A critical review of the toxicology of glutaraldehyde

Preparation and characterization of dimeric bovine hemoglobin tetramers

Dimeric bovine hemoglobin (Hb) tetramers were prepared by a one-step solid phase adsorption method. Briefly, Hb was absorbed by the solid phase, Q Sepharose Fast Flow media, followed by reaction with the glutaraldehyde and elution procedure. Then, dimeric bovine Hb tetramers were formed and purified from Hb tetramers by anion-exchange chromatography based on Protein-Pak DEAE 8HR. The dimeric Hb tetramer showed a P50 value of 15.9 mm Hg, oxygen transporting efficiency of 14.2%, and Hill coefficient of 1.72. The number of Bohr protons released for dimeric Hb tetramers was 0.59 H/tetramer, which was 39% of that of native bovine Hb. The number of chloride ions released on oxygenation was 0.60/tetramer for dimeric Hb tetramers, which was 46% of that of native bovine Hb.

Cytotoxicity of liquid disinfectants

This study was prompted by toxic responses to disinfecting agents reported in patients after surgical procedures and in sensitized health care personnel. We evaluated the cytotoxicity of seven substances used in the formulation of common liquid chemical disinfectants and sterilants. We found that a standard method based on direct microscopic examination of cell cultures was insensitive and may result in an underestimation of the risk that disinfectants pose to health care personnel or patients who are exposed to these substances. Using independent quantitative tests measuring the integrity of the cellular membrane, metabolic activity, or cell growth, we found that there is a several-hundredfold difference in the relative toxicity of various disinfecting substances. The concentration toxic in 50% of the cell population (TC(50)) that was found for each disinfectant was similar in a variety of cell lines from human, monkey, or mouse origin. Statistical analysis of TC(50)s suggests that liquid disinfecting agents could be classified in three main groups according to their relative toxicity, with: (1) mild (TC(50) > 1 mM, including phenol, hydrogen peroxide, and formaldehyde); (2) moderate (1mM > TC(50) > 0.1 mM, sodium hypochlorite); and (3) severe (TC(50) < 0.1 mM, glutaraldehyde, cupric ascorbate, and peracetic acid) toxicity. These data suggest a vast difference in the potential risk of various disinfectants and sterilants. The data presented in this study should help to define the relative toxic risk of different disinfecting substances to patients and health care personnel and assist in the selection of safer microbicidal formulations.

Symptoms and lung function in health care personnel exposed to glutaraldehyde

BACKGROUND

Glutaraldehyde is widely used as a disinfectant for endoscopic equipment. The aim of this study was to investigate work practices and glutaraldehyde exposure in relation to symptoms and lung function.

METHODS

A questionnaire was administered to 76 nurses. Exposed nurses (n = 38) also completed lung function tests and visual analogue scales before and after a work session in which glutaraldehyde exposure occurred. Disinfection activities were timed and counted, personal exposures established, and control measures documented.

RESULTS

Exposure values above the exposure limit (0.10 ppm) were found for all exposure control methods except for the enclosed washing machine. Skin symptoms were 3.6 times more likely to be reported by exposed workers. None of the other symptoms were significantly associated with glutaraldehyde exposure. There were significant cross-shift reductions in FVC and FEV(1) in the exposed group. No evidence of a dose-response relationship for symptoms or lung function was found.

CONCLUSIONS

Further exposure controls for both glutaraldehyde and gloves are required to improve skin care in glutaraldehyde exposed nurses. Exposure monitoring methods also need review.

Chronic toxicity and oncogenicity study with glutaraldehyde dosed in the drinking water of Fischer 344 rats

