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Cuffaro F, Dahm G, Marson C, Berlemont P, Yegles M, Allar C, Fauchet L, Creta M, Schneider S. Contamination of a drug consumption room with drugs and potential risks for social health care workers. Harm Reduct J 2024; 21:149. [PMID: 39148047 PMCID: PMC11328477 DOI: 10.1186/s12954-024-01074-y] [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] [Received: 02/22/2024] [Accepted: 08/08/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Studies have shown that contamination of surfaces by illicit drugs frequently occurs in forensic laboratories when manipulating seized samples as well as in pharmacies and hospitals when preparing medicinal drugs. In this project, we extended these studies to a Drug Consumption Room to investigate drug levels and possible exposure of the staff members. METHODS We investigated pre and post cleaning contamination by heroin and cocaine and their degradation products 6-monoacetylmorphine and benzoylecgonine on different surfaces (tables, counters, computers and door handles) and in the ambient air. We also collected urine and hair samples from staff members to check for potential short and long term contaminations. RESULTS Medium to heavy contamination has been detected on most surfaces and door handles; as expected, air contamination was particularly high in the smoking room. Drug levels were < LOD to very low in the urine and the hair samples of staff members tested. CONCLUSION The cleaning efficiency of the surfaces, carried out by staff and drug users after drug consumption, was often not satisfactory. The very low drug levels in hair indicate that acute health risks for staff members are low.
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Affiliation(s)
- Flore Cuffaro
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
| | - Georges Dahm
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
| | - Claude Marson
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
| | - Patrick Berlemont
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
| | - Michel Yegles
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
| | - Claudia Allar
- , Abrigado, 8, Route de Thionville, L-2610, Luxembourg
| | | | - Matteo Creta
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
| | - Serge Schneider
- Laboratoire national de santé, 1, rue Louis Rech, Dudelange, L-3555, Luxembourg
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2
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Brechtelsbauer E. Identification and reduction of hazardous drug surface contamination through the use of a novel closed-system transfer device coupled with a point-of-care hazardous drug detection system. Am J Health Syst Pharm 2023; 80:435-444. [PMID: 36370411 DOI: 10.1093/ajhp/zxac336] [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: 11/10/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Minimizing hazardous drug (HD) contamination is critical for protecting the health of healthcare workers (HCWs) and patients. Alarmingly, widespread HD contamination has been documented across a variety of clinical settings. Quantitative wipe sampling presents significant time and cost barriers, resulting in routine monitoring adherence rates around 25%. Closed-system drug transfer devices (CSTDs) and qualitative point-of-care tests can be implemented to overcome these barriers. METHODS In this study, we tested the effects of the BD PhaSeal Optima (Becton, Dickinson and Company), a recently introduced CSTD, on HD contamination at 2 chemotherapy infusion centers. Wipe samples were taken at 29 workstations at each location prior to and a year following CSTD implementation. Additionally, traditional liquid chromatography with mass spectrometry (LCMS/MS) analyses were compared against a novel lateral flow immunoassay HD testing device (BD HD Check; Becton, Dickinson and Company) to determine the validity of the qualitative assay. RESULTS We found a 46% reduction in HD contamination after incorporating the CSTD into clinical workflows. Across time points and sites, HD contamination reported by the BD HD Check device was 91% accurate against LCMS/MS and 98% accurate within its limits of detection. CONCLUSION Collectively, the evaluated CSTD and lateral flow immunoassay device may help to reduce HD contamination and provide real-time measures of contamination, respectively. As part of a multifaceted approach, these devices may help minimize barriers to routine monitoring, ultimately improving the safety of HCWs and patients.
