ESGE-ESGENA Guideline: Cleaning and Disinfection in Gastrointestinal Endoscopy Update 2008

Guidelines 939
ESGE–ESGENA guideline: Cleaning and disinfection

in gastrointestinal endoscopy
Update 2008
Authors U. Beilenhoff1, C. S. Neumann2, J. F. Rey3, H. Biering4, R. Blum5, M. Cimbro6, B. Kampf7, M. Rogers8, V. Schmidt9,
and the ESGE Guidelines Committee
Institutions Institutions are listed at the end of article.
submitted Contents 9.3.2. Process specifications for automated disinfection

9 September 2008 ! devices
accepted after revision 1. Introduction 9.3.3. Specific recommendations for automated
2. Definition of terms disinfection devices
23 September 2008 3. Endoscopy-related infections 9.3.4. Advantages and disadvantages of automated
4. Principles of infection control disinfection devices
Bibliography 9.4. Manual reprocessing of endoscopes
5. Chain of infection
DOI 10.1055/s-2008-1077722 9.4.1. Definition and process basics for manual
6. Health and safety of endoscopy personnel
Endoscopy 2008; 40: reprocessing
7. General requirements
939–957 Georg Thieme 9.4.2. Process specifications for manual reprocessing
7.1. Classification of endoscopic equipment
Verlag KG Stuttgart · New York 9.4.3. Advantages and disadvantages of manual
7.2. Aims of the reprocessing procedure
ISSN 0013-726X reprocessing
7.3. Staff requirements
7.4. Reprocessing room 9.5. Drying, storage and reuse of endoscope
Corresponding author
7.5. The reprocessing procedure 10. Quality assurance
ESGE Secretariat, HG Editorial
7.6. Manual versus automated reprocessing 10.1. Documentation
& Management Services
8. Process chemicals 10.2. Maintenance of washer-disinfectors and automated
Mauerkircher Str. 29
8.1. Detergents disinfection devices
81679 Munich
8.1.1. Detergents with enzymatic boosters 10.3. Process validation and microbiological surveillance
Germany
8.1.2. Detergents with alkaline boosters 10.4. Outbreak management
Fax: +49-89-907793620
8.1.3. Detergents with enzymatic and alkaline 11. Reprocessing of endoscopic accessories
[email protected]
boosters 11.1. General recommendations
8.1.4. Detergents containing antimicrobial active 11.2. Process specifications
substances 11.2.1. Manual cleaning
8.2. Disinfectants 11.2.2. Reprocessing in washer-disinfectors
8.2.1. Glutaraldehyde 11.2.3. Manual reprocessing
8.2.2. Orthophthalaldehyde (OPA) 11.2.4. Sterilization
8.2.3. Peracetic acid (PAA) 11.2.5. Storage
8.2.4. Chlorine dioxide 11.3. Specific recommendations
8.2.5. Electrolytically generated disinfectants 11.3.1. Biliary and pancreatic procedures
8.3. Rinse aid 11.3.2. Injection needles
8.4. Combination of products from different manufacturers 11.3.3. Biopsy forceps
8.5. Change of products 11.3.4. Water bottle and its connectors
9. Reprocessing of endoscopes 12. Appendices
9.1. Manual cleaning Appendix 1: Manual cleaning of flexible endoscopes
9.1.1. Pre-cleaning in the endoscopy room Appendix 2: Reprocessing of flexible endoscopes in
9.1.2. Manual cleaning in the reprocessing room washer-disinfectors and automated disinfection devices
9.2. Reprocessing in washer-disinfectors Appendix 3: Manual reprocessing of flexible endoscopes
9.2.1. Definition and process basics for washer-disinfectors Appendix 4: Manual reprocessing of reusable endoscopy
9.2.2. Process specifications for washer-disinfectors accessories
9.2.3. Specific recommendations for washer-disinfectors Appendix 5: Reprocessing of endoscopic accessories
9.2.4. Advantages and disadvantages of washer- in washer-disinfectors and automated disinfection devices
disinfectors 13. References
9.3. Reprocessing in automated disinfection devices
9.3.1. Definition and process basics for automated
disinfection devices
Beilenhoff U et al. ESGE–ESGENA guideline: Cleaning and disinfection in gastrointestinal endoscopy … Endoscopy 2008; 40: 939 – 957
940 Guidelines
1. Introduction 2. Definition of terms

! !
The appropriate reprocessing of flexible endoscopes and endo- Automated disinfection devices: Automated disinfection devices
scopic accessories is an essential part of safety and quality assur- are intended to disinfect flexible endoscopes in a closed system
ance in gastrointestinal endoscopy. Since 1994, the ESGE–ES- after manual cleaning; thus their cycle includes disinfection and
GENA Guideline Committee of the European Society of Gastroin- rinse steps only, and does not include cleaning.
testinal Endoscopy (ESGE) and the European Society of Gastro- Clean conditions: Conditions where surfaces have been cleaned
enterology and Endoscopy Nurses and Associates (ESGENA) has satisfactorily and/or are known to contain minimal levels of or-
developed a number of guidelines focused on hygiene and infec- ganic and/or inorganic substances (EN 14885) [5].
tion control in endoscopy. The present guideline updates and Cleaning: Removal of blood, secretions, and any other contami-
combines the following guidelines and technical notes: nations and residues from endoscopes and accessories.
" Guidelines on cleaning and disinfection in gastrointestinal Clinical service provider: An organization, person, or persons leg-
endoscopy – update 1999 [1] ally responsible for the provision of a clinical service. This could
" ESGE/ESGENA Technical note on cleaning and disinfection be an institution (such as the health service), a hospital or de-
(2003) [2]. partment, or doctors working in their own premises.
The aims of this updated ESGE–ESGENA guideline are: Detergent: A compound, or a mixture of compounds, intended to
" To set standards for the reprocessing of endoscopes and en- assist cleaning. The term is often used to distinguish between
doscopic devices prior to each individual procedure, whether soap and other chemical surfactants used for cleaning medical
performed in hospitals, private clinics, or doctors’ offices devices.
" To support individual endoscopy departments in developing Disinfectants: Antimicrobial agents that are applied to nonliving
local standards and protocols for cleaning and disinfection in objects to destroy microorganisms; the process is termed disin-
gastrointestinal endoscopy fection. Disinfectants should generally be distinguished from an-
" To support national societies and official bodies in developing tibiotics (these destroy microorganisms within the body), and
national recommendations and quality assurance programs from antiseptics (these destroy microorganisms on living tis-
for hygiene and infection control in gastrointestinal endosco- sue).
py. Dirty conditions: Conditions where surfaces are known to or
This guideline focuses only on flexible endoscopes and the ac- may contain organic and/or inorganic substances (EN 14885) [5].
cessories used in gastrointestinal endoscopy. It addresses a Disinfection: Reduction of the number of viable microorganisms
number of important aspects of safety in gastrointestinal endos- on a device by irreversible destruction, to a level appropriate for
copy with special emphasis on avoiding infection that may re- safe use on a patient, where sterilization of the device is not nec-
sult from inadequate reprocessing of endoscopes or endoscopic essary. Disinfection is a prerequisite to sterilization. Disinfection
accessories. In addition to the general statements, it provides de- should be carried out immediately after cleaning.
tailed technical protocols for the daily work of nurses and associ- Endoscopes: Flexible endoscopes used in gastroenterology.
ates, as we are aware of multiple local variations in the use of Endoscopic accessories: All devices used in conjunction with an
general guidelines. endoscope to perform diagnosis and therapy, excluding periph-
This ESGE–ESGENA guideline is a consensus prepared by endos- eral equipment.
copists, microbiologists, hygienists, endoscopy nurses, and re- High level disinfectant: A germicide that inactivates all microbial
presentatives of the biomedical industry. pathogens, except large numbers of bacterial endospores, when
In 2007 two guidelines were published that also address the ne- used according to labelling [6]. The US Food and Drug Adminis-
cessity of cleaning and reprocessing standards in gastrointesti- tration (FDA) further defines a high level disinfectant as a steri-
nal endoscopy: lant used under the same contact conditions except for a shorter
" the ESGE/ESGENA guideline for process validation and rou- contact time [7].
tine testing for reprocessing endoscopes in washer-disinfec- Pre-cleaning: Rinsing and flushing of scope channels at the ex-
tors, according to the European Standard prEN ISO 15 883 amination site. The outer surfaces of the scope must be wiped
parts 1, 4 and 5 [3] off, preferably with a dedicated detergent solution.
" the ESGE–ESGENA guideline for quality assurance in repro- Process chemicals: All chemicals used during the reprocessing
cessing: Microbiological surveillance testing in endoscopy procedures, including detergents, disinfectants, alcohol, etc.
[4]. Reusable accessories: Reusable accessories should be sterilized.
These two guidelines must be taken into account in the process Sterilization is carried out after cleaning, as detailed below. Man-
of establishing local quality management of hygiene and infec- ufacturers provide validated standard reprocessing parameters
tion control in endoscopy. The ESGE–ESGENA guidelines are (e. g. temperature and time) for cleaning, disinfection, and steri-
strong recommendations, but within each country, endosco- lization.
pists, nurses, and hospital administrators have to comply with Standard operating procedures (SOPs): Describe each step of the
local regulations and national law, and at all times, it is impor- reprocessing process in detail including:
tant to follow manufacturers’ instructions. " What manual handling processes must be carried out in each
individual step in the correct sequence
" Who should carry out these steps
" Which tools must be used
" Which process chemicals must be applied and under what
conditions, e. g. of concentration, temperature, contact time.
Single-use accessories: Also called “disposable” accessories.
These are provided sterile, ready for use. The opening of a sterile
Guidelines 941
a. Inadequate reprocessing of endoscopes and accessories Table 1 Potential weaknesses

