Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) – Update 2018

Abstract

This Position Statement from the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology Nurses and Associates (ESGENA) sets standards for the reprocessing of flexible endoscopes and endoscopic devices used in gastroenterology. An expert working group of gastroenterologists, endoscopy nurses, chemists, microbiologists, and industry representatives provides updated recommendations on all aspects of reprocessing in order to maintain hygiene and infection control.

• References

• 1 Kampf B, Makowski T, Weiss H. et al. ESGE Newsletter: Definition of “endoscope families” as used in EN ISO 15883-4. Endoscopy 2013; 45: 156-157
• 2 Guidelines on cleaning and disinfection in GI endoscopy. Endoscopy 2000; 32: 76-83
• 3 ESGE/ESGENA Technical Note on Cleaning and disinfection (2003). Endoscopy 2003; 35: 869-877
• 4 Beilenhoff U, Neumann CS, Rey JF. et al. ESGE-ESGENA guideline for quality assurance in reprocessing: Microbiological surveillance testing in endoscopy. Endoscopy 2007; 39: 175-181
• 5 Beilenhoff U, Neumann CS, Rey JF. et al. ESGE/ESGENA guideline for process validation and routine testing for reprocessing endoscopes in washer-disinfectors, according to the European Standard prEN ISO 15883 parts 1, 4 and 5. Endoscopy 2007; 39: 85-94
• 6 Beilenhoff U, Neumann CS, Rey JF. et al. ESGE-ESGENA guideline: Cleaning and disinfection in gastrointestinal endoscopy. Update 2008. Endoscopy 2008; 40: 939-957
• 7 Beilenhoff U, Biering H, Blum R. et al. ESGE-ESGENA technical specification for process validation and routine testing of endoscope reprocessing in washer-disinfectors according to EN ISO 15883, parts 1, 4, and ISO/TS 15883-5. Endoscopy 2017; 49: 1262-1275
• 8 Beilenhoff U, Biering H, Blum R. et al. Prevention of multidrug-resistant infections from contaminated duodenoscopes: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA). Endoscopy 2017; 49: 1098-1106
• 9 Gastroenterological Society of Australia and Gastroenterological Nurses College of Australia. Infection control in endoscopy. 2010 3rd. edn. Available at: http://www.genca.org/public/5/files/Endoscopy_infection_control%20(low).pdf [Accessed 13 Oct 2018]
• 10 Ministère des affaires sociales et de la santé. Instruction N° DGOS/PF2/DGS/VSS1/2016/220 du 4 juillet 2016 relative à relative au traitement des endoscopes souples thermosensibles à canaux au sein des lieux de soins. Available at: http://www.cclin-arlin.fr/nosobase/Reglementation/2016/instruction/4072016.pdf [Accessed 13 Oct 2018]
• 11 Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert-Koch- Institut (RKI) und des Bundesinstituts für Arzneimittel und Medizinprodukt (BfArM). Anforderungen an die Hygiene bei der Aufbereitung von Medizinprodukten. Bundesgesundheitsbl 2012; 55: 1244-1310
• 12 Dutch Advisory Board Cleaning and Disinfection Flexible Endoscopes (SFERD). Professional standard handbook – Cleaning and disinfection flexible endoscopes. Version 4.1. 2017 Available from: http://www.infectiepreventieopleidingen.nl/downloads/SFERDHandbook3_1.pdf [Accessed 11 Mar 2018]
• 13 Health Technical Memorandum (HTM) 01–06: Management and decontamination of flexible endoscopes (HTM 01–06). Part A: Decontamination of flexible endoscopes – policy and management. 03/2016 Available from: https://www.gov.uk/government/publications/management-and-decontamination-of-flexible-endoscopes [Accessed 13 Oct 2018]
• 14 Health Technical Memorandum (HTM) 01–06: Management and decontamination of flexible endoscopes (HTM 01–06). Part B: Decontamination of flexible endoscopes: design and installation. 03/2016 Available from: https://www.gov.uk/government/publications/management-and-decontamination-of-flexible-endoscopes [Accessed 13 Oct 2018]