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3
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Saint-Lorant G, Vasseur M, Allorge D, Beauval N, Simon N, Odou P. Four-year follow-up of surface contamination by antineoplastic drugs in a compounding unit. Occup Environ Med 2023; 80:146-153. [PMID: 36717254 DOI: 10.1136/oemed-2022-108623] [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: 08/24/2022] [Accepted: 12/21/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study aimed to monitor the contamination by antineoplastic drugs on work surfaces in a compounding unit 4 years after its implementation. METHODS This descriptive study was done in a unit performing on average 45 000 preparations per year. Surface sampling points (N=23) were monitored monthly in the frame of routine activity from the opening of an anticancer drug compounding unit. Contamination with nine antineoplastic drugs (cyclophosphamide, ifosfamide, dacarbazine, 5-fluorouracil, methotrexate, gemcitabine, cytarabine, irinotecan and doxorubicin) was assessed on wipes with a local liquid chromatography coupled with a tandem mass spectrometer analysis. The contamination rate (CR, %) was prospectively monitored every month during the entire study period. The occurrence of critical incidents was also registered. The effect of each safety measure implemented during this period was also analysed. RESULTS Based on the 1104 samples collected between March 2016 and March 2020, the CR was 18.5%. If three different critical incidents among a vial breakage that occurred were individually considered, this CR was slightly lower than that in the literature. Eight months after opening and taking different corrective actions, the overall CR dropped from 42.39% to 11.52% (p<0.001). Contamination was limited to the area that includes the compounding room and, more precisely, the welder and the QC-Prep+ sampling points. CONCLUSIONS From the beginning of the study and from month to month, surface contamination was limited to the nearest sampling points to the compounding unit. This 4-year monitoring study allowed us to determine the intravenous conventional antineoplastic drugs and sampling points to be focused on.
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Affiliation(s)
- Guillaume Saint-Lorant
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France .,Pharmacy, CHU Caen, Caen, France
| | - Michèle Vasseur
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
| | - Delphine Allorge
- ULR-4483-IMPECS-IMPact de l'Environnement Chimique sur la Santé humaine, University of Lille, Lille, France.,CHRU, Lille, France
| | | | - Nicolas Simon
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
| | - Pascal Odou
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
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4
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Papastergiou J, Smiley T. Evaluation of Current Hazardous Drug Exposure Control in Community Pharmacy. J Pharm Technol 2022; 38:155-158. [PMID: 35600277 PMCID: PMC9116126 DOI: 10.1177/87551225211072743] [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: 11/16/2022] Open
Abstract
Purpose: To evaluate effectiveness of current hazardous drug exposure control practices in community pharmacies through identification of commonly contaminated surfaces. We also assessed the decontamination effectiveness of 5 different cleaning agents. Methods: This study was prospective and nonrandomized and conducted in 2 phases. In phase 1, 15 common areas used in the dispensing process were tested at each of 4 pharmacies in Toronto Ontario, Canada. Testing was conducted using the BD® HD Check System, a rapid, point-of-care, hazardous drug detection system that is able to identify contamination with methotrexate (MTX) and cyclophosphamide (CYP) and doxorubicin. In phase 2, 5 different cleaning agents (70% isopropyl alcohol, Lysol® spray, Ecolab® retail multiquat sanitizer, Ecolab retail multisurface and glass cleaner with peroxide, and Ecolab QSR heavy-duty degreaser) were tested for their ability to eliminate contamination. Results: All 4 pharmacies tested positive for contamination with MTX (25.8% of surfaces). Contamination with CYP was less frequent, with only 3 sites and 18.2% of surfaces testing positive. Of the 5 cleaning agents tested, only Ecolab QSR heavy-duty degreaser was able to eliminate contamination with MTX. None of the agents were successful against CYP. Conclusions: The results illustrate an unacceptable prevalence of hazardous drug contamination in community pharmacy settings. The BD HD Check System can serve to rapidly detect common high-risk areas for surface contamination. Decontamination protocols against MTX may include Ecolab QSR heavy-duty degreaser. Novel agents must be identified to remove contamination caused by CYP.
