title: POSAiDA: presence of Staphylococcus aureus/MRSA and Enterococcus/VRE in Danish ambulances. A cross-sectional study.
abstract: BACKGROUND
  Every year approximately one out of ten Danish patients contracts a healthcare associated infection (HAI). Staphylococcus aureus and Enterococcus are prominent in the group of pathogenic bacteria that underlie HAIs, causing unnecessary inconvenience and prolonging hospitalization. Bacterial colonization often occurs due to indirect patient-to-patient transmission, caused by poor hygiene compliance. This study aims to determine the level of contamination with S. aureus/MRSA and Enterococcus/VRE on presumed clean blood pressure cuffs in the Danish ambulances.
  
  
  METHODS
  Blood pressure cuffs were tested for contamination with S. aureus and Enterococcus when being cleaned according to everyday guidelines in this cross-sectional study. Imprints were performed with specific agar plates after cleaning with ethanol wipes. Positive imprints were typed and antibiotic susceptibility was determined.
  
  
  RESULTS
  Both S. aureus and Enterococcus were found on blood pressure cuffs thought to be clean, however, to a limited extent. The average level of contamination by S. aureus was 0.54 CFU per 25 cm(2) (SD 1.98). Minimum and maximum values ranged from 0 to 12 CFU per 25 cm(2) and 10% of the 50 samples were positive. The average level of contamination by Enterococcus was 0.06 CFU per 25 cm(2) (SD 0.42). Minimum and maximum values ranged from 0 to 3 CFU per 25 cm(2) and 2% of the 50 samples were positive. All S. aureus isolates were found to be methicillin susceptible S. aureus (MSSA) and the one Enterococcus isolate was identified as Enterococcus faecalis, negative for vancomycin resistance genes.
  
  
  CONCLUSIONS
  Staphylococcus aureus and Enterococcus were detectable on equipment thought to be clean. However, all detected bacteria showed susceptibility towards methicillin or vancomycin. Findings of pathogens after cleaning may be due to cross-contamination, improper cleaning and limited effect of the currently used cleaning procedure and are thought to affect the risk of infection. Therefore, we recommend a thorough evaluation of current cleaning procedures as well as increased focus on and further research into hygiene challenges in a prehospital setting. Future studies should be performed in order to demonstrate the level of bacterial contamination in all areas of the medical service, e.g., the ambulance environment, medical equipment, staff uniform and hand hygiene. Furthermore, in order to establish evidence for different cleaning procedures in situ we recommend testing the effect of different cleaning interventions by interventional designs.
authors.affiliation: Section of Research and Development, Medical Department, Falck Denmark A/S, Caspar Müllers Gade 2, 6000, Kolding, Denmark. hevi@falck.dk.
authors.forename: Heidi Storm
authors.initials: HS
authors.lastname: Vikke
authors.affiliation: Medical Department, Falck Denmark A/S, Kolding, Denmark.
authors.forename: Matthias
authors.initials: M
authors.lastname: Giebner
mesh_terms: D000552:Ambulances; D003428:Cross Infection / Q000382:microbiology*; D003430:Cross-Sectional Studies; D003718:Denmark; D016983:Enterococcus / Q000302:isolation & purification*; D006801:Humans; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification*; D020713:Vancomycin Resistance
keywords: Cleaning procedures; Contamination; Emergency care; Hygiene; Infection control; Prehospital