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E Silva LS, Machado CDSB, Linden R, Antunes MV, da Silva LC, Wayhs CAY, Capp E, Ness SLR. Residual contamination in antineoplastic drug packaging. J Oncol Pharm Pract 2023; 29:1862-1867. [PMID: 36659825 DOI: 10.1177/10781552231151693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The handling of antineoplastic drugs should follow strict supervision and safety rules to minimize the occupational exposure risks to professionals involved. The external surface contamination of drug vials is recognized as a health risk. So, our goal was to determine if there is residual contamination on the vials and containers surface of the antineoplastic drugs doxorubicin (DOX) and cyclophosphamide (CP). METHODS A cross-sectional study was conducted. Samples were collected using a uniform sampling procedure on the inner surfaces of the packages/boxes and the outer surfaces of the vials. The analyzes were executed by high-performance liquid chromatography/mass spectrometry (UHPLC-MS/MS). RESULTS A total of 209 samples were analyzed, 66 of CP and 143 of DOX. CP levels were detected in nine samples (13.63%), three were below the lower limit of quantification (LLQ) and the other six had contamination levels ranging from 1.24 to 28.04 ng/filter. DOX levels were detected in 36 samples (25.17%), two were below the LLQ and the others had levels between 1.32 and 664.84 ng/filter. The majority of samples with residual contamination were in vials (80.0%), however, boxes also showed contamination. CONCLUSIONS The results revealed the presence of residual contamination in the vials and packages of CP and DOX drugs. Although the residues found in each sample are small, special care should be taken in the handling and disposal of the antineoplastic drugs. The use of personal protective equipment is fundamental while handling the vials and packaging of cytotoxic drugs.
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Affiliation(s)
- Luciana Stein E Silva
- Post Graduate Program in Health Sciences: Gynecology and Obstetrics, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cibele da Silva Barbosa Machado
- Post Graduate Program in Health Sciences: Gynecology and Obstetrics, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rafael Linden
- Analytical Toxicology Laboratory, Feevale University, Novo Hamburgo, RS, Brazil
| | | | - Laura Cé da Silva
- Analytical Toxicology Laboratory, Feevale University, Novo Hamburgo, RS, Brazil
- Graduate Program in Toxicology and Toxicological Analysis, Feevale University, Novo Hamburgo, RS, Brazil
| | - Carlos Alberto Yasin Wayhs
- Center for Intravenous Drug Preparation, Department of Pharmacy, Hospital de Clínicas Porto Alegre, Porto Alegre, RS, Brazil
| | - Edison Capp
- Post Graduate Program in Health Sciences: Gynecology and Obstetrics, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Department of Gynecology and Obstetrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Sandro Luís Ribeiro Ness
- Center for Intravenous Drug Preparation, Department of Pharmacy, Hospital de Clínicas Porto Alegre, Porto Alegre, RS, Brazil
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2
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Vo N, Desmaris R, Brandely-Piat ML, Vasseur M, Rieutord A, Aboudagga H. [Robotic production of injectable anticancer drugs in hospital pharmacies]. Bull Cancer 2023:S0007-4551(23)00152-2. [PMID: 37105854 DOI: 10.1016/j.bulcan.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Following the 2005 decree on securing the medicine supply chain, the production of "chemotherapies", anticancer drugs (cytotoxic, cytostatic, immunotherapy), was centralised within hospital pharmacies. To cope with increasingly growing activities, pharmacies are moving towards robotisation. This work offers feedback from four French sites pioneers in robotic production. MATERIAL AND METHOD A review of the literature was carried out on the PubMed and Google Scholar scientific databases and GERPAC publications relating to the robotic production of chemotherapy preparations. This review allowed to select 25 articles. RESULTS The robotisation of the production of "chemotherapies" requires infrastructural prerequisites, a reengineering of the manufacturing process and the patient journey. This impacts all the parties involved in this complex process. The "cobotisation" concept or collaborative robotics must be anticipated by the teams. Robotisation is an institutional decision, which must be owned by the pharmaceutical team and endorsed by the medical team and management. DISCUSSION/CONCLUSION For reasons of optimisation, safeguarding and management of human resources, a large number of centres get equipped with robotic systems. Robotic preparation should extend to other non-hazardous preparation, as it is already the case in other countries. This strategic view should be carried out today to anticipate problems, ensure safety and improve the healthcare quality.
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Affiliation(s)
- Ngoc Vo
- Gustave-Roussy, Département de pharmacie clinique, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Romain Desmaris
- Institut Curie, département de pharmacie clinique, 8, rue Thuillier, 75005 Paris, France
| | - Marie-Laure Brandely-Piat
- Service pharmacie, groupe hospitalier Paris centre, Site Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Michèle Vasseur
- Pharmacie centrale, centre hospitalier universitaire de Lille, rue Philippe-Marache, 59037 Lille cedex, France
| | - André Rieutord
- Gustave-Roussy, Département de pharmacie clinique, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - Hail Aboudagga
- Gustave-Roussy, Département de pharmacie clinique, 114, rue Edouard-Vaillant, 94805 Villejuif, France.
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3
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Quartucci C, Rooney JPK, Nowak D, Rakete S. Evaluation of long-term data on surface contamination by antineoplastic drugs in pharmacies. Int Arch Occup Environ Health 2023; 96:675-683. [PMID: 36877242 DOI: 10.1007/s00420-023-01963-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/21/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The handling of antineoplastic drugs represents an occupational health risk for employees in pharmacies. To minimize exposure and to evaluate cleaning efficacy, wipe sampling was used to analyze antineoplastic drugs on surfaces. In 2009, guidance values were suggested to facilitate the interpretation of results, leading to a decrease in surface contamination. The goal of this follow-up was to evaluate the time trend of surface contamination, to identify critical antineoplastic drugs and sampling locations and to reassess guidance values. METHODS Platinum, 5-fluorouracil, cyclophosphamide, ifosfamide, gemcitabine, methotrexate, docetaxel and paclitaxel were analyzed in more than 17,000 wipe samples from 2000 to 2021. Statistical analysis was performed to describe and interpret the data. RESULTS Surface contaminations were generally relatively low. The median concentration for most antineoplastic drugs was below the limit of detection except for platinum (0.3 pg/cm2). Only platinum and 5-fluorouracil showed decreasing levels over time. Most exceedances of guidance values were observed for platinum (26.9%), cyclophosphamide (18.5%) and gemcitabine (16.6%). The most affected wipe sampling locations were isolators (24.4%), storage areas (17.6%) and laminar flow hoods (16.6%). However, areas with no direct contact to antineoplastic drugs were also frequently contaminated (8.9%). CONCLUSION Overall, the surface contaminations with antineoplastic drugs continue to decrease or were generally at a low level. Therefore, we adjusted guidance values according to the available data. The identification of critical sampling locations may help pharmacies to further improve cleaning procedure and reduce the risk of occupational exposure to antineoplastic drugs.