Glutaraldehyde (GA) has a wide spectrum of industrial, scientific and biomedical applications. Its potential to produce chronic toxic and/or oncogenic effects was investigated in Fischer 344 rats (100/sex/group) given GA in drinking water for a maximum of 104 weeks. GA concentrations were 0 (control), 50,250 and 1000 ppm, resulting in average daily GA consumptions, respectively, of 0, 4, 17 and 64 mg/kg for males and 0, 6, 25 and 86 mg/kg for females. Interim euthanasia (10/sex/group) was performed at 52 and 78 weeks. Parameters evaluated were clinical signs, body weight, food and water consumption, hematology, serum chemistry, urinalysis, organ weights, gross and microscopic pathology. There were no treatment-related effects on mortality. Absolute body weights and body weight gains of the 250 and 1000 ppm males and females were reduced over the study in a dosage-related manner. Food and water consumption by the 250 and 1000 ppm groups were decreased in a statistically significant dose-related manner over the study, and mean water consumption by the 50 ppm animals was slightly reduced but not with statistical significance. The 250 and 1000 ppm groups had a dose-related decrease in urine volume with increased osmolality, and pH was slightly reduced. Absolute kidney weights were increased in the 250 and 1000 ppm groups at the 52 and 78 week sacrifices, and decreased at 104 weeks. Relative kidney weights were increased at all sacrifice times for the 1000 ppm group, at 52 weeks for the 250 ppm group, and at 72 weeks for the 50 ppm group. The urinalysis and renal weight changes are compatible with a physiological compensatory adaptation to reduced water consumption. Gross and histological evidence for gastric irritation was observed principally in the 1000 ppm rats euthanized at 104 weeks and in animals that died during the study. Bone marrow hyperplasia and renal tubular pigmentation, seen in rats that died and the 104 week euthanasia animals, may have been secondary to a low grade hemolytic anemia in animals with large granular lymphocytic leukemia (LGLL). The only neoplasm that showed a statistically significant increase was LGLL, which occurred at a high incidence in both sexes and all groups, including the controls, for both animals that died and at the 104 week euthanasia. A few instances of LGLL were observed at 78 weeks. The overall incidence of LGLL in the spleen for the 0, 50, 250 and 1000 ppm groups was, respectively, 43, 51, 40 and 46% for males, and 24, 41, 41 and 53% for females. Statistical analyses indicated that the severity of LGLL was associated with the higher dosages of GA in female, but not male, rats. Due to the background and variable incidence of LGLL in the Fischer 344 rat, the finding of a statistical significance only for female rats, and because, there was no clear dose-response relationship, the biological significance of the LGLL findings is unclear. There is the possibility that the significance was a statistical artifact due to the low incidence of LGLL in the female control animals as a result of biological variability within the study. It is also considered to be possible that the chronic dosage of GA in the drinking water resulted in a modification of one or more of the factors responsible for the expression of this common and spontaneously occurring neoplasm in the Fischer 344 rat.

Gas chromatographic determination of glutaraldehyde in the workplace atmosphere after derivatization with 0-(2,3,4,5,6-pentafluorobenzyl)hydroxylamine on a solid-phase microextraction fibre

Glutaraldehyde is used primarily in hospital environments for the disinfection of various instruments (e.g., endoscopes). We describe in this paper the measurement of glutaraldehyde in a hospital environment using solid-phase microextraction. The method includes, prior to sampling, the adsorption of O-(2,3,4,5,6-pentafluorobenzyl)hydroxylamine on to the fibre (with polydimethylsiloxane-divinylbenzene). The fibre is then exposed to air, after which desorption is performed in the GC injection port. This process results in the formation of a stable derivative of the glutaraldehyde that is suitable for chromatographic purposes and detectable with classical detection methods, such as flame ionisation and electron-capture detection. We demonstrate that the procedure of adsorption, thermal desorption and derivatization is robust and reproducible. We were able to detect concentrations of 60 microg/m3 (10 s sampling) or 6 microg/m3 (120 s sampling) by electron-capture detection, and 80 microg/m3 (120 s sampling) by flame ionisation detection. We compared our method to currently existing methods of glutaraldehyde measurement and highlighted several important advantages of the method.

Safety in the histochemistry laboratory

Histochemistry and histopathology laboratories are extremely dangerous workplaces owing to the abundance of chemical hazards that constitute major safety and health concerns. A brief review is presented of some of the hazards to which laboratory personnel are exposed. These include fixatives, solvents, embedding media, dyes and stains, and histochemical substrates. Laboratory staff should be fully informed of the dangers and potential long-term health hazards and take the necessary precautionary measures. Despite the abundance of chemical hazards in the histochemistry laboratory, the overall number of work accidents and injuries remains low.

