There are many questions that surround the concept of prevention, recognition, evaluation, and treatment of infections that occur in athletes, which include the following:
- If you were to see a skin outbreak that looks suspect on one of your athletes, would you know what it was or who to refer them to?
- Do you allow athletes with a skin outbreak to continue to participate?
If so, what precautions do you take to prevent the spread to other athletes?
If not, when or how long do you prevent the athlete from participating?
- What steps should you take to prevent outbreaks?
If an athlete is diagnosed with having community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), do you know how to prevent the spread of infection to other athletes?
How often and what type of cleaning and disinfection protocol does your facility use?
The purpose of this article is to outline the responsibility of the athletic community, including strength and conditioning professionals, coaches, and athletic trainers, in the recognition, evaluation, treatment, and prevention of skin infection. Specifically, CA-MRSA will be reviewed. The differences between methicillin-resistant Staphylococcus aureus (MRSA) and CA-MRSA will be described, and the treatment and prevention of both will be discussed.
ETIOLOGY AND TREATMENT
Staphylococcus aureus (staph) is a common bacterium that causes a wide range of infections. These infections may range from mild skin and soft tissue infections to more serious systemic infections (31). Staph is commonly carried on the skin or in the nose of healthy people with approximately 32% of the population carrying staph in the nose (15). Other areas where staph may be present in large quantities are in the axilla and inguinal region; however, it may be present anywhere on the body. Staph may be present without a colonizing infection; however, if the skin is damaged (i.e., cut, scrape, incision, or other wounds), the staph may penetrate the wound and cause an infection (25).
Although staph is usually successfully managed, if overlooked, it may also cause serious infections such as pneumonia, systemic infections, and joint infections (22,30). Staph may be spread by the infected person to someone else or to an object. These bacteria have developed resistance to several important antibiotics. In 1959, methicillin was successfully used to treat penicillin-resistant S. aureus, but by 1961, cases were reported to have acquired resistance to methicillin (9). These cases were the first to be reported as methicillin-resistant Staphylococcus aureus, better known as MRSA. This resistance to antibiotics is making it more difficult to treat infections due to staph (1). MRSA has been shown, in patients admitted to a university hospital, to have a half-life of 40 months (27).
The selection of oral antibiotics to treat skin or soft tissue MRSA infection should be based on bacterial cultures and antibiotic susceptibility results. In athletes with mild localized infections without systemic signs of illness, at the advice of a physician, the use of warm soaks and drainage may be used, but they should be monitored for several days for their effectiveness before an antibiotic treatment is started. Antibiotic treatment alone may be ineffective in treating MRSA without incision and drainage (10). As stated previously, MRSA infections usually involve the skin and soft tissues, but occasionally, very serious deep-seated infections may occur (17). Examples of these serious deep-seated infections are rapidly fatal bacteremia, necrotizing pneumonia, and necrotizing fasciitis (18). These serious infections require antibiotics to be delivered intravenously (see Table 1 for currently used antibiotics).
MRSA has been reported as the leading cause of infections reporting to emergency departments across the United States, accounting for 59% of all skin and soft tissue infections (19). A different strain of MRSA (referred to as community-associated methicillin-resistant Staphylococcus aureus [CA-MRSA]) has emerged with increasing frequency in the community. CA-MRSA typically presents as boils, abscesses, and other soft tissue infections. One specific strain of CA-MRSA that is proficient at causing skin and soft tissue infections is the pulsed-field gel electrophoresis type USA300 (USA300), which has been recognized as the contributing agent in 97% of these infections (19).
The increase of CA-MRSA is occurring predominantly among persons who are healthy without typical health care-associated risk factors for MRSA acquisition (i.e., current or recent hospitalization, invasive devices, and living in a long-term care facility) (24,14). Outbreaks of CA-MRSA have been increasingly reported in sports teams around the United States (21). These outbreaks are often the result of environmental factors such as crowded living conditions, sharing of clothing, equipment, towels, and razors. Another reason for these outbreaks is related to improper care of skin trauma, skin-to-skin contact with MRSA lesions, and improper hygiene (5).
SIGNS AND SYMPTOMS
The athletic community should consider CA-MRSA infection when athletes report skin and soft tissue injuries that appear infected. Infection is recognized by the inflammation in the area. The 5 cardinal signs of inflammation are heat, rubor, swelling, pain, and loss of function. Heat in the area is due to the increased blood flow and increased metabolic rate due to infection. The redness in the potentially infected area is also due to the increased blood flow and increased metabolic rate but also due to the release of histamine associated with trauma. Swelling results from the leakage of inflammatory mediators into the surrounding tissues (28). Pain results from either mechanical or chemical irritation of the surrounding soft tissue and neural receptors. Tissue damage may lead to a loss of function, that is, loss of range of motion, loss of tissue flexibility, and loss of tissue mass (28). When CA-MRSA is suspected, the athlete should be referred to a physician.
