Direct contact with chemotherapy drugs (HDs), either by handling, reconstituting, or administering, represents an exposure risk.

The recommended location for chemotherapy preparation and administration is a quiet, low-traffic room that is dedicated to chemotherapy purposes, free from distractions, and easy to clean.

Many HDs have also been found to have drug residue on the outside of drug containers, which creates another opportunity for exposure of individuals who receive drugs and perform inventory control procedures.

Personal protective equipment (PPE) should be used to protect personnel from exposure during handling of HDs. PPE includes gloves, gowns, goggles for eye protection, a full face shield for head protection, and respiratory barrier protection.

Regular exam gloves are not recommended for use as standard protocol for handling chemotherapeutic agents. However, as an expedient, wearing two pairs of powder-free nitrile or latex gloves can be used as a last resort. Vinyl gloves do not provide protection against chemotherapy. Ideally, gloves should be powder free and rated for chemotherapy use by the American Society for Testing and Materials (ASTM). For receiving HDs, one pair of ASTM-tested chemotherapy gloves may be worn. When administering, managing, and disposing of HDs, two pairs of ASTM-tested chemotherapy gloves should be worn with the inner glove under the gown cuff and the outer glove over the cuff. If a glove becomes contaminated or if there is a breach in the glove, it should be removed and discarded promptly, while carefully avoiding contamination of the handler’s skin or nearby surfaces.

Disposable gowns made of polyethylene-coated polypropylene or other laminate materials offer the best protection.

Eye, face, and respiratory protection is mandatory when working with HDs outside of a clean room or isolator cabinet, or whenever there is a probability of splashing or uncontrolled aerosolization of HDs. A full face mask is a suitable alternative to goggles, although it does not form a seal or fully protect the eyes. A NIOSH N95 respirator mask is suitable for most situations, with the exception of large spills that cannot be contained by a commercially available spill kit.

PPE should be removed in the following order: chemotherapy gown (touching the outside of the gown, then rolling the outside inward to contain HD trace contamination), goggles and face shields (touching only the outside without making contact with the face), then chemotherapy gloves (touching the outside of the gloves away from the exposed skin while attempting to roll the glove outside-in).

Closed system transfer devices (CSTDs) are another type of PPE that can be used for any cytotoxic chemotherapy agent (although not necessarily for all HDs) during preparation and administration. Traditional needle and syringe techniques for mixing HDs create the potential for droplet or aerosol contamination. CSTDs prevent mechanical transfer of external contaminants and prevent harmful aerosols that are created by mixing HDs from escaping and exposing personnel. CSTDs are commercially available from a number of companies.

Male and female employees who are immunecompromised or attempting to conceive and women who are pregnant or breastfeeding should avoid working with chemotherapy agents.

Employees or pet owners who will be exposed to the patient’s waste (urine, feces, vomit, blood) within 72 hr of chemotherapy administration (sometimes longer for some drugs) should wear proper PPE.

Chemotherapy pills (tablets and capsules) are best handled within a biological safety cabinet (BSC) if available. If no BSC is available, a ventilated area or a respirator should be used to avoid inhalation of HD particles or aerosols.

Separate pill counters should be used for chemotherapy pills. Counters labeled for chemotherapy use will help avoid inadvertent use with conventional medications. The counters should be stored either within the BSC (not to be removed) or in a sealed container (e.g., a plastic box with a secure lid) dedicated to that pill counter and any other items that may come in contact with HD pills.