Locker room-acquired MRSA

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections were first reported in the literature in the mid-1990s. Soon thereafter, the disease became an epidemic.^1,2 Among the groups that have been identified as at risk for CA-MRSA are children and athletes.³

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Community-associated MRSA is easily transmitted, and the infections it causes can be serious and associated with significant morbidity. Therefore, pediatrician awareness of the high probability of CA-MRSA infection among patients participating in sports will help facilitate an accurate diagnosis and proper management. The features of CA-MRSA, however, also underscore the importance of infection control measures. By counseling patients and their families about the risk of CA-MRSA infection and preventive strategies, pediatricians can make a valuable contribution to limiting the burden of this disease.

Epidemiology and spectrum of CA-MRSA

Methicillin-resistant S aureus was originally recognized as a nosocomial pathogen causing infections among hospitalized patients and nursing home residents. Compared with hospital-associated MRSA (HA-MRSA), CA-MRSA strains have different bacteriologic characteristics, which include enhanced virulence, increased ability to spread, and a tendency for recurrence.^4,5

Good data on the epidemiology of CA-MRSA infection are not available because it is not generally a reportable disease.⁶ A variety of studies, however, highlight that CA-MRSA is a leading cause of skin and soft-tissue infections (SSTIs) and a common skin infection among sports participants.

In a study of 422 patients with SSTIs seen at university-affiliated emergency departments, MRSA was the cause in 59% of cases and nearly all the MRSA isolates were community-associated strains.⁷ Responses to a survey sent to athletic trainers at high schools throughout Texas showed that almost one-third of the nearly 200 respondents had seen cases of MRSA infection among their students.⁸ In a systematic review of French and English language articles reporting outbreaks of cutaneous infections among athletes, MRSA was the most commonly mentioned pathogen.⁵

Most published reports of MRSA infections in student athletes pertain to teenaged or young adult men on high school or college sports teams. Similarly aged women, however, as well as children aged as young as 7 years also have been affected.^5,9,10

Although CA-MRSA is most frequently associated with SSTIs, it causes a wide spectrum of disease. Most CA-MRSA cutaneous infections usually manifest as an abscess and/or cellulitis, but these can also appear as erythematous papules and nodules, erythematous pustules, and/or crusted plaques, or with deeper soft-tissue involvement, such as pyomyositis or necrotizing fasciitis.¹⁰ Authors of the systematic review found that 29% of athletes with MRSA cutaneous infections required hospitalization.⁵ The management of these serious SSTIs has included surgical debridement and skin grafting in addition to intravenous antibiotics.^10,11 In addition, CA-MRSA can cause invasive infections, and there are cases of healthy student athletes who developed CA-MRSA paraspinal myositis with bacteremia and infective endocarditis.^12,13

NEXT: Understanding the athlete's risk

Understanding the athlete’s risk

The Centers for Disease Control and Prevention (CDC) describes the risk factors for CA-MRSA transmission by the 5 “Cs”: frequent skin-to-skin Contact, Contaminated items and surfaces, Crowding, Compromised skin, and lack of Cleanliness.¹⁴ The likelihood that these factors will be present among children and teenagers who participate in sports explains the increased risk of CA-MRSA infection among young athletes.

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The roles of frequent skin-to-skin contact and compromised skin integrity correspond with the fact that most published reports of CA-MRSA skin infection outbreaks among student athletes involve individuals playing combat or contact sports including wrestling, football, and rugby.^9,10 In addition, it explains why players of certain team field positions (rugby forwards; linemen, linebackers, cornerbacks, wide receivers on football teams) have been identified as being at greater risk.^10,15,16

Community-associated MRSA infections also have been reported among participants in numerous noncontact sports, however, including baseball, basketball, canoeing, fencing, soccer, cross-country, volleyball, and weight lifting, as well as in the household members and social contacts of infected athletes.^5,9,10 The latter associations are understood through the potential for infection to occur in anyone with a skin break exposed to CA-MRSA through incidental contact with an infected individual, asymptomatic carrier, or contaminated object.

The skin break may be an apparent sports-related injury on uncovered skin. For instance, abrasions from frictional contact with the court floor are common among volleyball players. Less obvious is the potential for skin to be traumatized in athletes by chafing from clothing or other protective gear. Shaving of body hair for competition-related or cosmetic reasons is another source of skin breaks that have been sites of CA-MRSA infection on exposed and unexposed skin.¹⁶

The portal for pathogen entry does not need to be a sports-related injury, however, as there are reports of CA-MRSA infection at the site of an ingrown toenail in athletes.¹⁰ As a bottom line, although CA-MRSA SSTIs mostly occur on exposed skin sites, including the arms, legs, nape of the neck, and face, these can develop anywhere. In addition, transmission can occur through direct skin-to-skin contact and by indirect exposure occurring through sharing of sports equipment and other objects, including whirlpool tubs, clothing, towels, and items used for hygiene or skin care.