Inadequate cleaning (e. g. inadequate manual cleaning and brushing of endoscope channels) and deficiencies in endoscope
Contaminated cleaning accessories (e. g. cleaning brushes) reprocessing (modified from
Use of unsuitable or incompatible detergents and disinfectants references 10 and 11 [10, 11]).
Inadequate concentrations, contact time of agents and temperature
Contaminated or time-expired solutions
Contaminated rinsing water
Fixed organic material in endoscopes or washer-disinfectors
Use of nonsterile accessories in invasive diagnosis and treatment (e. g. nonsterile biopsy forceps,
polypectomy snares)
Inadequate reprocessing of water bottles (e. g. no sterilization)
Use of tap water in water bottles
b. Inadequate transport and storage of endoscopes
Insufficient drying before storage (e. g. Pseudomonas spp.)
Inappropriate storage conditions
c. Contaminated or defective washer-disinfector
Contaminated pipes, containers, etc.
Contaminated final rinsing water
Biofilms in water pipes, containers or washer-disinfectors
Mechanical/electronic defects of washer-disinfector
Incorrect use of washer-disinfector (e. g. wrong connections)
Wrong or inadequate load (i. e. bottles, flasks)
Lack of regular maintenance of washer-disinfector according to manufacturer’s recommendations
Lack of self disinfection cycle run
d. Design limitations and damaged endoscopes
Small lumina, branched channels, not accessible to cleaning brushes
Damage to the surfaces (internal and external) of the endoscope, providing potential for contamination
e. Contaminated water in the endoscopy unit
Contaminated mains water pipes/supply
Contaminated or inadequate water supply systems (filtration etc.)
f. Contaminated ultrasonic cleaner
g. Insufficient drying and storage
h. Shortcuts due to insufficient number of endoscopes and/or reprocessing resources for the clinical workload
package implies immediate use. After a single-use device has Microorganisms may be spread by inadequately reprocessed
been employed, all materials should be appropriately disposed equipment, from one patient to another, or from patients to staff
of. Under no circumstances should a single-use device be repro- members. There are a number of weaknesses and potential defi-
cessed. ciencies in endoscope reprocessing which might be sources for
Sterilization: Complete destruction of all microorganisms in- microbial contamination and transmission of infectious material
cluding bacterial spores. Also, a validated process used to render (l" Table 1).
a device free from all forms of viable microorganisms (ISO Since the late 1970 s there have been sporadic reports of nosoco-
11137) [8]. mial infections linked to endoscopic procedures. Bacterial infec-
User: Person or department using equipment; organization(s) or tions have been acquired during endoscopy, caused for example
persons within those organization(s) who operate and/or use by Salmonella spp, Helicobacter pylori and Pseudomona spp [12 –
the equipment 16]. Viruses such as hepatitis B and C have also been transmitted
Washer-disinfectors: According to the definition of EN ISO during endoscopy [17,18]. The majority of documented cases
15883, washer-disinfectors are intended to clean and disinfect were caused by noncompliance with national and international
medical devices, e. g. flexible endoscopes, within a closed system reprocessing guidelines [12 – 18]. Nevertheless, studies have
[9]. shown that endoscopic procedures do not increase the risk for
transmitting hepatitis C virus [19]. Additionally, fungi can be
transmitted via endoscopic procedures [20 – 22].
3. Endoscopy-related infections Patients with immune deficiency syndrome or severe neutrope-
! nia, those undergoing immunosuppressive chemotherapy, or
Endoscopic procedures are well established in the diagnosis and those having artificial cardiac valves have an increased risk of in-
therapy of gastrointestinal diseases. In addition to other proce- fection, and therefore therapeutic procedures carry a higher risk
dure-related risks, the risk of infection due to endoscopic proce- of infection. Patients harbouring clinically latent infections (he-
dures has to be taken into consideration. Endoscopy-associated patitis, HIV, tuberculosis, salmonellosis, infections caused by He-
infection risks are categorized as follows: licobacter pylori) may not be aware of their carrier status, and
" endogenous infection therefore, all patients should be considered potentially infective.
" exogenous infections caused by inadequately reprocessed Tuberculosis infection is becoming more common. The emer-
equipment. (endoscopes and accessories can be vehicles for gence of multi-drug-resistant strains of Mycobacterium tubercu-
pathogenic or facultative-pathogenic germs that are trans- losis and the high incidence of infections with M. avium intracel-
mitted from previous patients) lulare among HIV-infected patients has led to a greater aware-
" risks of infection to endoscopy staff. ness of the risk of transmission of mycobacteria during broncho-
scopy. Mycobacteria in general and especially some waterborne
942 Guidelines
mycobacteria (such as M. chelonae) show resistance to glutaral- 6. Health and safety of endoscopy personnel
dehyde [23]. !
Creutzfeldt–Jakob disease (CJD) and variant-CJD (vCJD) are so- Contamination-related hazards come in two forms: from cross-
called prion diseases. The infectious particles are extremely re- infection from patients or equipment and from chemicals used
sistant to standard reprocessing procedures. The ESGE and ES- in cleaning and disinfection. Microorganisms may also be trans-
GENA developed a guideline relating to vCJD and gastrointesti- mitted directly from the patient to endoscopy personnel. There-
nal endoscopy in 2001; this guideline is currently under review fore protection from direct contact with contaminated endo-
[24]. scopes, accessories and patient fluids is essential. Protection
against chemicals used for reprocessing is of the utmost impor-
tance to avoid toxic and allergic reactions.
4. Principles of infection control All staff involved in the reprocessing procedure should wear ap-
! propriate protective clothing including:
As the carrier status of patients is often unknown: " chemically resistant single-use gloves
" All patients should be treated as potentially infectious. " protective glasses and face masks
" All endoscopes and accessories used in endoscopy should be " protective full-face visors
reprocessed following every endoscopic procedure, using a " special examination gown or coat (long-sleeved, moisture-
uniform, standardized reprocessing protocol. resistant) or plastic aprons with arms.
Patients undergoing digestive endoscopy should be examined Changing from reusable to single-use devices additionally re-
and treated without risk of transmission of infection or side ef- duces risks to staff as the handling and reprocessing of contami-
fects that may result from inadequate reprocessing of endo- nated equipment is then unnecessary.
scopic equipment. A department-specific policy should be available that covers is-
Regular quality control and the institution’s adherence to valida- sues relating to spillages, chemicals, detergents, and body fluids,
ted reprocessing procedures is the responsibility of both endos- and the appropriate equipment to implement the policy should
copists and clinical service providers and should be monitored be available. Care must be taken in the handling of sharps, in-
by the hospital-based hygiene/cross-infection control depart- cluding spiked biopsy forceps and flexible needles, to avoid nee-
ment, or an external organization [3, 4] as appropriate. dlestick injury. Contaminated devices must be transported from
Traditionally patients with known infections are scheduled to the endoscopy room to the reprocessing room in closed contain-
the end of the daily patient list. However, given the universal en- ers, with attention paid to protective measures regarding staff
doscope reprocessing regime, which presumes that all patients and environment. It is emphasized that reprocessing must be
are potentially infectious, there is not normally a need to exam- started immediately after the procedure. Splashing should be a-
ine patients with known infection at the end of the daily clinic. voided throughout the reprocessing procedure in order to pre-
Nevertheless infection control policies should include this re- vent contact with infectious material and with disinfectants or
commendation in order to make staff aware of infections, to detergents.
minimize the potential risk of cross-infection, and to ensure a Staff known to be disease carriers should avoid duties that could
proper cleaning and disinfection of the working environment. transmit their disease to patients.
In order to correctly apply disinfection instructions, it is impor- Health surveillance is recommended for all staff working with
tant to understand what is required before an infection actually potentially sensitizing or allergy-inducing chemicals, e. g. relat-
takes place. All the links in the so-called “chain of infection” ed to allergic asthma, skin and/or mucosal sensitivity problems.
need to be intact before a pathogen can be transmitted. If only It is recommended that all staff be offered appropriate vaccina-
one link is broken, infection cannot occur. tion against infectious agents, for example hepatitis B.
The links of the chain of infection are:
" Viable microorganisms are present
" Sufficient number of pathogens needed to initiate infection 7. General requirements
" Host is susceptible to the infection present !
" Pathogen enters host through appropriate portal of entry 7.1 Classification of endoscopic equipment
(e. g., gastrointestinal agent into the gut, bloodborne agent According to the Spaulding classification, most flexible endo-
into the bloodstream). scopes used in gastrointestinal endoscopy are classified as
Infection control provides activities or precautions that may be semi-critical devices, as they come into contact with mucous
used to attack these links and break the chain of infection: membranes [25, 26]. Semi-critical devices require disinfection,
" cleaning, disinfection, and sterilization of medical equipment but sterilization is not necessary. In the case of percutaneous
" correct use of personal protective equipment procedures (e. g. laparoscopy, percutaneous cholangioscopy), en-
" personal hygiene doscopes are classified as critical and therefore must be sterile.
" engineering controls (ventilation, building design, clean wa- Accessories which come into contact only with the skin and mu-
ter supply) cosa (e. g. mouthguards) do not need to be sterile, but must un-
" cleaning, disinfection of environmental surfaces dergo high level disinfection. Mouthguards are often employed
" adequate administrative control and support as single-use items due to the need for traceability.
" training and continuing education Endoscopy accessories which penetrate the mucosal barrier (e. g.
" adequate written standardized operating procedures (SOPs) biopsy forceps, guide wires, polypectomy snares, injection nee-
" documentation. dles, etc) are classified as critical devices and therefore must be
sterile at the point of use [25, 26].
Single-use devices should not be reprocessed. National regula-
tions should be followed.
Guidelines 943
7.2. Aims of the reprocessing procedure of adequate size for washing, disinfection, and rinsing of endo-
The purpose of the reprocessing procedure is to reduce all patho- scopic equipment must be available. In addition a separate dedi-
gens to such a level that they do not cause any harm to future cated handwashing basin and hand-disinfection facility is re-
patients or to personnel handling the equipment. quired. The room should have the technical prerequisites for
As all patients must be considered to be potential risks, each en- washer-disinfectors.
doscope and device must be reprocessed to the same standards
following every endoscopic procedure (universal precautions). 7.5. The reprocessing procedure
The reprocessing of flexible endoscopes must be of guaranteed Reprocessing of flexible endoscopes generally includes the fol-
effectiveness in at least the following respects: lowing steps, regardless of whether the procedure is manual or
" cleaning efficacy automated:
" disinfecting efficacy " Pre-cleaning. Immediately after use, macroscopically visible
" bactericidal efficacy dirt is removed from external surfaces and the interior of
" mycobactericidal and/or tuberculocidal efficacy scope channels.
" fungicidal and/or yeasticidal efficacy " Manual cleaning. This consists of the manual leak test and the
" virucidal efficacy against enveloped and non-enveloped manual cleaning of external surfaces and the interior of scope
viruses. channels, including brushing.
Although for reprocessing of semi-critical instruments sporici- " Rinsing. This is removal of residual cleaning process chemi-
dal activity is not mandatory under used conditions (e.g. time, cals that may interfere with the following disinfection stage.
temperature), the EN ISO 15883-4 recommends the sporicidal " Disinfection. All microorganisms are reduced to such a level
activity of the disinfectant at extended time. The disinfectant that they will not harm future patients.
should reduce the population of bacterial spores in the efficacy " Rinsing. A further rinse removes the chemical load from the
test by not less than 6 log10 within 5 hours’ exposure at the instruments/scopes which have been disinfected.
minimum time, the minimum temperature and at the minimum " Drying. Internal and external surfaces are dried to avoid
concentration to be used in the washer-disinfectors (EN ISO growth of waterborne microorganisms
15883-4, paragraph 4.4.2.5) [27]. " Storage. Endoscopes are stored in a safe and closed cupboard
which is also ventilated if this is appropriate.
7.3. Staff requirements The most important step in the reduction of microorganisms is
To ensure appropriate and adequate reprocessing, the following the manual cleaning. It is impossible to disinfect or even sterilize
personnel issues should be considered: an inadequately cleaned instrument. Protein debris can become
" Sufficient number of trained staff and sufficient time are pre- fixed by chemicals on the channel surfaces of the scope if the
requisites for correct reprocessing of endoscopes and acces- cleaning and rinsing steps have not been carried out correctly.
sories. In short, all disinfection processes, whether done manually or
" Dedicated trained staff: only specially trained and competent by washer-disinfector, should be done only after appropriate
personnel should carry out the reprocessing of endoscopic manual cleaning.
equipment, and this applies to both routine and emergency The methods and requirements for testing the efficacy of the
endoscopy. process and/or the activity of the disinfectant are based on the
" Regular practice and updated training are essential to main- following standards.
tain competency " The required disinfection activity of the disinfectant is de-
" As the design of endoscopes varies according to type and scribed in the European standard EN 14 885 Chemical disin-
manufacturer, it is essential that staff are familiar with the fectants and antiseptics – Application of European standards
design and construction of all equipment in order to ensure for chemical disinfectants and antiseptics.
safe and satisfactory cleaning and disinfection. " For automated processes in washer-disinfectors, phase 2 step
1 tests according to EN ISO 14885 and additional tests
7.4. Reprocessing room according to EN ISO 15883 Washer-disinfectors, parts 1, 4 and 5
Reprocessing of endoscopic equipment should only be undertak- are applicable [9, 27, 28].
en in a separate, purpose-designed reprocessing room, in order Different reprocessing procedures are available (see l " Fig. 1 and
to: section 9):