Signs and symptoms of MRSA include small red bumps that resemble pimples, boils, or spider bites. These quickly turn into deep painful abscesses that may require surgical draining. Typically, the bacteria remain confined to the skin; however, on occasion, 23% of cases progress to a more serious infection (11). The progression develops from the bacteria that burrow deep into the body causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves, and lungs. When the athletes present with these signs and symptoms, they should be referred to a physician for further evaluation and a specific diagnosis. The athletic community should not attempt to diagnose the infection because incorrect assessment could become a life-threatening condition. Physicians diagnose MRSA by obtaining a culture of the infected tissue or nasal secretions for signs of drug-resistant bacteria. An accurate diagnosis of CA-MRSA usually takes up to 48 hours (6,29).
The foundation of preventive efforts against MRSA is good hygiene practices and efforts to minimize exposure or contact with the bacteria. These precautions seem to be common sense; however, many people overlook simple acts of daily hygiene that are essential in preventing infections. Good personal hygiene practices should be maintained by everyone (4).
Frequent hand washing is one of the most helpful, yet one of the most neglected practices that may help reduce MRSA infection. Hand washing should minimally occur upon entering and exiting the lavatory facilities (whether at home or in a public facility). Another time where hand washing should occur is when there is hand-to-hand contact with another person, which occurs frequently during the course of athletic activities (4). In these situations, hand washing may be difficult to perform; however, there are alternatives that may be used in the absence of soap and water. Minimally, facilities should offer alcohol-based hand sanitizers.
Alcohol-based hand sanitizers are more effective than soap and water in killing bacteria and viruses that may cause disease (13), but frequent use of alcohol-based hand sanitizers has been reported to cause a drying of the skin (2). To prevent the drying of skin as a result of hand washing and the use of alcohol-based hand sanitizers, frequent use of lotion and other skin-conditioning agents is advised. If hands are visibly soiled (dirty or stained), they should be washed with soap and water rather than using an alcohol-based hand sanitizer to remove the soil. Hand washing is more effective at removing soil than just sterilizing the soil. Hands should be dried using disposable paper towels or air blowers (7) for the most effective prevention of MRSA bacteria formation. While at home, towels may be used but the towels should be for the same person's use and not used communally with other members of the household.
PROPER HAND WASHING TECHNIQUE
Although it may seem elementary, a review of a proper hand washing technique is warranted. The Association for Professionals in Infection Control and Epidemiology (16) recommends the following steps be taken for proper hand washing.
To properly wash your hands, wet your hands with running water and apply soap (liquid is preferred rather than bar soap because bacteria may reside on the bar) (4).
- Lather your hands well by rubbing them together. Rub your hands vigorously together for at least 15 to 20 seconds (10,16).
- Ensure that all surfaces are scrubbed including the back of your hands, wrists, between your fingers, and under your fingernails.
- After 15 to 20 seconds of vigorous rubbing, rinse well.
- After all the soap has been removed from your hands, dry your hands using a disposable towel or air blower.
- If possible, use a disposable towel to turn off the faucet and open the facility door (16).
To properly use an alcohol-based hand sanitizer, apply about 3 mL of the product to the palm of your hand (26). After applying the alcohol-based hand sanitizer, rub your hands together covering all surfaces of your hands, including the back of your hands (32). Hands should be rubbed together for at least 10 to 30 seconds. An insufficient amount of the product may have been applied, if after 10 to 15 seconds of rubbing, the hands feel dry (2).
SHARED ATHLETIC EQUIPMENT AND FACILITIES
Athletes regularly share clothing, towels, personal items (i.e., razors, topical ointments, and deodorant), gloves, protective pads and equipment, benches, weight-training barbells and machines, aerobic exercise machines, exercise mats, medicine balls, and other small training equipments. The practice of sharing items is common, but not necessarily a safe practice to prevent infections from occurring. Therefore, the athletic community needs to take responsibility to make sure that any common sharing of items is kept to a minimum or if it is necessary for it to occur that maintenance and sanitation methods are used appropriately.
When shared equipment is used in a weight room or locker room, a towel or clothing may act as a barrier between surfaces of shared equipment and bare skin. To reiterate, towels should not be shared between athletes. Athletes should always wear proper attire during training that includes shirts, shorts, socks, and shoes (12).
