Although there have been reports of antibiotic-resistant organisms in medical journals since the 1960s, the media has recently peppered the public with reports about a surge in the prevalence and incidence of superbugs — MDROs. While PTs may associate MDROs with older, immunocompromised patients, MDRO outbreaks have hit the general population, even affecting unlikely groups such as school-aged children and professional athletes.

The CDC defines a superbug as a microorganism, predominantly bacteria, that is resistant to one or more classes of antimicrobial agents.¹ Two of the most common MDROs are methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). S. aureus can inhabit the dermis and the nares of asymptomatic individuals, while enterococci are commonly found in the digestive and urinary tracts of asymptomatic individuals. Normally these bacteria are harmless, but when they become resistant to commonly prescribed antimicrobials or antibiotics, they can increase in number and migrate to other areas of the body.

Morbidity and mortality

In 2007, the CDC reported that the number of patients affected by MRSA had doubled from 127,000 recorded cases in 1999, to 278,000 cases in 2005.² Even more alarming, the number of deaths increased from 11,000 to more than 17,000 during the same timeframe. Another CDC study published by the Journal of the American Medical Association estimated there were more than 94,000 serious MRSA infections with more than 18,000 related deaths in 2005.² Another study presented data suggesting that increases in hospital-related MRSA are related to increases in community-associated MRSA.³

A 2003 study indicated that a patient who contracted a resistant rather than a sensitive strain of bacteria faced a greater likelihood of morbidity and mortality.⁴ Additional research has shown an estimated 2.3% morbidity rate of patients in a hospital, while the morbidity rate of a nonhospitalized person infected with MRSA increases to 11.2%.5 Because MDROs more commonly affect patients in the pediatric and geriatric populations, it is not surprising to find the highest mortality rates in the intensive care units (ICUs) and neonatal intensive care units (NICUs) of hospitals.^4,6

VRE produces similarly daunting statistics. Data from a 2004 CDC report revealed one out of three infections in ICUs were secondary to VRE.7-11 Studies have also demonstrated when controlling for the severity of a given illness, VRE will increase the likelihood of mortality two to five fold.^12,13 Forty-six percent of deaths in patients with neutropenic bone transplantation and bacteremia, when controlling for various comorbidities, were attributable to VRE.¹⁴ Similarly, 62% of patients with VRE sepsis died as a result of bacteremia.¹³

Financial burden of MDROs

In addition to increased morbidity and mortality, MDROs pose an enormous financial burden on our healthcare system. The diagnosis and treatment of MRSA costs between $13,900 and $34,900 per case.^1,15 These soaring costs include the additional tests, medication, medical supplies, and healthcare personnel required to care for an infected patient.¹⁵ A diagnosis of MRSA also lengthens a patient’s stay in the hospital. Studies have demonstrated that patients with MRSA have three times the hospital stay and cost of uninfected patients.^5,16 This trend is reflected in patients diagnosed with MRSA following total joint replacement. These patients were at higher risk for treatment failure and subsequent removal of hardware.¹⁷ The surgery required to treat any total knee or total hip prosthetic joint infection has been estimated between $50,000 to $60,000 per episode.¹⁸

VRE imposes a great financial impact on healthcare institutions as well. Research has found that patients with VRE were hospitalized twice as long as those with a vancomycin-sensitive strain of enterococci. Additionally, patients with VRE were more likely to be placed on the medical service of the hospital than those patients with vancomycin-sensitive strains of the bacteria, increasing their costs by more than $27,000.¹³ Clearly, as the incidence of MDRO infection increases in hospitals, so will the financial impact.

Treatment and resistance

An understanding of antibiotics and how bacteria acquire resistance is necessary to fully understand the severity of antibiotic resistance. Antibiotics destroy bacteria in the body by one of the following methods:

1. A bactericidal effect where they kill bacteria outright.
2. A bacteriostatic effect when they bind to and disrupt the machinery that builds protein and amino acids for bacteria. Proteins are needed to manufacture new bacteria in order to replace the dying bacteria.
3. Altering or rupturing the bacterial cell wall structure by forcing fluids through the cell wall.
4. Interfering with DNA synthesis by upsetting the production of new chromosomes.

