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Prevalence of nosocomial pathogens in German ambulances: the SEKURE study
  1. M Wepler1,
  2. W Stahl1,
  3. H von Baum2,
  4. S Wildermuth2,
  5. B Dirks1,
  6. M Georgieff1,
  7. S Hafner1
  1. 1Department of Anaesthesiology, University Hospital Ulm, Ulm, Germany
  2. 2Institute of Medical Microbiology and Hygiene, University Hospital Ulm, Ulm, Germany
  1. Correspondence to Dr Martin Wepler, Department of Anaesthesiology, Albert-Einstein-Allee 23, Ulm 89081, Germany; martin.wepler{at}


Objective The increasing prevalence of multidrug resistant bacteria is a problem in the inpatient care setting, and in the emergency care system. The aim of this observational, cross-sectional study was to evaluate the prevalence of pathogens on well-defined surfaces in German ambulances that have been designated as ‘ready for service’.

Methods After informed consent was obtained, ambulance surfaces were sampled with agar plates for microbiological examination during an unannounced visit. A standardised questionnaire was used to obtain information regarding the disinfection protocols used at each rescue station.

Results Methicillin resistant staphylococcus aureus contamination was present in 18 sampling surfaces from 11 out of 150 ambulance vehicles (7%) that were designated as ready for service. Contact surfaces directly surrounding patients or staff were most frequently contaminated with pathogens. However, bacterial contamination was not related to annual missions, methods or frequency of disinfection.

Conclusions In accordance with previous studies, disinfection and cleaning of areas with direct contact to patients or staff seem to be the most challenging. This should also be reflected in disinfection guidelines and the related continuing education.

  • bacterial
  • infectious diseases
  • management, emergency department management
  • prehospital care
  • risk management

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In addition to resuscitating and stabilising critically ill patients, another goal in emergency medicine is to prevent the development of serious or life-threatening infections. However, the staff of the emergency medical service (EMS) must often care for patients in non-sterile environments or during situations where maintaining a sterile environment is challenging, for example, after accidents. Furthermore, since ambulances must be ‘ready for service’ shortly after the previous rescue operation, there is a limited amount of time to clean and decontaminate each vehicle. The aim of this study was to determine the prevalence of nosocomial pathogens on various surfaces in different ambulances within Germany. SEKURE stands for ‘Untersuchung der Keimbelastung im Rettungsdienst’, which means ‘examination of microbial load in German ambulances’.


All 78 rescue stations throughout the country were eligible for the study. Unannounced visits were performed randomly at different times of day and were made a few months after informed consent had been obtained. Agar plates were used for sampling according to the manufacturers’ instructions (Rodac-plates, Beckton & Dickinson, Sparks, Maryland, USA). Sampling points were selected based on how frequently each surface was used. We also considered that certain surfaces may not be routinely disinfected after patient transport and selected these surfaces as additional sampling points.

During the unannounced visit, staff on duty of the EMS base being assessed completed a questionnaire regarding rescue missions per year and the hygiene procedures of the base, qualification of the personnel and frequency of cleaning and disinfection.


In all, 56 of the eligible stations participated. Of these, questionnaires were completed by 49 (88%) of bases. A total of 2136 microbiological samples were collected from 150 out of 225 (67%) ambulance vehicles from all enrolled rescue stations. Overall, 124 samples were sterile (5.8%). However, 5% of samples contained bacteria that were potentially pathogenic (figure 1). Contact surfaces directly surrounding patients or staff were the most frequently contaminated with pathogens. The five most commonly infected areas of the emergency ambulances were: (1) carrying handles, (2) oxygen saturation clip, (3) carrying handle cardiovascular bag, (4) tourniquet and (5) ECG cable. Methicillin resistant staphylococcus aureus (MRSA) could be found on carrying handles, oxygen saturation clip, carrying handle cardiovascular bag, carrying handle patient stretcher, BP cuff, carrying handle pharmacists’ cabinet, headboard of patient stretcher, ECG control panel and carrying chair (table 1). Unfortunately, we were unable to correlate severity of contamination with disinfection protocols used by EMS personnel in this study (table 2).

Figure 1

Frequency of microorganisms detected in all rescue vehicles. Values represent the sum of agar plates on which the respective type of pathogen was found.

Table 1

Overall ranking and scoring of all sampling locations examined in emergency ambulances and patient transport ambulances

Table 2

Statistical analysis of selected factors documented in a standardised questionnaire designed to characterise differences in cleaning routines in participating rescue stations


Using data obtained from the SEKURE study, we were unable to determine a specific cause for the different levels of contamination observed between examined rescue stations. In most cases, the colonisation status of transported patients is unknown. Theoretically, these patients could be colonised with multidrug resistant pathogens such as MRSA.1 Alternatively, staff members may potentially carry pathogenic bacteria.2

The MRSA contaminated sampling points observed in our study confirm the observation made by others that contact surfaces directly surrounding patients or staff are more likely to be contaminated with gram-positive multidrug resistant pathogens.3 ,4


The SEKURE study was unable to identify a cause for the different prevalence of potentially pathogenic bacteria in the German ambulance vehicles examined. Areas in direct contact to patients or staff seem to be the most persistent source of contamination. However, to ensure a safe emergency transport for every patient by preventing development of serious or life-threatening infections, this should also be reflected in disinfection guidelines and related continuing education.


We thank all emergency medical services for unhesitant participation in our study. We are indebted to all medical technical assistants from the Institute of Medical Microbiology and Hygiene, University Hospital Ulm, Germany, for the excellent preparation of the numerous samples.


Supplementary materials

  • Abstract in German

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  • This work has been presented in part at both the 11th congress of “Deutsche interdisziplinäre Vereinigung für Intensiv– und Notfallmedizin (DIVI)”, 2011 in Leipzig, Germany, and the 11th congress of “Deutsche Gesellschaft für Krankenhaushygiene (DGKH)”, 2012 in Berlin, Germany, as oral presentations.

    This manuscript has been published in part in the journal Hygiene und Medizin (not indexed in Science Citation Index Expanded, Medline, EMBASE or Scopus) as an original article.

  • Contributors MW, SH and WS conceived the study, designed the trial, and obtained research funding together with HvB. MW, SH, WS, HvB and BD supervised the conduct of the trial and data collection. SW, MW, SH, WS and HvB undertook recruitment of participating centres and managed the data, including quality control. MW, SH, SW, WS and HvB analysed the data. MG is the head of the Department of Anaesthesiology. MW and SH drafted the manuscript, and all authors contributed substantially to its revision. MW takes responsibility for the paper as a whole.

  • Funding Financial support was provided by the Department of Anaesthesiology and Institute of Medical Microbiology and Hygiene, University Hospital Ulm, Germany.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.