The hidden danger of hand sanitizer
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The Centers for Disease Control and Prevention recommends that all health care professionals use an ethanol-based hand sanitizer to decontaminate their hands before and after direct contact with patients to prevent infection.1,2 As a result, many psychiatric hospitals use alcohol-based hand sanitizers as a primary infection control measure.
Patient misuse of these products as intoxicants has been reported in prisons, emergency rooms, and medical units.3-7 We report 2 cases of psychiatric inpatients who intentionally ingested alcohol-based hand sanitizers to become intoxicated; there were no permanent toxic effects in either case.
Mr. F, age 52, is diagnosed with polysubstance dependence and bipolar disorder and hospitalized for acute exacerbation of mania characterized by unrestrained buying sprees, racing thoughts, grandiosity, and a persistently irritable mood. On day 3 of admission, he presents as stuporous and disorganized, with a strong odor of alcohol on his breath. He admits drinking an alcohol-based hand sanitizer foaming solution, an empty bottle of which is found in his room. His serum alcohol level is 176 mg/dL; the threshold concentration above which a person is considered legally drunk when operating a motor vehicle is 100 mg/dL. Other laboratory values, including urine toxicology, were negative.
Mr. V, age 47, has schizophrenia, cocaine dependence, and antisocial personality disorder. He is admitted for command auditory hallucinations and a suicide attempt by overdose. On day 6 of hospitalization, staff members find him delirious and confused. Mr. V confesses to drinking an alcohol-based hand sanitizer solution for the past 3 days. His vital signs are stable, and his serum alcohol level is 142 mg/dL.
Hand sanitizer has a much higher alcohol concentration than several common alcoholic drinks Table8,9 Ethyl alcohol, the active ingredient in hand sanitizers, is responsible for the adverse effects seen in our patients; the inactive ingredients—glycerin, propylene glycol, tocopherol acetate, isopropyl myristate, and aminomethyl propanol—generally are recognized as safe by the FDA and the Cosmetic Ingredient Review Expert Panel.10,11 Although hospitals routinely restrict patients’ access to traditional forms of alcohol, hand sanitizer is easily accessible in many facilities. In our cases, having the alcohol-based sanitizer placed throughout the unit and readily available to patients made it easy for at-risk patients to become intoxicated. As suggested by Weiner,7 replacing bottles of hand sanitizer with self-contained, wall-mounted dispensers that are difficult for patients to remove might decrease the likelihood of ingestion.
Alcohol content of hand sanitizers and beverages
Percentage of alcohol by volume
Purell Foaming Hand Sanitizer
62% ethyl alcohol9
Purell Instant Hand Sanitizer
62% ethyl alcohol, 5% isopropanol by volume9
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. The Joint Commission National patient safety goals. http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed December 8 2011.
2. Emadi A, Coberly L. Intoxication of a hospitalized patient with an isopropanol-based hand sanitizer. N Engl J Med. 2007;356(5):530-531.
3. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(12 suppl):S3-S40.
4. Bookstaver PB, Norris LB, Michels JE. Ingestion of hand sanitizer by a hospitalized patient with a history of alcohol abuse. Am J Health Syst Pharm. 2008;65(23):2203-2204.
5. Doyon S, Welsh C. Intoxication of a prison inmate with an ethyl alcohol-based hand sanitizer. N Engl J Med. 2007;356(5):529-530.
6. Thanarajasingam G, Diedrich DA, Mueller PS. Intentional ingestion of ethanol-based hand sanitizer by a hospitalized patient with alcoholism. Mayo Clin Proc. 2007;82(10):1288-1289.
7. Weiner SG. Changing dispensers may prevent intoxication from isopropanol and ethyl alcohol-based hand sanitizers. Ann Emerg Med. 2007;50(4):486.-
8. National Institute on Alcohol Abuse and Alcoholism What’s a “standard” drink? http://rethinkingdrinking.niaaa.nih.gov/WhatCountsDrink/WhatsAStandardDrink.asp. Accessed February 17, 2012.
9. GOJO Industries. Purell instant hand sanitizier. http://www.gojo.com/United-States/Brands/PURELL/MSDS.aspx. Accessed December 8, 2011.
10. U.S. Food and Drug Administration. Generally Recognized as Safe (GRAS) notice inventory. http://www.fda.gov/Food/FoodIngredientsPackaging/GenerallyRecognizedasSafeGRAS/
GRASListings/default.htm. Accessed February 21, 2012.
11. The Cosmetic Ingredient Review Find ingredient reviews and documents. http://www.cir-safety.org/ingredients/glossary/all. Accessed February 21, 2012.