MRSA in Athletes

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Introduction to MRSA

Page by Robert Wennemer, Kenyon '13

Staphylococcus aureus, often referred to as "staph", is a type of bacteria that is typically found on the skin and/or in the noses of people [7]. Methicillin-Resistant Staphylococcus aureus, or MRSA, is a form of staph that is resistant to antibiotics of the penicillin class that are commonly used to treat infections [4]. MRSA is prevalent in both the healthcare setting, known as Hospital-Acquired Methicillin-Resistant Staphylococcus aureus (HA-MRSA), as well as the community setting, known as Community-Acquired Methicillin-Resistant Staphylococcus aureus (CA-MRSA) [10]. Recently, CA-MRSA has become a major problem for athletes due to the transfer of bacteria through person to person contact, sharing of personal items, and poor hygiene, all common aspects of athletics/athletic teams. At one point in time MRSA only infected people in hospitals and other medical facilities that were sick, but the new strain of MRSA and recent trends show that athletes are a main target of the bacteria. MRSA typically results in minor skin infections that appear in the form of boils and sores. These skin abrasions become swollen and painful, and often release some form of drainage [4]. Athletes that play high-physicality sports, such as football and rugby, have a greater chance of acquiring MRSA because athletes face more person to person contact in these sports. MRSA is more common among high school and college athletes than professional athletes due to the greater concentration on proper sanitation and education in professional sports, but MRSA still has made its way into some professional locker rooms [8]. Symptoms of MRSA include swelling, warmth, redness, and pain at areas on the body where abrasions develop. Approximately 30% of people have MRSA in their noses, but show no signs or symptoms. Although rare, MRSA can have more serious implications than just skin infections such as pneumonia, and bone or blood infections [4]. Incision and drainage of the infection is the most effective form of initial treatment, but doctors may prescribe oral antibiotics if the abrasion does not heal. MRSA raises an important health problem because it can be easily transferred from athlete to athlete if the proper steps are not taken to control it. Once contracted by an athlete, MRSA poses a threat for the entire team.

Figure 1: A town in Northern Canada shows an upward trend of MRSA cases from 2003 to 2006, very similar to that of the United States. An increase in infection is especially noticeable in the "Under 19" age group [3]. Graph provided by the Public Health Agency of Canada <www.publichealth.gc.ca>.

MRSA Studies in Sports

Several studies in both amateur and professional sports show that MRSA is a problem on the rise for athletes.

A study done by the Nebraska Department of Health and Human Services on MRSA in Nebraska high schools shows a rise of infection from the 2006-2007 to 2007-2008 school years.

312 Nebraska high schools were surveyed, 271 responded, an 87% response rate. [1]

In the 2006-2007 school year, 12 of the 271 high schools experienced MRSA infections among one or more of their athletes, a 4.4% infection rate. During the 2007-2008 school year, however, Nebraska high schools experienced an increase of MRSA infections. During this year, 39 of 271 high schools saw MRSA infections among one or more of their athletes, a 14.4% infection rate, which was a 10% increase from the previous school year. [1]

Nebraska high schools were then asked about specific athletes from football and wrestling. MRSA incidence per 10,000 wrestlers was 19.6% in the 2006-2007 school year. Numbers rose again during the 2007-2008 school year, as MRSA incidence per 10,000 wrestlers hit 60.1%, a 40.5% increase. In the case of football, MRSA incidence per 10,000 athletes was at 5.0% during the 2006-2007 school year. During the 2007-2008 school year, MRSA incidence rose to 25.1% per 10,000 football players. This was a 20.1% increase. [1]

Overall, a large increase in MRSA infections was observed in Nebraska high schools from the 2006-2007 to 2007-2008 school years. Infection was especially prevalent in the high contact sports of wrestling and football.

A study done by numerous doctors and published in The New England Journal of Medicine observed MRSA infection among members of the St. Louis Rams professional football franchise.

The study was retrospective as it entailed a nasal-swab survey of 84 St. Louis Rams football players and staff members, testing for MRSA infection during the 2003 NFL season. During the season, 8 MRSA infections were found among 5 of the 58 Rams players (9%) that were tested. All infections developed on areas of the body that are commonly places of turf injury. Linemen and linebacker positions were the most significant category to develop infections, most likely because these athletes encounter more person to person contact than players of other positions. [2]

Methicillin-susceptible Staphylococcus aureus, a MRSA clone, was found in team taping gel and whirlpool water samples. The clone was also found in 35 of the 84 team members that were tested (42%). [2]

The Evolution of MRSA & Subsequent Dangers

MRSA was first seen in U.S. hospitals during the 1970's as a pathogen that caused healthcare-associated infections among the elderly and sick. Since that time, MRSA has spread to healthcare facilities throughout the world, and has become the most common pathogen to cause healthcare-associated infections. In today's setting, MRSA accounts for about 50-70% of the Staphylococcus aureus infections that are present in healthcare facilities across the world [10]. In a recent study performed by the Association for Professionals in Infection and Epidemiology to investigate MRSA prevalence, it was found that 46 out of every 1,000 patients were infected or colonized with MRSA [10]. These numbers are approximately ten times greater than previous estimates [10]. Figure 1 shows a case regarding CA-MRSA, while Figure 3 shows a case involving HA-MRSA. Both forms, as shown by the figures, are on the rise.

