Correspondence

Intoxication of a Prison Inmate with an Ethyl Alcohol–Based Hand Sanitizer

N Engl J Med 2007; 356:529-530February 1, 2007

Article

To the Editor:

The Maryland Poison Center was called about a 49-year-old, usually calm prison inmate who was described as being “red-eyed,” “loony,” “combative,” and “intoxicated, lecturing everyone about life.” Other inmates and staff reported seeing this prisoner drinking from a gallon container of Purell hand sanitizer over the course of the evening. It was discovered that this sanitizer contains 62% ethanol by weight (more than 70% alcohol by volume). The inmate's blood alcohol level was found to be 335 mg per deciliter. It was later confirmed that he had not consumed any other forms of ethanol or other illicit substances. The patient was treated with fluid repletion and haloperidol, with no complications.

The Centers for Disease Control and Prevention has recommended that before and after having any direct contact with patients, health care workers use an alcohol-based hand sanitizer “if hands are not visibly soiled”1 or wash their hands with an antimicrobial soap and water. The Joint Commission on Accreditation of Healthcare Organizations and the Federal Bureau of Prisons have adopted these recommendations.2,3 As compared with the regular use of soap and water, alcohol-based hand rubs with moisturizer have been associated with a significant reduction in the number of microorganisms on skin; the sanitizers also act quickly and cause less skin irritation.

Alcohol-based hand sanitizers are widely used in the United States as low-viscosity rinses, gels, or foams. They contain 60 to 95% ethanol or isopropanol. Ethanol has greater activity against viruses than does isopropanol, and the ethanol-based formulations are used much more commonly in the United States than are the isopropanol-based formulations, under trade names such as Avagard D, Avant, Nexcare, Prevacare, Germ-X, and Purell. Many of the ethanol-based sanitizers also contain small amounts of polyethylene glycol or isopropanol.

Although the potential fire hazard associated with such cleansers has been addressed through use and storage recommendations,4 there are no similar recommendations for the potential misuse of the cleansers as intoxicants. Given the widespread use and national endorsement of these products in the United States, health care providers and administrators in hospitals and correctional facilities should be aware of the potential misuse of the products as intoxicants and should take steps to minimize such use in high-risk populations.

Suzanne Doyon, M.D.
Maryland Poison Center, Baltimore, MD 21201
sdoyon@rx.umaryland.edu

Christopher Welsh, M.D.
University of Maryland School of Medicine, Baltimore, MD 21201

4 References

1. 1

   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. MMWR Recomm Rep 2002;51:1-45
   Medline

2. 2

   Comprehensive accreditation manual for hospitals (CAMH). Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2006.
   

3. 3

   Management of methicillin-resistant Staphylococcus aureus (MRSA) infections: Federal Bureau of Prisons — Clinical Practice Guidelines. Washington, DC: Department of Justice, August 2005.
   

4. 4

   Medicare and Medicaid programs: fire safety requirements for certain health care facilities -- Amendment. 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485. Fed Regist 2005;70:15229-15239
   Medline

Citing Articles (7)

Citing Articles

1. 1

   Nicole J. Gormley, Alvin C. Bronstein, Joseph J. Rasimas, Maryland Pao, Angela T. Wratney, Junfeng Sun, Howard A. Austin, Anthony F. Suffredini. (2012) The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Critical Care Medicine 40:1, 290-294
   CrossRef

2. 2

   Jeffrey S. Engel, Henry A. Spiller. (2010) Acute Ethanol Poisoning in a 4-Year-Old as a Result of Ethanol-Based Hand-Sanitizer Ingestion. Pediatric Emergency Care 26:7, 508-509
   CrossRef

3. 3

   Rita Mrvos, Edward P. Krenzelok. (2009) Pediatric Ingestions of Hand Sanitizers. Pediatric Emergency Care 25:10, 665-666
   CrossRef

4. 4

   D. Steinmann, T. Faber, V. Auwärter, C. Heringhaus. (2009) Akute Intoxikation mit Isopropanol. Der Anaesthesist 58:2, 149-152
   CrossRef

5. 5

   J.A. Stockman. (2008) The Attitude of Physicians Toward Cold Remedies for Upper Respiratory Infection in Infants and Children: A Questionnaire Survey. Yearbook of Pediatrics 2008, 509-511
   CrossRef

6. 6

   Scott G. Weiner. (2007) Changing Dispensers May Prevent Intoxication From Isopropanol and Ethyl Alcohol-Based Hand Sanitizers. Annals of Emergency Medicine 50:4, 486
   CrossRef

7. 7

   Gita Thanarajasingam, Daniel A. Diedrich, Paul S. Mueller. (2007) Intentional Ingestion of Ethanol-Based Hand Sanitizer by a Hospitalized Patient With Alcoholism. Mayo Clinic Proceedings 82:10, 1288-1289
   CrossRef