" minimize the risks of infection and contamination for other " using washer-disinfectors
personnel and the general public " using disinfection devices (automated disinfection devices)
" protect from chemicals used in cleaning and disinfection " manual methods.
procedures (e. g. those associated with toxic/allergic reac-
tions, hazardous vapors) 7.6. Manual versus automated reprocessing
" protect from cross-contamination with potentially infectious ESGE and ESGENA strongly recommend the use of washer-disin-
material, blood, or body fluids. fectors covering cleaning and disinfection, in order to:
It is the responsibility of the service provider to ensure that ade- " provide a standardized and validated reprocessing cycle in a
quate facilities for reprocessing are available. closed environment
The reprocessing room must have separate dirty, clean, and sto- " document the process steps automatically (via a printer or
rage areas. Contaminated and clean working areas must be electronically)
strictly separated to avoid recontamination of reprocessed endo- " provide highly reliable reprocessing
scopes and accessories. " minimize staff contact with chemicals and contaminated
The room should have appropriate ventilation and extraction in equipment
order to minimize the risks from chemical vapors. Separate sinks " minimize contamination of the environment
944 Guidelines
Pre-cleaning Fig. 1 Different methods for reprocessing endo-

In the endoscopy
procedure room Rinsing and flushing scopes.
Function control
In the separate Manual cleaning

reprocessing room Including: manual leakage test, external and
internal cleaning, including brushing
Automated washer- Automated Manual

disinfectors disinfection devices reprocessing
All reprocessing steps Rinsing may be included Rinsing

are performed in in some automated
washer-disinfectors: disinfection devices
Integrated leakage test Disinfection and final Disinfecting
Cleaning rinsing are included in all
Rinsing automated disinfection
Disinfection devices
Final rinsing Final rinsing
Drying Drying is an additional
option in some
automated disinfection
Drying
devices
" facilitate the work involved for personnel scope have to be passed with no serious damage). Slight cosmet-
" lower the risk of damage of scopes. ic changes are acceptable.
However, if washer-disinfectors are not maintained and cleaned The ingredients of the detergent must be compatible with the
appropriately, they may themselves become an infection risk, disinfectant and not impair efficacy if small amounts of deter-
from potential contamination of endoscopes during reproces- gents are carried over. Rinsing between cleaning and disinfec-
sing. tion must be used to reduce the concentration of residues (pro-
Manual reprocessing also gives reliable results, if staff perform cess chemicals and soiling including microbial contamination)
the reprocessing conscientiously, according to defined standard to a level established as not exceeding that which would impair
operating procedures. However, manual reprocessing cannot be the efficacy of the chemical disinfectant (EN ISO 15883-4).
validated, and moreover, staff may be exposed to chemicals and For that reason it is recommended a detergent and disinfectant
infectious material. from the same supplier should be used. Alternatively approvals
Even if washer-disinfectors are used in the endoscopy unit, staff from the suppliers of the detergent and disinfectant should be
should also be trained in manual methods to ensure safe repro- requested for combined use, with respect to compatibility of
cessing of equipment in the case of any machine failure. How- the material with endoscopes and to the mix of chemicals.
ever, equipment for doing this without putting staff at risk
must be available (e. g. adequate fume extraction facilities, ap- 8.1. Detergents
propriate personal protective equipment [PPE], etc). Detergents can be divided in two main groups:
" with enzymatic and/or alkaline boosters
" with antimicrobial active substances.
8. Process chemicals Detergents containing antimicrobial active substances are main-
! ly used for manual cleaning steps.
Chemicals used in endoscope reprocessing must be designed, Most detergents from both groups contain low-foaming surfac-
tested and manufactured according to the European Medical De- tants to lift off the soil (including particulate soil) and microor-
vice Directive [29]. ganisms from surfaces and keep them dissolved, emulsified, or
" Detergents are class I medical device products identifiable by dispersed in the cleaning solution. The low-foaming behavior of
the CE sign on the label. the surfactant for the pre-cleaning and the manual cleaning step
" Disinfectants are class IIa medical device products identified at room temperature is necessary so that the device can be clear-
by the CE sign plus a four-digit number on the label that ly visualized during the cleaning process, to avoid injury to per-
identifies the responsible body. sonnel and to allow for complete cleaning of luminal surfaces.
Process chemicals should be compatible with endoscopes and For ultrasonic cleaning of endoscopic accessories it is recom-
washer-disinfectors/automated disinfection devices. Material mended that the same detergent as used for the manual cleaning
compatibility tests are performed on test pieces or complete en- step should be employed. The cleaning solution should not be
doscopes using the detergent and the disinfectant alone and in cloudy at elevated temperatures (up to 40 8C), to prevent injury
combination. Manufacturers of endoscopes, chemicals and to personnel. It is a challenge for detergent suppliers to provide
washer-disinfectors have to provide information about material a product that combines the features of low foaming at room
compatibility (for example: depending on the internal standards temperature with a clear solution at higher temperatures. Cur-
of the endoscope manufacturer and the endoscope type, be- rently only some detergents available on the market fulfill both
tween 1000 and 2000 reprocessing cycles with the same endo- criteria. Staff should be aware that some chemicals when heated
Guidelines 945
may exhibit increased vapor release, which could irritate the re- The use of detergents with antimicrobial active substances does
spiratory system. not replace the disinfection step.
Detergent solutions that are not claimed to have antimicrobial Detergents containing aldehydes must not be used for the clean-
activity should be single use. Detergent solutions with claimed ing step, because they denature and coagulate protein (fixation).
antimicrobial activity should be freshly prepared at least on a
daily basis. In case of visible contamination the solution should 8.2. Disinfectants
be changed immediately. In the case of high frequency of repro- Disinfectants used at room temperature manually or in automa-
cessing cycles, it is advisable to prepare fresh solutions at shorter ted disinfection devices should be effective according to Europe-
intervals. Ideally, and whenever possible, detergent solutions an standard EN 14 885. Microbiological tests can be performed
should not be reused [23]. under clean conditions.
Disinfectants used for endoscope reprocessing must be fully ef-
8.1.1. Detergents with enzymatic boosters fective at a designated temperature against a broad range of
Detergents with enzymatic boosters contain one or more differ- germs, such as bacteria, fungi, mycobacteria, and enveloped as
ent types of enzymes, e. g. protease, amylase, or lipase. Enzymes well as non-enveloped viruses.
are proteins with biological activity. Protease breaks protein Active materials such as oxidizing substances and aldehydes,
debris into smaller subunits that are more soluble. Amylase cat- that interact chemically with the microorganism, show the re-
alyzes the breakdown of starch and lipase breaks up fat-contain- quired broad efficacy against germs. Examples from the alde-
ing debris. These types of detergent require a specific contact hyde group include formaldehyde, glutaraldehyde, and ortho-
time as recommended by the manufacturer. When using enzy- phthalaldehyde and the oxidizing substances include hypochlor-
matic detergents for ultrasonic cleaning on endoscope accessor- ous acid, chlorine dioxide and peracetic acid and its salts.
ies the container must be covered properly to avoiding an ana- Nonactive substances such as alcohols, phenols, and ammonium
phylactic shock reaction caused by inhalation of enzyme-con- compounds are not recommended for endoscope disinfection as
taining aerosols. they do not show the required efficacy against germs.
8.1.2. Detergents with alkaline boosters 8.2.1. Glutaraldehyde