• 15 Health Technical Memorandum (HTM) 01–06: Management and decontamination of flexible endoscopes (HTM 01–06). Part C: Decontamination of flexible endoscopes: operational management. 2016 Available from: https://www.gov.uk/government/publications/management-and-decontamination-of-flexible-endoscopes [Accessed 13 Oct 2018]
• 16 British Society of Gastroenterology. BSG guidance on decontamination of equipment for gastrointestinal endoscopy: the report of a working party of the British Society of Gastroenterology Endoscopy Committee. 06/2014 [Available at: https://www.evidence.nhs.uk/search?q=endoscopy%20decontamination]
• 17 Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST91:2015. Flexible and semi-rigid endoscope processing in health care facilities. ISBN 1-57020-585-X Available at: http://www.aami.org
• 18 Association of periOperative Registered Nurses (AORN). Guideline for processing flexible endoscopes. Guidelines for perioperative practice 2017 . DOI: 10.6015/psrp.17.01.717
• 19 Society of Gastroenterology Nurses and Associates (SGNA). Standards of infection prevention in reprocessing flexible gastrointestinal endoscopes 2016. Available from: https://www.sgna.org/practice/standards-practice-guidelines
• 20 American Society for Gastrointestinal Endoscopy (ASGE). Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update. Gastrointest Endosc 2017; 85: 282e-294e
• 21 Bertschinger P, Brenneisen M, Cathomas A. et al. Schweizerische Richtlinie zur Aufbereitung flexibler Endoskope. Gemeinsame Richtlinie der Schweizerischen Gesellschaft für Gastroenterologie (SGG), Schweizerischen Gesellschaft für Pneumologie (SGP), Schweizerischen Gesellschaft für Spitalhygiene (SGSH), Schweizerischen Vereinigung für Endoskopiepersonal (SVEP). German Available at: https://svep-aspe.ch/fileadmin/user_upload/pdf/Schweizerische_ Hygienerichtlinie2013.pdf
• 22 Guyatt GH, Schünemann HJ, Djulbegovic B. et al. Guideline panels should not GRADE good practice statements. J Clin Epidemiol 2015; 68: 597-600
• 23 Guyatt GH, Alonso-Coello P, Schünemann HJ. Guideline panels should seldom make good practice statements: guidance from the GRADE Working Group. J Clin Epidemiol 2016; 80: 3-7
• 24 Dumonceau JM, Hassan C, Riphaus A. et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline development policy. Endoscopy 2012; 44: 626-629
• 25 Spach DH, Silverstein FE, Stamm WE. Transmission of infection by gastrointestinal endoscopy. Ann Intern Med 1993; 118: 117-128
• 26 Nelson DB, Muscarella LF. Current issues in endoscope reprocessing and infection control during gastrointestinal endoscopy. World J Gastroenterol 2006; 12: 3953-3964
• 27 Kovaleva J, Peters FTM, van der Mei HC. et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26: 231-254
• 28 Spaulding EH. Chemical disinfection and antisepsis in the hospital. J Hosp Res 1972; 9: 5-31
• 29 American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee. Technology Status Evaluation Report. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010; 72: 227-235
• 30 Herrin A, Loyola M, Bocian S. et al. Society of Gastroenterology Nurses and Associates (SGNA) Practice Committee. Standards of infection prevention in the gastroenterology setting 2015. https://www.sgna.org/Portals/0/Education/PDF/Standards-Guidelines/Standard%20of%20Infection%20Prevention_FINAL.pdf
• 31 Gutterman E, Horgensen L, Mitchell A. et al. Adverse staff health outcomes associated with endoscope reprocessing. Biomed Instrum Technol 2013; 172-179