Toxicological, medical and industrial hygiene aspects of glutaraldehyde with particular reference to its biocidal use in cold sterilization procedures

Aqueous solutions of > or =5% glutaraldehyde (GA) are of moderate acute peroral toxicity and those of < or =2% are of slight toxicity. By single sustained skin contact, aqueous GA solutions of > or =45% are of moderate acute percutaneous toxicity, those of 25% are of slight toxicity and those of </=15% do not present an acute percutaneous hazard. Vapor generated at ambient temperature may cause sensory irritant effects to the eye and respiratory tract, but not acute respiratory tract injury. The 50% decrease in respiratory rate (rd(50)) is 13.86 ppm. A 0.1% solution of GA is not irritating to the eye; the threshold for conjunctival irritation is 0.2% and for corneal injury it is 1.0%. Eye injury is moderate at 2% and severe at > or =5%. Primary skin irritation depends on the duration and contact site, occlusion and solvent. By sustained contact, the threshold for skin irritation is 1%, above which erythema and edema are dose related. With 45% and higher, skin corrosion may occur. There is a low incidence of skin sensitizing reactions, with an eliciting threshold of 0.5% aqueous GA. However, GA is neither phototoxic nor photosensitizing. Subchronic repeated exposure studies by the peroral route show only renal physiological compensatory effects, secondary to reduced water consumption. Repeated skin contact shows only minor skin irritant effects without systemic toxicity. By subchronic vapor exposure, effects are limited to the nasal mucosa at 1.0 ppm, with a no-effect concentration generally at 0.1 ppm. There is no evidence for systemic target organ or tissue toxicity by subchronic repeated exposure by any route. A chronic drinking water study showed an apparent increase, in females only, of large granular cell lymphocytic leukemia but this was not dosage related. This is most likely the result of a modifying effect on the factor(s) responsible for the expression of this commonly occurring rat neoplasm. A chronic (2-year) inhalation toxicity/oncogenicity study showed inflammatory changes in the anterior nasal cavity but no neoplasms or systemic toxicity. In vitro genotoxicity studies--bacterial mutagenicity, forward gene mutation (HGPRT and TK loci), sister chromatid exchange, chromosome aberration, UDS and DNA repair tests--have given variable results, ranging from no effect through to weak positive. In vivo genotoxicity studies--micronucleus, chromosome aberration, dominant lethal and Drosophila tests--generally have shown no activity but one mouse intraperitoneal study showed bone marrow cell chromosome aberrations. Developmental toxicity studies show GA not to be teratogenic, and a two-generation study showed no adverse reproductive effects. Percutaneous pharmacokinetic studies showed low skin penetration, with lowest values measured in vitro in rats and human skin. Overexposure of humans produces typical sensory irritant effects on the eye, skin and respiratory tract. Some reports have described an asthmatic-like reaction by overexposure to GA vapor. In most cases this resembles reactive airways dysfunction syndrome, and the role of immune mechanisms is uncertain. Local mucosal effects may occur if medical instruments or endoscopes are not adequately decontaminated. Protection of individuals from the potential adverse effects of GA exposure requires that there be adequate protection of the skin, eyes and respiratory tract. The airborne concentration of GA vapor should be kept below the recommended safe exposure level (e.g. the threshold limit value) by the use of engineering controls. Those who work with GA should, through a training program, be aware of the properties of GA, its potential adverse effects, how to handle the material safely and how to deal with accidental situations involving GA. If effects develop in exposed workers, the reasons should be determined immediately and corrective methods initiated. (c) 2001 John Wiley & Sons, Ltd.

