Drug resistant bacteria in the prehospital environment

While working in an infectious environment, taking precautions is key


Antibiotic-resistant bacteria are widespread and their numbers are growing. In 1974, only 2% of staph bacteria tested in United States hospitals were drug resistant (Panlilio et al., 1992). By 2008, that number increased to about 59% (Talan et al., 2011).

Antibiotic resistance among bacteria may be innate or acquired (Aldrin et al., 2013). Acquired resistance results from exposure to less than lethal antibiotic doses, as in cases where a patient stops taking prescribed antibiotics before the infection is over.

Future antibiotic exposure eradicates susceptible bacteria thereby allowing proliferation of the resistant strain, which can then spread from the treated individual to others in the surrounding environment (Livermore, 2003).

A number of multi-drug resistant organisms (MDRO) represent a threat to EMS professionals and their patients (Shlaes et al., 1997). It is beyond the scope of this article to review or even name each of those pathogens.

However, the predominant drug resistant pathogen responsible for most purulent skins and soft-tissue infections is methicillin-resistant Staphylococcus aureus, known simply as MRSA (Talan et al., 2011).

Drug resistance

Multi-drug resistance first appeared in nosocomial infections. Nosocomial infections result from pathogen exposure within the healthcare environment, which includes EMS personnel and the patient care compartment of the ambulance.

Epidemiologists can often trace these infections back to improper infection-control procedures including inadequate hand-washing techniques, inadequate cleaning of the patient care environment, or inadequate decontamination of patient care equipment. Researchers estimate that 85% of all MRSA infections began with a nosocomial exposure (Naimi et al., 2003).

In just one example, despite the best infection control efforts, a burn victim in a Southern California hospital transmitted MRSA to 34 other patients resulting in the deaths of half of them (Locksley et al., 1982).

In the 1990s, a disturbing trend emerged as individuals in the community without the traditional risk factors began developing MRSA infections (Herold et al., 1998; Lindenmayer, Schoenfeld, O'Grady, & Carney, 1998; Maguire, Arthur, Boustead, Dwyer, & Currie, 1996). Further investigation revealed a genetically different strain of Staph from the one causing problems in the healthcare community.

Epidemiologists differentiate these strains through the use the terms community-acquired MRSA (CA-MRSA) or hospital-acquired MRSA (HA-MRSA) (Kilbane & Reynolds, 2008). CA-MRSA tends to be more virulent than HA-MRSA as it carries genes for the production of a leukotoxin associated with tissue necrosis (Appelbaum, 2007; Chua, Laurent, Coombs, Grayson, & Howden, 2011; Naimi et al., 2003; Voyich et al., 2006).

Some groups are at higher risk for community-acquired infections than others. These include athletes, children in day care centers, military recruits, prisoners, IV drug abusers, patients in extended care facilities, and anyone who comes into contact with recently hospitalized people, especially ICU or surgical patients.

It is possible, however that people with no apparent risk factors can still develop significant infections. Within a two-year period in the mid-west, four children between the ages of 1 and 13 years without any identifiable risk factors died from MRSA infections (Centers for Disease Control and Prevention, 1999).

EMS studies

Researchers in Indiana swabbed the nasal cavities of EMS personnel from a hospital-based agency and students in an EMT training program (Miramonti et al., 2013). Overall, about 5% of the personnel tested positive for the presence of MRSA. This was about five times the prevalence found among the public (Kuehnert et al., 2006).

The researchers could not demonstrate a statistically significant difference between student and provider colonization rates although paramedics appear to have colonization rates twice that of EMT-Basics.

Researchers tested 21 ambulances in an urban ambulance fleet for the presence of MRSA (Roline, Crumpecker, & Dunn, 2007). The research staff swabbed various areas inside the ambulance including the steering wheel, the cot handrail, the cot cushion, the work area to the right of the patient, and the tip of the hard tonsil suction.

Almost fifty percent of the swabbed ambulances tested positive for the presence of MRSA.

In another study, researchers tested fifty stethoscopes used by EMS personnel in an urban service (Merlin et al., 2009). During the test, researchers asked EMS personnel to complete a questionnaire identifying the last time someone disinfected the stethoscope.

Sixteen of the fifty stethoscopes, or approximately 32% tested positive for the presence of MRSA. One-third of the EMS personnel could not pinpoint the time when someone last cleaned their stethoscopes.