Bacteria develop resistance by:

1. Preventing antibiotics from reaching their destined target.
2. Changing the target.
3. Destroying the antibiotic outright.
4. Mutation (i.e., spontaneous mutation, transformation, or plasmid transfer.)^{19, 20}

Patients who have been previously treated with methicillin, vancomycin, or other antibiotics that are within these classes of drugs face an increased risk of developing strains of S. aureus and enterococci that are resistant to these medications. There are also comorbidities that substantially increase a patient’s risk of developing an MDRO.

The role of the community

American society as a whole greatly contributes to antibacterial resistance and the spread of MDROs. Advertisements for new medications constantly bombard the public, prompting many people to self-diagnose based on information from websites. Frequently, these online enthusiasts insist that their providers prescribe antibiotics that may not be medically necessary. Nonadherence with antibiotic regimens, overmedication, and keeping unused medication for a later date all create an environment for superbugs to thrive.²¹

Documentation of community-associated forms of MRSA is on the rise^{2, 3, 22}. Community-associated MRSA (CA-MRSA) is the most commonly reported superbug and has been recognized as a major cause of skin and soft tissue infections.²² In one study in 2005,  86% of all invasive MRSA infections were associated with hospitalization or with a visit to a healthcare practitioner, while the remaining cases were CA-MRSA cases.² Infected individuals from the community can bring these strains into the hospital and inadvertently contaminate hospital surfaces or infect vulnerable patients.^{3, 23} Poor hand hygiene from patients, patients’ families, and hospital staff can further contribute to the transfer and spread of CA-MRSA. Furthermore, patients who do not follow medical advice upon discharge from the hospital can spread nosocomial infections to family and friends, creating an uncontrolled cycle of MDRO disease transmission.

Methicillin-resistant S. aureus

S. aureus can colonize the skin and nose of an otherwise healthy person for weeks to years without producing symptoms. However, if these bacteria colonize a person with a compromised immune system, there is a greater risk of becoming symptomatic.

MRSA typically affects sicker patients with compromised immune systems found in the ICU or NICU.^{4, 24} The CDC profiles patients who have the greatest risk for contracting MRSA as 65 or older, male, and of African-American descent.² While there is debate in the medical literature as to whether it is efficacious to screen all hospitalized patients for MRSA, special consideration should be paid to those patients who are at the greatest risk.

Patients with burns are also particularly susceptible to MRSA. Fifteen to 32% of patients infected with burns will develop bacteremia. These infected patients will experience delayed wound closure and the infection may make subsequent skin grafts more difficult.²⁵ Therefore, all PTs treating burn patients need to meticulously follow all precautions and maintain a sterile work environment when treating this population.

PTs need to understand the signs, symptoms, and clinical presentation of MRSA, because they may encounter patients with the disease both in the hospital and in the community. As the leading cause of both nosocomial pneumonia and surgical site infection, MRSA is also the second-leading cause of nosocomial bloodstream infection and is commonly associated with patients who have had surgery, dialysis, and cardiac or urinary catheterization.^{17, 26} Signs of MRSA infection include erythema, edema, drainage, or pain at the site of infection. If the infection is near the eye, a sty might be noted as well. Symptoms of MRSA include fever, chills, low blood pressure, arthralgia, reports of severe headache, shortness of breath, or rash.^{6, 27} Therapists may also notice small pustules, boils, abscesses, carbuncles, cellulitis, or impetigo.²⁸

Vancomycin-resistant enterococci

Enterococci often exist in the digestive and urinary tract of asymptomatic individuals. However, once a person becomes ill, these bacteria can become resistant to vancomycin, one of the leading antimicrobial medications. VRE is a leading cause of urinary tract infections, bacteremia, wound infections and endocarditis in U.S. hospitals.²³ VRE also contributes to pelvic and abdominal infections as well as meningitis and otitis media.¹⁹

VRE can be spread to patients via contact with contaminated urine, stool, or blood. It is also commonly spread through patient contact with contaminated surfaces or by the hands of healthcare workers who have not practiced good hand hygiene.²⁹ Rates of VRE tend to be the highest for patients who are on dialysis, ^{30, 31} or who have had organ transplants,^{8, 32} cancer^{,33, 34} or experienced cardiac, central intravenous, or urinary catheterization.^{13, 21, 35, 36} Previous exposure to beta-lactam antibiotics, such as vancomycin, also predisposes patients to VRE.^{13, 36} It is also more common with patients who have had abdominal, brain, or pelvic surgery.³⁷ Unfortunately, the majority of patients who have undergone these surgeries tend to be treated in hospital ICUs where MDROs are easily spread due to the close proximity of patients and frequent contact by healthcare workers.