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Affiliation(s)
- John Papastergiou
- Shoppers Drug Mart, Toronto, ON, Canada
- University of Toronto, Toronto, ON,
Canada
- University of Waterloo School of Pharmacy,
Waterloo, ON, Canada
| | - Tom Smiley
- University of Waterloo School of Pharmacy,
Waterloo, ON, Canada
- Pharmavision Health Consulting Inc., Paris,
ON, Canada
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5
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Eisenberg S. Closed safety system for administration (CSSA): proposal for a new cytotoxic chemotherapy acronym. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S26-S32. [PMID: 35648666 DOI: 10.12968/bjon.2022.31.10.s26] [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
Exposure to cytotoxic chemotherapy can result in acute and chronic conditions including nausea, headaches, rashes, miscarriages, infertility and genetic aberrations. Surface contamination can occur during drug administration, and can subsequently spread throughout the healthcare environment. Dermal contact with contaminated surfaces can lead to drug absorption. Closed system drug-transfer devices (CSTDs) were initially developed to protect pharmacists during compounding. Components include a vial adapter to prevent pressurisation leakage and a syringe connector for transferring the drug to the intravenous infusion bag. Membrane-based CSTDs require a Luer adapter for drug administration whereas Luer system-based products do not. Most European nurses are familiar with needleless connectors. Unfortunately, these devices do not provide protection from chemotherapy exposure. To decrease confusion, CytoPrevent, a multi-national, primarily European organisation has proposed the term 'closed safety system for administration' (CSSA) for Luer based CSTDs. Along with education, the new term can help promote safety for nurses administering cytotoxic chemotherapy.
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Affiliation(s)
- Seth Eisenberg
- Professional Practice Coordinator, Infusion Services, Seattle Cancer Care Alliance, Seattle, Washington USA
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6
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Gerding J, Anhäuser L, Eickmann U, Nienhaus A. A simple approach to assess the cancer risk of occupational exposure to genotoxic drugs in healthcare settings. J Occup Med Toxicol 2022; 17:8. [PMID: 35365163 PMCID: PMC8973544 DOI: 10.1186/s12995-022-00349-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Several drugs for human use possess genotoxic properties as a necessary consequence of their intended therapeutic effect (e.g. antineoplastics). Health workers may be exposed to these chemicals in various occupational settings such as dose preparation and administration. To date, there are no quantitative risk assessment models to estimate the cancer risk of health workers due to the handling of genotoxic drugs. We therefore developed a quantitative risk assessment model to assess the cancer risk of occupational exposure to genotoxic drugs in healthcare settings based on the threshold of toxicological concern (TTC) concept. This model was used to evaluate the cancer risk of health workers due to the handling of genotoxic drugs in modern health care facilities. Methods We modified the threshold of toxicological concern (TTC) concept to fit the purpose of occupational cancer risk assessment. The risk model underlying ICH guideline M7 (R1): “assessment and control of DNA reactive (mutagenic) impurities in pharmaceuticals to limit potential carcinogenic risk” was used as a starting point for our model. We conducted a short review of studies on the occupational exposure of health workers to genotoxic drugs. These occupational exposure data were compared to the acceptable exposure levels resulting from our TTC based risk model. Results Based on the threshold of toxicological concern (TTC) concept, we defined an acceptable daily intake (ADI) of 4 μg/day as threshold of no concern for the exposure of health workers to genotoxic drugs. Regarding the dermal exposure of health workers to genotoxic drugs, we derived a corresponding acceptable surface contamination level (ASCL) of 20 ng/cm2. Both ADI and ASCL are usually not exceeded in modern healthcare settings. Current safety precautions provide sufficient protection to health workers. Conclusions The application of our model indicates that workers in modern healthcare facilities are not at risk of developing work related cancer above widely accepted cancer risk levels due to the occupational exposure to genotoxic drugs. Hence, the present study may assist employers and public authorities to make informed decisions concerning the need for (further) protective measures and during risk communication to health workers.