Recently, a new strain of MRSA know as Community Acquired Methicillin-Resistant Staphylococcus aureus, or CA-MRSA, has left hospitals and began to spread in the community. This is the strain that is prevalent among athletes. The difference between CA-MRSA and Healthcare-Associated MRSA (HA-MRSA) lies in their effects, as CA-MRSA typically causes skin infection while HA-MRSA causes bloodstream, urinary tract, and surgical site infections [10]. As a result, CA-MRSA is less dangerous than HA-MRSA. Another major difference between the two strains is that CA-MRSA is more vulnerable to antimicrobials, most typically levofloxacin and clindamycin, than HA-MRSA [10]. Figure 2 shows MRSA up close under a microscope.

Figure 2: This image shows MRSA bacteria under a microscope [6]. Gathered from Massachusetts Institute of Technology online, provided by UCLA Newroom, 10/17/07.

Subsequent Dangers of MRSA-Related Injuries

A case study of a high school football player shows subsequent dangers that can arise after an athlete believes they have recovered from a MRSA infection.

Person: Boone Baker
Background: High school football player from Texas

Baker received a turf-abrasion one Friday night in October during his high school's football game. After the game, he cleaned and covered the injury on his own. At the beginning of the next week, Baker's abrasion turned into a purple, boil-like mark. Baker received medical attention; his physician drained and treated the wound with Septra, an antibiotic used to treat CA-MRSA. He was cleared to play football ten days after being healed. [9]

The following January, Baker's MRSA infection re-surfaced. Soon after the infection developed, he became sick with flu-like symptoms. Baker began to experience back and neck pain, irregular breathing, and lost the ability to move his legs. He was brought to the hospital, where two days after experiencing the symptoms, MRSA was found in Baker's body. After being placed in the intensive-care unit, Baker's body exploded with boils and abrasions. Doctors gave him massive quantities of antibiotics, but his condition still worsened. [9]

Doctors decided to take a full-body MRI, in which they discovered two large pustules at the base of his spine. Surgical removal of the pustules along with more antibiotics improved Baker's condition. More symptoms arose, however, as Baker was not able to see out of his right eye. The MRSA infection had moved into his eye. Antibiotic ointment was used to save the eye, which Baker regained full vision in. Lastly, blood clots in his legs and an infection on his lung required more surgery to help Baker make a full recovery. [9]

After more than a month in the hospital and severe weight loss, Baker was saved. The problem was a result of the CA-MRSA that entered his body during the turf-sustained injury. This is an example of what subsequent dangers can evolve after the generally less-dangerous altercations of a MRSA infection. This case study along with similar studies concerning athletes in California and Pennsylvania demonstrate some of the more dangerous implications that can arise resulting from MRSA infections. [9]

MRSA Prevention

There are several easy steps that can be taken to significantly reduce MRSA infections:

The Practice of Proper Personal Hygiene

It is very important to practice good personal hygiene. Athletes should wash their hands with soap and warm water frequently to protect against MRSA bacteria [7]. It is important to wash hands before and after participating in sports, sharing weights during work-out sessions, caring for wounds, and going to the bathroom [4]. Liquid soap is preferred over bar soap when washing hands to reduce sharing among individuals [4]. Athletes should also shower immediately following sport-activity. When showering, it is important to not share soap, towels, etc. to prevent the transmission of MRSA. Athletes should also take good care of their equipment and sport clothing, which can be done by regular washing and cleaning of anything that is used during sport-activity.

Skin Protection

Athletes should wear proper gear and clothing to protect from turf and contact injuries that would result in skin wounds. If a person is to receive a skin abrasion, it is important to take care of the wound by cleaning it out and covering it with the proper bandages/tape recommended by the team trainer [4]. One should also check bandages regularly to make sure that they are kept dry. The cleaning and dressing of the wound should be followed until it is completely healed. If athletes receive a skin wound that cannot be covered, it is important to stop from touching the area as much as possible [4].

Sharing of Items

Athletes should not share items that come in contact with the skin [7]. Such items include towels, soap, razors, personal equipment, clothing, footwear, etc [7]. This will reduce the chance of spreading MRSA. Athletes should also not share creams or ointments that require the use of hands to retrieve from a container. When working out, towels should be placed on benches or bars that athletes need to come in contact with to create a barrier between the individual's skin and the surface [4]. This rule also applies to saunas, locker rooms, etc.

Cleaning

Cleaning one's personal space will also help in preventing MRSA [7]. The use of chemical cleaning products is a good way to keep an athlete's area clean. MRSA bacteria can stay on a surface for weeks or months at a time, which is why it is important to disinfect regularly [4]. Areas that one should clean include their locker, shower, chairs, room, car, and work-out spaces. A janitor will clean some of these places, but it is important to check and make sure that the area is kept clean. Athletes can also carry alcohol-based wipes to disinfect areas that get dirty on a daily basis, such as dumbbells in a gym or handles in a shower.

