Environmental cultures revealed that a canister of cotton

balls soaked in aqueous benzalkonium chloride and two

multiple-dose vials of methylprednisolone previously used
by office personnel were contaminated with the epidemic
strain of S. marcescens. The canister may have served as a
potential reservoir for contamination of sterile solutions and
equipment used for joint injections, of skin at the injection
site, and of hands of personnel. No further cases occurred
after the use of aqueous benzalkonium chloride was
discontinued.
We report here the results of the outbreak investigation,
which identified contaminated aqueous benzalkonium
chloride as a possible source.
The available evidence suggested that for the eight patients
who developed S. marcescens septic arthritis following joint
injections in January 1982, the canister of Zephiran-soaked
cotton balls served as a reservoir for the epidemic strain of S.
marcescens.
Nakashima A, et al., Epidemic Septic Arthritis Caused by Serratis marcescens and
Associated with a Benzalkonium Chloride Antiseptic. Journal of Clinical Microbiology,
p1014-1018, June 1987.
Procedures such as catheterization and prolonged antibiotic
treatment also tend to predispose a patient to S. marcescens
infections. S. marcescens infections have been transmitted
hand-to-hand by hospital personnel, via solutions used for
medical procedures and by catheterization or need
puncture.
Cultures were taken from 21 benzalkonium chloride sponge
pots located in the ICU, surgery rooms, and outpatient clinic
areas; 13 were contaminated with S. marcescens. ... All S.
marcescens isolates showed multiple resistance to antibiotics.
Of the 36 isolates surveyed, 80% (24 of 30) of the catheter
isolates and 100% (6 of 6) of the aqueous benzalkonium
chloride isolates were resistant to four or more antibiotics. S.
marcescens was not isolated from any of the surface areas
tested.
In the present study, an environmental surveillance of the
ICU, surgery rooms, and outpatient clinic areas of the
hospital revealed a common source of S. marcescens: aqueous
benzalkonium chloride solutions used in skin antisepsis
before insertion of i.v. catheters. This finding was confirmed
by demonstrating that a single S. marcescens biotype was
present in most of the i.v. catheters and disinfectant
solutions...the contaminated disinfectant was a reservoir of
multiply antibiotic-resistant S. marcescens.
When aqueous benzalkonium chloride becomes
contaminated with these organisms, it becomes a potential
source of infection or transmission within a hospital.
Several nosocomial bacterial infections in humans have
been attributed to contaminated disinfectants, in particular,
to benzaklonium chloride solutions.
Our findings serve as a reminder of the potential hazards
of improper use of disinfectants in a hospital environment,
human or veterinary, and particularly, of the hazards of
using aqueous benzalkonium chloride solutions stored in
containers with cotton sponges.
Fox J, et al., Nosocomial Transmission of Serratia marcescens in a Veterinary Hospital Due
to Contamination by BenzalkoniumChloride. Journal of Clinical Microbiology, p157-160,
Aug 1981.
Multiple-dose medications and reliance on benzalkonium
chloride as a medication preservative provide a mechanism
for nosocomial spread of microorganisms, particularly if
infection control procedures are not carefully followed.
Outbreaks of nosocomial infections continue to occur
because of the improper use of multiple-dose medication
vials and because of reliance on benzalkonium chloride as
a medication preservative.
However, benzalkonium chloride works optimally as a
bacteriostatic agent at a neutral or alkaline pH.
Our results indicate that benzalkonium chloride may not
be an appropriate medication preservative because this
agent did not provide effective bacteriostasis on numerous
occasions.
Hamill R, et al., An Outbreak of Burholderia (Formerly Pseudomonas) cepacia
Respiratory Tract Colonization and Infection Associated with Nebulized Albuterol
Therapy. Annals of Internal Medicine, 1995;122(10):762-66.
The isolates resistance to pure benzalkonium chloride was
increased step-wise to a concentration of 16%. ... The
results indicate that it is critical that pharmaceutical
solutions containing benzalkonium chloride as an
antimicrobial preservative be formulated without
extraneous carbon and nitrogen sources or be preserved
with additional antimicrobial agents.
