dgkh000394 10.3205/dgkh000394 urn:nbn:de:0183-dgkh0003942 Letter to the Editor Exner Exner Martin M Prof. Dr. med.

Universitätsklinikum Bonn (AöR), Institut für Hygiene und Öffentliche Gesundheit, Venusberg-Campus 1, 53127 Bonn, GermanyInstitute of Hygiene and Public Health, Bonn University, Bonn, Germany

martin.exner@ukbonn.de author Bhattacharya Bhattacharya Sanjay S

Tata Medical Center, Kolkata, India

author Gebel Gebel Jürgen J

Institute of Hygiene and Public Health, Bonn University, Bonn, Germany

author Goroncy-Bermes Goroncy-Bermes Peter P

Schülke & Mayr GmbH, Norderstedt, Germany

author Hartemann Hartemann Philippe P

Departement Environnement et Santé Publique S.E.R.E.S., Faculté de Médecine, Nancy, France

author Heeg Heeg Peter P

Institute of Medical Microbiology and Hygiene, University of Tübingen, Germany

author Ilschner Ilschner Carola C

Institute of Hygiene and Public Health, Bonn University, Bonn, Germany

author Kramer Kramer Axel A

Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Germany

author Ling Ling Moi Lin ML

Infection Prevention & Control, Singapore General Hospital, Singapore

author Merkens Merkens Wolfgang W

Schülke & Mayr GmbH, Norderstedt, Germany

author Oltmanns Oltmanns Peter P

Schülke & Mayr GmbH, Norderstedt, Germany

author Pitten Pitten Frank F

IKI - Institut für Krankenhaushygiene & Infektionskontrolle GmbH, Gießen, Germany

author Rotter Rotter Manfred M

Hygiene Institute, Medical University Vienna, Austria

author Schmithausen Schmithausen Ricarda Maria RM

Institute of Hygiene and Public Health, Bonn University, Bonn, Germany

author Sonntag Sonntag Hans-Günther HG

Institute of Hygiene and Medical Microbiology, University of Heidelberg, Germany

author Steinhauer Steinhauer Kathrin K

Schülke & Mayr GmbH, Norderstedt, Germany

author Trautmann Trautmann Matthias M

Department of Hospital Hygiene, Stuttgart Hospital, Stuttgart, Germany

author German Medical Science GMS Publishing House

Düsseldorf

610 20210624 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2196-5226 16 GMS Hygiene and Infection Control GMS Hyg Infect Control 23 Authors’ statementWe are grateful for the question by Papke because it addresses an important issue regarding the risk-conscious use of hand disinfectants. The KRINKO does not recommend adding quaternary ammonium compounds (QAC) to hand disinfectants without mentioning the active ingredient mecetronium ethylsulfate (MES). However, mecetronium ethylsulfate (syn. Ethylhexadecyldimethylammonium-ethylsulfate) is a surface-active aliphatic quaternary ammonium compound, so that this active ingredient is also included in the KRINKO’s disapproval recommendation.MES was chosen as an example in our publication because it is used in hand disinfectants as well as in shampoos , but the reasons against its wide use are little known to the user. In this respect, the question may help to clarify the situation. The use of MES in hand disinfectants should be avoided for the following reasons: In the results of 23 studies, no improvement in efficacy was achieved by adding 0.2% MES to a propanol-based hand disinfectant, tested according to EN 12791 . The same applies to chlorhexidine digluconate and 2-phenylphenol . Also for surgical hand disinfection, no improvement in efficacy was demonstrated by addition of MES .After dermal application under occlusive conditions for 24 h, the percutaneous absorption of MES in the rat was approx. 2% . By extrapolation from dermal toxicity data, the absorption was calculated to be 3% .For the quaternary ammonium compounds benzalkonium chloride (BAC) and didecyldimethylammonium chloride (DDAC), blood levels of both compounds were measured for the first time in 2020 in a sample of healthy people, with quaternary ammonium compound (QAC) exposure (n=43) at concentrations with possible impact on cell metabolism in cell culture, reduction of mitochondrial function, and increase of inflammatory cytokines in volunteers in a dose-dependent manner . The reason for the occurrence in humans is the wide use of both QAC in disinfectants and cleaning agents, for the preservation of care products and in food preparation. In surface disinfection, the main exposure to QAC probably occurs by inhalation (aerosol, dust) . Unlike BAC and DDAC, MES is only used as an additive in hand disinfectants and shampoos. However, due to the dermal absorption of MES, a systemic toxic risk cannot be ruled out by daily application for hand disinfection up to >100 times, depending on the work area. Since the addition of MES to hand disinfectants is not associated with any improvement in efficacy, but absorptive toxic risks including unknown summation effects with BAC and DDAC may result, the use of hand disinfectants with the addition of MES should be discouraged in view of the new findings on the toxic hazard of BAC and DDAC, until the safety of the adsorptive uptake of MES has been proven by in-depth studies.A genetically encoded development of resistance with simultaneous increase in resistance to antibiotics has been demonstrated for BAC . When passaged in vitro at subinhibitory concentrations, tolerance is induced by both BAC and DDAC , , , . Although such studies have not been performed with MES, such a risk cannot be ruled out for MES due to the structural similarity, the mode of mechanism and, in particular, the application in a submicrobicidal concentration of 0.2%. ConclusionsThe occurrence of QAC in the blood of healthy people is an alarm signal that exposure to antimicrobial active QAC must be limited to the indispensable minimum. Since the addition of MES to propanol-based hand disinfectants did not improve their efficacy, but the active ingredient is absorbed dermally, the use of hand disinfectants containing MES cannot be recommended until toxic long-term risks and the development of tolerance and resistance have been reliably ruled out. NotesCompeting interestsThe authors declare that they have no competing interests. Hartmann The Sterillium® product range Hartmann. The Sterillium® product range. 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DOI: 10.1111/jam.13247 https://doi.org/10.1111/jam.13247 Exner M Bhattacharya S Gebel J Goroncy-Bermes P Hartemann P Heeg P Ilschner C Kramer A Ling ML Merkens W Oltmanns P Pitten F Rotter M Schmithausen RM Sonntag HG Steinhauer K Trautmann M Chemical disinfection in healthcare settings: critical aspects for the development of global strategies 2020 GMS Hyg Infect Control Doc36 Exner M, Bhattacharya S, Gebel J, Goroncy-Bermes P, Hartemann P, Heeg P, Ilschner C, Kramer A, Ling ML, Merkens W, Oltmanns P, Pitten F, Rotter M, Schmithausen RM, Sonntag HG, Steinhauer K, Trautmann M. Chemical disinfection in healthcare settings: critical aspects for the development of global strategies. GMS Hyg Infect Control. 2020 Dec 23;15:Doc36. DOI: 10.3205/dgkh000371 https://doi.org/10.3205/dgkh000371 Papke R Letter to the Editor regarding “Chemical disinfection in healthcare settings: critical aspects for the development of global strategies” 2021 GMS Hyg Infect Control Doc22 Papke R. Letter to the Editor regarding “Chemical disinfection in healthcare settings: critical aspects for the development of global strategies”. GMS Hyg Infect Control. 2021;16:Doc22. DOI: 10.3205/dgkh000393 https://doi.org/10.3205/dgkh000393 0 0 0 0