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Affiliation(s)
- Johannes Gerding
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany.
| | - Lea Anhäuser
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany
| | - Udo Eickmann
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany
| | - Albert Nienhaus
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany.,Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Germany
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7
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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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8
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Eisenberg S, Klein C. Safe Handling of Hazardous Drugs in Home Infusion. JOURNAL OF INFUSION NURSING 2021; 44:137-146. [PMID: 33935248 DOI: 10.1097/nan.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chemotherapy agents used for cancer treatment are considered hazardous drugs (HDs). Guidelines and standards for handling HDs have been in place for several decades to protect oncology nurses working in hospitals and outpatient infusion areas. However, chemotherapy is frequently being administered in home settings, often by infusion nurses who do not necessarily have the requisite knowledge and training. Providing appropriate education for home infusion nurses is key to ensuring they are practicing in a manner that minimizes potential exposure to HDs.
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Affiliation(s)
- Seth Eisenberg
- Infusion Services, Seattle Cancer Care Alliance, Seattle, Washington (Mr Eisenberg); Cancer Treatment Centers of America, Philadelphia, and Community College of Philadelphia, Philadelphia, Pennsylvania (Ms Klein)
- Seth Eisenberg, ASN, RN, OCN®, BMTCN®, has been practicing in the field of oncology since 1983. His experience includes 35 years in blood and marrow transplantation and 21 years in ambulatory oncology infusion. He has published numerous articles on chemotherapy and biotherapy, as well as 6 book chapters (including a chapter for the Joint Commission Resources), and was a contributing author to the Oncology Nursing Society's (ONS') Safe Handling of Hazardous Drugs. He has also coedited the ONS Hematopoietic Stem Cell Transplantation: A Manual for Nursing Practice. Mr Eisenberg has presented nationally and internationally at nursing and pharmacy conferences. He has been the recipient of numerous awards, including the 2017 March of Dimes Research Advancement Award, the 2018 ONS Susan Baird Excellence in Clinical Writing Award, the 2020 Ruth McCorkle Lectureship Award, and, most recently, the 2021 Distinguished Award for Consistent Contribution to Nursing Literature
- Christina Klein, MSN, RN, CRNI®, OCN®, has 31 years' experience across the care continuum working in inpatient medical/surgical and critical care, outpatient infusion, home care infusion, vascular access, clinical education, and adjunct faculty nursing education. She is currently an oncology clinical educator at Cancer Treatment Center of America and adjunct faculty at Community College of Philadelphia. Her roles include educating clinical staff and onboarding new-to-practice and experienced nurses, direct patient care in the oncology outpatient infusion suite, and working with first-year nursing students in the clinical arena. Ms Klein is a member of the Infusion Nurses Certification Corporation RN Examination Council and an editorial reviewer for the Journal of Infusion Nursing
| | - Christina Klein
- Infusion Services, Seattle Cancer Care Alliance, Seattle, Washington (Mr Eisenberg); Cancer Treatment Centers of America, Philadelphia, and Community College of Philadelphia, Philadelphia, Pennsylvania (Ms Klein)
- Seth Eisenberg, ASN, RN, OCN®, BMTCN®, has been practicing in the field of oncology since 1983. His experience includes 35 years in blood and marrow transplantation and 21 years in ambulatory oncology infusion. He has published numerous articles on chemotherapy and biotherapy, as well as 6 book chapters (including a chapter for the Joint Commission Resources), and was a contributing author to the Oncology Nursing Society's (ONS') Safe Handling of Hazardous Drugs. He has also coedited the ONS Hematopoietic Stem Cell Transplantation: A Manual for Nursing Practice. Mr Eisenberg has presented nationally and internationally at nursing and pharmacy conferences. He has been the recipient of numerous awards, including the 2017 March of Dimes Research Advancement Award, the 2018 ONS Susan Baird Excellence in Clinical Writing Award, the 2020 Ruth McCorkle Lectureship Award, and, most recently, the 2021 Distinguished Award for Consistent Contribution to Nursing Literature