This organism was also isolated from benzalkonium
chloride solutions by Gilardi. That benzalkonium chloride
solutions can support pseudomonas contaminants is well
established by the studies of Adair et al.
What the Experts Say
Benzalkonium Chloride Antiseptic
continued...
The organism was originally recovered from 0.15% N-alkyl
dimethyl benzyl ammonium chloride solution that
functioned as a cleansing germicidal agent in commercial
catheters.
Research Department, Pharmaceuticals Division, CIBA-GEIGY Corp, Summit, New
Jersey 07901, Fourteen-Year Survival of Pseudomonas cepacia in a Salts Solution
Preserved with Benzalkonium Chloride. Applied and Environmental Microbiology,
p505-510, Mar 1979.
Benzalkonium chloride (BC) continues to be used as an
antiseptic and contributes to serious outbreaks of disease.
At that time, a recommendation was made that BC be used
only for environmental disinfection.
The 4 mycobacteria-positive environmental specimens were
linked to BC preparations: BC-soaked cotton ball samples
taken from examination rooms 1 and 3, a swab sample from
the metal container of the soaked cotton balls from room 3,
and a sample of diluted BC that was obtained via a sterile
syringe from a container of BC-soaked gauze in room 2. At
least 1 culture-positive sample was obtained from each of the
3 examining rooms.
From 1955 through 1982, the misuse of BC was associated
with numerous other outbreaks or pseudooutbreaks of post-
injection infection caused by bacterial species. The most
common species were aerobic, gram-negative bacilli,
including Burkholderia (Pseudomonas) cepacia, Serratia
marcescens, and Enterobacter species.
Our study determined that BC is ineffective against M.
abscessus, even when used in accordance with the
manufacturers instructions, and infection with this organism
is a definite risk when BC is used.
Similar to other quaternary ammonium compounds, the
limited disinfecting property of BC is even more diminished
in the presence of organic material.
Tiwari T, et al., Forty Years of Disinfectant Failure: Outbreak of Postinjection
Mycobacterium abscessus Infection Caused by Contamination of Benzalkonium
Chloride. Clinical Infectious Diseases 2003;36:954-62
S. Enteritidis and S. Virchow became increasingly resistant
to ERY, BKC and TLN within 6 days of gradual exposure to
increasingly higher concentrations of these antimicrobial
agents.
Other gram-negative bacteria have been shown to alter their
CSH when challenged by BKC, which might be due to the
cationic nature of BKC making it more difficult to penetrate
a hydrophobic bacterial cell wall.
Braoudaki M, Hilton A, Mechanisms of resistance in Salmonella enterica adapted to
erythromycin, benzalkonium chloride and triclosan. International Journal of
Antimicrobial Agents 25 (2005) 31-37.
Benzalkonium chloride is restricted in cosmetics
(recommendations or requirements) - use, concentration,
or manufacturing restrictions - Use is prohibited and
restricted in Canadian cosmetics.
BZK Health Concerns, available at
www.ewg.org/skindeep/ingredient/700674/BENZALKONIUM-CHLORIDE/
Serratia species are responsible for 1.4% of nosocomial
bloodstream infections.
In a population-based study of Serratia bacteremia,
the 7-day and 6-month mortality rates were 5% and 37%,
respectively.
Serratia Epidemiology, available at http://emedicine.medscape.com/article/228495-
overview
PROFESSIONAL RECOMMENDATIONS
For general patient care, a plain, non-antimicrobial soap is
recommended in any convenient form (bar, leaflets, liquid,
powder). Such detergent-based products may contain very
low concentrations of antimicrobial agents that are used as
preservatives to prevent microbial contamination. If bar
soaps are used, small bars that can be changed frequently
and soap racks that promote drainage should be used.
American Journal of Infection Control (AJIC), Vol 23, No 4, pp 262, Aug 1995.
The Food and Drug Administration has categorized
benzalkonium chloride (BZK) as not generally regarded as
safe and effective in antimicrobial soaps.
Food and Drug Administration Federal Register, Vol 43, No 4, OTC Topical
Antimicrobial Products, Jan 1978.
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