NEXT: Preventive strategies

Preventive strategies

Measures to prevent CA-MRSA infection involve personal, environmental, and healthcare-initiated strategies that focus on maintaining good hygiene and eliminating the potential for bacteria transmission (Table 1).¹⁷ Findings of studies of professional and collegiate football teams affected by a cluster of MRSA infections demonstrate that the implementation of appropriate infection control measures is effective for limiting future outbreaks.^11,15

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The CDC recommends meticulous handwashing with soap and warm water and/or sanitation gels as the best way to prevent spread of any infection, and CA-MRSA is no exception. In addition, athletes should be instructed to shower with soap and warm-to-hot water as soon as possible after practices or competitions end.¹⁷

Use of liquid soaps rather than bar soaps for washing is recommended, and having waterless hand sanitizer gels available for sports participants to use before practice, competing, eating, or applying skin care products (eg, balms, lotions) is also helpful.⁶

In order to limit bacteria spread, sharing of towels, clothing, and personal hygiene (eg, razors, roll-on or stick deodorants) should be avoided. Labeling of all personal articles with an individual’s name or team number will help to prevent inadvertent sharing.⁶

Keeping nails trimmed short and removing jewelry prior to sports participation can help to minimize the risk of skin injury. To eradicate CA-MRSA from clothing and towels, the articles should preferably be laundered in hot water or with bleach added to the water, and the items should be thoroughly dried in a dryer rather than hung on a line.⁶

School athletic departments and private and public sports recreational facilities should have protocols in place for routine cleaning and disinfection of equipment and supplied clothing and towels.⁶ If there is a reason for concern, students and/or parents may wish to check about the availability of such protocols and confirm that they are being followed. Attention to personal hygiene and other precautions will help prevent infection if cleaning procedures are unknown.

Because infection is established at sites where the skin is disrupted, abrasions should be treated promptly by washing with soap and water, followed by covering the area with a dry clean dressing.^6,17 If the lesion cannot be adequately covered, the athlete should be excluded from practice or competition if there is concern about an infectious lesion.⁶ Any athlete with a draining skin lesion should be excluded until the lesion has been adequately treated.

Athletes and their parents should also be aware of the clinical features of CA-MRSA lesions so that they will promptly seek appropriate care and avoid picking at or trying to pop the lesion to encourage drainage (Table 2).¹⁷ It is worth mentioning to them that there are many reports of a CA-MRSA SSTI being initially mistaken as an insect or spider bite.¹⁰ Pain at a level that seems out of proportion to the appearance of the skin lesion is another sign that should raise particular suspicion of CA-MRSA infection.⁹

NEXT: Motivating positive behaviors

Motivating positive behaviors

Getting children and teenagers to practice the hygiene strategies for preventing CA-MRSA infection can be challenging. Furthermore, young athletes who do not want to sit out from participation may fail to report skin injuries and lesions.

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Because pictures may speak louder than words, brochures and websites that feature images of CA-MRSA lesions may make a greater impression than verbal counseling alone for encouraging good hygiene behaviors. Photos of MRSA skin infections are available on the CDC website (www.cdc.gov/mrsa/). In addition, hearing about CA-MRSA infection from affected individuals in their peer group may be a compelling way to get young athletes to appreciate the potential seriousness of the disease and the importance of following recommended strategies for prevention and care. Such real-life stories can be found on the website of the Infectious Diseases Society of America (www.idsociety.org/patient_stories/). Sports-specific posters about MRSA, skin care, and hygiene available from the CDC and the National Collegiate Athletic Association (www.ncaa.org/health-and-safety/medical-conditions/skin-issues) can also serve as useful on-site reminders.

Additional educational materials about CA-MRSA designed for school health professionals, parents, coaches, and student athletes are also available from the CDC website as well as from state and local health departments. A number of links can be found on the website of the University of Chicago Medicine, MRSA Research Center, at http://mrsa-research-center.bsd.uchicago.edu/patients_families/resources.html.   

