title: Inhalation but not transdermal resorption of hand sanitizer ethanol causes positive ethyl glucuronide findings in urine.
abstract: BACKGROUND
  Ethyl glucuronide (EtG) in urine is considered a specific marker of recent ethanol consumption. There is an ongoing debate about whether inhalation or transdermal resorption of sanitizer ethanol is the underlying cause for positive EtG findings after hand disinfection.
  
  
  METHODS
  Desderman(®) pure (Schülke & Mayr GmbH, Norderstedt) with 78.2g 96% (v/v) ethanol/100g and approx. 10% 2-propanol was used for multiple hand disinfection without and under an exhauster. Simulating a common working day in a clinic, 5 co-workers of our lab used the sanitizer 32 fold within 8h and 2 persons were merely exposed to the sanitizer vapor but without any dermal sanitizer contact. Any additional ethanol intake or exposition was reliably excluded. Spot urine was collected at baseline, after 1, 2, 4, 6 … 14, and finally 24h after the first sanitizer use. A validated LC-MS/MS was used for MRM and MS(3) of EtG and qualitative analyses of ethyl sulfate and 2-propyl glucuronide.
  
  
  RESULTS
  Multiple hand disinfection caused positive EtG findings of up to 2.1mg/L or 1.7mg/g creatinine in 4 out of 5 test persons and even of 0.6mg/L or 0.8mg/g for 2 controls which were merely exposed to the sanitizer vapor but without any sanitizer contact. EtG results between the clinical (0.5mg/g) and the forensic (0.1mg/g) cut-off were obtained even 6h after the last sanitizer exposition. An exhauster prevented the sanitizer vapor inhalation and reduced the EtG excretion to mostly below the detection limit of 0.02mg/g. The maximum value was 0.09mg/g. Ethyl sulfate and 2-propyl glucuronide (2-PpG) were detectable only in the EtG positive samples. 2-PpG is a metabolite of 2-propanol, which is quite frequently used in disinfectants. Thus, the detection of this substance can be used in cases of odd EtG results as an indicator of (unintended) sanitizer exposition.
  
  
  CONCLUSIONS
  Ethanol from hand sanitizers is predominantly incorporated by the respiratory tract but not via the skin. It can cause a distinct ethyl glucuronide excretion and thus analytically true-positive but forensically false-positive EtG findings in the urine of ethanol abstaining persons. Since accidental ethanol inhalation can occur quite frequently in the working place or even private household, such a situation should always be considered when EtG is used as a marker of recent ethanol consumption.
authors.affiliation: Bioscientia Institut für Medizinische Diagnostik GmbH, Zentrum für Toxikologie und Forensik, Konrad-Adenauer-Straße 17, D - 55218 Ingelheim, Germany. Electronic address: torsten.arndt@bioscientia.de.
authors.forename: Torsten
authors.initials: T
authors.lastname: Arndt
authors.affiliation: Bioscientia Institut für Medizinische Diagnostik GmbH, Zentrum für Toxikologie und Forensik, Konrad-Adenauer-Straße 17, D - 55218 Ingelheim, Germany.
authors.forename: Stefanie
authors.initials: S
authors.lastname: Schröfel
authors.affiliation: Bioscientia Institut für Medizinische Diagnostik GmbH, Zentrum für Toxikologie und Forensik, Konrad-Adenauer-Straße 17, D - 55218 Ingelheim, Germany.
authors.forename: Brunhilde
authors.initials: B
authors.lastname: Güssregen
authors.affiliation: Bioscientia Institut für Medizinische Diagnostik GmbH, Zentrum für Toxikologie und Forensik, Konrad-Adenauer-Straße 17, D - 55218 Ingelheim, Germany.
authors.forename: Karsten
authors.initials: K
authors.lastname: Stemmerich
mesh_terms: D019840:2-Propanol / Q000652:urine; D000891:Anti-Infective Agents, Local / Q000032:analysis; D002853:Chromatography, Liquid; D000431:Ethanol / Q000032:analysis; D005965:Glucuronates / Q000652:urine*; D064548:Hand Sanitizers / Q000737:chemistry*; D006801:Humans; D013058:Mass Spectrometry; D013463:Sulfuric Acid Esters / Q000652:urine; D014835:Volatilization
chemical_list: D000891:Anti-Infective Agents, Local; D005965:Glucuronates; D064548:Hand Sanitizers; D013463:Sulfuric Acid Esters; C093924:ethyl glucuronide; D000431:Ethanol; C011612:diethyl sulfate; D019840:2-Propanol
keywords: Alcohol; Ethanol; Ethyl glucuronide; LC-MS/MS; Propyl glucuronide