Detergents with alkaline boosters contain chemical substances Disinfectants based on glutaraldehyde are offered as concentra-
forming a mild alkaline cleaner. Alkaline substances lift off soil ted or as ready-to-use (RTU) products applicable manually, for
and help to dissolve it in the cleaning solution. Strong alkaline automated disinfection devices and in washer-disinfectors.
cleaners in the pH range >11 are not recommended for flexible The RTU glutaraldehyde solutions range in concentration from
endoscope cleaning, due to material incompatibility with some 2.0 % to 3.4 % and have variable maximum use lives. The maxi-
endoscope parts. mum use life of an alkaline (activated) 2 % glutaraldehyde with-
out surfactants is 14 days, 28 days for one product containing
8.1.3 Detergents with enzymatic and alkaline boosters 3.4 % active substance. Accurate monitoring of the glutaralde-
Detergents with both types of booster combine the properties of hyde concentration is required to ensure efficacy, which is not
enzymatic and alkaline detergents. guaranteed at lower concentrations. The immersion time need-
ed to cover the full range of germs is variable and needs to be de-
8.1.4. Detergents containing antimicrobial active termined according to EN 14885 or local standards.
substances The dilution ratio of concentrated glutaraldehyde-based disin-
In some European countries detergents containing antimicrobial fectants depends on the composition and the detected concen-
active substances are commonly used and recommended by the tration–time relationship tested according to EN 14 885 or local
health authority, in the manual cleaning steps. Use of this type of standards. Concentrated products based on glutaraldehyde are
product may reduce the infection risk to reprocessing personnel. often used in combination with other aldehydes such as glyoxal
The efficacy of these antimicrobial active detergents should be and succinic aldehyde or other active substances such as qua-
rated according European standard EN 14 885. It is very impor- ternary ammonium compounds. Equivalent microbiological effi-
tant that the microbiological testing is done under dirty condi- cacy is achieved with a reduced concentration of glutaraldehyde
tions. The minimal efficacy comprises bactericidal and yeastici- in the application solution.
dal activity and activity against enveloped viruses. Glutaraldehyde has the advantages that it is effective, relatively
Detergents containing antimicrobial active substances can be inexpensive, and does not damage endoscopes, accessories, or
used for up to one working day depending on national guide- processing equipment.
lines, manufacturer’s instructions, and the amount of contami- However, there are a number of disadvantages to glutaralde-
nation. In general the Guideline Committee recommends that hyde, both for clinical staff and for patients. It has irritant and
cleaning solutions are not reused. If detergents containing anti- sensitizing properties. It can lead to allergic reactions (in skin,
microbial active substances are used, the cleaning solutions eyes, and ear, nose, and throat), and can cause dermatitis, con-
should be changed at shorter intervals and at least once a day. junctivitis, nasal irritation, and occupational asthma [23, 30].
In this type of detergent, commonly used active substances are Glutaraldehyde has been found to exhibit cytotoxicity [31] in
amine compounds, peracetic acid and its salts, biguanidine, and cultured human cells. The hazards of glutaraldehyde use for staff
quaternary ammonium compounds. are considerable, and toxicity has been suspected in 35 % of en-
Tests of effective cleaning performance demonstrate that deter- doscopic units [32] and detrimental effects established in up to
gents containing amine compounds or salts of peracetic acid 80 % [33]. Use in a well-ventilated area and in closed containers
combine an alkaline booster effect with antimicrobial efficacy. with tight-fitting lids is recommended.
Analogous combination effects are achieved by detergents con-
taining enzymes and quaternary ammonium compounds.
946 Guidelines
Advantages Disadvantages Table 2 Advantages and

disadvantages of glutaralde-
– In-use solution stable for 14 days (28 days for one – Slow action against bacterial spores and
hyde.
product) (product-specific data) mycobacteria at 25 8C
– Excellent compatibility with materials; does not – Sensitizing, irritant to skin, eyes and respiratory
damage tract; stains skin; ventilation is recommended
– Adverse effects for patients after insufficient
rinsing of devices
– Fixative, tends to create residue film; thorough
cleaning is essential
– Environmental health and safety measures are
expensive

disadvantages of ortho-
– In-use solution is stable for 7–14 days – Slow action against bacterial spores
phthalaldehyde (OPA).
– Excellent compatibility with materials; – Irritant to eyes and respiratory tract; stains skin;
does not damage ventilation is recommended
– Little data on hazards of long-term exposure and
on safe exposure levels
– “Anaphylaxis-like” reactions after repeated use
have been reported in other endoscopy application
areas [33]
– Little data on fixation behavior
In patients, residues of glutaraldehyde left after insufficient rin- ment. In other endoscopy application areas OPA has caused
sing can cause colitis, abdominal cramps, and bloody diarrhea “anaphylaxis-like” reactions after repeated use [40].
[33 – 38]. Advantages and disadvantages of OPA are listed in l " Table 3.
Other disadvantages of glutaraldehyde are coagulation and fixa-

tion of proteins and failure to eliminate atypical mycobacteria 8.2.3. Peracetic acid (PAA)
within standard contact times. The latter creates diagnostic Disinfectants based on PAA and its salts are commercially avail-
problems in bronchoscopy and the risk of cross-infection in im- able for endoscope reprocessing, as liquids or powder and as
munocompromised patients with, for instance, organisms of the two-component systems comprising two liquids or liquid and
Mycobacterium avium complex. This situation is further compli- powder. Depending on the composition, the products are used
cated by the emergence of glutaraldehyde-resistant mycobacter- at room temperature or higher temperatures up to 56 8C. Con-
ia [39]. centrated products need to be diluted with water, in a ratio de-
Advantages and disadvantages of glutaraldehyde are listed in termined by microbiological testing according to European or lo-
l" Table 2. cal standards. The efficacy of PAA is strongly influenced by the
pH value of the disinfecting solution. In the commonly used pH
8.2.2. Orthophthalaldehyde (OPA) range (between 3 and 8.5) the efficacy is higher than that of glu-
Disinfectants based on orthophthalaldehyde (OPA) are offered as taraldehyde.
RTU solutions containing 0.55 % of the active substance. Com- Regarding staff safety, PAA is claimed to cause less irritation
mercially available products can be used manually, in automated than glutaraldehyde and to be safer for the environment. Even
disinfection devices and in washer-disinfectors. Studies have though PAA is not believed to cause allergic reactions or asthma,
shown better microbiological efficacy compared with glutaral- there have been reports of skin, eye and respiratory irritation
dehyde. OPA requires longer exposure times to be effective from PAA [30]. Adverse effects are strongly linked to the pH val-
against glutaraldehyde-resistant mycobacteria. It does not pro- ue of the disinfectant solution, with minimal effects observed in
duce noxious fumes, it requires no activation, and is stable at a a pH range between 7.5 and 10.0. It would, however, seem un-
wider pH range of 3 to 9. wise to state that PAA can be used safely without adequate ven-
Exposure to OPA vapors may be irritating to the respiratory tract tilation or personal protective measures, especially in reproces-
and eyes [30]. Use in a well-ventilated area and in closed con- sing. However in automated processing in a closed system, the
tainers with tight-fitting lids is recommended. pH value of the used solution is less relevant with respect to staff
Advantages of OPA are its higher efficacy compared with glutar- safety and to the environment.
aldehyde and its long lifespan (2 weeks). Very accurate monitor- PAA has the ability to remove hardened material in biopsy chan-
ing of the OPA concentration is always required. nels that has resulted from the use of glutaraldehyde, as demon-
There are some disadvantages of OPA, and its efficacy and prop- strated by surface spectroscopy. In the long history of PAA use in
erties need to be evaluated further. Data on safe exposure levels the food industry and medicine, no development of microorgan-
and the hazards of long-term exposure are scarce. ism resistance has been reported; its broad spectrum of chemi-
OPA causes coagulation and fixation of proteins. Exposure to the cal reactivity suggests that microorganisms are unlikely to de-
agent can lead to staining of linen, clothing, skin, instruments velop resistance to it.
etc., by reaction with amino and thiol groups. Specific detailed One disadvantage of liquid PAA is that it is less stable than glu-
instructions are necessary to ensure adequate rinsing of equip- taraldehyde. The shelf-life of liquid products containing PAA is
Guidelines 947
Advantages Disadvantages Table 4 Advantages and dis-

advantages of peracetic acid
– Fast high level disinfection and sporicidal activity – Depending on pH value, irritant to skin, eyes and
(PAA).
– Preferably single-shot use respiratory tract; strong odor of vinegar;
– Depending on formula, in-use solutions are stable ventilation is recommended
for 1–14 days – Material compatibility depends on the pH value
– Environmentally friendly substance and temperature; endorsement of compatibility
– No chemical cross-linking of protein residues with endoscopes and processor is required
– Acid-related coagulation of proteins is possible,
depending on pH value

disadvantages of chlorine
– Fast high level disinfection and sporicidal activity – Irritant to skin, eyes, and respiratory tract; strong
dioxide.
– In-use solution stable for 7–14 days odor of chlorine; ventilation is recommended
– Damage to endoscopes has been reported;
endorsement of compatibility with endoscopes is
required (an additional coating might be required
with some types of endoscopes – manufacturer-
specific)
– Waste water restriction for chlorine compounds in
some countries
between 12 and 18 months depending on storage conditions. Advantages and disadvantages of chlorine dioxide are listed in
The shelf-life of powdered products is 3 years. " Table 5.
l
Multiply used solutions require replacement between 24 h and 7
days. Very accurate monitoring of the PAA concentration is re- 8.2.5. Electrolytically generated disinfectants
quired. Electrolytically generated disinfectants are produced on site by
Further disadvantages of PAA are its vinegary odour and corro- the electrolysis of sodium chloride solutions. The efficacy of the
sive action, depending on the formulation. Both properties are disinfectant is influenced by the concentration and ratio of oxi-
strongly linked to the pH value, temperature, PAA concentration, dant constituents governed by the pH value. An advantage of
and the composition of the disinfectant (i. e. inclusion of anticor- these disinfectants is that commercially available systems at dif-
rosive agent, etc.). Damage to flexible scopes has been reported ferent pH levels are much more effective than glutaraldehyde. In
after disinfection with some brands of PAA. The oxidizing ability addition electrolytically generated disinfectants have excellent
of PAA may expose leaks in the scope’s internal channels, espe- user and patient safety profiles. A disadvantage of these disinfec-
cially if it has been previously disinfected with glutaraldehyde, tants is that the biocidal effect is decreased in the presence of a
where biofilm might have covered minor perforations. PAA may heavy soil load. To ensure a full microbicidal effect, it is essential
also cause cosmetic changes of endoscope surfaces, but without that items are cleaned thoroughly. Antimicrobial efficacy and
any functional impairment. materials compatibility are strongly influenced by the pH value
It should be noted that various brands of disinfectants based on and the oxidant concentration. Similarly to some peracetic acid-
PAA are available with variations in effectiveness and side-ef- based products, electrolytically generated disinfectants are able
fects. There are also on the market disinfectants based on PAA to remove organic layer and biofilm from surfaces. Development
with various labelled claims, depending on composition and on of microorganism resistance has not been reported and the
the microbiological test procedure that has been applied to broad spectrum of chemical reactivity suggests that microorgan-
check microbiological efficacy. isms are unlikely to develop resistance to it.
Advantages and disadvantages of peracetic acid (PAA) are listed Electrolysed acid water (EAW) systems operate at pH £ 2.7, an oxi-
in l" Table 4. dation–reduction potential (ORP) > 1000mV, and free released
chlorine concentration (FRCC) 10 2 ppm. The generation and
8.2.4. Chlorine dioxide use of EAW must operate at the same time in the same device.
Disinfectants based on chlorine dioxide are commercially avail- Since the pH and the oxidation–reduction potential are con-
able as two-component systems applicable in automated disin- stantly monitored, this method minimizes the major disadvan-
fection devices. Chlorine dioxide is more effective than glutaral- tage of electrolysed acid water, that is, its instability. In spite of
dehyde. its strong acidity, EAW rarely shows adverse effects on the hu-
Depending on the composition, disinfectants based on chlorine man skin and mucosa, unlike hydrochloric acid and other solu-
dioxide can be more damaging to the instrument and processor tions with the same acidity.
components than glutaraldehyde. Experience with chlorine di- Electrolytically generated hypochlorous acid systems operate at
oxide has demonstrated discoloration of the black plastic casing pH 5.75 – 6.75 and ‡ 180 ppm of available free chlorine (AFC). Ty-
of flexible endoscopes, but this change may be only cosmetic. If pically the disinfectant is produced and supplied on site via an
chlorine dioxide is used in automated disinfection devices, com- external generator that directly supplies the washer-disinfec-
ponent contact times are likely to be much longer and, therefore, tors. The generator controls disinfectant production, utilizing va-
damage is even more likely. Chlorine dioxide is another possible lidated system monitoring that ensures only product complying
alternative to glutaraldehyde, if approved by the instrument and with the specification is delivered to the washer-disinfectors.
processor manufacturers. The generator controls pH, conductivity, power, and cell flow
948 Guidelines