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Affiliation(s)
- Caroline Quartucci
- Bavarian Health and Food Safety Authority, Institute for Occupational Health and Product Safety, Environmental Health, Munich, Germany.,Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
| | - James P K Rooney
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany.,Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Dennis Nowak
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Rakete
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany.
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4
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Charlier B, Coglianese A, De Rosa F, Cozzolino A, Boccia G, Borrelli A, Capunzo M, Genovese G, De Caro F, Filippelli A, Dal Piaz F, Izzo V. A LC-MS/MS based methodology for the environmental monitoring of healthcare settings contaminated with antineoplastic agents. J Public Health Res 2023; 12:22799036231160629. [PMID: 36923326 PMCID: PMC10009035 DOI: 10.1177/22799036231160629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/13/2023] Open
Abstract
Background Adverse health events associated with the exposure of healthcare workers to antineoplastic drugs are well documented in literature and are often related to the chemical contamination of work surfaces. It is therefore crucial for healthcare professionals to validate the efficiency of safety procedures by periodic biological and environmental monitoring activities where the main methodological limitations are related to the complexity, in terms of chemical-physical features and chemical-biological stability, of the drugs analyzed. Materials and methods Here we describe the evaluation and application of a UHPLC-MS/MS based protocol for the environmental monitoring of hospital working areas potentially contaminated with methotrexate, iphosphamide, cyclophosphamide, doxorubicin, irinotecan, and paclitaxel. This methodology was used to evaluate working areas devoted to the preparation of chemotherapeutics and combination regimens at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" in Salerno (Italy). Results Our analyses allowed to uncover critical aspects in both working protocols and workspace organization, which highlighted, among others, cyclophosphamide and iphosphamide contamination. Suitable adjustments adopted after our environmental monitoring campaign significantly reduced the exposure risk for healthcare workers employed in the unit analyzed. Conclusion The use of sensitive analytical approaches such as LC-MS/MS coupled to an accurate wiping procedure in routine environmental monitoring allows to effectively improve chemical safety for exposed workers.
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Affiliation(s)
- Bruno Charlier
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy.,Graduate School in Clinical Pharmacology and Toxicology, University of Salerno, Baronissi, Campania, Italy
| | - Albino Coglianese
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,Graduate School in Clinical Pathology and Clinical Biochemistry, University of Salerno, Baronissi, Campania, Italy
| | - Federica De Rosa
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,Graduate School in Clinical Pharmacology and Toxicology, University of Salerno, Baronissi, Campania, Italy
| | - Armando Cozzolino
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,Graduate School in Clinical Pharmacology and Toxicology, University of Salerno, Baronissi, Campania, Italy
| | - Giovanni Boccia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
| | - Anna Borrelli
- Medical School and Hospital "Secondo Policlinico," University Federico II of Naples, Italy
| | - Mario Capunzo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
| | - Giovanni Genovese
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
| | - Francesco De Caro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
| | - Viviana Izzo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana," University of Salerno, Baronissi, Campania, Italy.,University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno (SA), Italy
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Kadlcikova D, Musilova P, Hradska H, Vozdova M, Petrovova M, Svoboda M, Rubes J. Chromosomal damage in occupationally exposed health professionals assessed by two cytogenetic methods. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2022; 78:158-169. [PMID: 36073861 DOI: 10.1080/19338244.2022.2118213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The study assessed occupationally induced chromosomal damage in hospital personnel at risk of exposure to antineoplastic drugs and/or low doses of ionizing radiation by two cytogenetic methods. Cultured peripheral blood lymphocytes of eighty-five hospital workers were examined twice over 2 to 3 years by classical chromosomal aberration analysis and fluorescence in situ hybridization. The comparison of the 1st and the 2nd sampling of hospital workers showed a significant increase in chromatid and chromosomal aberrations (all p < .05) examined by classical chromosomal aberration analysis, and in unstable aberrations (all p < .05) detected by fluorescence in situ hybridization. Both cytogenetic methods were able to detect an increase of unstable aberrations in the 2nd sampling. The raised frequency of unstable cytogenetic parameters suggested higher recent exposure to genotoxic agents.
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Affiliation(s)
- Dita Kadlcikova
- Department of Genetics and Reproductive Biotechnologies, Central European Institute of Technology - Veterinary Research Institute, Brno, Czech Republic
| | - Petra Musilova
- Department of Genetics and Reproductive Biotechnologies, Central European Institute of Technology - Veterinary Research Institute, Brno, Czech Republic
| | - Hana Hradska
- Department of Genetics and Reproductive Biotechnologies, Central European Institute of Technology - Veterinary Research Institute, Brno, Czech Republic
| | - Miluse Vozdova
- Department of Genetics and Reproductive Biotechnologies, Central European Institute of Technology - Veterinary Research Institute, Brno, Czech Republic
| | - Marketa Petrovova
- Clinic of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Marek Svoboda
- Clinic of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Jiri Rubes
- Department of Genetics and Reproductive Biotechnologies, Central European Institute of Technology - Veterinary Research Institute, Brno, Czech Republic
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6
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Cotteret C, Secretan PH, Gilles-Afchain L, Rousseau J, Vidal F, Salguero-Hernandez G, Batista J, Valverde V, Guitton J, Cisternino S, Schlatter J. External contamination of antineoplastic drug vials: an occupational risk to consider. Eur J Hosp Pharm 2022; 29:284-286. [PMID: 32978219 PMCID: PMC9660623 DOI: 10.1136/ejhpharm-2020-002440] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/03/2020] [Accepted: 09/15/2020] [Indexed: 11/03/2022] Open
Abstract
Risk management for workers involved in the handling and preparation of cytotoxic drugs is challenging. This study aims to investigate drug contamination of the exterior surfaces of cytotoxic drug vials. Two batches of commercially available cytotoxic drugs in unprotected vials (ifosfamide, etoposide phosphate and cyclophosphamide) and plastic shrink wrap vials (doxorubicin, cytarabine and busulfan) were tested without removing the flip-off cap or the plastic wrap, and without prewashing. The results showed significant trace amounts of cytotoxic drugs on the exterior surfaces in both unprotected (eg, cyclophosphamide, ifosfamide) and protected plastic shrink wrap vials (eg, cytarabine), indicating that the secondary packaging of protected vials does not systematically prevent exposure to the handlers. These results focus on the need for guidelines to prevent cytotoxic vial contamination and safety recommendations for staff in the handling and storage of these vials.
