8/11/2019 Experts Benzalkonium Chloride_21776.pdf

1/2

Environmental cultures revealed that a canister of cottonballs soaked in aqueous benzalkonium chloride and twomultiple-dose vials of methylprednisolone previously usedby office personnel were contaminated with the epidemicstrain of S. marcescens. The canister may have served as apotential reservoir for contamination of sterile solutions andequipment used for joint injections, of skin at the injectionsite, and of hands of personnel. No further cases occurredafter the use of aqueous benzalkonium chloride wasdiscontinued.

We report here the results of the outbreak investigation,which identified contaminated aqueous benzalkonium

chloride as a possible source.The available evidence suggested that for the eight patientswho developed S. marcescens septic arthritis following jointinjections in January 1982, the canister of Zephiran-soakedcotton balls served as a reservoir for the epidemic strain of S.marcescens.Nakashima A, et al., Epidemic Septic Arthritis Caused by Serratis marcescens and Associated with a Benzalkonium Chloride Antiseptic. Journal of Clinical Microbiology, p1014-1018, June 1987.

Procedures such as catheterization and prolonged antibiotictreatment also tend to predispose a patient to S. marcescens

infections. S. marcescens infections have been transmittedhand-to-hand by hospital personnel, via solutions used formedical procedures and by catheterization or needpuncture.

Cultures were taken from 21 benzalkonium chloride spongepots located in the ICU, surgery rooms, and outpatient clinicareas; 13 were contaminated with S. marcescens. ... All S.marcescens isolates showed multiple resistance to antibiotics.Of the 36 isolates surveyed, 80% (24 of 30) of the catheterisolates and 100% (6 of 6) of the aqueous benzalkoniumchloride isolates were resistant to four or more antibiotics. S.marcescens was not isolated from any of the surface areastested.

In the present study, an environmental surveillance of theICU, surgery rooms, and outpatient clinic areas of thehospital revealed a common source of S. marcescens: aqueousbenzalkonium chloride solutions used in skin antisepsisbefore insertion of i.v. catheters. This finding was confirmedby demonstrating that a single S. marcescens biotype waspresent in most of the i.v. catheters and disinfectantsolutions...the contaminated disinfectant was a reservoir of multiply antibiotic-resistant S. marcescens.

When aqueous benzalkonium chloride becomescontaminated with these organisms, it becomes a potentialsource of infection or transmission within a hospital.

Several nosocomial bacterial infections in humans havebeen attributed to contaminated disinfectants, in particular,to benzaklonium chloride solutions.

Our findings serve as a reminder of the potential hazardsof improper use of disinfectants in a hospital environment,human or veterinary, and particularly, of the hazards of using aqueous benzalkonium chloride solutions stored incontainers with cotton sponges.

FoxJ, et al., Nosocomial Transmissionof Serratiamarcescens ina VeterinaryHospitalDueto Contamination by Benzalkonium Chloride. Journal of Clinical Microbiology, p157-160, Aug 1981.

Multiple-dose medications and reliance on benzalkoniumchloride as a medication preservative provide a mechanismfor nosocomial spread of microorganisms, particularly if infection control procedures are not carefully followed.

Outbreaks of nosocomial infections continue to occurbecause of the improper use of multiple-dose medicationvials and because of reliance on benzalkonium chloride asa medication preservative.

However, benzalkonium chloride works optimally as abacteriostatic agent at a neutral or alkaline pH.

Our results indicate that benzalkonium chloride may notbe an appropriate medication preservative because thisagent did not provide effective bacteriostasis on numerousoccasions.Hamill R, et al., An Outbreak of Burholderia (Formerly Pseudomonas) cepaciaRespiratory Tract Colonization and Infection Associated with Nebulized AlbuterolTherapy. Annals of Internal Medicine, 1995;122(10):762-66.

The isolates resistance to pure benzalkonium chloride wasincreased step-wise to a concentration of 16%. ... Theresults indicate that it is critical that pharmaceuticalsolutions containing benzalkonium chloride as anantimicrobial preservative be formulated withoutextraneous carbon and nitrogen sources or be preservedwith additional antimicrobial agents.