• 32 Drysdale SA. The incidence of upper extremity injuries in endoscopy nurses working in the United States. Gastroenterol Nurs 2013; 36: 329-338
• 33 Beilenhoff U, Brljak J, Neumann C. et al. European Society of Gastroenterology Nurses and Associates (ESGENA). ESGENA Position Statement on health and safety in GI endoscopy. [In press] www.esgena.org
• 34 Hugonnet S, Chevrolet JC, Pittet D. The effect of workload on infection risk in critically ill patients. Crit Care Med 2007; 35: 76-81
• 35 Erasmus V, Daha TJ, Brug H. et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010; 31: 283-294
• 36 Santos LY, Souza Dias MB, Borrasca VL. et al. Improving hand hygiene adherence in an endoscopy unit. Endoscopy 2013; 45: 421-425
• 37 Ofstead CL, Wetzler HP, Snyder AK. et al. Endoscope reprocessing methods: a prospective study on the impact of human factors and automation. Gastroenterol Nurs 2010; 33: 304-311
• 38 Aumeran C, Poincloux L, Souweine B. et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010; 42: 895-899
• 39 Beilenhoff U, Brljak J, Neumann C. European Society of Gastroenterology Nurses and Associates (ESGENA). et al. European curriculum for reprocessing of flexible endoscopes 2018. [In press] www.esgena.org
• 40 European Society of Gastroenterology Nurses and Associates (ESGENA). European job profile for endoscopy nurses. Endoscopy 2004; 36: 1025-1030
• 41 European Council. Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Official Journal L169, 12/07/1993 P0001–0043 . Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:31993L0042
• 42 Costa DM, Lopes LKO, Hu H. et al. Alcohol fixation of bacteria to surgical instruments increases cleaning difficulty and may contribute to sterilization inefficacy. Am J Infect Control 2017; 45: e81-e86
• 43 International Organization for Standardization. ISO 15883–4: Washer-disinfectors – Part 4: Requirements and tests for washer-disinfectors employing chemical disinfection for thermolabile endoscopes. 2008 Available at: https://www.iso.org/standard/63696.html
• 44 Rutala WA, Weber DJ. Gastrointestinal endoscopes: a need to shift from disinfection to sterilization?. JAMA 2014; 312: 1405-1406
• 45 Roberts CG. The role of biofilms in reprocessing medical devices. Am J Infect Control 2013; 41: S77-S80
• 46 Otter JA, Vickery K, Walker JT. et al. Surface-attached cells, biofilms and biocide susceptibility: implications for hospital cleaning and disinfection. J Hosp Infect 2015; 89: 16-27
• 47 Gastroenterological Society of Australia/Gastroenterological Nurses College of Australia (GESA/GENCA). Draft document for discussion. Infection control in endoscopy – Multidrug resistant outbreaks response. 04/2016 Available from: http://www.genca.org/public/5/files/Infection%20Control%20Guidelines%20Draft%20April%202016.pdf
• 48 Epstein L, Hunter JC, Arwady MA. et al. New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312: 1447-1455
• 49 Wendorf K, Kay M, Baliga C. et al. Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol 2015; 36: 634-642
• 50 Smith ZL, Young SO, Saeian K. et al. Transmission of carbapenem-resistant Enterobacteriaceae during ERCP: time to revisit the current reprocessing guidelines. Gastrointest Endosc 2015; 81: 1041-1045
• 51 Kola A, Piening B, Pape UF. et al. An outbreak of carbapenem-resistant OXA-48-producing Klebsiella pneumonia associated to duodenoscopy. Antimicrob Resist Infect Control 2015; 4: 8
• 52 Verfaillie CJ, Bruno MJ, in’t holt Voor AF. et al. Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa. Endoscopy 2015; 47: 493-502
• 53 Klebisch FR, Schweizer C, Kola A. et al. A flexible bronchoscope as a source of an outbreak with OXA-48 carbapenemase producing Klebsiella pneumoniae. Hyg Med 2015; 40: 8-14