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Affiliation(s)
- Camille Cotteret
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
| | | | | | - Julia Rousseau
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
| | - Fabrice Vidal
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
| | | | - Jonathan Batista
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
| | - Vicky Valverde
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
| | - Jerome Guitton
- Pharmacy, Centre Régional de Lutte Contre le Cancer Centre Léon Bérard, Lyon, France
| | - Salvatore Cisternino
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
- Faculté de Pharmacie, Université Paris Descartes, Inserm UMR-S1144, Paris, France
| | - Joël Schlatter
- Pharmacie clinique, Hôpital universitaire Necker-Enfants Malades, Paris, France
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7
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Acramel A, Blondeel-Gomes S, Matta C, Narayani S, Madar O, Desmaris R, Escalup L, Fouque J. Reporting environmental contamination results to healthcare workers could play a crucial role in decreasing the risk of occupational exposure to antineoplastic drugs. Front Public Health 2022; 10:989977. [PMID: 36091516 PMCID: PMC9452744 DOI: 10.3389/fpubh.2022.989977] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/05/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
- Alexandre Acramel
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France,Université Paris Cité, CiTCoM, UMR8038 CNRS, U1268 Inserm, Paris, France,*Correspondence: Alexandre Acramel
| | - Sandy Blondeel-Gomes
- Département de Radiopharmacologie, Institut Curie, PSL Research University, Paris, France
| | - Carla Matta
- Département d'Oncologie Médicale, Institut Curie, Saint-Cloud, France
| | | | - Olivier Madar
- Département de Radiopharmacologie, Institut Curie, PSL Research University, Paris, France,Département de Radiopharmacologie, Institut Curie, Saint-Cloud, France
| | - Romain Desmaris
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
| | - Laurence Escalup
- Département de Pharmacie, Institut Curie, PSL Research University, Paris, France
| | - Julien Fouque
- Département de Radiopharmacologie, Institut Curie, Saint-Cloud, France
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8
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Yu B, Wang Y, Geng Z, Qu Y, Pan J, Zhai Q. Establishment and validation of analytical methods for 15 hazardous drugs by UPLC-Q/Orbitrap-HRMS. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:686. [PMID: 35845485 PMCID: PMC9279804 DOI: 10.21037/atm-22-2330] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
Background Cytotoxic drug residues in pharmacy intravenous admixture services (PIVAS) have always been a major problem for pharmaceutical workers and the PIVAS environment,which is not only pollutes the PIVAS environment, but also causes serious harm to the life and health of the staff. This study aimed to establish an ultra-high performance liquid chromatography quadrupole orbitrap high resolution mass spectrometry (UPLC-Q/Orbitrap-HRMS) method for the rapid detection and monitor of 15 cytotoxic drugs. Methods UPLC-Q/Orbitrap-HRMS method was used to establish a rapid detection method for 15 cytotoxic drugs such as cytarabine, gemcitabine and so on. The daily precision and accuracy of this method were verified by injecting four concentrations of standard solution on the same day, and the same four concentrations of standard solution were injected within three days respectively to verify the daily precision of this method. The signal-to-noise ratio (SNR) of 10:1 was calculated as the limit of quantity. The mixed standard solution of 15 cytotoxic drugs with concentrations of 0.5, 1, 3, 10, 30, 100, 300, and 1,000 ng/mL was configured and detected by this method for linearity and range.The stability of this method was investigated using a mixture of 15 drugs (15MIX) standard solutions at high concentration (300 ng/mL) and low concentration (10 ng/mL) at room temperature for 12 and 24 hours, respectively. A standard solution of each drug, 15MIX and blank solution were taken to verify the exclusivity of the method. Results The results showed that the method had good specificity, and the intraday precision of all drugs was less than 10% and the intraday precision was less than 15%. At the same time, the standard curve had good linearity, R2 was greater than 0.99, and the limit of quantification of most drugs was about 1 ng/mL. Conclusions In this study, an UPLC-Q/Orbitrap-HRMS method was established for the rapid detection of 15 cytotoxic drugs, providing technical support for the monitoring of cytotoxic drug residues in PIVAS, which is of great significance for environmental contamination mornitoring as well as occupational exposure alert.
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Affiliation(s)
- Bo Yu
- Department of Pharmacy, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Wang
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhou Geng
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuchen Qu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Pan
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing Zhai
- Department of Pharmacy, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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9
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Leso V, Sottani C, Santocono C, Russo F, Grignani E, Iavicoli I. Exposure to Antineoplastic Drugs in Occupational Settings: A Systematic Review of Biological Monitoring Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063737. [PMID: 35329423 PMCID: PMC8952240 DOI: 10.3390/ijerph19063737] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 01/10/2023]
Abstract
The high toxicity of antineoplastic drugs (ADs) makes them dangerous not only for patients, but also for exposed workers. Therefore, the aim of this review was to provide an updated overview of the biological monitoring of occupational AD exposure in order to extrapolate information useful to improve risk assessment and management strategies in workplaces. Several studies demonstrated that remarkable portions of healthcare workers may have traces of these substances or their metabolites in biological fluids, although with some conflicting results. Nurses, directly engaged in AD handling, were the occupational category at higher risk of contamination, although, in some cases, personnel not involved in AD-related tasks also showed quantifiable internal doses. Overall, further research carried out on greater sample sizes appears necessary to gain deeper insight into the variability retrieved in the reported results. This may be important to understand the impact of the extent of ADs use, different handling, procedures, and cleaning practices, spill occurrence, training of the workforce, as well as the adoption of adequate collective and personal protective equipment in affecting the occupational exposure levels. This may support the achievement of the greatest clinical efficiency of such therapies while assuring the health and safety of involved workers.
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Affiliation(s)
- Veruscka Leso
- Department of Public Health, Section of Occupational Medicine, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (V.L.); (C.S.); (F.R.)
| | - Cristina Sottani
- Environmental Research Center, Istituti Clinici Scientifici Maugeri IRCCS, Via Salvatore Maugeri, 10, 27100 Pavia, Italy; (C.S.); (E.G.)
| | - Carolina Santocono
- Department of Public Health, Section of Occupational Medicine, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (V.L.); (C.S.); (F.R.)
| | - Francesco Russo
- Department of Public Health, Section of Occupational Medicine, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (V.L.); (C.S.); (F.R.)
| | - Elena Grignani
- Environmental Research Center, Istituti Clinici Scientifici Maugeri IRCCS, Via Salvatore Maugeri, 10, 27100 Pavia, Italy; (C.S.); (E.G.)
| | - Ivo Iavicoli
- Department of Public Health, Section of Occupational Medicine, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (V.L.); (C.S.); (F.R.)