Shared equipment, including weight benches, bars, and weight machines, should be cleaned and disinfected daily to reduce the possibility of MRSA. Surfaces of equipment should be wiped clean before and after use, especially if the surface has become wet with sweat. Any surfaces that may be touched should be routinely disinfected (10). This is made possible by making available spray bottles of disinfectant to athletes so that they may clean frequently touched surfaces of shared equipment between uses (see Table 2 for a partial list of Environmental Protection Agency-registered products).
Equipment should be cleaned daily with the purpose of removing soil. Shared equipment surfaces should be disinfected daily with an Environmental Protection Agency-registered detergent disinfectant according to the manufacturer's instructions. Following the manufacturer's instructions is important because many products used for destroying bacteria need to be left on the surface for a set amount of time. Therefore, following the guidelines on the container is essential for controlling disease transmission. In the instance of an equipment or a furniture becoming damaged in a way that it may not be adequately cleaned (i.e., tears in surface coverings and padding or foam that does not have a protective barrier), it should be repaired or discarded (20).
A time effective way to disinfect large areas, such as locker rooms, weight rooms, restrooms, shower facilities, and meeting rooms, is through the use of aerosolized sanitizer (fogging). Studies have shown that fogging is an effective method in reducing MRSA colonization on flat surfaces (8,23). Examples of flat surfaces are weight benches, locker room benches, walls, and floors. When fogging an area, all doors, windows, and ventilation outlets should be closed or turned off. The area should be fogged for at least 2 hours. During fogging, access to the area should be restricted. To facilitate airflow during fogging, box fans may be used to circulate the disinfectant in the area without filtering. Although this is an effective method for reducing the colonization of MRSA, there are areas that are not susceptible to fogging. These areas, such as the insides of lockers, undersurfaces, hardware, and other appliances, should be sprayed directly with a disinfectant on a routine basis (23).
Shared towels, sheets, blankets, or uniforms should be washed with a laundry detergent in a water temperature of 160°F (71°C) for at least 25 minutes for best results (7). If a lower temperature wash cycle is selected, use a laundry detergent that is appropriate for cold or warm cycles and wash for at least 25 minutes. If you choose to use laundry additives (like bleach and fabric softener), follow the manufacturer's instructions. A mechanical dryer set on a hot temperature cycle should be used to complete the disinfection process (3). Towels, sheets, blankets, and uniforms should not be allowed to air-dry. Towels and uniforms should only be distributed when they are dried completely. Towels and washcloths should be washed on a daily basis (7,10). Athletes should not be allowed to wear the same uniform or clothing multiple times before they are washed.
TREATMENT SAFETY TECHNIQUES
When an athlete has a skin lesion/wound, such as boils, insect bites, open sores, or cuts present, it should be covered with a clean dry dressing as part of the management of the injury. The wound must remain covered at all times. The dressing must be changed at least twice a day or more frequently if drainage is apparent or as directed by the physician. Consider using clean, disposable, nonsterile gloves to change bandages (3). Use barriers between skin and shared equipment to prevent transmission of bodily fluids and/or exudates.
Athletes should refrain from sharing products that require placing your hand in an open container (3,7). A barrier should be used between the skin and shared product such as disposable gloves to decrease the risk of product contamination. As a common practice, athletes should shower after workouts to help reduce the possibility of infection or cross-contamination (3).
Guideline 4.3 of the National Strength and Conditioning Association's (NSCA) Strength and Conditioning Professional Standards and Guidelines states that “all equipment, including free weights, should be cleaned and/or disinfected regularly as deemed necessary by staff,” furthermore, “users should be encouraged to wipe down skin-contact surfaces after each use”(20). In following Guideline 4.3, it is important for the strength and conditioning professionals to develop infection control plans for the facilities in which they work. It has been recommended that the strength and conditioning professionals develop a more specific definition of “regular” cleaning and disinfection than the one the NSCA recommends (30). This article has attempted to give the strength and conditioning professional the tools to develop an infection control plan and better define “regular” cleaning and disinfection.
Although it is impossible to eradicate the infection, the occurrence of CA-MRSA may be greatly reduced through good personal hygiene, reduction of shared equipment use, effective laundering of clothing and towels, cleaning of shared equipment and facilities, and properly managing current infections. It is the responsibility of the staff as a whole to take part in the reduction of CA-MRSA by working diligently and making a conscious effort to follow CA-MRSA prevention guidelines, thus providing athletes a safer environment in which they train and compete.
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