In vitro evaluation of the genotoxicity of a naturally occurring crosslinking agent (genipin) for biologic tissue fixation

The objective of the present study was to evaluate in vitro, using Chinese hamster ovary (CHO-K1) cells, the genotoxicity of genipin, a naturally occurring crosslinking agent. Glutaraldehyde, the most commonly used crosslinking agent for biologic tissue fixation, was employed as a reference chemical. The selected procedures for this evaluation were the micronucleus (MN) and sister chromatid exchange (SCE) assays with or without the addition of a metabolic activation system (S9 mix). Before starting the genotoxicity assays, the maximum noncytotoxic amounts of glutaraldehyde and genipin were determined using the MTT assay. The results obtained in the MTT assay revealed that the cytotoxicity of genipin was significantly lower than that of glutaraldehyde with or without S9 mix. The frequencies of MN observed in the cases drugged with varying concentrations of glutaraldehyde or genipin were not statistically different from those seen in the negative controls (blank) in the presence or absence of S9 mix. However, it was noted that glutaraldehyde significantly inhibited the cell-cycle progression while the cells drugged with genipin did not result in cell-cycle delay. In the SCE assay, the numbers of SCE per cell observed in the cases drugged with varying concentrations of glutaraldehyde were significantly greater than those found in the negative controls with or without S9 mix. Nevertheless, these numbers were still low compared to the numbers of SCE induced by the strong mutagens used as our positive control substances. This suggests that glutaraldehyde may produce a weakly clastogenic response in CHO-K1 cells. In contrast, the numbers of SCE per cell obtained in the cases drugged with genipin were comparable to those observed in the negative controls in those that were except drugged with the highest dose (50 ppm). This suggests that genipin does not cause clastogenic response in CHO-K1 cells provided its concentration is lower than 50 ppm. In conclusion, as far as cytotoxicity and genotoxicity are concerned, genipin is a promising crosslinking agent for biologic tissue fixation.

Antimicrobial mechanism of action of surfactant lipid preparations in enteric Gram-negative bacilli

Two surfactant lipid preparations (SLPs) were investigated to determine their mechanism of antimicrobial action. 8N8, a water-in-oil emulsion, and W60C, a liposome, both have bactericidal activity against Gram-positive bacteria and non-enteric Gram-negative bacteria. Additionally, W60C is bactericidal for enteric Gram-negative bacilli when suspended in deionized water. Zeta potential measurements suggested that the resistance of Gram-negative bacilli to 8N8 might be caused by ionic repulsion. Addition of 50 micromol 1(-1) ethylene diamine tetra acetic acid in 100 mmol 1(-1) Tris buffer to either SLPs yielded efficient bactericidal activity against Gram-negative bacilli. This appeared to be due to disruption of the outer membrane and the chelation of divalent cations, as the addition of excess calcium inhibited the antimicrobial effect. Electron microscopy studies documented that 8N8 disrupts the bacterial cell wall, lysing the bacteria, while W60C fuses and internalizes within the cell, causing damage without immediate cell lysis. Understanding the mechanisms of action of these biocidal formulations will help to produce improved formulations with broader spectra of activity.

[Respiratory distress in three newborns after mask disinfection with Endosporine. Probable role of glutaraldehyde]

BACKGROUND

Disinfectants for medical devices are uncommonly a cause of iatrogenic adverse effects. Nevertheless, when misused, they can induce severe complications. Three cases of acute respiratory distress in newborns probably induced by glutaraldehyde are reported.

CASE REPORTS

Three children born by Caesarean section between 8 and 19 May 1999 in the same hospital presented acute respiratory distress requiring hospitalization in the neonatal intensive care unit; one child was premature. The clinical appearance, which was initially normal, deteriorated with a respiratory distress in 30 to 60 minutes. Recovery was uneventful in all cases. The diagnosis considered was a hyaline membrane disease. The enquiry conducted after this cluster onset identified, as a main contributing factor, the disinfection procedure recently introduced in the surgical theater.

CONCLUSION

Review of toxicologic data on glutaraldehyde shows this is a highly irritating chemical for the respiratory tract, even at low concentrations. Clinical and radiologic features in these three neonates are compatible with a pulmonary sub-edema on an immature alveolar setting. The hypothesis proposed is that glutaraldehyde, the active ingredient of the biocidal formula used to disinfect the respiratory masks, was massively desorbed from the rubber and foam of which masks are made.