- Correspondence: ; Tel.: +39-0817462430
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10
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Valero García S, Centelles-Oria M, Palanques-Pastor T, Vila Clérigues N, López-Briz E, Poveda Andrés JL. Analysis of chemical contamination by hazardous drugs with BD HD Check ® system in a tertiary hospital. J Oncol Pharm Pract 2021; 28:1583-1593. [PMID: 34565241 DOI: 10.1177/10781552211038518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The presence of contamination in the healthcare work environment by one of the types of hazardous drugs, cytostatics, has been found in multiple international studies. Recent studies and guidelines recommend surface monitoring for risk assessment of healthcare professionals' exposure. The availability of detection techniques is critical to successfully carry out this type of monitoring. The use of new semi-quantitative techniques allows quicker results. The main objective of this study was to determine the existence of hazardous drugs on the working surfaces in different locations of a tertiary hospital using the BD HD Check® semi-quantitative device. The presence of methotrexate, doxorubicin and cyclophosphamide was analysed at 80, 89 and 82 locations in 10, 13 and 11 clinical units, respectively. A total of 251 samples were analysed. The monitoring results were positive for 13.1% of the analysed samples, with 36.3% of the methotrexate samples, 0% of the doxorubicin samples and 4.9% of the cyclophosphamide samples. Mapping the presence of HD in our hospital has allowed us to evaluate the effectiveness of controls established in the hospital to minimise the exposure of healthcare professionals to hazardous drugs. The speed in obtaining results has enabled immediate corrective actions in cases where contaminated surfaces were detected.
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11
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Portilha-Cunha MF, Ramos S, Silva AMT, Norton P, Alves A, Santos MSF. An Improved LC-MS/MS Method for the Analysis of Thirteen Cytostatics on Workplace Surfaces. Pharmaceuticals (Basel) 2021; 14:ph14080754. [PMID: 34451851 PMCID: PMC8398795 DOI: 10.3390/ph14080754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/27/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Cytostatics are drugs used in cancer treatment, which pose serious risks to healthcare workers. Dermal absorption via surface contamination is the key exposure route; thus, rapid, reliable, and validated analytical methods for multicomponent detection are crucial to identify the exposure risk. A surface-wipe-sampling technique compatible with hospitals' safety requirements (gauze, 1 mL isopropanol) and a fast and simple extraction method (1 mL acetonitrile, 20 min ultrasonic bath, evaporation, reconstitution in 200 µL acetonitrile), coupled with liquid chromatography-tandem mass spectrometry analysis, were developed. It allowed identification and quantification of 13 cytostatics on surfaces: cyclophosphamide, doxorubicin, etoposide, ifosfamide, paclitaxel, bicalutamide, capecitabine, cyproterone, flutamide, imatinib, megestrol, mycophenolate mofetil, prednisone. Good linearity, sensitivity, and precision were achieved (R2 > 0.997, IDLs < 4.0 pg/cm2, average CV 16%, respectively). Accuracy for four model surfaces (melamine-coated wood, phenolic compact, steel 304, steel 316) was acceptable (80 ± 12%), except for capecitabine and doxorubicin. Global uncertainty is below 35% for concentrations above 100 pg/cm2 (except for capecitabine and doxorubicin)-a guidance value for relevant contamination. Method application in a Portuguese university hospital (28 samples) identified the presence of seven cytostatics, at concentrations below 100 pg/cm2, except for three samples. The widespread presence of cyclophosphamide evinces the necessity to review implemented procedures.
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Affiliation(s)
- Maria Francisca Portilha-Cunha
- LEPABE—Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal; (M.F.P.-C.); (A.A.)
| | - Sara Ramos
- Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal;
| | - Adrián M. T. Silva
- Laboratory of Separation and Reaction Engineering—Laboratory of Catalysis and Materials (LSRE–LCM), Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal;
| | - Pedro Norton
- Departamento de Saúde Ocupacional, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal;
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal
| | - Arminda Alves
- LEPABE—Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal; (M.F.P.-C.); (A.A.)
| | - Mónica S. F. Santos
- LEPABE—Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal; (M.F.P.-C.); (A.A.)
- Correspondence: ; Tel.: +351-225084854
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12
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Cytostatics in Indoor Environment: An Update of Analytical Methods. Pharmaceuticals (Basel) 2021; 14:ph14060574. [PMID: 34204005 PMCID: PMC8232629 DOI: 10.3390/ph14060574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022] Open
Abstract
Periodic and adequate environmental monitoring programs are crucial to assess and reduce the occupational exposure of healthcare workers to cytostatics. The analytical methods employed should be rapid, reliable, sensitive, standardized, and include multiple compounds. A critical overview of recent overall procedures for surface and air contamination with cytostatics in workplace settings is presented, with a focus on sampling, sample preparation, and instrumental considerations. Limitations are also addressed and some recommendations and advice are provided. Since dermal absorption is the main exposure route, surface contamination is the preferred indicator of biological uptake and its methods have significantly improved. In contrast, cytostatics’ inhalation is rare; thus, air contamination has been poorly studied, with little improvement. Still, some elements of the analytical methods have not been extensively explored, namely: the amount of wetting solution, the extraction procedure, surface chemistry and roughness, recovery studies from specific surfaces, and cytostatics stability (in surfaces and during shipping and storage). Furthermore, complete validation data (including precision, accuracy, and instrumental and method detection limits) and estimation of global uncertainty are still lacking in most studies, thus preventing method comparison and proposal of standardized procedures.
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13
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Eisenberg S, Ito K, Rodriguez A. Hazardous Drug Contamination: Presence of Bathroom Contamination in an Ambulatory Cancer Center. Clin J Oncol Nurs 2021; 25:151-156. [PMID: 33739338 DOI: 10.1188/21.cjon.151-156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many hazardous drugs (HDs) are excreted in urine and feces, and evidence has shown that bathrooms of patients receiving chemotherapy at home are contaminated with HDs. However, little information exists on bathroom contamination in ambulatory clinics where HDs are administered. OBJECTIVES This project aimed to determine the presence of HD residue in the patient and staff bathrooms of an ambulatory cancer center. METHODS A quality improvement project was initiated to examine potential contamination by the HDs 5-fluorouracil and oxaliplatin in a patient bathroom and a secured badge-access staff bathroom in the infusion department of an ambulatory comprehensive cancer center. Twice-daily wipe testing was conducted on the floor in front of the toilet and the flush handle for five consecutive days. FINDINGS Sixty-five percent of the samples from the floor of the patient bathroom were positive for at least one of the HDs. In the staff bathroom, 35% of the floor samples were positive for at least one HD. None of the flush handle samples were above the level of detection.
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14
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Charlier B, Coglianese A, De Rosa F, De Caro F, Piazza O, Motta O, Borrelli A, Capunzo M, Filippelli A, Izzo V. Chemical risk in hospital settings: Overview on monitoring strategies and international regulatory aspects. J Public Health Res 2021; 10. [PMID: 33849259 PMCID: PMC8018262 DOI: 10.4081/jphr.2021.1993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/17/2021] [Indexed: 01/21/2023] Open
Abstract
Chemical risk in hospital settings is a growing concern that health professionals and supervisory authorities must deal with daily. Exposure to chemical risk is quite different depending on the hospital department involved and might origin from multiple sources, such as the use of sterilizing agents, disinfectants, detergents, solvents, heavy metals, dangerous drugs, and anesthetic gases. Improving prevention procedures and constantly monitoring the presence and level of potentially toxic substances, both in workers (biological monitoring) and in working environments (environmental monitoring), might significantly reduce the risk of exposure and contaminations. The purpose of this article is to present an overview on this subject, which includes the current international regulations, the chemical pollutants to which medical and paramedical personnel are mainly exposed, and the strategies developed to improve safety conditions for all healthcare workers.
