionPhysicians frequently use point-of-care ultrasound for intravenous access and bloodwork in the ED. Recently, AIUM and ACEP released recommendations on ultrasound-guided peripheral intravenous lines (USPIVs), but there are no agreed upon standardized policies. We sought to determine whether the use of sterile-covered transducers (SCT) decreases the rate of contamination when compared to uncovered transducers (UCT) after standard low-level disinfection (LLD).MethodsThis is a randomized control trial comparing contamination rates of US transducers between SCT and UCT after their use for USPIV by the vascular access team, also known as the “PICC” team, over a 3-month period. A sample of admitted patient with an USPIV order were included and randomized to SCT (experimental) or UCT (control) arms. Transducers were swabbed and inserted into the SystemSURE Plus Adenosine Triphosphate (ATP) Luminometer to calculate Relative Light Units (RLU). We performed a cost analysis of requiring sterile covers for USPIVs.ResultsThe UCT and SCT arms contained 35 and 38 patients, respectively. The SCT group had a mean of 0.34 compared to the UCT group mean of 2.29. Each sterile cover costs $8.49, and over 3000 USPIVs are placed annually by the “PICC” team.ConclusionContamination rates were similar among the UCT and SCT groups after LLD. 254 inpatient USPIVs are performed monthly, not including failed attempts or covers used in the ED where USPIV placement is an essential part of ED workflow. This study suggests that the use of SCT does not significantly affect transducer contamination rates. These findings question burdensome regulatory hospital policies that are not evidence-based.

Investigation of Evaporation Rate for Covered and Uncovered (using recycled materials) Conditions in UiTM Shah Alam

The evaporation rate varies according to temperature, humidity, and wind. The evaporation rate tends to be higher in the hot, dry months and lower in the wetter ones. This may affect the nation’s energy use, indoor air quality, and water availability. This study conducted experiments under three conditions—uncovered, partially, and fully covered to ascertain the evaporation rate at UiTM Shah Alam, Malaysia. Recycled materials such as bottle caps were used in the experiment. The study examined the evaporation rate at UiTM Shah Alam in Selangor. The study discovered that the uncovered surface area evaporated at the highest rates in the morning, noon, and afternoon due to direct solar exposure. As some or all of the surface was shielded from the sun’s rays, partially covered and fully covered surface areas had lower evaporation rates. It shows the evaporation rate for fully covered condition reduced 22 – 50 percent from uncovered condition. Meanwhile, evaporation rate for partially covered condition decreased by 10 – 17 percent compared to uncovered condition. The study offers important information about the variables influencing evaporation rate, which can be used to enhance understanding of evaporation processes and optimize evaporation in various applications. The findings may shed important light on the evaporation process and the variables that influence it, such as temperature, humidity, and cover material. The research results can be used to enhance building design and construction methods, increase building energy efficiency, and guide water management and conservation policies.

A STUDY TO COMPARE EFFICACY OF DISINFECTANTS AGAINST STAPHYLOCOCCUS AUREUS IN UNIVERSITI SAINS ISLAM MALAYSIA

Different levels of active ingredients in disinfectants can be classified into three levels of disinfectants. Low-level and low-to-intermediate level disinfectants are commonly used in clinical contact surfaces, while high-level disinfectants are used on submerged inanimate objects that are heat sensitive. This study aimed to compare the disinfection efficacy of different disinfectants used in USIM Dental Polyclinic on rough and smooth surfaces against Staphylococcus aureusisolated from USIM Dental Polyclinic. 19 operators were enrolled to get 19 environmentalsamples from the glove-dominant hand after non-surgical extraction in the Oral Surgery Clinic. Staphylococcus aureus wasidentified, and an antibiotic susceptibility test was done to determine the methicillin-esistant Staphylococcus aureus(MRSA) strain. Two different levels of disinfectants for the disinfection of dental chairs were tested on rough and smooth surfaces that were contaminated experimentally by Staphylococcus aureus. The number of colonies without and after disinfection was counted, and the reduction percentagewas calculated and analyzed.Staphylococcus aureuswas detected in 68.42% (n=13) of the samples. 5.26% (n=1) of the samples were Staphylococcus sp. 26.32% (n=5) had no bacterial growth. No methicillin-resistant Staphylococcus aureusstrain was identified. There was no statistically significant difference (p&gt;0.05) between the efficacy of the three disinfectants from two different levels used in USIM Dental Polyclinic on rough and smooth surfaces against Staphylococcus aureus. Theefficacy of different levels of disinfectants used in USIM Dental Polyclinic was comparable to each other on rough and smooth surfaces against Staphylococcus aureus

Point of Use Treatment for Medical Devices: From Bedside to Battlefield.

