Dealing with infectious disease in athletes is, perhaps, not as dramatic as attending to a sudden on-field injury, but it can have a much greater effect on the team’s success. Military history shows that infectious disease routinely disables more fighting men than battle wounds, and the situation is similar in competitive sports. Just imagine yourself, as a team physician, confronting an outbreak of herpes gladiatorum on the wrestling team during the final weeks of the season, or the specter of half your football team suddenly developing vomiting and diarrhea on Saturday morning just before facing the toughest opponent of the year, or six simultaneous cases of influenza on the basketball team in January. Under these circumstances, the importance of infectious disease prevention in sports becomes crystal clear.
Luckily, most situations involving infectious disease in sports are not that sensational, but prevention can play a huge role in athletes’ success. Some infectious disease that may be spread during sports participation can threaten long-term health or even life itself. Team members, team physicians, and the entire sports medicine team must practice the principles of infection prevention routinely.
Recently, cases of skin infections caused by Methicillin-Resistant Staphylococcus aureus (MRSA) have been identified in the community. While most cases have involved athletes, cases involving non-athletes have also occurred. Staphylococcus aureus, often refered to simply as “staph,” are bacteria commonly carried on the skin or in the nose of healthy people. Approximately 25% to 30% of the population is colonized (when bacteria are present, but not causing an infection) in the nose with staph bacteria. Sometimes, staph can cause an infection. Staph bacteria are one of the most common causes of skin infections in the United States. Most of these skin infections are minor (such as pimples and boils) and can be treated without antibiotics (also known as antimicrobials or antibacterials). However, staph bacteria also can cause serious infections (such as surgical wound infections, bloodstream infections, and pneumonia).
Some Staph bacteria are resistant to antibiotics. MRSA is a type of staph that is resistant to antibiotics called beta-lactams. Beta-lactam antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. While 25% -30% of the population is colonized with staph, approximately 1% is colonized with MRSA.
The treatment of infections due to Staphylococcus aureus was revolutionized in the 1940s by the introduction of the antibiotic penicillin. Unfortunately, most strains of Staphylococcus aureus are now resistant to penicillin. This is because Staphylococcus aureus has learned to make a substance called beta-lactamase that degrades penicillin, destroying its antibacterial activity. Some related antibiotics, such as methicillin and flucloxacillin, are not affected by beta-lactamase and can still be used to treat many infections due to beta-lactamase-producing strains of Staph. Unfortunately, however, certain strains of Staph, known as MRSA, have now also become resistant to treatment with methicillin and flucloxacillin.
Although other types of antibiotics can still be used to treat infections caused by MRSA, these alternative drugs are usually not available in tablet form and must be administered through a drip inserted into a vein.
Staph including MRSA can be spread among people having close contact with an infected person. MRSA is almost always spread by direct physical contact and not through the air. However, spread may also occur through indirect contact by touching objects (e.g. towels, sheets, wound dressing, clothes, workout areas, or sports equipment) contaminated with Staph bacteria or MRSA.
Staph bacteria can live on the skin or in the nose of healthy individuals without causing any symptoms of disease. This is known as colonization and MRSA can also be carried in this way. However, injury to the skin (e.g. scrape or cut) can allow an opportunity for bacteria to enter the skin and cause an infection.
Infections caused by Staph or MRSA are usually mild, limited to the surface of the skin, and can be treated successfully with proper hygiene and antibiotics. In rare cases, if left untreated or not recognized early, MRSA infections can be difficult to treat and can progress to life-threatening blood or bone infections because there are fewer effective antibiotics available for treatment.
To diagnose an MRSA infection, a sample from the infected wound (either a small biopsy of skin or pus taken with a swab) must be obtained to grow the bacteria in the microbiology laboratory. Once the Staph is growing, the organism is tested to determine which antibiotics will be effective for treating the infection. A culture from a known or suspected skin infection is especially useful in recurrent or persistent cases of skin infection, in cases of antibiotic failure, and in cases that present with advanced or aggressive infections (e.g. bloodstream infections).
Athletes, athletic personnel, and parents can help prevent and control MRSA infections within the athletic setting by following these simple health and hygiene practices:
1. Wash hands frequently with soap and water, especially after using any sports facilities.
2. Avoid sharing personal items (e.g., towels, washcloths, razors, clothing, or uniforms) that may have had contact with an infected individual or potentially infectious material.
3. Report any suspicious skin sore or boil to your healthcare provider and school nurse immediately.
4. If you participate in sports involving close personal contact (e.g. wrestling and football) shower with soap immediately after each practice, game, or match.
5. Non-washable gear (e.g. head protectors), should be wiped down with alcohol after each use.
6. Athletic equipment such as wrestling or gymnastics mats should be wiped down regularly with an antibacterial solution (e.g. Hibiclens).
7. Individuals with an infection involving drainage (e.g. pus drainage), who are involved in close contact sports, should be excluded from participation in sporting events and practices until no pus drainage is present and the infected site can be adequately covered with a bandage and clothing.
8. Any cut or break in the skin should be washed with soap and water and a clean, dry dressing applied on a daily basis, before and after participation in close contact sports, and after using any sports facilities.
9. Tell your healthcare provider (e.g. primary care doctor or school nurse) and the appropriate athletic personnel if you currently have or have had a history of an antibiotic-resistant Staph skin infection(s).
MRSA has been recognized as a problem in the healthcare setting for over 20 years. The CDC believes that MRSA has been emerging in the community over the last several years for reasons that are unknown. It is difficult to determine whether there is an increase in MRSA disease in the community or an increased awareness and recognition of MRSA disease. However, it is clear that some of the recently recognized outbreaks of CA-MRSA are associated with strains that have some unique properties compared to the traditional hospital-based MRSA strains. However, further testing and confirmation of CA-MRSA are needed.
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