GI endoscopic reprocessing practices in the United States

BACKGROUND

Patient infection from contaminated gastrointestinal (GI) endoscopes can generally be attributed to failure to follow appropriate reprocessing guidelines. Recently, the Food and Drug Administration recommended a 45-minute exposure of GI endoscopes to 2.4% glutaraldehyde solutions heated to 25 degrees C. Simultaneously, the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association, and the Society of Gastroenterology Nurses and Associates endorsed a reprocessing guideline that emphasized manual precleaning and recommended a 20-minute exposure to a 2.4% glutaraldehyde solution at room temperature. Since then, little information has become available regarding actual reprocessing practices in the United States.

METHODS

A previously developed questionnaire regarding endoscopic disinfection practices was mailed to randomly selected members of the ASGE.

RESULTS

The survey was sent to 730 members and 294 responded (40.3%). Appropriate manual cleaning (suctioning detergent through the accessory channel and brushing the channel and valves) is performed by 90.7% of respondents; 69.9% then use automated reprocessors for disinfection or sterilization. Glutaraldehyde is the most widely used chemical disinfectant; 85.3% use glutaraldehyde as one of their primary disinfectants. The most commonly used disinfection time with 2.4% glutaraldehyde is 20 minutes (83.9%) followed by 45 minutes (11.4%). Only 23.8% of users of 2.4% glutaraldehyde heat their solution; 59.6% of centers test disinfectant concentration daily or more frequently; 74.0% sterilize nondisposable forceps before use; 29.2% of centers re-use disposable endoscopic accessories (which are more frequently disinfected rather than sterilized). Twelve respondents reported cases of endoscopic cross infection.

CONCLUSIONS

A significant minority of endoscopy centers still do not completely conform to recent ASGE, American Gastroenterological Association, and the Society of Gastroenterology Nurses and Associates guidelines on disinfection, and they may not be appropriately disinfecting GI endoscopes. Rigid adherence to recommended guidelines is strongly encouraged to ensure patient safety.

Histopathological study in B6C3F1 mice chronically exposed by inhalation to glutaraldehyde

Glutaraldehyde vapors are irritating for the skin, eyes, nose and lungs; respiratory symptoms and headaches have been described among workers exposed to low concentrations of glutaraldehyde far below to 190 ppb. This study was initiated to determine the chronic effects in mice of inhaled glutaraldehyde vapors. B6C3F1 mice were exposed using whole-body inhalation chambers, 6 h/day, 5 days/week, for 52 and 78 weeks to 100 ppb, or to filtered air (controls). In nasal passages at the level of the vestibule, hyperplasia of the squamous epithelium lining of the dorsal wall and lateral aspect of the atrioturbinate was observed in a greater number of exposed females than in controls. Epidermal erosion and ulceration as well as squamous and inflammatory exfoliation were also seen in the nasal lumens. All these changes were dependent on the length of glutaraldehyde exposure. The present data suggest that glutaraldehyde long term exposure only led to changes in nasal passages of female mice but did not induce mortality and/or tumors in nasal passages, in all mice. These results, along with the previous subchronic inhalation study of Gross et al., 1994, demonstrates that in a long term study, chronic glutaraldehyde exposure close to the current threshold limit values induced lesions at the more anterior part of the nasal passages in mice and that they likely result from an irritation mechanism (antero-posterior gradient).

Mutagenic activity of various dentine bonding agents

The potential mutagenicity of bonding agents of the new generation was characterised by employing an in vitro gene mutation assay. Eight different components of three dentine bonding systems (Scotchbond Multi Purpose, Prisma Universal Bond 3 and C&B Metabond) were tested in the Ames test using four different Salmonella strains (TA97a, TA98, TA100 and TA102). The materials were eluted in dimethyl sulphoxide and physiological saline; aliquots of the serially diluted eluates were then used in the standard plate incorporation assay. No mutagenic effects were found with Scotchbond Multi Purpose primer and adhesive, Prisma Universal Bond 3 primer, and C&B Metabond base, powder and activator. However, the glutaraldehyde-containing Prisma Universal Bond 3 adhesive elicited a strong mutagenic effect in S. typhimurium strain TA102. Mutation rates caused by dimethyl sulphoxide eluates as well as physiological saline eluates were about five times higher than solvent control values. A mutagenic effect was also observed with C&B Metabond catalyst, especially in strain TA97a when the material was eluted in physiological saline. Both mutagenic responses were not influenced by a metabolically active microsomal fraction from rat liver. We consider the results observed in the Ames test as a first indication of possible mutagenic activity in higher organisms. Therefore, the materials are currently under further investigation using a quantitative in vitro mammalian cell mutation assay.