disadvantages of electrolyti-
– Fast high level disinfection and sporicidal activity – Fast deactivation of in-use solution where residual
cally generated disinfectants.
– In-use solution is reusable as long as the generator organic load is present
works – Endorsement of material compatibility with
– In-use solution is nonirritant to skin, eyes, and endoscopes is required (an additional coating
respiratory tract might be required with some types of endoscopes
– manufacturer-specific)
– Acid-related coagulation of proteins is possible,
depending on pH value
– Waste water restriction for chlorine compounds in
some countries
rate, with each parameter having a specific tolerance range 9 Reprocessing of endoscopes
which is continually checked by the monitoring system. The dis- !
infectant is safe to handle, requiring minimal personal protective 9.1. Manual cleaning
equipment. It is nontoxic, nonsensitizing, nonirritating, and 9.1.1. Pre-cleaning in the endoscopy room
nonmutagenic. As soon as the endoscope is withdrawn from the patient, pre-
Advantages and disadvantages of electrolytically generated dis- cleaning should begin. Before the endoscope is detached from
infectants are listed in l
" Table 6. the light source and video processor, detergent solution is
sucked through the working channel and the air/water channel
8.3. Rinse aid is flushed with water in order to remove debris and to check
A new procedure improves the drying of flexible endoscopes by the correct functioning of the channel. The insertion tube is
adding a rinse aid into the final rinse water, based on surfactants cleaned externally with a soft, disposable cloth/sponge and
that reduce the surface tension of residual water. The drying checked for any damages.
time can be reduced as well as the energy requirements of the After the endoscope has been detached from the light source and
process. As the rinse aid remains on the endoscope, toxicological video processor it is transported in a closed container to the re-
issues must be assessed according to ISO 10993-1 (Biological as- processing room to avoid environmental contamination.
sessment of medical devices).
9.1.2. Manual cleaning in the reprocessing room
8.4. Combination of products from different manufac- The leak test must be performed according to the manufacturer’s
turers instructions, in order to check the inner and outer surfaces of the
The combination of different product groups for cleaning and endoscope for any damage.
disinfection could cause compatibility problems. Therefore In the case of any leakage, the reprocessing procedure must be
manufacturers’ recommendations have to be followed at all interrupted immediately and repair of the endoscope should be
times. Interactions can cause a change of colour of endoscope initiated. In such cases, the user should clearly mark the endo-
surfaces, or depositions or sedimentation on endoscope surfaces scope as “Not disinfected.” The leak test should be performed be-
and inside washer-disinfectors and automated disinfection devi- fore each reprocessing cycle.
ces. In case of any interactions, the user should contact the man- Thorough manual cleaning with detergent remains an important
ufacturers of the chemicals, the endoscopes, and the washer-dis- step of the endoscope reprocessing procedure. This includes:
infectors. " Dismantling of all detachable parts of the endoscope such as
For example, detergents containing antimicrobial substances suction and air/water valves, distal caps, and water bottle in-
based on amine compounds should not be used in combination lets.
with glutaraldehyde. In some cases colored residues have been " Cleaning of all external surfaces, valve ports and channel
observed as a result of a suspected chemical interaction. openings, using a soft, disposable cloth, suitable brushes and
sponges
8.5. Change of products " Brushing of all accessible channels using flexible, purpose-
If an endoscopy department plans to change detergents and/or designed brushes. The size and type of cleaning brush must
disinfectants, the user must inform the service provider and the be matched appropriately to size and type of endoscope
responsible persons/department for infection control and occu- channels, to ensure contact with channel walls. To ensure
pational health. The manufacturers need to provide compatibil- maximum effectiveness of cleaning and to avoid tissue car-
ity evidence for washer-disinfectors, endoscopes, and chemicals. ryover, ESGE and ESGENA recommend the use of single-use
Unauthorised use may invalidate guarantees and/or service con- brushes as these have undamaged bristles without any tissue
tracts. remnants from previous examinations. All reusable brushes
As chemicals are important components of cleaning and disin- must be thoroughly cleaned manually, followed by ultrasonic
fection, the reprocessing cycle has to be revalidated [3]. cleaning and decontamination (preferably sterilization) after
Staff need to be trained in the changed reprocessing procedure, each usage.
regarding new products, contact time, concentration, and pro- " Flushing of all lumens in order to remove organic material
tection measures. (blood, tissue, stool, etc.). All auxiliary water channels, wire
channels, and balloon inflation channels (in endoscopic ul-
trasound [EUS] endoscopes and probes) have to be cleaned
Guidelines 949
according to manufacturers’ recommendations, even if they be monitored and should not go below the specified concen-
have not been used in that examination. tration range.
Rinsing solution should not be reused. " Rinse (optional, only if required): removal of residual cleaning
It is important to make sure that all external and internal surfa- process chemicals that could interfere with the subsequent
ces are completely wetted by the cleaning solution and are sub- disinfection stage.
jected to mechanical action. " Disinfection: reduction of all bacteria, mycobacteria, fungi,
With manual cleaning it is important to follow the contact time, yeasts, and viruses to a level such that patients will not be
temperature and concentration recommended by the manufac- harmed at a later time.
turer in order to ensure a sufficient effect of the cleaning solu- " Rinse (optional, only if required): removal of chemical residues
tion. from the instruments/scopes that have been disinfected.
After thorough manual cleaning the endoscope is ready for auto- " Final rinse: a second rinse for removal of the chemical load
mated or manual reprocessing. from the instruments/scopes that have been disinfected. Re-
contamination of the disinfected scopes by use of rinsing
9.2. Reprocessing in washer-disinfectors water of inappropriate quality must be prevented.
9.2.1. Definition and process basics for washer-disinfectors " Drying (optional). Drying can be of two kinds:
Washer-disinfectors (also called automated endoscope repro- 1. Drying in between examinations, which involves removal
cessors [AERs]) have become an essential part of most endo- of residual fluid from outside surfaces and interior channels.
scope reprocessing areas as they ensure a validated and stand- 2. Extended drying at the end of the working day in order to
ardized reprocessing cycle and also reduce staff contact with keep endoscopes safely stored at least overnight and to pre-
process chemicals. The machine must be effective, safe, reliable, vent recontamination from residual liquids or from environ-
and able to cope with endoscope design and throughput. mental effects.
According to the definition of EN ISO 15883, washer-disinfectors A variety of different functions of washer-disinfectors should be
are intended to clean and disinfect medical devices, e. g. flexible considered. They are:
endoscopes, within a closed system. Cleaning is an essential part " Monitoring of quantity of water supplied to washer-disinfec-
of the reprocessing cycle. Therefore, washer-disinfectors that of- tors
fer the relevant cycle steps (cleaning plus disinfection plus rinse) " Single or controlled multiple use of all process chemicals that
should be recommended for use. are used during reprocessing cycles EN ISO 15883
The washer-disinfectors should fulfill the following basic crite- " Dosage monitoring of all chemicals that are added during the
ria: reprocessing cycle
" Ensure complete irrigation of all scope channels including: " Monitoring of specified process temperature profiles during
biopsy, suction, air/water, auxiliary water and elevator chan- all process phases
nel " Means of preventing mixing or wrong placement of process
" Avoid cross-contamination with other reprocessing batches chemicals into the washer-
" Offer a more reliable and reproducible decontamination pro- disinfectors
cedure than manual processing " Automatic leak testing of endoscopes, including monitoring
" Reduce the likelihood of eye, skin and respiratory exposure and control of critical overpressure situations in order to
(closed system). avoid damage to endoscopes
The most important and influential process parameters for " Monitoring of flow through endoscope channels (flow con-
achieving correct results are: trol)
" water quantity and quality required for each cycle phase/step " Heating devices for fluids, to reach specified process tem-
" temperature during each cycle phase (minimum effective perature levels
temperature) " Independent control system that prevents escape of irritating
" mechanical actions or sensitizing process chemical vapors into the environment
" concentration of chemicals (minimum effective concentra- " Trays and adapters for reprocessing of all compatible equip-
tion) ment
" contact time during each cycle phase. " A rinse water treatment system that prevents recontamina-
tion of processed instruments during rinsing
9.2.2. Process specifications for washer-disinfectors " Self-disinfection of water supply and water treatment com-
According to the standard EN ISO 15883-4, washer-disinfectors ponents
may carry out the following cycle steps: " Optional thermal disinfection cycle for reprocessing of ther-
" Leak testing: monitoring the integrity of the scope to be re- mostable accessories
processed (no leaks that may endanger further use of the en- " Air-drying facilities to expel fluids and to dry the channels of
doscope). the endoscope at the end of a cycle
" Flushing: removal of residues from the external surfaces and " Documentation of all relevant endoscope and process data
the interior of the scope channel. and recording of reprocessing reports
" Cleaning: removal off all visible dirt and residuals from scope " A printout of cycle, disinfection parameters, and endoscope
surfaces and interior of scope channels, by means of specified data that can be retained for quality assurance records
detergents. Cleaning inside washer-disinfectors is done by " A cycle counter and fault indicator
water that must be pumped through the scope channel sys- " Interfaces that may allow communication with hospital net-
tems at specified temperatures for a specified time. The works for process documentation.
amount of detergent added during the cleaning phase must
950 Guidelines