• 54 Ramsey AH, Oemig TV, Davis JP. et al. An outbreak of bronchoscopy-related Mycobacterium tuberculosis infections due to lack of bronchoscope leak testing. Chest 2002; 121: 976-981
• 55 Seki M, Hashiguchi K, Tanaka A. et al. Characteristics and disease severity of healthcare-associated pneumonia among patients in a hospital in Kitakyushu, Japan. J Infect Chemother 2011; 17: 363-369
• 56 Riebe O, Beilenhoff U, von Rheinbaben F. et al. HYGENDA 2013 hygiene in endoscope reprocessing: a study on the reprocessing of flexible endoscopes in hospitals and private practices. Hyg Med 2015; 40: 8-16
• 57 Muscarella LF. Risk of transmission of carbapenem-resistant Enterobactericeae and related “superbugs” during gastrointestinal endoscopy. World J Gastrointest Endosc 2014; 6: 457-474
• 58 Petersen BT. Duodenoscope reprocessing: risk and options coming into view. Gastrointest Endosc 2015; 82: 484-486
• 59 Humphries RM, McDonnell G. Superbugs on duodenoscopes: the challenge of cleaning and disinfection of reusable devices. J Clin Microbiol 2015; 53: 3118-3125
• 60 U.S. Food and Drug Administration. Medical Device Safety Communications. Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication March 4, 2015. Available at: https://wayback.archive-it.org/7993/20170723124407/https:/www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/Gastroenterology-UrologyDevicesPanel/UCM445597.pdf [Accessed 13 Oct 2018]
• 61 Empfehlungen des BfArM: Hinweis des BfArM und des RKI zu komplex aufgebauten Endoskopen (Duodenoskopen), deren Aufbereitung und damit verbundenen Infektionsrisiken. 17.07.2015 https://www.bfarm.de/SharedDocs/Risikoinformationen/Medizinprodukte/DE/bfarm_rki_aufbereitung_endoskop.html [Accessed 13 Oct 2018]
• 62 Jung M, Beilenhoff U. Multiresistente Darmkeime und kontaminierte Endoskope. Z Gastroenterol 2016; 54: 173-176
• 63 Gastroenterological Society of Australia/Gastroenterological Nurses College of Australia (GESA/GENCA). Infection Control in Endoscopy Consensus Statements on carbapenemase-producing Enterobacteriaceae. 08/2017 Available at: http://cart.gesa.org.au/membes/files/Clinical%20Guidelines%20and%20Updates/Infection%20Control%20in%20Endoscopy%20Consensus%20Statements%2020170821.pdf, or www.genca.org/standards-positions/position-statements/ [Accessed 13 Oct 2018]
• 64 Pietsch M. Safe storage of endoscopes: change in our guidelines?. Endoscopy 2007; 39: 831-832
• 65 Rex DK, Sieber M, Lehmann GA. et al. A double-reprocessing high-level disinfection protocol does not eliminate positive cultures from the elevators of duodenoscopes. Endoscopy 2018; 50: 588-596
• 66 Sethi S, Huang RJ, Barakat MT. et al. Adenosine triphosphate bioluminescence for bacteriologic surveillance and reprocessing strategies for minimizing risk of infection transmission by duodenoscopes. Gastrointest Endosc 2017; 85: 1180-1187
• 67 International Organization for Standardization. ISO 15883–1: Washer-disinfectors – Part 1: General requirements, terms and definitions and tests. 2006 https://www.iso.org/standard/41076.html [Accessed 13 Oct 2018]
• 68 International Organization for Standardization. ISO/TS 15883–5: Washer-disinfectors – Part 5: Test soils and methods for demonstrating cleaning efficacy. 2005 https://www.iso.org/standard/41175.html [Accessed 13 Oct 2018]
• 69 West AB, Kuan SF, Bennick M. et al. Glutaraldehyde colitis following endoscopy: clinical and pathological features and investigation of an outbreak. Gastroenterology 1995; 108: 1250-1255
• 70 Ryan CK, Potter GD. Disinfectant colitis. Rinse as well as you wash. J Clin Gastroenterol 1995; 21: 6-9