NEXT: Treating a CA-MRSA infection

Treating CA-MRSA infection

Incision and drainage is the recommended management for any purulent SSTI, and it may be adequate as stand-alone therapy for simple cutaneous abscesses.¹⁸ There is some evidence, however, that adding an appropriate antibiotic will improve cure rates and limit relapse. The addition of antimicrobial therapy to incision and drainage is recommended to treat CA-MRSA in certain situations (Table 3).¹⁸ Oral antibiotic therapy alone may be appropriate for treatment of CA-MRSA purulent cellulitis in cases in which there is not a drainable abscess.¹⁸

In contrast to HA-MRSA, CA-MRSA remains susceptible to a variety of older antibiotics. Oral antimicrobial agents recommended for empirical therapy of suspected MRSA SSTIs include trimethoprim-sulfamethoxazole, clindamycin, tetracyclines (doxycycline, minocycline), and linezolid, which is more expensive than the older agents and has no advantage.¹⁸ Practitioners should consider patient age, allergies, and the local antibiogram when choosing an antibiotic for suspected CA-MRSA infection. A conservative approach would be to obtain a specimen for culture and sensitivity testing prior to initiating antibiotic treatment so that culture-directed therapy can be instituted if needed.

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The role of nasal decolonization in management and prevention of CA-MRSA infections is controversial, but it can be considered in cases of recurrent CA-MRSA SSTIs.¹⁸

NEXT: What pediatricians should do

Conclusion

Community-associated MRSA infections remain common, and children and teenagers who play sports are at increased risk. Nevertheless, CA-MRSA infections are preventable. Therefore, pediatricians should ask their patients about athletic participation so that they can identify those who are at risk. By providing information that will raise awareness of patients and their families about these potentially serious infections and educating them about preventive measures, pediatricians can help keep their patients healthy and active.

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REFERENCES

1. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA. 1998;279(8):593-598.

2. University of Chicago Medicine MRSA Research Center. MRSA history timeline: 1959-2012. http://mrsa-research-center.bsd.uchicago.edu/timeline.html. Accessed July 21, 2015.

3. David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(3):616-687.

4. DeLeo FR, Otto M, Kreiswirth BN, Chambers HF. Community-associated methicillinresistant Staphylococcus aureus. Lancet. 2010;375(9725):1557-1568.

5. Grosset-Janin A, Nicolas X, Saraux A. Sport and infectious risk: a systematic review of the literature over 20 years. Med Mal Infect. 2012;42(11):533-544.

6. Many PS. Preventing community-associated methicillin-resistant Staphylococcus aureus among student athletes. J Sch Nurs. 2008;24(6):370-378.

7. Moran GJ, Krishnadasan A, Gorwitz RJ, et al; EMERGEncy ID Net Study Group. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-674.

8. Barr B, Felkner M, Diamond PM. High school athletic departments as sentinel surveillance sites for community-associated methicillin-resistant staphylococcal infections. Tex Med. 2006;102(4):56-61.

9. Kirkland EB, Adams BB. Methicillin-resistant Staphylococcus aureus and athletes. J Am Acad Dermatol. 2008;59(3):494-502.

10. Cohen PR. The skin in the gym: a comprehensive review of the cutaneous manifestations of community-acquired methicillin-resistant Staphylococcus aureus infection in athletes. Clin Dermatol. 2008;26(1):16-26.

11. Romano R, Lu D, Holtom P. Outbreak of community-acquired methicillin-resistant Staphylococcus aureus skin infections among a collegiate football team. J Athl Train. 2006;41(2):141-145.

12. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus infections among competitive sports participants-Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000-2003. MMWR Morb Mortal Wkly Rep. 2003;52(33):793-795.

13. May CL, Hodde JP, Badylak SF, Smith GF. Infective endocarditis in a collegiate wrestler. J Athl Train. 1995;30(2):105-107.

14. Centers for Disease Control and Prevention. MRSA and the workplace. http://www.cdc.gov/niosh/topics/mrsa/. Accessed July 21, 2015.

15. Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med. 2005;352(5):468-475.

16. Begier EM, Frenette K, Barrett NL, et al; Connecticut Bioterrorism Field Epidemiology Response Team. A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis. 2004;39(10):1446-1453.

17. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus (MRSA) infections. Prevention information and advice for athletes. http://www.cdc.gov/mrsa/community/team-hc-providers/advice-for-athletes.html. Accessed July 21, 2015.

18. Liu C, Bayer A, Cosgrove SE, et al; Infectious Diseases Society of America. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55. Erratum in: Clin Infect Dis. 2011;53(3):319.

Ms Krader has 30 years’ experience as a medical writer. She has worked as both a hospital pharmacist and a clinical researcher/writer for the pharmaceutical industry and is presently a freelance writer in Deerfield, Illinois. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.