When MRSA Strikes

The question is not if, but when MRSA will show up in your athletic department. This author recounts his school’s experience in stopping the infection’s spread.

By Chuck Kimmel

Chuck Kimmel, MA, LAT, ATC, is the Head Athletic Trainer and Assistant Athletic Director at Austin Peay State University. He is also President of the National Athletic Trainers’ Association and can be reached at: KimmelCW@apsu.edu.

Training & Conditioning, 16.2, March 2006, http://www.momentummedia.com/articles/tc/tc1602/mrsastrikes.htm

It starts innocently enough, as a lesion on the skin. And how many athletes don’t have those? But, if not treated quickly, it can result in serious illness and even death.

I am talking about methicillin-resistant staphylococcus aureus or MRSA (pronounced mer-sa), a staph infection that is becoming more and more prevalent in high school and college athletic departments. It is difficult to detect, easily misdiagnosed, and not always seen as a significant threat. The American Journal of Sports Medicine reported in November that “many sports medicine physicians are unfamiliar with the epidemiology of this pathogen.”

However, MRSA should be on the mind of every athletic trainer and team doctor. In 2003, a college football player in Pennsylvania died of MRSA. This fall, a high school football player in Georgia was hospitalized and attached to an artificial lung for weeks before recovering from MRSA. These are just two stories of many.

Here at Austin Peay State University, we had our first experience with MRSA this past fall. Through the course of the season, 10 football players and one volleyball player were diagnosed with MRSA. Two of the football players were hospitalized and the remaining athletes were treated and kept out of participation for about a week.

We were lucky. We caught the initial illness fairly early and were given the resources to prevent a larger outbreak. We found that, overall, the most important factors in keeping MRSA at bay are: being on the lookout for it and being aggressive about preventing its spread. If an outbreak has not occurred in your area, it will. Be prepared to deal with it when it strikes.

WHAT IS MRSA?
The key letter in MRSA is the R, which stands for “resistant.” MRSA is a significant threat because it is resistant to commonly used antibiotics, including methicillin, penicillin, and cephalosporins. That means if a physician prescribes a common antibiotic, it will have no effect and the infection will have the opportunity to spread.

MRSA’s resistance to commonly used antibiotics has developed over time as a result of the widespread use of antibiotics, individuals who do not complete the prescribed course of medications, improper prescribing of antibiotics, and the sharing of medications. For many years, prescribing antibiotics was the standard of practice whether it was appropriate or not. Over time, the “bugs” have adapted to the drugs in their efforts to survive, and drugs that were once effective can no longer kill the infection.

The first reported incident of MRSA was in 1968, but the disease was confined to hospitals and nursing homes for many years. Over the last decade it has started to show up in other settings, including the athletic community. The first published report of an incident in athletics occurred in 1998. Over the past two years, athletic departments across the country have been reporting cases with increased frequency.

MRSA presents itself as a skin lesion with a pustule, which can easily be overlooked as a normal pimple or other skin problem. Because MRSA is relatively new, even physicians are not spotting it. It is often initially misdiagnosed as a spider bite, even within the medical community.

If it is caught early, it can be treated fairly easily with specialized antibiotics. If not treated, it can lead to pneumonia, bloodstream infections, or surgical wound infections. In the case of the high school athlete in Georgia, the staph infection spread to his lungs when he came down with the flu.

The experience of our first Austin Peay athlete with MRSA was typical. He noticed a bad skin rash that wasn’t healing and went to an emergency room in his hometown, where he was diagnosed with a spider bite. Forty-eight hours later, he came to the athletic training room.

Since his was an untreated case of MRSA and the infection had progressed, he was immediately referred to Boyd Health Services on Austin Peay’s campus. From there, he was referred to Cooper Beazley, MD, a team physician. Because of the progression of the infection, the athlete was admitted and IV antibiotic treatment commenced. He remained in the clinic for four days.

In retrospect, that was the easy part of our ordeal. The hard part was trying to stop the spread of MRSA to other athletes.

HARD TO STOP
In most contexts, MRSA is not highly contagious, but it spreads easily in an athletic setting. And once it enters an athletic department, it is very difficult to eradicate.

The usual mode of transmission of MRSA is through body-to-body contact from an infected wound to an open wound on another person. The condition can also be easily transmitted from an object (a towel, for example) that has come in contact with the infection and then is used by another person who contacts a wound on their body. The bacterium is not, however, carried through the air, nor is it found in dirt, mud, or grass. It cannot live on artificial turf.

MRSA can also spread through “carriers,” people who carry the disease in its colonized state but do not suffer from it. It is believed that less than one percent of the population in the United States is colonized with MRSA (25 to 30 percent of Americans are colonized with nonresistant staphylococcus aureus). The infection is most frequently found in the nose in its colonized state. So, if a carrier sneezes and the spray comes in contact with an open wound, it can infect the person with the wound.