disadvantages of reprocessing
– High level of standardization in reprocessing – High cost
in washer-disinfectors.
– Low risk of either patient or staff infection – Dedicated user skills and knowledge still required
– Complete documentation – Added validation costs to be covered by users
– Full compatibility with latest European norms – More complexity and more training required
– Economic use of chemicals and other resources – Without regular maintenance there is a risk of
– More user-friendly infection
– More reliable
– Regular validation of full process will increase
reliability
– Separation between clean/dirty areas
9.2.3. Specific recommendations for washer-disinfectors 9.3.2. Process specifications for automated disinfection
The use of washer-disinfectors does not remove the need for devices
manual cleaning of the insertion tube, suction/biopsy channel, Automated disinfection devices usually have the following ma-
instrument tip, and valves. Manual cleaning (including brush- jor features, which may vary significantly among devices.
ing) of endoscopes and their accessories (valves, distal caps, " Monitoring for renewal of disinfectant solution
etc) is mandatory. " Heater to keep disinfectant solution at specified temperature.
Local reprocessing regulations must be followed. In some Euro- " Adapters for reprocessing of all compatible equipment
pean countries, double cleaning in the washer-disinfectors is re- " A rinse water treatment system that prevents recontamina-
quired before the disinfection stage can be initiated (i. e., France, tion of processed instruments during rinsing
Austria). " Self-disinfection of water supply and water treatment com-
ponents
9.2.4. Advantages and disadvantages of washer- " Printer interface for documentation of the disinfection data
disinfectors " Fault indicator.
These are summarized in l
" Table 7.
9.3.3. Specific recommendations for automated disinfec-

9.3. Reprocessing in automated disinfection devices tion devices
9.3.1. Definition and process basics for automated Numerous manual steps are necessary before an endoscope can
disinfection devices be processed in automated disinfection devices. Manual pre-
Automated disinfection devices are intended to disinfect flexible cleaning is mandatory, as with washer-disinfectors.
endoscopes in a closed system after manual cleaning, thus their The cleaning stage must be done manually. There needs to be as-
cycle includes disinfection and rinse steps but not cleaning. surance that detergent residues will be removed effectively from
There is a great variety of automated disinfection devices on the the endoscope before it is reprocessed in the automated disin-
market. All of these perform the disinfection step and final rin- fection devices. Residues may interfere with the disinfectant so-
sing step. Additionally, some automated disinfection devices of- lution in the automated disinfection devices.
fer the following: The most important and influential process factors for achieving
" integrated leakage testing suitable results are as follows:
" automated rinsing step using water " Users must comply strictly with the endoscope manufactur-
" optional drying step after the final rinsing. er’s instructions for pre-treatment of the instruments.
A manual leakage test and manual cleaning must be done after " In the case of reuse of disinfectant solutions, regular efficacy
manual pre-cleaning (see section 9.1.) and before the endo- tests are required (according to the instructions of the manu-
scopes can be placed in the automated disinfection devices for facturer of the chemicals and depending on the frequency of
further disinfection treatment. As these disinfection devices do use).
not have an integrated cleaning phase, it is even more important " Manual drying must be adequate.
for the user to carefully clean the endoscope manually. The ma-
chine must be effective, safe, reliable and able to cope with the 9.3.4. Advantages and disadvantages of automated disin-
endoscope design and the throughput. fection devices
Automated disinfection devices must fulfill the following basic These are summarized in l
" Table 8.
criteria:
" Ensure complete irrigation of all scope channels, including 9.4. Manual reprocessing of endoscopes
the biopsy, suction, air/water, auxiliary water and elevator 9.4.1. Definitions and process basics for manual reproces-
channels. sing
" Avoid cross-contamination of other reprocessing batches All steps of the reprocessing cycle are performed manually (see
" Offer a more reliable and reproducible decontamination pro- " Fig. 1 and section 9.1).
l
cedure than manual processing
" Reduce the likelihood of eye, skin, and respiratory exposure 9.4.2. Process specifications for manual reprocessing
for patients and hospital staff to the process chemicals Manual reprocessing of endoscopes gives reliable results,
(closed system). provided that well-trained staff perform the reprocessing con-
scientiously according to defined standard operating procedures
(SOPs). The SOP should take into account the different types of
Guidelines 951

disadvantages of reprocessing
– Low purchase costs compared with washer- – Lack of standardization of manual cleaning
in automated disinfection
disinfectors – In case of reuse of disinfectant, efficacy problems
devices.
– Lower workload compared with full manual and cross-contamination need to be considered
reprocessing – Increased workload of routine testing
(i. e. disinfectant efficacy testing)
– Traceability and documentation is more time-
consuming
– More complexity and more training required
– Without regular maintenance there is a risk of
infection
endoscope used in the department. It should be documented and if necessary, dry the endoscope manually with compressed
and be easily available to the staff who are carrying out the pro- filtered air before storage.
cedures. With manual drying the external parts of the endoscope, espe-
Cleaning. Manual pre-cleaning and cleaning, including brushing, cially the control body, light/video connectors, and plugs, should
is mandatory to remove all gross debris from internal and exter- be dried carefully. Endoscope channels should be dried with
nal surfaces. The procedure is described in section 9.1. compressed filtered air.
Disinfection. In manual disinfection the endoscope must be im- According to some guidelines, flushing with 70 % – 90 % alcohol
mersed completely. All channels must be filled with disinfec- or isopropyl alcohol is recommended for drying of endoscope
tant. With manual disinfection it is important that the manufac- channels [41, 42], but this should only be used at the end of a
turer’s recommendations regarding correct concentration, tem- clinic as residual alcohol poses a risk during electrosurgical pro-
perature, and contact time are followed, to ensure adequate dis- cedures. There is no clear evidence that flushing with alcohol is
infection. effective in either drying endoscopes or preventing the prolifera-
The disinfecting solution should be freshly prepared at least on a tion of waterborne bacteria [26, 43]. Due to the fixative proper-
daily basis. If the disinfectant is a concentrated product, it ties of alcohol, its use is not recommended in some countries.
should be diluted with filtered water or water of drinking quali- Flexible endoscopes should be stored vertically in well ventila-
ty, to the correct dilution. If the disinfecting solution is used for ted cupboards. Specially designed cupboards are commercially
longer than 1 day, based on the manufacturer’s recommenda- available which assist the drying process by means of special
tion, the active ingredient content should be checked at least ventilation methods, using filtered air or container systems.
daily as the concentration can be lowered by: Valves should be disconnected as they may block the air flow
" decomposition of the active substance through the endoscope channels. Valves and distal caps should
" adsorption of the active substance on surfaces be stored separately but with the endoscope.
" inactivation of the active substance by reaction with protein Valves (including rinsing valves) should stay with a named en-
" dilution of the disinfecting solution by rinse water remaining doscope as a set, to prevent cross-infection and enable full trace-
in the endoscope from the previous reprocessing step. ability [23].
Note: Up to 50 ml of solution can remain in an endoscope (de- Local policies must be in place that define for how long a repro-
pending on endoscope type) if the solution is not removed by cessed endoscope can be used before it needs re-disinfection.
compressed air. If a storage cabinet is used, a risk assessment will determine the
Final rinsing. The disinfecting solution must be rinsed off from period over which a disinfected endoscope can stored and re-
the internal and external surfaces of the endoscope. used without further reprocessing.
" The endoscope is rinsed and the channels flushed, with water There is a new procedure to improve the drying of flexible endo-
of at least drinking quality, to remove the disinfecting solu- scopes. This involves adding a measured amount of a medical
tion. rinse aid into the final rinse water. The characteristics of this
" Sterile water is preferable for the final rinse. new procedure remain to be examined.
" National requirements regarding water quality must be taken
into account.
" The rinse water is discarded after each use/cycle. 10. Quality assurance
!
9.4.3. Advantages and disadvantages of manual reproces- Quality assurance processes and standards vary from country to
sing country and practitioners need to comply with national regula-
These are summarized in l
" Table 9. tions. The ESGE–ESGENA guideline may help in the development
of such regulations in countries where they do not exist at pres-
9.5. Drying, storage, and reuse of endoscopes ent, or may help individual endoscopy departments in develop-
Before storage, thorough drying of endoscopes is necessary to ing local standards and protocols.
prevent the growth of waterborne microorganisms.
Endoscopes are not usually completely dried in between endo- 10.1. Documentation
scopic procedures. Washer-disinfectors offer a short drying cycle The complete reprocessing cycle of every endoscope should be
which is used between endoscopic procedures and an intensive documented.
final drying cycle to be used at the end of the endoscopy clinic. " Each reprocessing step is recorded manually or electronically,
Nevertheless staff should check the quality of the final drying including the name of the person undertaking each step.
952 Guidelines