Researchers in New Jersey compared nosocomial infection rates between in-patients who arrived at a level-one trauma center by paramedic-staffed ambulance with patients who arrived by other means (Alter & Merlin, 2011). Although the community-acquired infection rate was not significantly different between the two groups, the rate of nosocomial infections was greater in the group of admitted patients who arrived by ambulance compared to those who arrived by other means.

The results of this study do not suggest that paramedic transport causes higher infection rates but it does suggest that patients transported by ambulance are at a higher risk for nosocomial infection once admitted to the hospital. EMS agencies must at least consider the possibility that inadequate or ignored infection control procedures in the field may allow colonization during transport.

The role of the provider

You play an important role in stopping the spread of MRSA and other pathogens. Most experts agree that proper hand washing is the single most effective way of preventing the spread of infection (Fridkin & Raynes, 1999) as the hands appear to be the main source of cross transmission for nosocomial infections (Hardy, Hawkey, Gao, & Oppenheim, 2004).

Many healthcare providers do not wash their hands as often or as effectively as they should (Karabey, Ay, Derbentli, Nakipoglu, & Esen, 2002; Pittet, Mourouga, & Perneger, 1999). Medical personnel could significantly reduce the rate of resistant organism colonization by increasing hand hygiene compliance (Pittet et al., 2000; Sebille, Cheveret, & Valleron, 1997).

In the field, use commercial waterless hand cleaners. However, after arrival at the hospital, wash your hands as soon as possible after transferring patient care to the emergency department staff.

Wear disposable, single-use gloves for all patient contact and change them when moving from one patient to another or when they become heavily soiled. It is important to remember, however that wearing gloves is not a substitute for proper hand washing.

You should take additional measures of protection such as wearing a gown when caring for a patient with a known MRSA contamination. The eyes, nose, and mouth are common portals of entry for infectious agents.

If the patient is producing respiratory droplets, you should wear a facemask and eye protection. It is also a good idea to put a facemask on the patient to prevent the spread of bacteria into the patient care environment.

After delivering the patient to the hospital, you must properly decontaminate the patient care compartment. Wipe all surfaces with a commercial disinfectant and allow it air dry.

Staphylococci can survive for at least a day on common medical materials with some viability even after 56 to 90 days on polyester and polyethylene plastics (Duckworth & Jordens, 1990; Lacey, Barr, Barr, & Inglis, 1986; Mortimer, Wolinsky, Gonzaga, & Rammelkamp, 1966).

One of the most important equipment decontamination practices is to clean surfaces with soap and water before disinfection (Rutala, 1996). Cleaning removes the foreign material from the objects while disinfection removes the microorganisms.

Before disinfecting, clean all equipment that came into contact with the patient or your gloves with soap and water. This includes the stethoscope, blood pressure cuff, ECG monitor cable, stretcher, and clipboard.

The disinfectant should be a commercial solution or a 1:10 concentration of household bleach and water (Goodman & Cone, 2001).

Drug resistant bacteria pose a risk for all EMS providers, their families, and their patients. Some groups of patients are at an increased risk from this pathogen. EMS personnel and their equipment are a source of exposure and contamination.

Once infected, eradication of MRSA is very difficult and complicated. Pre-hospital care providers must protect themselves by using standard precautions, washing their hands often and especially between patient contacts, thoroughly cleaning and disinfecting all equipment and patient care surfaces with an appropriate disinfectant, and carefully disposing of contaminated materials such as pus, blood, or urine.


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Voyich, J. M., Otto, M., Mathema, B., Braughton, K. R., Whitney, A. R., Welty, D., Long, R. D., Dorward, D. W., Gardner, D. J., Lina, G., Kreiswirth, B. N., & DeLeo, F. R. (2006). Is Panton-Valentine leukocidin the major virulence determinant in community-associated methicillin-resistant Staphylococcus aureus disease? Journal of Infectious Disease, 194(12), 1761–1770. doi:10.1086/509506

The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned.

Send correspondence concerning this article to Kenneth W. Navarro, The University of Texas Southwestern School of Health Professions, 5323 Harry Hines Blvd, MC 9134, Dallas, Texas 75390-9134. E-mail: kenneth.navarro@utsouthwestern.edu

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