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Affiliation(s)
- Bruno Charlier
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
| | - Albino Coglianese
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
| | - Federica De Rosa
- University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno.
| | - Francesco De Caro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
| | - Ornella Piazza
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
| | - Oriana Motta
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi .
| | - Anna Borrelli
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno.
| | - Mario Capunzo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
| | - Viviana Izzo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA).
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15
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Simon N, Odou P, Decaudin B, Bonnabry P, Fleury-Souverain S. Chemical Decontamination of Hazardous Drugs: A Comparison of Solution Performances. Ann Work Expo Health 2021; 64:114-124. [PMID: 31848570 DOI: 10.1093/annweh/wxz093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/15/2019] [Accepted: 11/29/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Over the past 40 years, numerous actions have been undertaken to decrease the contamination of hospital facilities by intravenous conventional antineoplastic drugs (ICADs) such as centralizing compounding in pharmacies, using personal protective equipment, specific compounding, or infusion devices. As recently proposed in the <USP800> monograph, an additional specific decontamination step must be envisaged. A recent literature review analysed and discussed the different solutions tested in terms of decontamination efficacy. This article aims to discuss the performance of these solutions in the framework of aseptic compounding. METHODS The same dataset used in the previous literature review was reanalysed according to other parameters so as to select decontamination solutions: overall decontamination efficiency (EffQ), tested contaminants, and the risks of use in daily practice. RESULTS Using an EffQ threshold of 90% resulted in discarding 26 out of the 59 solutions. Solutions were tested differently: 8 on 1 contaminant, 11 on 2 contaminants, and 14 solutions on between 3 and 11 contaminants. Three risks were identified to help make choices in routine practice: the mutagenicity of degradation products, the safety of operators and facilities, and respect for the aseptic environment. CONCLUSIONS From the results, performance is discussed according to specific situations: a one-time incident or the basic chemical contamination due to daily practice. Accordingly, the decontamination solution selected then required a risk analysis and an evaluation before implementing it in the daily practice of a compounding unit.
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Affiliation(s)
- Nicolas Simon
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Univ. Lille, CHU Lille, EA 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, EA 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Bertrand Decaudin
- Univ. Lille, CHU Lille, EA 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Sandrine Fleury-Souverain
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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16
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Telleria N, García N, Grisaleña J, Algaba N, Bergareche E, Tamés MJ, Cajaraville G. Evaluation of the efficacy of a self-cleaning automated compounding system for the decontamination of cytotoxic drugs. J Oncol Pharm Pract 2020; 27:1343-1353. [PMID: 32854575 PMCID: PMC8438772 DOI: 10.1177/1078155220951866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction Low surface contamination levels of hazardous drugs in compounding areas can be used as indicators of exposure and efficacy of cleaning procedures. We report the efficacy results of the KIRO® Oncology self-cleaning automated compounding system for decontamination of cytotoxic drugs, assessed in an oncology health center using a sanitizing method and an alkaline method. Methods The study was conducted for six-days over a three-week period. A mixture with known levels of 5-fluorouracil, ifosfamide, cyclophosphamide, gemcitabine, etoposide, methotrexate, paclitaxel, docetaxel and carboplatin was added to the KIRO® Oncology’s compounding area surface before each self-cleaning method was used. Contamination levels were determined, with a surface wipe sampling kit, at the end of the self-cleaning process. Results Background surface contamination for quantified levels of cytotoxic drugs during routine use of KIRO® Oncology was below limit of quantification (<LOQ) for all drugs, except for carboplatin, which has a very low LOQ (0.2 ng/sample). The quantified drug levels detected on surface wipe samples after self-cleaning using both methods in the KIRO® Oncology’s compounding area surface sections were all <LOQ when spiking with 1 ng/cm2 (ten times the ‘safe’ reference value), except for carboplatin (alkaline method only), although its levels were still below the ‘safe’ reference value (0.1 ng/cm2). For surface contamination levels when spiking with 100 ng/cm2, both self-cleaning methods had decontamination efficacies >99.8% for all cytotoxic drugs analyzed. Conclusion This study provides evidence on the efficacy of the KIRO® Oncology automatic self-cleaning system for surface area decontamination during the preparation of cytotoxic drugs.
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Affiliation(s)
- Naiara Telleria
- Pharmacy Department, KIRO Grifols S.L., Arrasate, Gipuzkoa, Spain
| | - Nerea García
- Pharmacy Department, KIRO Grifols S.L., Arrasate, Gipuzkoa, Spain
| | - Jaione Grisaleña
- Pharmacy Department, KIRO Grifols S.L., Arrasate, Gipuzkoa, Spain
| | - Naiara Algaba
- Pharmacy Department, KIRO Grifols S.L., Arrasate, Gipuzkoa, Spain
| | - Eider Bergareche
- Pharmacy Department, KIRO Grifols S.L., Arrasate, Gipuzkoa, Spain
| | - María José Tamés
- Hospital Pharmacy Department, Fundación Onkologikoa, Donostia, Gipuzkoa, Spain
| | - Gerardo Cajaraville
- Hospital Pharmacy Department, Fundación Onkologikoa, Donostia, Gipuzkoa, Spain
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17
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Simon N, Odou P, Décaudin B, Bonnabry P, Fleury Souverain S. Occupational exposure to conventional antineoplastic drugs: can it be further limited? Eur J Hosp Pharm 2020; 27:251-252. [PMID: 32839255 DOI: 10.1136/ejhpharm-2019-002165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Nicolas Simon
- Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France .,Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University Hospital of Geneva, University of Lausanne, Geneva, Switzerland
| | - Pascal Odou
- Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Bertrand Décaudin
- Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University Hospital of Geneva, University of Lausanne, Geneva, Switzerland
| | - Sandrine Fleury Souverain
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University Hospital of Geneva, University of Lausanne, Geneva, Switzerland
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18
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Soteriades ES, Economidou SC, Tsivitanidou A, Polyviou P, Lorimer A, Katodritis N, Theophanous-Kitiri S. Environmental assessment of cytotoxic drugs in the Oncology Center of Cyprus. PLoS One 2020; 15:e0216098. [PMID: 32134912 PMCID: PMC7058296 DOI: 10.1371/journal.pone.0216098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 12/27/2019] [Indexed: 11/18/2022] Open
Abstract
Background Cytotoxic drugs constitute an important workplace hazard in the hospital environment. Our aim was to conduct an environmental assessment of hazardous drugs in the Oncology Center of Cyprus. Methods Wipe samples were obtained from 42 workplace areas of the Oncology Center including two pairs of gloves in an initial assessment, while 10 samples were obtained at follow-up 3 years later. Potential contamination with cyclophosphamide (CP), ifosphamide (IF) and 5-fluorouracil (5-FU) and other cytotoxic medications was examined using the GC-MSMS system (CP, IF) and the HPLC system with UV detection (5-FU) method, respectively. Results Wipe sample contamination was detected at 11.9% and 15% in the initial and follow-up assessment, respectively. Both pairs of gloves assessed were free from contamination. The results showed contamination with cyclophosphamide on the work space inside the isolator, on a day-care office phone and on the central pharmacy bench. Ifosphamide was only detected on the floor of a patient’s room. Contamination with 5-fluorouracil was found only on the surface of a prepared IV infusion bag. The levels of contamination in the positive samples ranged from 0.05 to 10.12 ng/cm2. Conclusions The overall percentage of sample contamination at the Oncology Center was very low compared to other centers around the world. In addition, the detected levels of contamination with cytotoxic drugs were relatively low with the exception of the workspace inside the biological safety cabinet. These results in both assessments may reflect the implementation of comprehensive control measures including employee training, technological equipment and effective cleaning procedures.