disadvantages of manual
– Easy to establish without any major investments – Validation not possible, but standardization for all
reprocessing.
reprocessing steps is possible
– Staff exposure to process chemicals
– Increased workload, because staff are involved in
each reprocessing step
– In case of reuse of disinfectant, efficacy problems
can be expected
– Traceability and documentation is more time-
consuming
– Increased risk of infection and re-contamination
" The process parameters of the washer-disinfectors and auto- mends routine testing at intervals no longer than 3 months [4].
mated disinfection devices are documented by printouts or Endoscopes, washer-disinfector, and the water used in endosco-
electronically, to show that the reprocessing cycle was py must be tested at the same time, in order to identify a cause of
successful and complete. infection.
" All endoscopes have a record of their decontamination such
that they are ready for use on patients. 10.4. Outbreak management
" The decontamination record is documented in the patient’s If any contamination is found it is the responsibility of the clini-
notes. cal service provider to take the suspect piece of equipment out of
service (e. g. endoscopes, washer-disinfector, accessories, etc),
10.2. Maintenance of washer-disinfectors and until corrective actions have been taken and satisfactory results
automated disinfection devices have been achieved [3, 4].
Washer-disinfectors and automated disinfection devices may
pose an additional infection risk. Therefore they must:
" be cleaned and maintained on a daily basis according to 11. Reprocessing of endoscopic accessories
manufacturer’s recommendations !
" have regular engineering maintenance 11.1. General recommendations
" have regular microbiological surveillance. Endoscopic accessories are used for diagnosis and treatment
Washer-disinfectors and automated disinfection devices must during endoscopic procedures. They are available as reusable
be capable of self-disinfection and should use water of at least and single-use devices. Manufacturers have to give clear instruc-
drinking quality. tions on how to reprocess reusable accessories (EN 17664). The
The cleaning solution and rinsing water in washer-disinfectors trend to employing single-use devices is increasing in many
and automated disinfection devices should not be reused. western European countries.
Regular maintenance is essential in order to ensure and main- Reusable accessories should be reprocessed appropriately. If this
tain appropriate performance in washer-disinfectors and auto- is technically not possible (e. g. in the case of balloons or bougie
mated disinfection devices; the manufacturers are responsible dilators), they should be employed as single-use devices.
for specifying the required maintenance. In some countries single-use accessories are preferred as they
" Prevent cross-infection in both patients and in staff
10.3. Process validation and microbiological " Avoid potential staff injuries during cleaning
surveillance " Ensure a fully functioning accessory each time (providing a
Manufacturers are responsible for providing information and in- good cut, etc)
structions on how to validate the reprocessing process. " Make the use of ultrasonic cleaning equipment obsolete/un-
" Process validation for washer-disinfectors can be performed necessary and therefore, also reduce the risk of cross-infec-
according to the following: tion from contaminated solutions, and of potential release of
" EN ISO15883 parts 1, 4, and 5 [9, 27, 28] harmful vapors.
" ESGE/ESGENA guideline for process validation and routine test- Local recommendations must be respected.
ing for endoscope reprocessing in washer-disinfectors, accord-
ing to the European standard prEN 15 883 parts 1, 4 and 5 [3] 11.2. Process specifications
" ESGE–ESGENA guideline for quality assurance in reprocessing: After manual pre-cleaning with dismantling and brushing, en-
Microbiological surveillance testing in endoscopy [4]. doscopic accessories should be cleaned in an ultrasonic cleaner.
Process validation for disinfection devices must be done accord- Further reprocessing (see l" Fig. 2) can be done either
ing to the manufacturer’s instructions. " manually

Periodic microbiological surveillance testing should be per- " using a washer-disinfector, or
formed according to the ESGE–ESGENA guideline for quality as- " with sterilization in central sterilization departments.
surance in reprocessing: Microbiological surveillance testing in en-
doscopy [4] 11.2.1. Manual cleaning
Routine quality assurance of the whole endoscope reprocessing Manual cleaning is the most important step in the removal of or-
system must be established, that covers the endoscopes, wash- ganic material from accessories. This includes thorough cleaning
er-disinfectors, and water supply used in endoscopy. As a point by:
of reference, the ESGE–ESGENA Guideline Committee recom-
Guidelines 953
In some countries, such as Germany, disinfection is recommen-

Manual cleaning ded as an additional step after ultrasonic cleaning in order to re-
including ultrasonic cleaning duce the germ load before sterilization and for staff protection
purposes [10]. In other countries, thorough rinsing and drying
is done before the accessories are sterilized [23].
The detailed protocol for manual reprocessing of endoscopic ac-
Washer disinfectors Manual reprocessing
cessories is listed in Appendix 4.
All reprocessing steps are Rinsing 11.2.4 Sterilization

performed in washerdisinfectors: After thorough rinsing and drying, endoscopic accessories
Cleaning should be packed according to EN 868 [44] and sterilized accord-
Rinsing Disinfecting
Thermal disinfection ing to European sterilization standards (e. g. EN 285 [45]) in line
Drying with manufacturers’ instructions (recommendation: steam au-
Final rinsing
toclave, pre-vacuum, 134 8C).
11.2.5. Storage
Drying Endoscopic accessories should be stored in a closed cupboard.
Before use, the sterilization package should be checked for any
Packaging Sterilization damage and for expiry date (EN 868).
11.3. Specific recommendations

Storage 11.3.1. Biliary and pancreatic procedures
All accessories used in the biliopancreatic duct system must be
Fig. 2 Reprocessing of endoscopic accessories.
sterile. Reusable devices should be autoclavable. Balloons can-
not be sterilized for technical reasons. The use of reprocessed
" Dismantling of accessories as far as possible (follow manu- (i. e. disinfected) balloons carries a risk of serial contamination
facturers’ recommendations) of the biliopancreatic ducts.
" Cleaning of external surfaces with a soft, disposable cloth/
sponge and brushes 11.3.2 Injection needles
" Thorough brushing of biopsy forceps’ cups Injection needles should be used once only. Under no circum-
" Flushing all available channel lumens stances should injection needles be reprocessed. ESGE and ES-
" Ultrasonic cleaning GENA recommend the use of disposable needles for several rea-
" Rinsing. sons:
Ultrasonic cleaning is essential for the removal of debris from in- " Dismantling of needles is dangerous for endoscopy personnel
accessible areas of complex accessories. The tray of the ultraso- " The narrow lumen is difficult to clean
nic cleaner should not be overloaded, in order to avoid ultra- " The needles are likely to be contaminated with blood
sound “shadows” or dead space. Ultrasonic cleaning must be " The types of patients in whom they are used are often infec-
performed before any disinfection or sterilization step. The use tious.
of a medical grade ultrasonic cleaner with a frequency range This is in line with the recommendations for hypodermic need-
over 30 kHz (38 to 47 kHz) and a maximum operating tempera- les.
ture of 45 8C is recommended.
Accessories should be cleaned manually immediately after use 11.3.3 Biopsy forceps
to prevent any body fluids or debris drying on the instruments There is a clear trend towards employment of single-use biopsy
as this might cause ineffective reprocessing or malfunction. If forceps, despite studies having shown that it is possible to effec-
immediate reprocessing is not possible, accessories should be tively reprocess and sterilize biopsy forceps [46].
placed in detergent.
The water quality available in the endoscopy unit should be spe- 11.3.4. Water bottles and their connectors
cified. In addition to the endoscopes themselves, water bottles can be a
source of endoscope contamination. This can be caused by in-
11.2.2. Reprocessing in washer-disinfectors adequate cleaning of water bottles, lack of sterilization or use of
For the reprocessing of accessories, thermal disinfection pro- tap water instead of sterile water [47].
grammes are recommended (EN ISO 15883). Some washer-dis- Therefore, water bottles and connecting tubes must be cleaned
infectors for flexible endoscopes offer special programmes for and sterilized on a daily basis. The water bottles should be filled
heat-stable accessories. Washer-disinfectors for surgical instru- with sterile water and changed after each endoscopy session.
ments, according to EN ISO 15883-2, also offer loading systems Additionally, testing of water bottles should be included in regu-
and programs for heat-stable accessories. lar quality control [4, 23, 47].
11.2.3. Manual reprocessing Competing interests: None

If reusable accessories are reprocessed manually, manual clean-
ing and ultrasonic cleaning are the most important steps (see
section 11.2).
954 Guidelines
Appendix 1: Manual cleaning of flexible Step 4: Rinsing