The majority of MRSA cases have occurred on football teams, where open wounds and body-to-body contact are frequent. Many football athletes delay covering wounds they judge as insignificant, and they see blood on their uniform as a badge of courage. The tackling and blocking that occurs during games and practices allow body-to-body transmission.

Wrestling would also appear to be a contender for the easy transmission of MRSA. But because the sport has strict rules about covering wounds, its reported numbers have been less than football’s.

However, all athletes are at risk because of the hygiene, or lack thereof, they tend to practice. Oftentimes, showers are delayed following practices for any number of reasons. It is common for team members to share towels, soap, equipment, razors, and so on. Since being a part of a team is an important psychological aspect of participation, sharing items with a teammate may be seen as not only normal, but as desirable.

PREVENTION MODE
When our initial case was diagnosed, the entire Austin Peay sports medical team went on high alert for MRSA. We put into place aggressive preventive and treatment measures. Within the span of a week, $5,000 was spent to help prevent the spread of MRSA (and that was from a cash-strapped athletics department).

In spite of the initial efforts, a second football player was admitted later that first week for IV treatment. Hospitalization of affected athletes was fortunately limited to two players. But the infection continued to spread for two months. The other players were diagnosed quickly, treated with a course of effective antibiotics (Bactrim DS, Doxycycline 100, or both, depending on the severity of the infection), and kept out of participation for a period of time that usually was less than one week. These athletes were also monitored closely until their wounds healed.

The first thing we did to halt the spread of MRSA was to carefully treat those who were infected. Wound dressings were changed as needed, and there were very strict rules about handling the wound so the bacterium would not infect others. Most important, gloves were worn until the wound was covered completely and hand washing was mandatory afterward.

Also as a part of the protocol, intact skin was cleaned with antimicrobial soap without mashing or scrubbing the area of cellulitis. When the area of cellulitis had induration present, heat was applied. With open skin, while immersed in water, the wound was cleaned with soap while gently rubbing it with a soft clean cloth.

We also went on the warpath, looking to catch any cases as soon as they presented themselves. Any athlete with a suspicious looking pustule, abscess, or cellulites was referred to Boyd Health Services, which cultured each wound if it was draining sufficiently to provide what was needed. We felt it was much better to refer too many suspicious athletes than not and miss a case of MRSA.

Once a possible case was identified, all subsequent lesions were treated as MRSA until it was officially ruled out. During the outbreak at Austin Peay, there were 26 athletes referred for skin lesions, and although only 10 were MRSA positive, all were treated as if they were MRSA until we had word of a negative test.

Any athlete with a suspicious wound was also given a bottle of antimicrobial soap and instructions to bathe with this soap for the next month. They were told not to squeeze or pop lesions and required to keep the wounds covered at all times.

It has been found that proximity is linked to acquiring the infection, so we were especially vigilant with players who had lockers adjacent to an infected teammate and players who are often in close contact with teammates (e.g., interior linemen). We also paid particular attention to starters because they are involved in a higher number of repetitions during practices and games than non-starters.

We provided cotton and neoprene sleeves to help prevent abrasions to athletes’ knees and elbows—MRSA cannot become an issue if there are no skin lesions that allow it to enter the body. Although use of the sleeves was highly recommended, it was not mandated. As the number of incidents decreased, so did the use of the sleeves, which is not the desired outcome, although easily understood.

Insisting on good hygiene was another key part of our prevention plan. Because of the cavalier attitude by many athletes, prevention had to be forced on them very strictly. For example, our first athlete to contract MRSA, after being released from the hospital, went through many practices and games with uncovered wounds and without wearing the sleeves we provided to him. He epitomizes the belief of many athletes that they are “10 feet tall and bulletproof” and would never contract MRSA—even if they already have! We tried to look at it this way: They are counting on us to help them.

Use of community towels was suspended for the remaining 10 football games. Towels used in the athletic training room and on the sideline were single use and were not to be shared. Razors had to be single use and disposed of after use. When possible, paper towels were used. Athletes were told to shower with warm water as soon as possible after activity and to always use a clean, dry towel.

Antimicrobial soaps were purchased and placed in every locker room. Since it has been found that MRSA not only survives but thrives on bar soap, we installed and only used liquid soap dispensers. Each locker room, including its shower area and surfaces, went through a weekly sanitization.

In addition, an antimicrobial additive was purchased for use in the department’s laundry room. MRSA can survive many laundry detergents, so each load of laundry was treated with a chemical (Vanguard) that kills MRSA.