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Affiliation(s)
- Elpidoforos S. Soteriades
- College of Medicine and Health Sciences, Institute of Public Health, United Arab Emirates University, Al Ain, UAE
- Department of Environmental Health, Environmental and Occupational Medicine and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- * E-mail:
| | | | | | - Petros Polyviou
- Department of Radiology, Bank of Cyprus Oncology Center, Nicosia, Cyprus
| | - Amanda Lorimer
- Department of Nursing, Bank of Cyprus Oncology Center, Nicosia, Cyprus
| | - Nikos Katodritis
- Department of Radiation Oncology, Bank of Cyprus Oncology Center, Nicosia, Cyprus
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19
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Palamini M, Gagné S, Caron N, Bussières JF. Cross-sectional evaluation of surface contamination with 9 antineoplastic drugs in 93 Canadian healthcare centers: 2019 results. J Oncol Pharm Pract 2020; 26:1921-1930. [DOI: 10.1177/1078155220907125] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The primary objective was to describe environmental contamination with National Institute for Occupational Safety and Health Group 1 hazardous drugs in oncology pharmacies and outpatient clinics in Canada in 2019, as part of an annual surveillance project. Methods In each participating center, 12 standardized sites (6 in the oncology pharmacy and 6 in outpatient clinic) were sampled. Each sample was prepared to allow quantification of six antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, gemcitabine, 5-fluorouracil, and irinotecan) by ultra-performance liquid chromatography-tandem mass spectrometry. Samples were also tested for three additional antineoplastic drugs (docetaxel, paclitaxel, and vinorelbine) without quantification. The impact of certain characteristics of the sampling sites was evaluated with a Kolmogorov–Smirnov test for independent samples. Results Ninety-three Canadian centers participated in 2019, with a total of 1045 surfaces sampled. Cyclophosphamide was the drug most often found in the surface samples (32.4% of samples with positive result), followed by gemcitabine (20.3%). The front grille inside the biological safety cabinet (81.5% of samples positive for at least one antineoplastic drug) and the armrest of a treatment chair (75.8%) were the most frequently contaminated surfaces. Centers with more oncology inpatient and outpatient beds, those that prepared more antineoplastic drugs each year, and those that used more cyclophosphamide each year had higher concentrations of cyclophosphamide contamination on the surfaces tested ( p < 0.0001). Conclusion Traces of dangerous drugs were found in oncology pharmacies and oncology outpatient clinics in 93 Canadian hospitals in 2019. However, the quantities measured were very small. Every healthcare worker should consider these work areas to be contaminated and should wear appropriate protective equipment.
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Affiliation(s)
- Marie Palamini
- Unité de Recherche en Pratique Pharmaceutique, Département de pharmacie, CHU Sainte-Justine, Montréal, Canada
| | - Sébastien Gagné
- Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Québec City, Canada
| | - Nicolas Caron
- Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Québec City, Canada
| | - Jean-François Bussières
- Unité de Recherche en Pratique Pharmaceutique, Département de pharmacie, CHU Sainte-Justine, Montréal, Canada
- Faculté de pharmacie, Université de Montréal, Montréal, Canada
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20
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Jureczko M, Kalka J. Cytostatic pharmaceuticals as water contaminants. Eur J Pharmacol 2019; 866:172816. [PMID: 31758938 DOI: 10.1016/j.ejphar.2019.172816] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 11/30/2022]
Abstract
Due to the growing problem of cancer diseases, cytostatic drugs have become a great environmental threat. Their main sources are hospital effluents, household discharge and drug manufacturers. As these compounds are not removed during wastewater treatment with sufficient efficiency, they are found in the surface, ground and drinking water in quantities up to 2.12 × 10-4 mg/l. The current knowledge about their harmful influence on humans does not indicate a significant risk to the health of water consumers, although it points to certain groups of risk (children and lactating women) in particular. In aquatic organisms, anticancer drugs in detected concentrations can cause chronic toxicity and have a detrimental impact on their genetic material. The acute toxicity effect is less likely. The HC5 value calculated by us (the concentration at which 5% of the species is potentially affected) equalling 2.1 × 10-4 mg/l shows that anticancer drugs are real hazardous contaminants for the environment. It indicates that effective elimination of cytostatics from water still requires intensive research.
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Affiliation(s)
- Marcelina Jureczko
- Environmental Biotechnology Department, Faculty of Energy and Environmental Engineering, The Silesian University of Technology, Akademicka 2 Str., 44-100, Gliwice, Poland; The Biotechnology Centre, The Silesian University of Technology, Krzywoustego 8 Str., 44-100, Gliwice, Poland.
| | - Joanna Kalka
- Environmental Biotechnology Department, Faculty of Energy and Environmental Engineering, The Silesian University of Technology, Akademicka 2 Str., 44-100, Gliwice, Poland
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21
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Rossignol E, Amiand MB, Sorrieul J, Bard JM, Bobin-Dubigeon C. A fully validated simple new method for environmental monitoring by surface sampling for cytotoxics. J Pharmacol Toxicol Methods 2019; 101:106652. [PMID: 31734280 DOI: 10.1016/j.vascn.2019.106652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/24/2019] [Accepted: 11/05/2019] [Indexed: 11/19/2022]
Abstract
A wipe sampling procedure followed by a simple ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) method was developed and validated for simultaneous quantification of six cytotoxic drugs: 5-fluorouracil (5FU), doxorubicin (DOXO), epirubicin (EPI), ifosfamide (IF), cyclophosphamide (CP) and gemcitabine (GEM), as surrogate markers for occupational exposure. After a solid-phase extraction of wiping filter on 10 × 10 cm surface, the separation was performed within 6.5 min, using a gradient mobile phase and the analytes were detected by mass spectrometry in the multiple reaction ion monitoring mode. The method was validated according to the recommendations of the US Food and Drug Administration. The method was linear (r2 > 0.9912) between 2.5 and 200 ng per wiping sample (25 to 2000 pg/cm2) for 5FU, doxorubicin and epirubicin and between 0.2 and 40 ng per wiping sample (2 to 400 pg/cm2) for cyclophosphamide, ifosfamide and gemcitabine. The lower limits of quantification were 2.5 ng (25 pg/ cm2) for 5FU, doxorubicin and epirubicin, and 0.2 ng (2 pg/cm2) for CP, IF and GEM. Within-day and between-day imprecisions were <14.0, 10.6, 11.1, 8.7, 11.2 and 10.9% for 5-fluorouracil, doxorubicin, epirubicin, ifosfamide cyclophosphamide and gemcitabine, respectively. The inaccuracies did not exceed 2.7, 10.9, 1.1, 4.5, 1.6 and 2.9% for the studied molecules, respectively. This new sensitive validated method for surface contamination studies of cytotoxics was successfully applied on different localizations in hospital. This approach is particularly suitable to assess occupational exposure risk to cytotoxic drugs.