endoscopes " Rinse all outer surfaces and all channels by flushing with wa-
! ter followed by air to expel as much fluid as possible prior to
Step 1. Pre-cleaning disinfection. The rinsing removes detergent residues and
Before the endoscope is detached from the light source and/or avoids interactions between detergents and disinfectants.
video processor " Drain, disinfect and rinse the container/basin before the next
" Suck detergent through the working channel (minimum reprocessing procedure.
250ml).
" Ensure that the working channel is not blocked.
" Flush the air/water channel with water from the water bottle. Appendix 2: Reprocessing of flexible endoscopes in
" Use rinsing valves if available. washer-disinfectors and automated disinfection
" Wipe down the insertion tube with a soft, disposable cloth/ devices
sponge. !
" Check the outer surface of the endoscope for any damage. Thorough manual cleaning is a prerequisite for effective disin-
" Detach the endoscope from the light source and/or video fection. Therefore, manual cleaning including brushing must al-
processor. ways be done before automated reprocessing is performed. The
" Transport the endoscope in a closed system to the reproces- standard cleaning procedure for flexible endoscopes, steps 1–4
sing room. of Appendix 1: Manual cleaning of flexible endoscopes, must be
All further reprocessing steps must be performed in the repro- done before a washer-disinfectors is used.
cessing room.
Step 5: Loading of washer-disinfector
Step 2. Leakage test " Load the basket, immersion trays or tank of the washer-dis-
" Dismantle all detachable parts of the endoscope, e. g. suction infector in accordance with the manufacturer’s recommen-
valves and air/water valves, distal caps and water bottle in- dations.
lets. " Attach channel connectors/separators to ensure complete
" Attach a soaking cap if necessary. and thorough irrigation of all lumens.
" Before starting the cleaning step, perform the leakage test " Ensure that all channels are connected. The specific design of
according to manufacturer’s instructions in order to check the the machine must be taken into account.
inner and outer surfaces of the endoscope for any damage. " Valves and distal caps must be placed into a special basket.
Note: If the leakage test is positive, the reprocessing procedure " Remove gloves and close the washer-disinfectors.
must be interrupted immediately and repair of the endoscope
must be initiated. Step 6: Reprocessing
" Select and start the cycle.
Step 3: Manual cleaning " After completion of the automated cycle, ensure that all cycle
" Immerse the endoscope completely in water with detergent. stages have been completed in accordance with set param-
" Fill all channels with cleaning solution. Use the endoscope- eters.
specific adapters to ensure complete filling/rinsing with de- " Open the washer-disinfector and remove the endoscope.
tergent.
" Clean all external surfaces, valve ports, and channel openings, Step 7: Drying and storage
using a soft, disposable cloth/sponge, and brushes. The distal " Dry the endoscope externally and flush each channel with air.
end is brushed with a soft toothbrush and special attention is The drying process may be supported by flushing 70 % alcohol
paid to the air/water outlet nozzle and the bridge/elevator through the endoscope channels.
where fitted. " If there is to be further use, wipe the eyepiece and light guide
" Brush all accessible channels with a flexible, purpose-de- connector as well as the plugs, before connecting the endo-
signed brush. Appropriately sized brushes for each channel scope to the light source.
should be used to ensure good contact with the channel " Fit the disinfected and rinsed valves. The endoscope is now
walls. The brush must be passed through each channel sev- ready for use again.
eral times until clean and the brush itself must be cleaned in " Before storage, the endoscope channels and outer surfaces
detergent with a soft toothbrush each time it emerges. must always be dried completely, in order to prevent the
" Brushing/cleaning should be done with the endoscope com- growth of microorganisms.
pletely immersed in the fluid in order to avoid splashing of " Endoscopes should be stored vertically in a well ventilated
contaminated liquids. storage cupboard.
" Valves and distal caps must also be cleaned according to the " Valves should not be connected as this might block the air
manufacturer’s instructions (mainly in the same way as the ventilation in the endoscope channel. Valves and distal caps
endoscope but additionally using an ultrasonic bath). should be stored separately next to the endoscope.
Note: Concentrations and exposure times should be in line with
the manufacturer’s instructions.
Guidelines 955
Appendix 3: Manual reprocessing of flexible " Inject detergent solution into all accessible lumina to remove
endoscopes secretions and debris (at least 10–20 ml solution in each lu-
! men).
Thorough manual cleaning is a prerequisite for effective disin- " Ensure that all lumina are flushed completely to avoid air
fection. Therefore manual cleaning must always be done before blockages.
disinfection is performed. Steps 1–4 detailed in Appendix 1: " Remove the instruments from the detergent solution.
Manual cleaning of flexible endoscopes must always be done be- Notes:
fore disinfection. " All types of detergents recommended for reprocessing of
medical devices can be used for cleaning endoscopy acces-
Step 5: Disinfection sories. Compatibility of materials must be respected. Instruc-
" After thorough manual cleaning, including brushing of all actions from the manufacturers of the process chemicals must
cessible channels, the endoscope is immersed completely in be complied with.
disinfectant solution. " Aldehydes cannot be used for cleaning steps because they
" Fill all endoscope channels completely with disinfectant. Use denature and coagulate protein, thus fixing it, and this may
the endoscope-specific rinsing adapters to ensure complete impair cleaning.
contact with disinfectant and to avoid any dead spaces. " Cleaning must be done before disinfection.
" Valves and distal caps must be disinfected with the endo- " The water quality available in the endoscopy unit should be
scope. specified.
" Manufacturers’ recommendations must be followed with re-
gard to concentration and contact time of the disinfectant. Step 2: Ultrasonic cleaning
" Use a medical grade ultrasonic cleaner with a frequency
Step 6: Rinsing range over 30kHz (38 to 47kHz) and a maximum operating
" Rinse all outer surfaces and all channels by flushing with wa- temperature of 45 8C, following the manufacturer’s instruc-
ter to remove all traces of disinfectant. tions.
" Rinse all valves and distal caps under water as well. " Ensure that the detergent used is a non-foaming solution,
" The water must be of at least drinking water quality and suitable for manual cleaning as well as for ultrasonic clean-
should be free of pathogens such as Pseudomonas aeruginosa. ing.
If necessary, filtered water may be used for rinsing. " Renew the cleaning solution at least daily or more frequently
Note: Always discard the rinse water after each use in order to if the solution is contaminated.
avoid any recontamination. " Ensure that the tray is large enough and deep enough to allow
for complete immersion of the devices.
Step 7: Drying and storage " Load the basket/tray of the ultrasonic cleaner with the dis-
" Dry the endoscope externally and flush each channel with air. mantled and pre-cleaned accessories.
The drying process may be supported by flushing 70 % alcohol " Avoid any ultrasound “shadows“ or dead spaces where ultra-
through the endoscope channels. sound waves cannot act. Do not overload the tray.
" If there is to be further use, wipe the eyepiece and light guide " The instrument should be coiled with a diameter of not less
connector as well as the plugs, before connecting the endo- than 15–20 cm, in accordance with manufacturer’s instruc-
scope to the light source. tions.
" Fit the disinfected and rinsed valves. The endoscope is now " Flush all channels and lumens completely again with at least
ready for use again. 10 ml of detergent solution, to avoid air blockage.
" Before storage, always dry the endoscope channels and outer " Follow the instructions of both the manufacturer of the ul-
surfaces completely in order to prevent the growth of micro- trasonic cleaner and the manufacturer of the device.
organisms. " Cover the ultrasonic cleaner with a lid.
" Endoscopes should be stored vertically in a well ventilated " Leave the accessories in the ultrasonic cleaner and complete
storage cupboard. the recommended contact time for ultrasonic cleaning, fol-
" Valves should not be connected as this might block the air lowing the manufacturers’ instructions for the devices, the
ventilation in the endoscope channel. Valves and distal caps ultrasonic cleaner and the detergents.
should be stored separately next to the endoscope. " Remove the accessories from the ultrasonic cleaner.
" Flush all channels with air to remove excess fluid.
Notes:
Appendix 4: Manual reprocessing of reusable During ultrasonic cleaning the temperature can range from 40 8C
endoscopy accessories to 60 8C. Proteins can be fixed at higher temperatures. When using en-
! zymatic detergents ensure that the temperature is not over 45 8C, as
Step 1: Cleaning compatible with detergent efficacy.
" Disconnect and dismantle accessories as far as possible. The temperature in the ultrasonic cleaner should be monitored.
" Immerse accessories in detergent solution immediately after
use. Step 3: Rinsing
" Clean the single components of the devices externally using a " Transfer the cleaned accessories to a bowl or tray containing
soft cloth/sponge, and brushes. water of at least drinking quality and renew the water after
" Brush or clean with the accessories completely immersed in each rinsing cycle.
the fluid, in order to avoid splashing of contaminated liquids.
956 Guidelines
" Flush all lumina completely and thoroughly in the water to " Open the washer-disinfector and remove the accessories.
remove detergent residues. Flush the lumina with at least " Dry the accessories if necessary with a non-shedding cloth.
20 ml water. " Dry each lumen with compressed air.
" Rinse external surfaces thoroughly, using water of at least To complete the cycle, follow steps 5 and 6 of Appendix 4: Man-
drinking quality, to remove chemical residues. ual reprocessing of reusable endoscopic accessories.
" Remove the devices from the water.
" Drain or aspirate all lumina with air to remove residual rinse Institutions
water. 1
ESGENA President, Ulm, Germany
2
ESGENA Past President, Birmingham, UK
3
ESGE Guidelines Commitee Chairman, Institute A. Tzanck, Saint Laurent du
Step 4: Drying Var, France
" Dry the external surfaces with a non-shedding cloth and 4
R,D&E Health Care EMEA, Ecolab GmbH & Co OHG, Dsseldorf, Germany
5
compressed air. BU Endoscopy Reprocessing Systems, Olympus Medical Systems Europa
GmbH, Hamburg, Germany
" Dry each lumen completely with compressed air. 6
CBC (Europe) Ltd., MILAN Branch, Nova Milanese (MI), Italy
" Dry all coiled accessories in a hanging position to support the 7
PENTAX Europe GmbH, Service Division, Hamburg, Germany
8
drying procedure. Sterilox Endoscopy, PuriCore International Limited, Stafford, UK
9
Microbiology and Hygiene Department, Chemische Fabrik Dr. Weigert
" Assemble the accessories and check their correct functioning.
GmbH & Co. KG, Hamburg, Germany
Step 5: Sterilization
13. References and guidelines
" Put the accessories into sterile packaging for special instru- 1 Guidelines on cleaning and disinfection in GI endoscopy. Endoscopy
ments. 2000; 32: 76 – 83
" Select the appropriate adequate sterilization procedure for 2 ESGE/ESGENA Technical note on cleaning and disinfection (2003).
the thermostable and thermolabile instruments in accord- Endoscopy 2003; 35: 869 – 877
3 ESGE/ESGENA Guideline for process validation and routine testing for
ance with manufacturers’ instructions (general recommen-
reprocessing endoscopes in washer-disinfectors, according to the Eu-
dation: steam autoclave, pre-vacuum, and national laws). ropean Standard prEN 15 883 parts 1, 4 and 5. Endoscopy 2007; 39:
" After completion of the sterilization cycle, ensure all cycle 85 – 94
stages have been completed in accordance with set param- 4 ESGE–ESGENA guideline for quality assurance in reprocessing: Micro-
eters. biological surveillance testing in endoscopy. Endoscopy 2007; 39:
175 – 181
" Check the sterile packaging for any damage and check the
5 International Organization for Standardization. EN 14885: Chemical
sterilization indicators. disinfectants and antiseptics – Application of European Standards for
chemical disinfectants and antiseptics. (2006) Section 3.3.1 http://
Step 6: Storage www.iso.org
" Store sterilized instruments (in the sterile packaging) in a 6 Rutala W. APIC Guidelines for selection and use of disinfectants. APIC
1990. Am J Infect Control 1990; 58: 99 – 117
closed cupboard, protected from dust, humidity, and tem- 7 Food and Drug Administration. Guidance for industry and FDA review-
perature fluctuation. ers: Content and format of premarket notification [510(k)] (2000).
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8 International Organization for Standardization. ISO 11137: Sterilization
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sories in washer-disinfectors and automated Washer-disinfectors – Part 1: General requirements, terms and defi-
disinfection devices nitions and tests. 2006; http://www.iso.org
! 10 Empfehlungen der Kommission fr Krankenhaushygiene und Infek-
tionsprvention beim Robert-Koch-Insitut zu den Anforderungen an
As an additional step, washer-disinfectors may be used. Before die Hygiene bei der Aufbereitung flexibler Endoskope und endoskopi-
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12 Spach DH, Silverstein FE, Stamm WE. Transmission of infection by gas-
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" Select and start the cycle. 18 Birnie GG, Quigley EM, Clements GB et al. Endoscopic transmission of
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Guidelines 957
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Guidelines 939

ESGE–ESGENA guideline: Cleaning and disinfection

Institutions Institutions are listed at the end of article.

submitted Contents 9.3.2. Process specifications for automated disinfection

1. Introduction 2. Definition of terms

a. Inadequate reprocessing of endoscopes and accessories Table 1 Potential weaknesses

to: section 9):

Pre-cleaning Fig. 1 Different methods for reprocessing endo-

In the separate Manual cleaning

Automated washer- Automated Manual

All reprocessing steps Rinsing may be included Rinsing

8.1.2. Detergents with alkaline boosters 8.2.1. Glutaraldehyde

Advantages Disadvantages Table 2 Advantages and

Advantages Disadvantages Table 3 Advantages and

Other disadvantages of glutaraldehyde are coagulation and fixa-

Advantages Disadvantages Table 4 Advantages and dis-

Advantages Disadvantages Table 5 Advantages and

Advantages Disadvantages Table 6 Advantages and

Advantages Disadvantages Table 7 Advantages and

9.3.3. Specific recommendations for automated disinfec-

Advantages Disadvantages Table 8 Advantages and

Advantages Disadvantages Table 9 Advantages and

ing to the manufacturer’s instructions. " manually

In some countries, such as Germany, disinfection is recommen-

All reprocessing steps are Rinsing 11.2.4 Sterilization

11.3. Specific recommendations

11.2.3. Manual reprocessing Competing interests: None

Appendix 1: Manual cleaning of flexible Step 4: Rinsing

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