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Infections in Sports

CA-MRSA, Herpes, Impetigo, and More

Playe, Stephen J. MD

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    Athletics promote unusually close contact between participants, facilitating the transmission of infectious diseases. Skin infections can be transmitted by direct person-to-person contact or by shared contaminated equipment. Respiratory infections can be transmitted by droplet spread caused by coughing, sneezing, or direct deposit of respiratory fluids. Lacerations can theoretically lead to bloodborne transmission. And there have even been reports of fecal-oral spread of gastrointestinal disease when passion for the game apparently supersedes common sense concerning personal and communal hygiene.

    All team sports can promote the transmission of droplet spread illnesses, including influenza and upper respiratory tract infections when proper cough hygiene and droplet precautions are not employed. Sharing drinking water sources or hot tubs also can promote disease transmission among team members.

    CA-MRSA is becoming increasingly common, with many reports of infection transmitted between athletes

    Wrestling provides the greatest opportunity for spreading disease due to the prolonged close physical contact that is essentially always involved. Herpes simplex frequently infects wrestlers, and has earned the label “herpes gladiatorum.” Wrestlers also are prone to tinea corporis (“tinea gladiatorum”) as well as furunculosis, impetigo, and molluscum contagiosum.

    Rugby, particularly in the scrum (in which players link arms with heads down to try to obtain possession of the ball), affords similar close, prolonged physical contact. Ruggers are prone to herpes infections (“herpes rugbeiorum”) as well as streptococcal infections (“scrum strep”).

    Football has made the news because of the spread of community-acquired MRSA (CA-MRSA) skin and soft tissue infections. The St. Louis Rams professional football team, once referred to as the “greatest show on turf,” has the dubious distinction of being the source of a report describing “turf burns” infected by MRSA that was then transmitted to opponents, particularly linemen and linebackers. (N Engl J Med 2005;52[5]:468.) This is just one of a growing number of reports of CA-MRSA transmission among football players at all levels of competition. A notorious football game between Florida State University and Duke University (referred to cryptically as a “Florida team” and a “North Carolina team”) was reported because the Duke team suffered an outbreak of Norwalk virus, and transmitted the disease to the Florida State team. (N Engl J Med 2000;342[17]:1223.)

    In response to reports of players retching on the sidelines and playing in uniforms “soiled with vomitus and feces,” the author suggests that “both fecal-oral transmission and aerosol transmission of vomitus probably occurred, given the intense physical contact and the use of bare hands that are characteristic of the game of football.” (N Eng l J Med 2000;342[17]:1223.) Give the Duke players credit: They lost the game 62–13, but their willingness to play while ill led to a unique form of revenge.

    Even fencing, a sport that involves very little personal contact, has been implicated in an outbreak of MRSA. It is suggested that this could be because fencers wear a sensor wire under their clothes to record when they have been touched by an opponent's weapon. These wires were routinely shared, and had no routine schedule of cleaning. (MMWR 2002;52[33];793.)

    The Infections

    Community-acquired MRSA is becoming increasingly common, and there are many reports of this infection being transmitted between athletes. Our index of suspicion for skin and soft tissue infections being caused by CA-MRSA must be high particularly when there is purulence or necrotic tissue. In addition to drainage, debridement, and generally thorough wound care, cultures are advised and empiric therapy might best be high-dose trimethoprim/sulfamethoxizole (two double-strength tablets BID for seven days) with the possible addition of rifampin (300 mg PO BID), which enhances the effectiveness against MRSA and provides additional coverage for potential streptococcal involvement.

    Athletes should be kept out of competition until wounds are completely healed. Recurrent infections can be prevented by chlorhexidine body washes daily for three days and then three times per week. Nasal carriage of MRSA can be treated with intranasal povidine-iodine or mupirocin. Beware that CA-MRSA can cause severe infections, including necrotizing fasciitis and necrotizing pneumonia. Hospitalization, with intravenous vancomycin or linezolid therapy, is frequently required.

    Impetigo can develop on any exposed skin surface after skin-to-skin contact in sports such as wrestling, rugby, and football, and perhaps from fomites (i.e., mats, equipment, and towels), even in sports such as gymnastics that entail very little skin-to-skin contact. Topical mupirocin should be used with the possible addition of oral antibiotics, such as a second-generation oral cephalosporin. The athlete may return to competition after five days of therapy if the lesions have become crusted.

    Rugby played in the scrum where players link arms with heads down to try to obtain possession of the ball makes ruggers prone to herpes and streptococcal infections.

    Hot tub folliculitis, caused by Pseudomonas aeruginosa, can result from inadequately chlorinated water, prolonged exposure in the spa, or skin abrasions. It tends to respond spontaneously in seven to 10 days, and individuals who receive antibiotics are more likely to have recurrences. (Derm Nursing 2001;13[5].)

    Furunculosis should be treated with topical mupirocin as well as oral antibiotics. Cultures may be necessary to rule out MRSA. Athletes may participate if their lesions are appropriately bandaged, but if the prevalence of furunculosis is high on the team, participation should be restricted during active infection.

    Herpes simplex is relatively common, particularly among wrestlers and rugby players. The well-defined, grouped vesicles are diagnostic, and may be accompanied by systemic symptoms, including fever, chills, and headache. Treatment can be with acyclovir, valacyclovir, or famciclovir for 10 days. Wrestling can be resumed four to seven days after the initiation of treatment if the vesicles have resolved.

    There have been no validated cases of HIV transmission in the athletic setting. There has been one documented case of hepatitis B virus transmission among sumo wrestlers in Japan. It is recommended that all competitors in athletics receive affective HBV vaccination. Bleeding wounds must be appropriately dressed before the athlete returns to competition.

    Tinea corporis is particularly common among wrestlers. Treatment should include a topical agent (such as clotrimazole BID for three weeks) as well as an oral antifungal agent (such as fluconazole 200 mg po weekly for three weeks). The athlete may return to competition after five, but preferably after 10, days of therapy.


    Athletes should be fully immunized, particularly against measles, hepatitis B, and tetanus. Good personal hygiene, including soap and water showers after practice or competition, as well as team adherence to proper cough etiquette, should be encouraged. Sharing equipment, towels, and drinking water should be discouraged. Ill and potentially infectious athletes should refrain from participation (even if it is a big game against Florida State).

    Athletic trainers and medical personnel should practice universal precautions, contact precautions, and droplet precautions. Team physicians and trainers should be vigilant in the surveillance of infectious diseases to enable timely implementation of measures to avoid outbreaks.

    © 2006 Lippincott Williams & Wilkins, Inc.