• 71 Janos G, Mahoney A, Murray J. et al. Chemical colitis due to endoscope cleaning solutions: a mimic of pseudomembranous colitis. Gastroenterology 1988; 95: 1403-1408
• 72 Hanson JM, Plusa SM, Bennett MK. Glutaraldehyde as a possible cause of diarrhoea after sigmoidoscopy. Br J Surg 1998; 85: 1385-1387
• 73 Zullo A, Hassan C, Guarini A. et al. Chemical colitis due to peracetic acid: A case report and review of literature. J Dig Endosc 2011; 2: 15-17
• 74 Pineau L, Villard E, Duc DL. et al. Endoscope drying/storage cabinet: interest and efficacy. J Hosp Infect 2008; 68: 59-65
• 75 Muscarella LF. Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying. Am J Gastroenterol 2006; 101: 2147-2154
• 76 Moayyedi P, Lynch D, Axon A. Pseudomonas and endoscopy. Endoscopy 1994; 26: 554-558
• 77 European Committee for Standardization (Cen). European Standard EN 16442: Controlled environment storage cabinet for processed thermolabile endoscopes. 2015 Available at: https://www.din.de/en/getting-involved/standards-committees/named/european-committees/wdc-beuth:din21:216540194 [Accessed 13 Oct 2018]
• 78 Osborne S, Reynolds S, George N. et al. Challenging endoscopy reprocessing guidelines: a prospective study investigating the safe shelf life of flexible endoscopes in a tertiary gastroenterology unit. Endoscopy 2007; 39: 825-830
• 79 Rejchrt S. et al. Bacteriologic testing of endoscopes after high-level disinfection. Gastrointest Endosc 2004; 60: 76-78
• 80 Riley R, Beanland C, Bos H. Establishing the shelf life of flexible colonoscopes. Gastroenterol Nurs 2002; 25: 114-119
• 81 Vergis AS, Thonson D, Pieroni P. et al. Reprocessing flexible gastrointestinal endoscopes after a period of disuse: is it necessary?. Endoscopy 2007; 39: 737-739
• 82 Kommentar zur Anlage 8 “Anforderungen an die Hygiene bei der Aufbereitung flexibler Endoskope und endoskopischen Zusatzinstrumentariums“ der Empfehlung “Anforderungen an die Hygiene bei der Aufbereitung von Medizinprodukten“ (1). Epidemiologisches Bulletin Nr. 28 des Robert-Koch-Institutes vom 15. Juli 2013. https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2013/Ausgaben/28_13.pdf?__blob=publicationFile
• 83 Schmelzer M, Daniels G, Hough H. Safe storage time for reprocessed flexible endoscopes: a systematic review. JBI Database System Rev Implement Rep 2015; 13: 187-243
• 84 Bader L, Blumenstock G, Birkner B. HYGEA (Hygiene in der Gastroenterologie−Endoskop−Aufbereitung): Studie zur Qualität der Aufbereitung von flexiblen Endoskopen in Klinik und Praxis [HYGEA (Hygiene in gastroenterology – endoscope reprocessing): Study on quality of reprocessing flexible endoscopes in hospitals and in the practice setting]. Z Gastroenterol 2002; 40: 157-170
• 85 Ofstead CL, Wetzler HP, Johnson EA. et al. Simethicone residue remains inside gastrointestinal endoscopes despite reprocessing. Am J Infect Control 2016; 44: 1237-1240
• 86 van Stiphout SH, Laros IF, van Wezel RA. et al. Crystallization in the waterjet channel in colonoscopes due to simethicone. Endoscopy 2016; 48 (Suppl. 01) E394-E395
• 87 Dwyer DM, Klein EG, Istre GR. et al. Salmonella newport infections transmitted by fiberoptic colonoscopy. Gastrointest Endosc 1987; 33: 84-87
• 88 Langenberg W, Rauws EA, Oudbier JH. et al. Patient to patient transmission of Camphylobacter pylori by fiberoptic gastroduodenoscopy and biopsy. J Infect Dis 1990; 161: 507-511
• 89 Nürnberg M, Schulz HJ, Rüden H. et al. Do conventional cleaning and disinfection techniques avoid the risk of endoscopic Helicobacter pylori transmission?. Endoscopy 2003; 35: 295-299
• 90 Muscarella LF. Investigation and prevention of infectious outbreaks during endoscopic retrograde cholangiopancreatography. Endoscopy 2010; 42: 957-959
