Although the potential for infections to be transmitted between patients due to inadequately reprocessed duodenoscopes was initially identified >30 years ago,1 several recent fatal outbreaks of carbapenem-resistant Enterobacteriaceae associated with duodenoscope-transmission have brought this issue worldwide attention.2-4 To date, up to 350 patients at 41 facilities may have acquired infections from contaminated duodenoscopes since 2010.5 Unlike previous instances of endoscope-related transmission of infections, no significant breaches in manufacturer-recommended reprocessing protocols were identified at the affected sites when reviewed by the Centers for Disease Control and Prevention and the device manufacturers.