Physicians Expect to See More Cases in Athletes
The Physician and Sports Medicine -- Lisa Schnirring
As football, wrestling, and other contact sports seasons get underway, physicians are bracing for more waves of methicillin-resistant Staphylococcus aureus (MRSA) infections. The first report of MRSA infection on sports teams was published in 1998.1 Since then, clusters of MRSA outbreaks in sports settings have been reported by the Centers for Disease Control and Prevention (CDC).2 According to media reports, two Miami Dolphins football players were hospitalized with MRSA infections early in the 2003-2004 National Football League season.
Prompted by the CDC report, the National Federation of State High School Associations and the National Collegiate Athletic Association (NCAA) issued alerts to their members in October 2003 urging vigilance about MRSA infections.
David D. Cosca, MD, a family practice physician in the sports medicine department at the University of California, Davis, says the UC-Davis football team has had several occurrences of MRSA infection, and that many players required hospitalization for intravenous (IV) antibiotics, surgical incision, and drainage. "I have been impressed with the virulence of this organism, the invasiveness, and the seemingly little skin trauma that serves as a means of entry—even something as little as a bruise with no skin breakage," Cosca says.
About MRSA
Once associated only with nosocomial outbreaks, MRSA skin and soft-tissue infections among athletes appear to be part of a trend toward wider community emergence. In the past few years, pockets of MRSA infections have also been documented in military recruits, correctional facilities, minority populations, and indigenous people.
Heightened concerns about MRSA infections focus on their resistance to all commonly prescribed beta-lactam antibiotics as well as the difficulties identifying and treating the infections. Treatment with antimicrobials must often begin before MRSA is cultured and identified as the cause of the infection.
Jeff Hageman, MHS, an epidemiologist with the CDC, says sports-related clusters of MRSA infection are still being reported to the CDC. He attributes some of the volume of recent reports to increased awareness of MRSA infections.
The CDC's response to the reports, Hageman says, has been to educate healthcare staff, coaches, and players about the risk factors for MRSA, which the CDC has distilled into the five Cs:
•
close skin-to-skin contact,
•contaminated items (ie, towels, razors, soap),
•crowding,
•cleanliness (ie, poor hygiene), and
•compromised skin integrity.
In the recent CDC report2 documenting outbreaks in sports, MRSA was thought to be spread by shared pads and a sensor wire in fencers and shared balms, lubricants, and unwashed towels in football players. Authors of the report emphasized the potential of MRSA spread, even in sports that involve little skin-to-skin contact.
In addition to ongoing updates about MRSA on the CDC Web site,3 Hageman says the agency is currently working with the NCAA to develop educational materials that will initially be targeted to athletic trainers, whom he notes are often the first line of defense in detecting infectious skin conditions in athletes. Educational materials will also be created for coaches and players, and he says all materials will be available to the public.
Managing MRSA Infections
An informal poll of physicians who responded to a query posted by the physician and sportsmedicine on the American Medical Society for Sports Medicine e-mail listserv reveals that MRSA infections are not uncommon.
Jon G. Divine, MD, MS, medical director of the Sports Medicine and Biodynamic Center at Cincinnati Children's Hospital Medical Center, says he first encountered MRSA in high school and university football players in the fall of 2000 when he worked in Houston. He says the typical presentation appears as a pimplelike lesion that popped, a spider bite, or an infected mosquito bite that started small and progressed quickly to a painful, inflamed, indurated area that is much larger than the original lesion.
He says almost every school district in the Houston area has experienced a small outbreak among athletes. Initially, the MRSA cultures were sensitive to trimethoprim with sulfamethoxazole (TMP-SMZ), tetracycline hydrochloride, and quinolones. However, he says healthcare professionals became very concerned after some isolates came back with resistance to quinolones. "This class [quinolones] should be avoided in children and in athletes; reports of tendinous ruptures still circulate," Divine says.
"We have not seen very much of this in Cincinnati yet, but I know it's coming," Divine says. "The hard part has been to get other community physicians to understand that this is a new pathogen, basically, and we need to change how we treat the acute boil," he says, adding that cephalosporins that are often prescribed for folliculitis and infected carbuncles will not work. "I would strongly recommend that we change our initial empirical treatments to either TMP-SMZ or a member of the tetracycline family," he says. For patients who have MRSA infections, Divine also institutes alternating warm and cold compresses, application of drying agents, and nonsteroidal anti-inflammatory drugs (NSAIDS).
James E. Dunlap, MD, family practice physician in Las Vegas, recently treated four patients (not all were athletes) who had MRSA-infected pilonidal cysts and boils that developed into abscesses and cellulitis. Two required hospitalization for IV antibiotic treatment, incision, and drainage. Three of the four patients responded well to double-strength TMP-SMZ twice daily along with rifampin for 2 weeks. Dunlap says his experience with TMP-SMZ alone or in combination with rifampin was reaffirmed by what he read in a dermatology journal and in recent literature on MRSA pneumonia prevention in burn patients. "Thank goodness, because most of the athletes I see could not afford treatment with levofloxacin," Dunlap says.
Ken Anderson, DO, a family practice physician in San Diego, has seen several patients with MRSA infections, usually on the extremities. He says that none of these have exhibited systemic effects; all were young, otherwise healthy patients. While waiting for the cultures to return in 2 or 3 days, Anderson usually starts patients who have suspected MRSA infections on an empiric course of clindamycin hydrochloride. "The lesions are usually sensitive to it," Anderson says.
Divine says the symptoms that would prompt him to hospitalize a patient with a MRSA infection include high fever, fatigue, and localized pain that is difficult to manage on an outpatient basis.
Colonization Issues
Several sports medicine physicians who shared their experiences treating MRSA infections suggest that if a player has a repeat MRSA infection, swabbing the patient's and teammates' noses should be performed to identify a carrier. Those identified as carriers should be treated with mupirocin ointment.
Hageman says infectious disease experts are still trying to learn more about the characteristics of MRSA, especially how it interacts with athletes and other fit, healthy hosts. He says that on nasal swab tests, about 30% of the general population are colonized with S aureus and that less than 1% are colonized with MRSA.
Return to Play and Prevention
There are no published return-to-play recommendations specifically for athletes who have MRSA infections, so many physicians are using general guidance for other bacterial skin infections and the NCAA guidelines for wrestlers. In the fall of 2003, Rollin Perkins, MD, chief of sports medicine and team physician at Southern Illinois University in Carbondale, encountered MRSA in a college football player who was treated for MRSA-infected furuncles on his arm, chin, and leg at various times throughout the past year.
Perkins informed the coach that if the player develops a furuncle that cannot be covered or if a teammate develops a furuncle that is positive for MRSA, he will not be allowed to practice or play until the lesions are dry. "Also, the player carries a bottle of disinfectant with him when he is in the weight room or using treatment tables. He cleans everything after he uses it," Perkins says.
Once a player on a team has been diagnosed with a MRSA infection, several physicians responded that they, their staffs, and teams use standard precautions to avoid spreading the infection.
Divine says lesions often develop at friction sites, so his medical team focuses on frequent changes of clothing, regularly washing players' gear in bactericidal soap, and adding a topical bactericidal soap to the showers. He adds that the medical staff is more vigilant when players sustain abrasions on artificial turf.
Players should be taught to report and avoid picking at any suspicious lesions, Divine says, particularly those that change rapidly and those that seem small, but are extremely tender or painful. "Basically, it's what your kindergarten teacher taught you: Wash your hands, don't pick your nose, and don't pick at your skin," says Divine.