• 91 Birnie GG, Quigley EM, Clements GB. et al. Endoscopic transmission of hepatitis B virus. Gut 1983; 24: 171-174
• 92 Bronowicki JP, Vernard V, Botte C. et al. Patient-to-patient transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997; 337: 237-240
• 93 Ciancio A. Digestive endoscopy is not a major risk factor for transmitting hepatitis C virus. Ann Intern Med 2005; 142: 903-909
• 94 Singh S, Singh R, Kochhar R. et al. Contamination of an endoscope due to Trichosporon beigelli. J Hosp Infect 1989; 14: 49-53
• 95 Fronmeyer L, Bihl P, Schmidt-Wilcke HA. Iatrogene Candidainfektion von Pankreaspseudozsten. Z. Gastroenterol 1991; 29: 392-394
• 96 Lo Passo C, Pernice I, Celeste A. et al. Transmission of Trichosporon asahii oesophagitis by a contaminated endoscope. Mycoses 2001; 44: 13-21
• 97 Griffiths PA, Babb JR, Bradley CR. Glutaraldehyde resistant Mycobacterium chelonae from endoscope washer disinfectors. J Appl Microbiol 1997; 82: 519-526
• 98 Muscarella LF. Evaluation of the risk of transmission of bacterial biofilms and Clostridium difficile during gastrointestinal endoscopy. Gastroenterol Nurs 2010; 33: 28-35
• 99 Selinger CP, Greer S, Sutton CJ. Is gastrointestinal endoscopy a risk factor for Clostridium difficile associated diarrhea?. Am J Infect Control 2010; 38: 581-582
• 100 Kampf G, Bloss R, Martiny H. Surface fixation of dried blood by glutaraldehyde and peracetic acid. J Hosp Infect 2004; 57: 139-143
• 101 Strodtholz I, Kamer M, Tschoerner M. Reiniger zur Vorbehandlung flexibler Endoskope. Endo-Praxis 2013; 29: 90-92
• 102 Pineau L, De Phillippe E. Evaluation of endoscope cleanliness after reprocessing: a clinical-use study. Zentralsterilisation – Central Service 2013; 21: 15-27
• 103 Büttgen S, Gebel J, Hornei B. et al. Comparison of chemo resistance of Clostridium difficile ribotype 027 spores and Bacillus subtilis spores against disinfectants. Hyg Med 2008; 33: 513-517
• 104 Rideout K, Teschke K, Dimich-Ward H. et al. Considering risks to healthcare workers from glutaraldehyde alternatives in high-level disinfection. J Hosp Infect 2005; 59: 4-11
• 105 Wen SunH, Feigal RJ, Meser HH. Cytoxicity of glutaraldehyde and formaldehyde in relation to time of exposure and concentration. Pediatr Dent 1990; 12: 303-307
• 106 Cowan RE, Manning AP, Ayliffe GAJ. et al. Aldehyde disinfectants and health in endoscopy units. British Society of Gastroenterology Endoscopy Committee. Gut 1993; 34: 1641-1645
• 107 Van Drongelen AW, de Bruijn ACP, Janssen PJCM. et al. Aldehyde residues on endoscopes – practical values and allowable limits. Hyg Med 2006; 31: 453-456
• 108 Emmrich M, Bloss R, Martiny H. Glutaraldehyde (GA) residues in flexible endoscopes Part II: Analytical method and factors for detection of GA residues. Zentralsterilisation - Central Service 2014; 22: 84-87
• 109 Biering H. The impact of disinfectant substances on residue formation on the surfaces of flexible endoscopes. Zentralsterilisation - Central Service 2014; 22: 99-101
• 110 Medicine and Healthcare product Regulatory Agency (MHRA). Cidex OPA ortho-phthalaldehyde high level disinfectant solution. MDA/2004/022. Available at: https://mhra.filecamp.com/public/file/29fq-loq9kim0 [Accessed 13 Oct 2018]
• 111 Tucker RC, Lestini BJ, Marchant RE. Surface analysis of clinically used expanded PTFE endoscopic tubing treated by the STERIS process. ASAIO J 1996; 42: 306-313
• 112 Meyer B. Cleaning efficacy of peracetic acid based disinfectants for medical instruments. Hyg Med 2004; 29: 110-112
• 113 Becker B, Brill FHH, Todt D. et al. Virucidal efficacy of peracetic acid for instrument disinfection. Antimicrob Resist Infect Control 2017; 6: 114