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Affiliation(s)
- E Rossignol
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France
| | - M B Amiand
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France
| | - J Sorrieul
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France
| | - J M Bard
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France; Université de Nantes Faculté de Pharmacie, EA 2160 MMS, IUML FR3473 CNRS, 1 rue Gaston Veil, 44000 Nantes, France
| | - C Bobin-Dubigeon
- ICO René Gauducheau, Bd J Monod 44805, Nantes, Saint Herblain Cedex, France; Université de Nantes Faculté de Pharmacie, EA 2160 MMS, IUML FR3473 CNRS, 1 rue Gaston Veil, 44000 Nantes, France.
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22
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Hilliquin D, Tanguay C, Gagné S, Caron NJ, Bussières JF. Cross-Sectional Evaluation of Surface Contamination with Antineoplastic Drugs in Canadian Health Care Centres. Can J Hosp Pharm 2019; 72:377-384. [PMID: 31692608 PMCID: PMC6799961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Surfaces in health care centres are often contaminated with traces of antineoplastic drugs. Such contamination should be limited as much as possible, to reduce workers' exposure. OBJECTIVES The primary objective was to monitor environmental contamination with 9 antineoplastic drugs in oncology pharmacy and patient care areas of Canadian health care centres. The secondary objective was to explore the use of sodium hypochlorite as a cleaning agent for cyclophosphamide contamination. METHODS This cross-sectional evaluation was conducted from January to April 2018. Twelve standardized sites were sampled at each participating centre: 6 in the oncology pharmacy and 6 in patient care areas. Six of the antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, gemcitabine, 5-fluorouracil, and irinotecan) were quantified by ultra-performance liquid chromatography - tandem mass spectrometry. For the other 3 antineoplastic drugs (docetaxel, paclitaxel, and vinorelbine), samples were screened for contamination but not quantified. The effect of using sodium hypochlorite as a cleaning agent was evaluated with a Kolmogorov-Smirnov test for independent samples. RESULTS Of 202 Canadian centres invited, 79 participated. A total of 887 surface samples were analyzed, 467 from pharmacy areas and 420 from patient care areas. Cyclophosphamide was the drug most often found as a contaminant (32.2% [286/887] of samples positive, 75th percentile of measured contamination 0.0017 ng/cm2, 90th percentile 0.021 ng/cm2). The front grille inside the hood (80.8% [63/78] of samples positive for at least one antineoplastic drug), treatment chair armrest (78.9% [60/76]), storage shelf in pharmacy (61.5% [48/78]), and floor in front of the hood (60.3% [47/78]) were the most frequently contaminated surfaces. Cleaning with a sodium hypochlorite solution was highly variable. Among centres that reported using sodium hypochlorite to clean armrests on patient chairs, the concentration of cyclophosphamide was lower (0.00866 versus 0.0300 ng/cm2, p = 0.014). CONCLUSIONS Despite growing awareness and implementation of new safe-handling guidelines, surfaces in health care centres were contaminated with traces of many antineoplastic drugs. Providing centres with attainable goals (e.g., 75th to 90th percentile relative to other similar centres) would help in identifying the sampling sites where improvements are needed and in achieving lower surface contamination.
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Affiliation(s)
- Delphine Hilliquin
- , DPharm, is a Research Assistant with the Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, Montréal, Québec. At the time of the study, she was also a student in the DPharm program at Université Angers in Angers, France
| | - Cynthia Tanguay
- , BSc, MSc, is Coordinator with the Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec
| | - Sébastien Gagné
- , MSc, is a Chemist with the Centre de toxicologie du Québec, Institut national de santé publique du Québec, Québec, Quebec
| | - Nicolas J Caron
- , PhD, is a Chemist with the Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Québec, Quebec
| | - Jean-François Bussières
- , BPharm, MSc, MBA, FCSHP, FOPQ, is Head of the Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, and Clinical Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
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Guichard N, Boccard J, Rudaz S, Bonnabry P, Fleury Souverain S. Wipe-sampling procedure optimisation for the determination of 23 antineoplastic drugs used in the hospital pharmacy. Eur J Hosp Pharm 2019; 28:94-99. [PMID: 33608437 DOI: 10.1136/ejhpharm-2019-001983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Optimise a wipe sampling procedure to evaluate the surface contamination for 23 antineoplastic drugs used in the hospital pharmacy. METHODS The influence of various parameters (ie, sampling device, sampling solution, desorption modes) was evaluated using a validated liquid chromatography-mass spectrometry (LC-MS/MS) method able to quantify 23 antineoplastic drugs widely used in the hospital pharmacy: 5-fluorouracil, busulfan, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, docetaxel, doxorubicin, epirubicin, etoposide, etoposide phosphate, fludarabine phosphate, ganciclovir, gemcitabine, idarubicin, ifosfamide, irinotecan, methotrexate, paclitaxel, pemetrexed, raltitrexed, topotecan and vincristine. Best conditions were tested with real samples from a hospital pharmacy chemotherapy compounding unit. RESULTS Polyester swabs (TX714 and TX716) gave satisfactory results for the desorption step for all compounds with mean recoveries of 90% and 95%, respectively. For the wiping step, higher recoveries were obtained using TX716 and isopropanol 75% as wiping solution. As anticipated, most intense contaminations were found close to the chemotherapy production site, on surfaces the most frequently in contact with operators' hands. CONCLUSION Wipe sampling method was successfully developed and applied to real samples to determine surface contamination with 23 antineoplastic agents in trace amounts.