- Christina Klein, MSN, RN, CRNI®, OCN®, has 31 years' experience across the care continuum working in inpatient medical/surgical and critical care, outpatient infusion, home care infusion, vascular access, clinical education, and adjunct faculty nursing education. She is currently an oncology clinical educator at Cancer Treatment Center of America and adjunct faculty at Community College of Philadelphia. Her roles include educating clinical staff and onboarding new-to-practice and experienced nurses, direct patient care in the oncology outpatient infusion suite, and working with first-year nursing students in the clinical arena. Ms Klein is a member of the Infusion Nurses Certification Corporation RN Examination Council and an editorial reviewer for the Journal of Infusion Nursing
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Béchet V, Benoist H, Beau F, Divanon F, Lagadu S, Sichel F, Delépée R, Saint-Lorant G. Blood contamination of the pharmaceutical staff by irinotecan and its two major metabolites inside and outside a compounding unit. J Oncol Pharm Pract 2021; 28:777-784. [PMID: 33878975 DOI: 10.1177/10781552211012059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Caregivers in healthcare settings are exposed to a risk of antineoplastic drug contamination which can lead to adverse health effects. Biological monitoring is necessary to estimate the actual level of exposure of these workers. This study was conducted with the aim of assessing blood contamination levels by irinotecan and its metabolites of pharmaceutical staff operating inside and outside a compounding unit. METHODS The study took place within the pharmaceutical unit of a French comprehensive cancer centre. Blood samples were collected from the pharmacy workers operating inside and outside the compounding unit, and analysed by UHPLC-MS/MS. Plasma and red blood cell irinotecan and its metabolites (SN-38; APC) were determined with a validated analytical method detection test. RESULTS A total of 17/78 (21.8%) plasma and red blood cell-based assays were found to be contaminated among staff. Overall, the total number of positive assays was significantly higher for staff members working outside the compounding unit than for workers working inside it (P = 0.022), with respectively 5/42 (11.9%) and 12/36 (33.3%) positive assays. For plasma dosages, the "outside" group had a significantly higher number of positive assays (P = 0.014). For red blood cell-based assays, no significant difference was found (P = 0.309). CONCLUSIONS This study reveals that pharmaceutical staff serving in health care settings are exposed to a risk of antineoplastic drug contamination, not only inside the compounding room but also in adjacent rooms. The results would help to raise awareness and potentially establish protective measures for caregivers working in areas close to the compounding room as well.
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Affiliation(s)
| | - Hubert Benoist
- Department of Pharmacy, CHU de Caen, Caen, France.,UNICAEN, UNIROUEN, ABTE, Comprehensive Cancer Centre F. Baclesse, Normandie University, Caen, France
| | - Frédéric Beau
- Departement of Pharmacy, Comprehensive Cancer Centre F. Baclesse, Caen, France
| | - Fabienne Divanon
- Departement of Pharmacy, Comprehensive Cancer Centre F. Baclesse, Caen, France
| | - Stéphanie Lagadu
- UNICAEN, UNIROUEN, ABTE, Comprehensive Cancer Centre F. Baclesse, Normandie University, Caen, France
| | - F Sichel
- UNICAEN, UNIROUEN, ABTE, Comprehensive Cancer Centre F. Baclesse, Normandie University, Caen, France
| | - Raphael Delépée
- UNICAEN, UNIROUEN, ABTE, Comprehensive Cancer Centre F. Baclesse, Normandie University, Caen, France
| | - Guillaume Saint-Lorant
- Department of Pharmacy, CHU de Caen, Caen, France.,UNICAEN, UNIROUEN, ABTE, Comprehensive Cancer Centre F. Baclesse, Normandie University, Caen, France
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10
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Chabut C, Tanguay C, Gagné S, Caron N, Bussières JF. Surface contamination with nine antineoplastic drugs in 109 canadian centers; 10 years of a monitoring program. J Oncol Pharm Pract 2021; 28:343-352. [PMID: 33567975 DOI: 10.1177/1078155221992103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Healthcare workers exposure to antineoplastic drugs can lead to adverse health effects. Guidelines promote the safe handling of antineoplastic drugs, but no safe exposure limit was determined. Regular surface sampling contributes to ensuring workers safety. METHODS A cross-sectional monitoring is conducted once a year with voluntary Canadian centers, since 2010. Twelve standardized sampling sites were sampled. Samples were analyzed by high performance mass coupled liquid chromatography. The limits of detection (in ng/cm2) were: 0.001 for cyclophosphamide and gemcitabine; 0.3 for docetaxel and ifosfamide; 0.04 for 5-fluorouracil and paclitaxel; 0.003 for irinotecan; 0.002 for methotrexate; 0.01 for vinorelbine. RESULTS The surfaces from 109 centers were sampled between 01/01/2020-18/06/2020. Twenty-six centers delayed their participation because of the COVID-19 pandemic. 