A report on the top 10 health technology hazards of 2018 ranked failure to consistently and effectively reprocess flexible endoscopes as one of the biggest threats to health-care delivery and patient health, second only to threats to cybersecurity. This ranking reflects the increasing awareness and recognition of the risks of endoscopy-associated pathogen transmission—as described in a Review in this issue of the journal, 32 outbreaks involving almost 400 patients were reported between 2002 and 2007. Most of these outbreaks were associated with duodenoscope use, but others reportedly involved bronchoscopes and urological scopes. This tally is likely to increase over time due to the increasing number of minimally invasive techniques now possible, and their increasing complexity, with the growing threat of multidrug antibiotic resistance giving the matter an increasing sense of urgency.

During an endoscopic investigation, both internal and external surfaces of endoscopes are exposed to body fluids and potential contaminants; disinfection for re-use can prove difficult—for instance, devices may be heat sensitive, and thus cannot be sterilised with steam, and complex design features (eg, elevator mechanisms on duodenoscopes) can make for difficult-to-reach surfaces. A recent study of reprocessing, drying, and storage procedures for endoscopes used for gastrointestinal or non-gastrointestinal purposes at three hospitals in the USA found microbial growth after reprocessing on nearly three-quarters of endoscopes. Residual fluid was found inside almost half the endoscopes examined, which was associated with higher ATP levels (an indicator of microbial growth). Although the identified microbes were not multidrug resistant, potential pathogens were discovered. Reprocessing and drying practices were noted to be deficient at two of the three centres studied, and all three sites used old, damaged devices, creating rough surfaces that promote residual contamination.

While headlines about multidrug-resistant infectious outbreaks related to endoscopy are alarming, and precautions to minimise the risks of infection from endoscopic procedures are clearly sensible and necessary, it is important to recognise that the risk of infection is likely to be low. Indeed, millions of gastrointestinal endoscopies are done every year, and it is reassuring that reports of associated outbreaks remain infrequent. Nonetheless, the absolute risk of infection after an endoscopic procedure remains unclear, and outbreaks reported in the literature probably underestimate the true incidence given the likelihood of under-reporting. To gain a full appreciation of the scale of the problem, and to better assess risk factors, mandatory reporting of endoscopy-related infections, perhaps to a central register, should be considered.

It is also important not to lose sight of the benefits of endoscopy. Compared with surgery, endoscopy offers a simple, low-risk, and cost-effective means to diagnose and treat a wide range of gastrointestinal disorders, and is an essential part of the gastroenterologist's armamentarium. To maintain this central role, adherence to guidelines for reprocessing endoscopes—such as those recently issued by the American Society for Gastrointestinal Endoscopy—is vital, as are improved training and enhanced checks on the effectiveness of reprocessing procedures, in order to reduce human error and non-compliance. Adoption of sterilisation procedures (using heat, gas, or liquid chemicals), rather than manual cleaning and high-level disinfection, is also warranted but relies on manufacturers developing more resilient devices capable of withstanding the harsh conditions needed for such sterilisation. More resilient devices might also limit physical damage, thus reducing the risk of colonisation; regardless, devices should also be regularly inspected for defects and be adequately maintained.

Manufacturers must also act to improve the design of endoscopy devices such that they are easier to clean. Disposable tips have been developed, and while single-use, disposable devices are feasible, they are likely to prove expensive and wasteful. Endoscopists might also wish to examine their use of lubricants and defoaming agents (eg, simethicone), which are not water soluble and can interfere with the effectiveness of reprocessing. It is imperative that regulatory bodies, reprocessing facilities, clinicians, and manufacturers come together to find a long-term solution to ensure ongoing patient safety.

top 10 health technology hazards for 2018 see For thesee http://www.ecri.org.uk/resource-category/articles/ For more on safe reprocessing of duodenoscopes see Review page 499 study of microbes on reprocessed endoscopes see Am J Infect Control 2018; published online March 30. For thesee Am J Infect Control 2018; published online March 30. DOI:10.1016/j.ajic.2018.03.002 For the AGSE infection control guidelines see Gastrointest Endosc 2018; 87: 1167–79

Copyright © 2018 Arno Massee/Science Photo Library

Article Info Publication History Identification DOI: https://doi.org/10.1016/S2468-1253(18)30168-7 Copyright © 2018 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect