Outbreaks of healthcare associated infections caused by multi-drug resistant bacteria were associated with some endoscopic procedures. Endoscopes, in particular duodenoscopes and bronchoscopes, were pointed as the responsible for such situations, whose analysis revealed the inability of current reprocessing processes to effectively eliminate biological contamination. The combination of new design of duodenoscopes, increased invasiveness and the emergence of Gram negative resistant bacteria, such as carbapenem-resistant Enterobacterales made the perfect storm to these outbreaks. Worldwide market calls and corrective maintenance measures carried out by the manufacturers proved unable to correct the problem and to extinguish the risk of transmission related to the use of these devices.

Reprocessing of endoscopes is a complex process that requires adequate facilities, equipment and human factors. Design of facilities should focus on the possibility of having correct circuits of circulation of clean and contaminated devices. Adequate transport, cleaning, decontamination and storage should be considered in order to maximize safety. Manual or automated reprocessing can be done according to available resources. Teams of healthcare workers involved in the process should be appropriately selected, trained and maintained as constant as possible.

Reprocessing of endoscopes in this complex setting has become a major challenge for patient safety. Several methods are in use for this purpose, aiming the quality of high-level washing and disinfection processes of the endoscopes, namely ATP tests, microbiological studies for both endoscopes, reprocessing machines and validations of reprocessing cycles. In addition, traceability is a major component of endoscopic reprocessing in order to provide epidemiologic links whenever an endoscopic associated infection is suspected or confirmed.

Endoscopic procedures have become more and more aggressive, invading the mucosae and not simply touching them, as it was their primary purpose. The observed evolutions in the endoscopic procedures do contrast with the constancy of the Spaulding classification. According to this classification, these procedures do require higher levels of reprocessing in order to achieve appropriate safety. Given the possibility of incomplete microbiologic decontamination of endoscopes, sterilization can become the golden procedure for the reprocessing of endoscopic equipment, at least for specific devices and procedures. However, several limitations do exist for the implementation of this recommendation, namely related to the endoscopes, turnaround time, sterilization technologies, compatibility, the design of reprocessing units and the economic impact of such change. In this setting, the single-use endoscopes has also emerged as a new possibility to be taken into account.