1217 samples were analyzed. Surfaces were frequently contaminated with cyclophosphamide (34% positive, 75th percentile 0.00165 ng/cm2) and gemcitabine (16% and <0.001 ng/cm2). The armrest of patient treatment chairs (84% to at least one drug), the front grille inside the biological safety cabinet (BSC) (73%) and the floor in front of the BSC (55%) were frequently contaminated. Centers that prepared ≥5000 antineoplastic drugs annually had higher concentration of cyclophosphamide on their surfaces (p < 0.0001). Contamination measured on the surfaces was reduced from 2010 to 2020. CONCLUSIONS This large-scale study showed reproducible long term follow up of the contamination of standardized sites of Canadian centers and a reduction in surface contamination from 2010 to 2020. Periodic surface sampling help centers meet their continuous improvements goals to reduce exposure as much as possible. The COVID-19 pandemic had a limited impact on the program.
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Affiliation(s)
- Claire Chabut
- Pharmacy Practice Research Unit, Pharmacy Department, CHU Sainte-Justine, Montreal, Canada
| | - Cynthia Tanguay
- Pharmacy Practice Research Unit, Pharmacy Department, CHU Sainte-Justine, Montreal, Canada
| | - Sébastien Gagné
- Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Quebec, Canada
| | - Nicolas Caron
- Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Quebec, Canada
| | - Jean-François Bussières
- Pharmacy Practice Research Unit, Pharmacy Department, CHU Sainte-Justine, Montreal, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, Canada
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11
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Chabut C, Bussières JF. Characteristics of wipe sampling methods for antineoplastic drugs in North America: comparison of six providers. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2020. [DOI: 10.1515/pthp-2020-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Several societies have published guidelines to limit the occupational exposure of workers. Several of these guidelines recommend periodic (once or twice a year) environmental monitoring of specific sites where antineoplastic drugs are prepared and administered. However, most of the guidelines provide no guidance concerning which antineoplastic drugs should be monitored, the preferred sampling sites, appropriate test methods or limits of detection. The aim of this study was to characterize providers that quantify antineoplastic drug measured on surfaces.
Methods
This was a cross-sectional descriptive study. To identify service providers offering environmental monitoring tests, we searched the PubMed database and used the Google search engine. We contacted each service provider by email between June 3rd and June 15th, 2020. We specified the objective of our study and described the information needed and the variables of interest with standardized questions. Additional questions were sent by emails or via teleconferences. No statistical analyses were performed.
Results
We identified six providers offering services to Canadian hospitals, either based in Canada or in the United States. Five of these providers were private companies and one was a public organization. Each service provider was able to measure trace contamination of 3–17 antineoplastic drugs. Five of the providers quantified drugs using ultra performance liquid chromatography coupled with tandem mass spectrometry (UPLC-MSMS), which allowed for lower LODs. The sixth provider offered quantification by immunoassay, which has higher LODs, but offers near real-time results; the surface area to be sampled with this method was also smaller than with UPLC-MSMS. The services offered varied among the service providers. The information about LODs supplied by each provider was often insufficient and the units were not standardized. A cost per drug quantified could not be obtained, because of variability in the scenarios involved (e.g. drug selection to be quantified, number of samples, nondisclosure of ancillary costs). Four of the six service providers were unable to report LOQ values.
Conclusions
Few data are available from Canadian service providers concerning the characteristics of wipe sampling methods for antineoplastics. This study identified six north-American providers. Their characteristics were very heterogeneous. Criteria to consider when choosing a provider include the validation of their analytical method, a low limit of detection, the choice of drugs to be quantified and the sites to be sampled, obtaining details about the method and understanding its limits, and price. This should be part of a structured multidisciplinary approach in each center.
