Shelby Scott, M.D., FACSM, is part-time faculty at Natividad Medical Center in Salinas, CA and associate clinical faculty at UCSF School of Medicine. She practices Family Practice and Sports Medicine in the Santa Cruz area of California.
Everyone knows wrestlers pass skin maladies between each other because of the skin-to-skin contact involved in the sport. Less well known, however, is that some skin infections can be spread through less casual sport contact. Recently, sports-related resistant bacterial infections have been reported from gyms and locker rooms alike (1-3). There have been outbreaks of bacterial skin infections reported from different professional football teams, fencing clubs, and college locker rooms. There also have been outbreaks reported among inmates in an epidemic spreading across the United States (4, 5). Because inmates are a captive population, cases in the jails are easier to recognize and document. Based on anecdotal evidence and the increase of cases contracted through health clubs in Santa Cruz County, it is likely that there are many more outbreaks than reported in the literature.
The multiple drug-resistant germ, methicillin-resistant Staphylococcus aureus (MRSA), has been reported in the medical literature since the 1960s. Some bacteria have the ability to share pieces of their genetic material with each other, enabling them to pass on genes to prevent damage caused by antibiotics or infection-fighting cells. Staphylococcus aureus is one of these germs. This resistant bacterium infected people primarily in hospitals and nursing homes until the 1990s. Methicillin-resistant S. aureus is opportunistic, infecting people with weakened immune systems, people on large doses of antibiotics that eliminate resident skin flora, and people with postoperative wounds. It is called health-care-associated MRSA (HA-MRSA). In the 1990s, a new strain of MRSA emerged. The new strain, known as community-associated MRSA (CA-MRSA), infects otherwise healthy people outside the health-care setting. The two strains of MRSA are distinct. HA-MRSA is more difficult to eradicate and requires intravenous antibiotics. CA-MRSA is usually susceptible to oral antibiotics (6). There is emerging resistance to some of the antibiotics, but trimethoprim-sulfamethoxazole or clindamycin alone will treat the infection. Table 1.
CA-MRSA abscesses, or collections of pus, often respond well to surgical drainage in the office. Interestingly, in a recent study of CA-MRSA treated in emergency departments, most infections respond to treatment even when patients were given antibiotics to which the bacterium was resistant (6). Despite responding more readily to treatment, the CA-MRSA can cause serious infections and even death. Currently, one in seven people infected with CA-MRSA fails outpatient treatment and requires hospitalization (6).
Both HA-MRSA and CA-MRSA are spread by direct contact, so the primary defense against infection is strict adherence to universal infection precautions as outlined by the U.S. Centers for Disease Control and Prevention (Table 2).
These standards are already implemented in health-care settings. Federal accreditation for health-care facilities requires clinical standards for teaching, testing, and monitoring adherence to the hand washing and infection control guidelines.
This may help to quell HA-MRSA, but recent trends in MRSA show a rise in the number of CA-MRSA cases. A recent article in the New England Journal of Medicine documented that 59% of soft tissue and skin infections treated at 11 university-affiliated emergency departments in August 2004 were of CA-MRSA (6). More than 97% were of a single strain of MRSA bacteria, which is noteworthy considering the geographic diversity of the study. Approximately 25% to 30% of the population harbors the nonresistant bacterium in the patients' nose. This bacterium varies only slightly from CA-MRSA and, in some studies, has been linked as a possible source of transmission (2). In addition, two million people harbor CA-MRSA in their noses (7). With the extra genes making the bacterium more virulent, all it takes to spread it is a rub of the nose and shaking of hands without washing first. This emphasizes the importance of hand washing and helps to explain why CA-MRSA is becoming so prevalent.
In addition to hand washing, there are some ways to decrease the spread of CA-MRSA (Table 3). It is important to examine any wounds and for supervisory personnel to routinely check for skin lesions. Any painful pimples on any part of the body may be the start of a CA-MRSA infection. Athletes with any suspicious lesion should be referred for medical evaluation and proper treatment. Any skin lesions must be properly and completely covered because wounds offer a portal of entry for the bacteria. If the wound cannot be completely covered, consider excluding athletes with potentially infectious skin rashes or wounds from practice or play until the lesions are healed or can be completely covered. Any athletes with covered wounds must remain vigilant about checking the dressing. Anyone working with athletes needs to instruct them about the spread of infection and the need to follow proper hygiene guidelines. Instruct athletes in the importance of showering with soap and hot water after working out. As obvious as this seems, not all athletes shower after workouts. The mechanical friction associated with showering removes "transient" skin bacteria picked up from incidental contact with other athletes and athletic equipment during turnouts and can significantly reduce all forms of communicable skin diseases. To help athletes follow this protocol, facilities need to provide clean showers, soap, and properly laundered towels.
Educating athletes about the spread of bacteria can cut the rate of infections. Athletes need to know about transmission of germs through sharing towels, razors, clothing, and equipment, including creams and gels. Simple protocols such as covering shared equipment, such as weight benches, with a clean towel and providing sanitary wipes for the athletes to clean equipment after each use can cut down on shared infections. In addition, all facilities need to implement a regular cleaning schedule. This includes lockers, showers, whirlpools, and exercise equipment.
In summary, CA-MRSA is increasing in the community and is easily passed between athletes by incidental contact or sharing of equipment. Implementation of simple cleaning procedures in gyms can decrease the rate of infection. Most importantly, instruction of athletes and coaches in the recognition and prevention of CA-MRSA will significantly cut down on the rapidly increasing spread of CA-MRSA in athletes. The U.S. Centers for Disease Control and Prevention Web site has information and fliers for all athletic facilities to use (8).
1. Methicillin-resistant Staphylococcus aureus
infections among competitive sports participants-Colorado, Indiana, Pennsylvania, and Los Angeles County, 2002-2003. MMWR. Morbidity and Mortality Weekly Report
2. Kasakova, S.V., J.C. Hageman, M. Matava, et al. A clone of methicillin-resistant Staphylococcus aureus
among professional football players. The New England Journal of Medicine
4. Methicillin-resistant Staphylococcus aureus
infections in correctional facilities-Georgia, California, and Texas, 2001-2003. MMWR. Morbidity and Mortality Weekly Report
5. Public health dispatch: outbreaks of community-associated methicillin-resistant Staphylococcus aureus
skin infections-Los Angeles County, California, 2002-2003. MMWR. Morbidity and Mortality Weekly Report
6. Moran, G.J., A. Krishnadasan, R.J. Gorwitz, et al. Methicillin-resistant Staphylococcus aureus infections among patients in the Emergency Department. The New England Journal of Medicine
7. Voyich, J.M., K.R. Braughton, D.E. Sturdevant, et al. Insights into mechanisms used by Staphylococcus aureus
to avoid destruction by human neutrophils. Journal of Immunology