Glutaraldehyde colitis following endoscopy: clinical and pathological features and investigation of an outbreak

Although potentially noxious compounds are used routinely to disinfect endoscopes, reports of their inadvertent introduction to the gastrointestinal tract, usually attributed to the retention of disinfectant within endoscope channels, are rare. This case report describes the clinical features of glutaraldehyde-induced colitis and the pathology of the mucosal injury in four patients, in at least one of whom the disinfectant was not retained in the endoscope itself. Within 3 months, three patients experienced severe acute proctocolitis < 6 hours after a sigmoidoscopy showing no abnormalities, performed in a small endoscopy unit. Investigation of the unit's protocols suggested that the most likely cause was retention of 2% glutaraldehyde disinfectant in the endoscope channels, and changes were made to prevent this. When a fourth case occurred 5 months later, the source of the glutaraldehyde was found to be the tubing connecting water bottles to the endoscopes, which was disinfected rigorously but flushed inconsistently between cases. Glutaraldehyde-induced colitis seems similar to ischemic colitis in biopsy specimens and cannot be diagnosed by histological analysis alone. Acute colitis occurring within 24 hours of a colonoscopy showing no abnormalities should be considered iatrogenic and should lead to an investigation of procedures in use for cleaning and disinfecting endoscopic equipment.

Mutagenicity of dentin bonding agents

Aside from the considerable number of reports on the physical and chemical properties of dental bonding agents, information concerning their biologic effects is sparse. Three dentin bonding agents (Prisma Universal Bond, Pertac Universal Bond, and Syntac) and the ingredients methylmethacrylate, 2-hydroxyethyl-methacrylate, and glutaraldehyde were investigated in the Salmonella typhimurium mutagenicity test system using five different bacterial strains (TA97a, TA98, TA100, TA102, and TA104). The materials as well as the ingredients were eluted in both dimethyl sulfoxide and physiologic saline, and serially diluted eluates were used in the plate incorporation test. Pertac Universal Bond and Prisma Universal Bond did not elicit any mutagenic effects in any of the bacterial strains. In contrast, Syntac adhesive showed clear mutagenicity in S. typhimurium strain TA102. Dimethyl sulfoxide eluates, as well as physiologic saline eluates of the Syntac bonding agent, caused numbers of revertants that were about 6 times higher than control values. Reversion rates with other strains were moderately enhanced. Glutaraldehyde, an ingredient of Syntac adhesives, caused mutagenicity in a manner similar to Syntac adhesive eluates. Neither 2-hydroxyethyl-methacrylate nor methylmethacrylate monomer was found to be mutagenic over a broad concentration range.

Nasal and pulmonary toxicity of glutaraldehyde in mice

A concentration-dependent expiratory bradypnea, indicative of sensory irritation, occurred during a 15-min oronasal exposure of mice to glutaraldehyde in the concentration range of 0.7-4.5 ppm. The level of exposure which led to a 50% decrease in the respiratory rate (RD50) was found to be 2.6 ppm. For assessment of nasal toxicity, mice were exposed to glutaraldehyde vapours with concentrations of 2.6, 1.0, 0.3 ppm for periods of 6 h/day over the course of 4, 9 and 14 days and were immediately killed. Recovery was studied with another group of mice exposed to 1.0 ppm for 14 days and sacrificed after 1, 2 and 4 weeks rest time. Control groups were concurrently exposed to clean filtered air. The earliest lesions were observed in the respiratory epithelium of the septum, the naso- and maxilloturbinates, after 4 days of exposure to 0.3 ppm. Severe histopathological changes were still observed 2 weeks after the end of the exposure to 1.0 ppm. No exposure-related histological abnormalities were detected in the trachea and lungs. In conclusion, this experiment demonstrates that repeated exposure to 1/10 RD50 is associated with upper respiratory tract damage in mice, and this value does not seem to be an acceptable concentration limit for occupational exposure.