Conclusion

Studies and statistics show that MRSA is a major health issue for many people, especially those involved in athletics. Proper steps must be taken by athletes both on and off the field to protect against MRSA infections. Trends show that in recent years the number of MRSA infections have been on the rise in athletics, most significantly in the high school and college age groups. There is hope, however, that shows if athletes take the problem seriously and follow through with the procedures of defending against MRSA, that infection trends can begin to decrease. In a study done at the University of Southern California, players took the steps necessary to stop MRSA during the three football seasons from 2002 to 2004, which resulted in a decline in the number of MRSA infections during those years [8]. Players and staff were educated on the necessary procedures which consisted of covering wounds, using antibacterial cleaner, refraining from sharing cream/ointments, and proper maintenance of equipment and personal items [8]. Through following these guidelines, the football organization saw a decrease in the number of MRSA infections [8].

Another example of MRSA awareness in the community can be seen through DICON, an organization formed by Duke University. This group works to minimize healthcare-associated infections, and has put a strong emphasis on MRSA, as it has become a significant problem in the world of sports [5]. Members of DICON took the initiative to form an educational program with the goal of reducing MRSA infections in athletes [5]. The organization meets with trainers and players to educate them on the steps that can be taken to defend against MRSA, and does evaluations of the team's athletic facilities to see if they are adequate to stop MRSA [5]. DICON also provides the institutions with educational aids, maps, and lectures to prevent MRSA, which the teams can refer to both on the field and in the locker room.

These sorts of initiatives are vital to prevent MRSA. As presented, infections can be easily stopped at a very low cost. Education on the procedures that need to be taken to stop infection is the most crucial part of such programs. Teaching athletes what they need to do to defend against MRSA is the foundation for stopping infection and staying healthy.

Figure 3: Increase in HA-MRSA infections among patients in Seattle Children's Hospital through 2007. HA-MRSA is more dangerous than CA-MRSA. <http://scienceblogs.com/digitalbio/mrsa_incidence_at_seattle_childrens.gif>.

References

1. Buss, BF., Mueller, SW., Theis, M., Keyser, A., Safranek, TJ. "Populaiton-based estimates of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections among high school athletes--Nebraska, 2006-2008". "U.S. National Library of Medicine National Institutes of Health". 2009. Volume 4. p. 282-291.

2. Kazakova, S., Hageman, J., Matava, M., Srinivasan, A., Phelan, L., Garfinkel, B., Boo, T., McAllister, S., Anderson, J., Jensen, B., Dodson, D., Lonsway, D., McDougal, L., Arduino, M., Fraser, V., Killgore, G., Tenover, F., Cody, S., Jernigan, D. "A Clone of Methicillin-Resistant Staphylococcus aureus among Professional Football Players". "The New England Journal of Medicine". 2005. Volume 352. p. 468-475.

3. Larcombe, L., Waruck, J., Schellenberg, J., Ormond, M. "Rapid emergence of methicillin-resistant Staphylococcus aureus (MRSA) among children and adolescents in Northern Manitoba, 2003-2006". "Canada Communicable Disease Report". 2007. Volume 33. No. 02.

4. "About Methicillin-Resistant Staphylococcus aureus (MRSA) among Athletes." Centers for Disease Control and Prevention. 2008. Department of Health and Human Services. 28 November 2009. <http://www.cdc.gov/ncidod/dhqp/ar_MRSA_AthletesFAQ.html>.

5. "MRSA Infections in Athletes." Duke University School of Medicine. 2009. Duke Infection Control Outreach Network. 29 November 2009. <https://dicon.mc.duke.edu/modules/dicon_mrsa/index.php?id=2>.

6. Payne, Oran. "Combating Methicillin-resistant Staphylococcus aureus." Angles/2009. 2009. Massachusetts Institute of Technology: Writing about Science and Technology. 1 December 2009. <http://web.mit.edu/angles/Oran_Payne.htm>.

7. "MRSA: Information for Coaches and Athletes." Minnesota Department of Health online. 2007. Minnesota Department of Health. 27 November 2009. <http://www.health.state.mn.us/divs/idepc/diseases/mrsa/mrsaathletes.html>.

8. "Athletes Susceptible to Antibitotic-resistant Staph Infections." Newswise. 2008. American Academy of Dermatology. 28 November 2009. <http://www2.team-logic.com/userfiles/file/154/3%20Am%20Academy%20of%20Dermatology%20Athletes%2008.pdf>.

9. Zeigler, Terry. "CA-MRSA: An Athlete's Life-Threatening Story." Suite 101. 2009. Sports Injuries. 28 November 2009. <http://sportsinjuries.suite101.com/article.cfm/camrsa_an_athletes_lifethreatening_story>.

10. "National Prevalence Study of Methicillin-Resistant Staphylococcus aureus (MRSA) in U.S. Healthcare Facilities." Hawaii Primary Care Association. 2007. Managing Infection Control. 2 December 2009. <http://www.hawaiipca.net/files/mrsa_study_results.pdf>.