Signs and symptoms of VRE include erythema, drainage, or pain at the site of the wound infection, or patient reports of increased fatigue, fever, nausea, or vomiting. Patients with urinary tract infections and a history of recent urinary catheterization should be screened for VRE.¹⁹

MDROs across healthcare settings

Obvious implications arise for PTs who work in the intensive care unit or acute care settings of hospitals. Therapists should understand the signs and symptoms of MRSA and VRE and discuss any potential signs and symptoms of these diseases noted during the physical therapy session with the patient’s nurse or primary care provider. Although the rates of CA-MRSA have increased over the last several years, both MRSA and VRE are considered healthcare-associated infections and greatly affect those on the acute care service. Although MDROs can affect any patient, statistically patients who have experienced coronary artery bypass grafting, total joint replacements, spine surgery, burns, cardiac or urinary catheterization, abdominal or pelvic surgery, organ transplants, brain surgery, dialysis,  compromised immune systems, and a history of taking steroids are most susceptible to MDRO transmission and infection. ^{2, 6, 8,13,17,19, 25-27,29-37}

All healthcare providers in the acute care setting should practice appropriate hand hygiene, both before and after patient contact, to prevent the spread of bacteria. PTs should wash their hands or properly utilize hand sanitizer between patients, even if gloves are worn during the treatment session. The most effective strategy for reducing the rate of microbe transmission is to increase the rate of good hand hygiene.^38-40 Hands should be washed with soap and water if visibly soiled; otherwise, hand sanitizers can sufficiently eliminate germs and bacteria. Unfortunately, research has shown that healthcare workers have lower handwashing compliance in ICUs and NICUs where patients are the sickest and most susceptible to MDROs.⁴¹ Hand hygiene compliance is often lower in these busy units, where staff members may be assigned to treat a large number of patients and may not have the time to practice proper hand hygiene.

As inadequate cleaning of hospital surfaces has been linked to MRSA outbreaks at several hospitals,^42-46 it is recommended that all patient equipment, such as walkers, crutches, commodes, blood pressure cuffs, stethoscopes, and goniometers, be disinfected with antibacterial wipes before and after patient use.^{19, 35} PTs should disinfect common areas that patients come into contact with, such as the stairs and handrails, following patient use as well. PTs must observe all isolation precautions, contact precautions, and standard precautions as established by their hospital’s infection control department and should be sure to educate patients, patients’ visitors, and other staff members of such precautions. Patients and their families should be encouraged to maintain proper hand hygiene while outside of patient rooms, and patients should be reminded to not share personal care items that can spread MDROs, such as towels, shaving razors, bar soaps, cosmetics, combs, and clothing.^{6, 27} While rehabilitation nurses should remain at the forefront of patient and family education regarding the spread of MDRO transmission, the entire healthcare team needs to demonstrate proper infection control practices.³⁵

PTs working in inpatient rehabilitation facilities, subacute rehabilitation, or long-term care centers encounter similar obstacles on the job. A majority of the patients who reside in these facilities are advanced in age, have several comorbidities predisposing them to MDROs, have undergone surgery, or are immunocompromised. PTs in these settings should observe all of the same rules as those in acute care. Emphasis should be placed on infection control guidelines and patient/visitor education. A 1998 study demonstrated that VRE was not spread by direct patient-to-patient contact or by exposure to contaminated surfaces as some studies suggest, but was solely transmitted by the hands of contaminated healthcare workers who had not practiced proper hand hygiene.⁴⁷

In the rehabilitation setting, patients are often exercising in a physical therapy gym. PTs need to cover gym mats or treatment tables with pillows and sheets before patient use and must be sure to wipe down these areas with antimicrobial agents after use. Common treatment areas touched by patients, such as stairs, handrails, parallel bars, treadmills, exercise bikes, weights, or assistive devices, should also be cleaned before and after patient use.^{35, 48} If possible, patients at these facilities should be assigned their own walkers or wheelchairs for their exclusive use throughout their stay at the facility and be given their own elastic exercise bands, tape, orthoses or other items typically used during the PT treatment session. Therapists should also make sure that all patients who come to the gym with open wounds have them properly dressed.