Proper cleaning procedures were reviewed with the equipment personnel and our equipment was regularly sanitized. Athletic training room tables were wiped down after each treatment. The use of whirlpools was restricted to very few athletes and we sanitized the tub after each use.

The weightroom was given special attention. All surfaces were disinfected and the floor and benches were cleaned on a regular basis. Carpet is a very hospitable place for MRSA and should be avoided if possible. If carpet is used, it should be disinfected regularly.

For everyone involved on every level of athletics, frequent and thorough hand washing was the mode of operation. Hands were washed regularly with antimicrobial soap for at least 15 seconds while working up a good lather. Hands were dried with a clean, dry cloth or paper towel.

And the sports medicine staff took even more precautions. Although proper use of gloves had become standard procedure in the athletic training room, proper procedures were reviewed and strictly adhered to. Antimicrobial hand wipes and hand sanitizer use was required following contact with any athlete, whether they had a wound or not.

Another point for discussion was that healthcare providers are often “carriers” of the infection because of their close contact with patients. Because of this, some doctors advocate that athletic trainers be tested for MRSA. When a person is found to be a carrier, mupirocin ointment is placed in the nose, which kills the bacteria. In our case, because the outbreak was brought under control relatively quickly, our physician felt we did not need to take this step.

The last key to prevention is education, so we spent time communicating all we knew to everyone in the athletic department. Dr. Beazley spoke to the football team and emphasized their responsibilities to protect both themselves and their teammates. We educated and updated coaches and administrators, and they were very cooperative, reminding teams on a daily basis about proper hygiene and wound management.

In addition, from the start, everyone was aware that this cluster would probably include a larger portion of the team before it was brought under control. All this communication definitely helped: By the end of the first week of the outbreak at Austin Peay, any athlete with any break in their skin was coming in for an evaluation.

Statistically, approximately 10 percent of our football players were diagnosed with MRSA and it was spread throughout the team. The illness was first seen on Sept. 1, 2005 and the last case was diagnosed on Nov. 9, 2005, the week of the final game.

BEFORE IT STRIKES
It’s easy to think, “MRSA won’t touch our athletic department.” Or, “We’ll worry about it if and when it happens.” But the truth is that it can strike quickly, and all schools should implement preventive measures now. MRSA invariably gets a head start on those who are responsible for caring for the condition, and ongoing prevention is the only way to keep it from spiraling.

Preventive education can also help catch a case quickly, which is imperative to avoiding hospitalization or fatality. At this point, you may be more knowledgable about MRSA than a physician your athlete sees. Therefore, you may need to be vigilant in checking athletes even if they have been cleared by a doctor. Ask them to get a follow-up appointment or a second opinion if you feel the athlete’s wound is being misdiagnosed.

If there were only one tool in the toolbox to fight MRSA, hand washing would be the most valuable one. The occurrence of MRSA would be significantly reduced if everyone washed their hands aggressively and often. For healthcare providers, hand sanitizer should and must become a part of their practice with frequent use throughout the day. By following and teaching proper hygiene, we can best serve those who depend on us to keep them healthy and involved in their chosen sport.

A version of this article is running in our sister publication, Athletic Management.

Resources:
The Centers for Disease Control (CDC) has the most up-to-date information on MRSA. Type “MRSA” in the search window at:
www.cdc.gov.

The CDC also provides a page of handouts for the public:
www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html.

The National Athletic Trainers’ Association’s official statement on MRSA is a valuable resource that can be distributed to healthcare providers and made available to athletics administrators, coaches, and athletes:
www.nata.org/publicinformation/docs/MRSA_Statement.pdf.

The NCAA’s Web site has a list of further resources about MRSA. Click on “Injury Prevention”, then “Skin Infection Prevention” at:
www.ncaa.org/health-safety.

The NFHS has recently revised its communicable diseases policy to address infectious skin diseases. It can be found on the “Sports Medicine” link at:
www.nfhs.org.


Sidebar: From the NATA
As part of its official statement on MRSA, the NATA suggests the following prevention and management recommendations for MRSA:

1. Keep hands clean by washing thoroughly with soap and warm water or using an alcohol-based hand sanitizer routinely.
2. Encourage immediate showering following activity.
3. Avoid whirlpools or common tubs when an athlete has open wounds, scrapes, or scratches.
4. Avoid sharing of towels, razors, or daily athletic gear.
5. Properly wash athletic gear and towels after each use.
6. Maintain clean facilities and equipment.
7. Refer to appropriate health care personnel all active skin lesions and lesions that do not respond to initial therapy.
8. Administer or seek proper first aid.
9. Encourage health care personnel to seek bacterial cultures to establish a diagnosis.
10. Care for and cover skin lesions appropriately before participation.

The above is reprinted with permission of the National Athletic Trainers’ Association.