This organism was also isolated from benzalkoniumchloride solutions by Gilardi. That benzalkonium chloridesolutions can support pseudomonas contaminants is wellestablished by the studies of Adair et al.

What the Experts SayBenzalkonium Chloride Antiseptic

continued...

8/11/2019 Experts Benzalkonium Chloride_21776.pdf

2/2

The organism was originally recovered from 0.15% N -alkyldimethyl benzyl ammonium chloride solution thatfunctioned as a cleansing germicidal agent in commercialcatheters.Research Department, Pharmaceuticals Division, CIBA-GEIGY Corp, Summit, New Jersey 07901, Fourteen-Year Survival of Pseudomonas cepacia in a Salts SolutionPreserved with Benzalkonium Chloride. Applied and Environmental Microbiology, p505-510, Mar 1979.

Benzalkonium chloride (BC) continues to be used as anantiseptic and contributes to serious outbreaks of disease.

At that time, a recommendation was made that BC be usedonly for environmental disinfection.

The 4 mycobacteria-positive environmental specimens werelinked to BC preparations: BC-soaked cotton ball samplestaken from examination rooms 1 and 3, a swab sample fromthe metal container of the soaked cotton balls from room 3,and a sample of diluted BC that was obtained via a sterilesyringe from a container of BC-soaked gauze in room 2. Atleast 1 culture-positive sample was obtained from each of the3 examining rooms.From 1955 through 1982, the misuse of BC was associatedwith numerous other outbreaks or pseudooutbreaks of post-injection infection caused by bacterial species. The mostcommon species were aerobic, gram-negative bacilli,including Burkholderia (Pseudomonas) cepacia, Serratiamarcescens, and Enterobacter species.

Our study determined that BC is ineffective against M.abscessus, even when used in accordance with themanufacturers instructions, and infection with this organismis a definite risk when BC is used.

Similar to other quaternary ammonium compounds, thelimited disinfecting property of BC is even more diminishedin the presence of organic material.Tiwari T, et al., Forty Years of Disinfectant Failure: Outbreak of PostinjectionMycobacterium abscessus Infection Caused by Contamination of BenzalkoniumChloride. Clinical Infectious Diseases 2003;36:954-62

S. Enteritidis and S. Virchow became increasingly resistantto ERY, BKC and TLN within 6 days of gradual exposure toincreasingly higher concentrations of these antimicrobialagents.

Other gram-negative bacteria have been shown to alter theirCSH when challenged by BKC, which might be due to thecationic nature of BKC making it more difficult to penetratea hydrophobic bacterial cell wall.Braoudaki M, Hilton A, Mechanisms of resistance in Salmonella enterica adapted toerythromycin, benzalkonium chloride and triclosan. International Journal of Antimicrobial Agents 25 (2005) 31-37.

Benzalkonium chloride is restricted in cosmetics(recommendations or requirements) - use, concentration,or manufacturing restrictions - Use is prohibited andrestricted in Canadian cosmetics.BZK Health Concerns, available atwww.ewg.org/skindeep/ingredient/700674/BENZALKONIUM-CHLORIDE/

Serratia species are responsible for 1.4% of nosocomial

bloodstream infections.In a population-based study of Serratia bacteremia,the 7-day and 6-month mortality rates were 5% and 37%,respectively.Serratia Epidemiology, available at http://emedicine.medscape.com/article/228495-overview

PROFESSIONAL RECOMMENDATIONS

For general patient care, a plain, non-antimicrobial soap isrecommended in any convenient form (bar, leaflets, liquid,powder). Such detergent-based products may contain verylow concentrations of antimicrobial agents that are used aspreservatives to prevent microbial contamination. If barsoaps are used, small bars that can be changed frequentlyand soap racks that promote drainage should be used.

American Journal of Infection Control (AJIC), Vol 23, No 4, pp 262, Aug 1995.

The Food and Drug Administration has categorizedbenzalkonium chloride (BZK) as not generally regarded assafe and effective in antimicrobial soaps.Food and Drug Administration Federal Register, Vol 43, No 4, OTC Topical Antimicrobial Products, Jan 1978.

21776 2012 Sage Products, Inc. 3909 Three Oaks Road, Cary, Illinois, 60013 800-323-2220 www.sageproducts.com