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Affiliation(s)
- Claire Chabut
- Centre Hospitalier Universitaire Sainte-Justine , 3175 Chemin de la Côte-Sainte-Catherine , Montreal , QC , Canada
| | - Jean-François Bussières
- Centre Hospitalier Universitaire Sainte-Justine , 3175 Chemin de la Côte-Sainte-Catherine , Montreal , QC , Canada
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12
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Claraz P, Riff I, Vert C, Wolff E, Perriat S, Grand A, Cretu Y, Hennebelle I, Canonge JM, Puisset F. Assessment of efficacy of postinfusion tubing flushing in reducing risk of cytotoxic contamination. Am J Health Syst Pharm 2020; 77:1866-1873. [PMID: 33124655 DOI: 10.1093/ajhp/zxaa357] [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: 11/14/2022] Open
Abstract
PURPOSE Infusion of cytotoxic drugs carries the risk of occupational exposure of healthcare workers. Since disconnecting an infusion line is a source of contamination, flushing of tubing after infusion of cytotoxic agents is recommended, but the optimal volume of rinsing solution is unknown. The objective of this study was to assess whether postinfusion line flushing completely eliminates cytotoxics. METHODS Infusions were simulated with 3 cytotoxics (gemcitabine, cytarabine, and paclitaxel) diluted in 5% dextrose injection or 0.9% sodium chloride injection in 250-mL infusion bags. Infusion lines were flushed using 5% dextrose injection or 0.9% sodium chloride solution at 2 different flow rates. The remaining concentration of cytotoxics in the infusion line was measured by a validated high-performance liquid chromatography (HPLC) method after passage of every 10 mL of flushing volume until a total of 100 mL had been flushed through. RESULTS All cytotoxics remained detectable even after line flushing with 80 mL of flushing solution (a volume 3-fold greater than the dead space volume within the infusion set). Gemcitabine and cytarabine were still quantifiable via HPLC even after flushing with 100 mL of solution. Efficacy of flushing was influenced by the lipophilicity of drugs but not by either the flushing solvent used or the flushing flow rate. After 2-fold dead space volume flushing, the estimated amount of drug remaining in the infusion set was within 0.19% to 0.56% of the prescribed dose for all 3 cytotoxics evaluated. CONCLUSION Complete elimination of cytotoxics from an infusion line is an unrealistic objective. Two-fold dead space volume flushing could be considered optimal in terms of administered dose but not from an environmental contamination point of view. Even when flushed, the infusion set should still be considered a source of cytotoxic contamination.
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Affiliation(s)
- Pauline Claraz
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, Institut Claudius Regaud, Toulouse, France
| | - Isabelle Riff
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, CHU de Toulouse, Toulouse, France
| | - Charlotte Vert
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, CHU de Toulouse, Toulouse, France
| | - Elina Wolff
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, Institut Claudius Regaud, Toulouse, France
| | - Sophie Perriat
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, CHU de Toulouse, Toulouse, France
| | - Anaïs Grand
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, CHU de Toulouse, Toulouse, France
| | - Yann Cretu
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, CHU de Toulouse, Toulouse, France
| | - Isabelle Hennebelle
- Risk Management Unit, Institut Universitaire du Cancer (IUCT) Oncopole, Institut Claudius Regaud, Toulouse, France
| | - Jean-Marie Canonge
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, CHU de Toulouse, Toulouse, France
| | - Florent Puisset
- Department of Pharmacy, Institut Universitaire du Cancer (IUCT) Oncopole, Institut Claudius Regaud, Toulouse, France, and Centre de Recherches en Cancérologie de Toulouse (CRCT), Team 14, INSERM UMR1037, Université de Toulouse, Toulouse, France
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Walton A, Bush M, Douglas C, Allen D, Polovich M, Spasojevic I. Surface Contamination With Antineoplastic Drugs on Two Inpatient Oncology Units. Oncol Nurs Forum 2020; 47:263-272. [DOI: 10.1188/20.onf.263-272] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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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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