Point of use (POU) treatment is a critical first step of medical device reprocessing. Reusable instruments and flexible endoscopes require a minimum of terminal sterilization or high-level disinfection, neither of which can be guaranteed if POU is performed incorrectly. Compliance considerations for POU include hospital accreditation readiness, unique austere surgical mission requirements, and the transition of future conflict towards Large Scale Combat Operations. This integrative review aims to describe POU for reusable instruments and endoscopes, and extrapolate implications for Military Health System policies and future considerations. The authors performed an integrative review and comprehensive literature search in PubMed and CINAHL with the keywords "point of use," "point of use cleaning," "POU," "instrument," "high-level disinfection," "endoscope," and "clean." Articles were limited to "English" and "human" from 2017 to 2023. The authors also performed a thorough review of the Defense Health Agency and service-specific doctrine, as well as national guidelines regarding POU adherence. The literature review yielded 18 articles that discussed the transport and reprocessing of reusable medical devices. Regulatory standards and national guidelines were used to supplement the literature. Seventeen evidence-based criteria were extrapolated from the literature to generate two step-by-step guides for the POU treatment of endoscopes and reusable instruments (Tables I and II). Despite increased morbidity and mortality rates linked to inadequate device reprocessing, compliance with POU procedures remains low. Barriers to practice included complex POU processes, intricately designed surgical instruments and endoscopes, lack of healthcare worker (HCW) knowledge and competency, and inadequate or ambiguously written policies. Training, competency assessments, and clearly written policies and procedures can be cost-effective, evidence-based, and feasible solutions. Completing POU treatment is critical to a successful surgical mission in both the hospital and austere environment. Implications to practice include implementing evidence-based POU programs that improve patient outcomes and readiness while decreasing costs.

Assessment of endoscope reprocessing at World Gastroenterology Organisation training centers using adenosine triphosphate testing.

Background and study aims Adequacy of endoscope disinfection in resource-limited settings is unknown. Adenosine triphosphate (ATP) testing is useful for evaluation of endoscope reprocessing, and ATP <200 relative light units (RLUs) after manual endoscope cleaning has been associated with adequacy of endoscope disinfection. Methods Consecutive endoscopes undergoing reprocessing at five World Gastroenterology Organisation (WGO) training centers underwent ATP testing before and after an on-site educational intervention designed to optimize reprocessing practices. Results A total of 343 reprocessing cycles of 65 endoscopes were studied. Mean endoscope age was 5.3 years (range 1-13 years). Educational interventions, based on direct observation of endoscope reprocessing practices at each site, included refinements in pre-cleaning, manual cleaning, high-level disinfection, and endoscope drying and storage. The percentage of reprocessing cycles with post-manual cleaning ATP ≧200 decreased from 21.4% prior to educational intervention to 14.8% post-intervention ( P =0.11). In multivariable logistic modelling, gastroscopes were significantly less likely (odds ratio [OR] 0.04, 95% confidence interval [CI] 0.01-0.19; P <0.001) than colonoscopes to achieve post-manual cleaning ATP < 200. No other factor (educational intervention, study site, endoscope age) was significantly associated with improved outcomes. Endoscope ID was not significantly associated with ATP values, and sites that performed manual versus automated HLD did not have significantly different likelihood of post-manual cleaning ATP <200 (OR 1.18, 95% CI 0.56-2.50; P =0.67). Conclusions In resource-limited settings, approximately 20% of endoscope reprocessing cycles may result in inadequate disinfection. This was not significantly improved by a comprehensive educational intervention. Alternative approaches to endoscope reprocessing are needed.