Although MDRO infections can be transmitted at any location, the CDC emphasizes several factors that contribute to the spread of such diseases in the community. According to the CDC, the five Cs include: crowding, compromised skin, frequent skin contact between individuals, contaminated surfaces or items, and a lack of cleanliness.²⁸ For these reasons, CA-MDROs tend to spread quickly in schools, day care centers, dormitories, crowded households, shelters, locker rooms, gyms, military barracks, and correctional facilities.⁴⁹ As PTs encounter patients as a primary care provider in some states, they need to know the signs and symptoms of both MRSA and VRE.

Therapists working in outpatient clinics or health and wellness centers need to recognize the importance and impact of nosocomial versus CA-MDRO infections as reports of CA-MRSA affecting healthy athletes is on the rise.^{50, 51} Patients participating in contact sports, such as football or wrestling, are at high risk for infection.^52-54 MDROs can easily be spread in locker rooms, gyms, and artificial turf and therefore, these areas should be disinfected regularly by custodial staff.²⁸ Patients with open wounds, turf burns, or skin abrasions should be encouraged to cover the opened area with appropriate dressings.^{28, 52, 55} All equipment found in the gym should be cleaned before and after patient use. Individuals should not share towels, uniforms, personal care items, clothing, or electrodes for electrical stimulation.^{28, 52} If possible, therapists should use disposable cryotherapy and moist heat modalities. Hydrocollators should be cleaned on a regular basis by custodial staff according to manufacturer guidelines because these units can harbor and spread MDROs.²⁸ PTs should be encouraged to follow proper hand hygiene precautions, don gloves if necessary during patient contact, and educate patients and staff members about proper handwashing guidelines and infection control practices.⁵²

Reports of MDROs proliferating in school-based settings have increased recently. Although mandatory MDRO-reporting regulations vary by state, therapists in this type of work environment need to be aware of their school’s policies and procedures in regard to this matter.²⁸ PTs should be alert for the signs and symptoms of MDROs and know to whom they should report any medical issues regarding potential student infection. As in the outpatient sector, schools often contain several rooms or areas that could foster infection, including the physical therapy gym, locker rooms, or gymnastic or wrestling mats. All toys, games, mats, assistive devices, or other surfaces that come in contact with children’s skin should be disinfected before and after student use. All school staff should be aware of proper hand hygiene practices and educate students accordingly.²⁸

School-based PTs can play a pivotal role in educating fellow staff members about the dangers of MRSA. Specifically, physical education instructors should follow similar precautions to those used in the physical therapy gym and be sure that athletic gear, such as pads and helmets, are not shared by students. Students should keep any open wounds or abrasions covered during contact sports and are encouraged to shower after playing contact sports or using gym equipment.²⁸ All uniforms should be laundered in hot water with laundry detergent and placed in a hot dryer to prevent the spread of MRSA skin infections.⁶

A majority of patients receiving homecare physical therapy have experienced a recent hospitalization or a change in functional status. PTs practicing in the homecare setting need to understand patients’ medical and surgical histories and comorbidities and consistently document patients’ wounds, especially if the patient is not receiving homecare nursing services. Incisions should be closely observed for any signs of infection, and therapists should accurately document any significant changes in patients’ functional status. Most importantly, therapists should educate the patient and the patient’s family about the signs, symptoms, and transmission of MDROs. This may include patient and family education about proper wound care, hand hygiene practices, and ways to reduce the spread of MDROs to other family members and the community.

All therapists need to maintain proper hand hygiene and follow standard precautions when working with patients who have been diagnosed with MDROs. Patients should always be encouraged to cover open wounds when in common areas of a hospital or clinic and properly dress wounds while in the community. Patients with confirmed infections should be reminded to not share personal care items and to practice proper handwashing. However, patient and staff education remains the most important component in the decrease of the transmission of MDROs in the hospital or in the community.