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Affiliation(s)
- Nicolas Guichard
- CYTOXLAB, Geneva University Hospitals, Geneva, Switzerland .,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Pharmacy, Geneva University Hospitals, Geneva, Switzerland
| | - Julien Boccard
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Serge Rudaz
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Pascal Bonnabry
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Pharmacy, Geneva University Hospitals, Geneva, Switzerland
| | - Sandrine Fleury Souverain
- CYTOXLAB, Geneva University Hospitals, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Pharmacy, Geneva University Hospitals, Geneva, Switzerland
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24
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Simon N, Odou P, Decaudin B, Bonnabry P, Fleury-Souverain S. Efficiency of degradation or desorption methods in antineoplastic drug decontamination: A critical review. J Oncol Pharm Pract 2019; 25:929-946. [DOI: 10.1177/1078155219831427] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although considerable efforts have been made over the last 40 years, occupational exposure to antineoplastic drugs is still a daily concern, since eradicating such contamination from workplaces seems unattainable. Considerable data are currently available on the risks associated with their use at work. Hospital facilities are often cleaned with marketed antimicrobials whose chemical decontamination efficacy certainly differs but remains unknown. To keep compounding facilities sterile, alcohol-based solutions are frequently used but with very limited efficiency. It would be particularly useful if a decontamination method could be added to the means already available so that all conventional antineoplastic drug contamination could be removed. Several degradation methods or desorption methods have previously been experimented, with varying success. They have never been compared or discussed in terms either of efficiency or usability. This review aims to analyse and discuss the results of each degradation or decontamination procedure and to compare them. This should facilitate selection of the method to be implemented in daily practice.
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Affiliation(s)
- Nicolas Simon
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
- Univ. Lille, CHU Lille, EA 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, EA 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Bertrand Decaudin
- Univ. Lille, CHU Lille, EA 7365 – GRITA – Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Sandrine Fleury-Souverain
- Pharmacy, Geneva University Hospitals and School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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25
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Abstract
While background studies have been commonplace in many occupational fields for a long time, attempts to understand the chemical background in forensics labs has been largely understudied. Such studies can help define the efficiency of cleaning procedures and the integrity of collected data, which is becoming increasingly important due to improving sensitivity of instrumentation and the prevalence with which potent drugs of abuse, such as the opioids, are being seen. The results from this study provide a snapshot of the drug background levels on surfaces in a laboratory system comprised of a central laboratory and two satellite laboratories. Samples were collected from work surfaces by swiping with meta-aramid wipes, and extracted for analysis by LC/MS/MS, for quantitation, and TD-DART-MS, for non-targeted screening. Surfaces were sampled from within the drug unit (where drug evidence is processed) and the evidence receiving unit (where drug cases are handled) in all laboratories as well as the report writing area, the toxicology unit and the crime scene unit in the central laboratory. Results showed that the background was restricted primarily to the benches, balances, and instrumentation within the drug unit – with approximately an order of magnitude higher concentrations observed on the balances, compared to the benches. Higher levels were also observed in analyst specific surfaces when compared to general use surfaces within the drug unit – which corresponded to where bulk evidence handling was completed. Background in the evidence receiving and report writing sections was minimal. Comparison of the main laboratory to the satellite laboratories showed similarities amongst frequently encountered drugs like cocaine, but noticeable differences in opioids which could be attributed to differences in the make-up of exhibits each laboratory receives. Understanding the background levels of drugs in a forensic laboratory environment is crucial to improving cleaning protocols, helping define detection limits for highly sensitive analyses, and providing additional results to the broader community that has been establishing background levels in other environments.
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Affiliation(s)
- Edward Sisco
- National Institute of Standards and Technology, Gaithersburg, MD 20899, United States
| | - Marcela Najarro
- National Institute of Standards and Technology, Gaithersburg, MD 20899, United States
| | - Amber Burns
- Maryland State Police, Forensic Science Division, Pikesville, MD 21208, United States
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26
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A new approach to assessing occupational exposure to antineoplastic drugs in hospital environments. Arh Hig Rada Toksikol 2018; 69:226-237. [DOI: 10.2478/aiht-2018-69-3125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/01/2018] [Indexed: 11/21/2022] Open
Abstract
Abstract
Cytotoxic antineoplastic drugs (ADs) pose occupational risk and therefore require safe handling practices. We created, optimised, and validated an innovative monitoring protocol for simultaneously assessing 21 ADs in the healthcare environment, and also proposed surface exposure levels (SELs) to facilitate the interpretation of monitoring results, as there are currently no occupational exposure limits for ADs. The environmental AD monitoring data were collected in nine Italian hospitals between 2008 and 2017 and include 74,565 measurements in 4,814 wipe samples. Excellent overall recovery and sensitivity of the analytical methods along with innovative desorption automation make this protocol useful for routine monitoring. AD contamination was found in 3,081 measurements, confirming potential exposure in healthcare workers. Samples taken at the beginning and the end of work shifts, allowed to calculate 75th and 90th percentile values for each ADs both in preparation and administration units and we created a traffic-light colour-coding system to facilitate interpretation of the findings. The introduction of SELs will provide a solid basis for improving occupational safety and focusing on contamination control.
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27
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Izzo V, Charlier B, Bloise E, Pingeon M, Romano M, Finelli A, Vietri A, Conti V, Manzo V, Alfieri M, Filippelli A, Dal Piaz F. A UHPLC-MS/MS-based method for the simultaneous monitoring of eight antiblastic drugs in plasma and urine of exposed healthcare workers. J Pharm Biomed Anal 2018; 154:245-251. [PMID: 29558725 DOI: 10.1016/j.jpba.2018.03.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/26/2018] [Accepted: 03/12/2018] [Indexed: 01/20/2023]
Abstract
Exposure of healthcare workers to anticancer drugs requires the combined action of environmental and biological monitoring to assess the effective level of exposure to these chemicals, to improve awareness and to avoid adverse health effects on this category of workers. Cancer chemotherapeutic drugs show different mechanisms of action due to diverse chemical structures; consequently, they differ in hydrophobicity, pharmacokinetics and pharmacodynamics. Therefore, the appearance, accumulation and elimination of each of these molecules in body fluids and tissues might be extremely variable; this prompts the need for a rapid and versatile analytical protocol for the biological monitoring of possible exposure of workers involved in the manipulation, administration and disposal of cancer chemotherapeutic drugs. In this paper we describe the development, optimization and validation of a UHPLC-MS/MS method for the simultaneous quasi-quantitative analysis of eight widely used antineoplastic drugs, which can be used for the analysis of both urine and blood samples. This methodology was applied to the biological monitoring of healthcare workers exposed to different extents to antiblastic drugs at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" in Salerno (Italy), and allowed to identify two subjects exposed to irinotecan out of a total of fifteen workers analyzed.
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Affiliation(s)
- Viviana Izzo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Bruno Charlier
- Postgraduate School in Hospital Pharmacy, University of Salerno, Fisciano, Salerno, Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Elena Bloise
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Marine Pingeon
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy
| | - Marianna Romano
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy
| | - Antonietta Finelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy
| | - Alfonso Vietri
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy
| | - Valeria Conti
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Valentina Manzo
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy; Postgraduate School in Clinical Pharmacology and Toxicology, University of Salerno, Fisciano, Salerno, Italy
| | - Maria Alfieri
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Salerno, Italy; University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy.
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