Transmission of Salmonella enteritidis after endoscopic retrograde cholangiopancreatography because of inadequate endoscope decontamination.

We report a historic nosocomial outbreak of Salmonella enteritidis affecting 4 inpatients who underwent endoscopic retrograde cholangiopancreatography. The cause was attributed to inadequate decontamination of an on-loan endoscope used over a weekend. This report highlights the risks of using on-loan endoscopes, particularly regarding their commissioning and adherence to disinfection protocols.