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Athletes seemingly innocuous superficial skin infection may actually be CA-MRSA
Colonization rates are about 1%, but athletes can rapidly spread it by direct or indirect contact.
Community-associated methicillin-resistant Staphylococcus aureus infections are causing concern among sports medicine physicians and athletes.
Recently Kathleen M. Weber, MD, MS, and Gary W. Dorshimer, MD, FACP, addressed the unique challenges in the sports setting for preventing and managing community-associated methicillin resistant S aureus (CA-MRSA) infection. Weber and Dorshimer run primary care/sports medicine fellowship programs in Chicago and Philadelphia.
“We know this is a worldwide problem,” Weber said at the American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meeting. “The trend for both community-associated and health care-associated MRSA is on the rise.”
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Early detection
Currently about 50% of nosocomial ICU and 40% of non-ICU infections seen in U.S. hospitals are from MRSA. Likewise, CA-MRSA is on a steady rise and some U.S. emergency rooms, although it varies by geographic area, have reported greater than 80% of all skin and soft tissue infections seen are MSRA related, Weber told Orthopedics Today. She noted the increased numbers of CA-MRSA cases have helped researchers learn more about infection transmittal in the community setting and some new, more effective treatments.
Weber and Dorshimer agreed the optimal approach for tackling CA-MRSA in athletes should involve early detection and treatment.
“CA-MRSA is usually a mild, superficial infection of the skin. It looks innocent when it first begins,” Weber noted. Dorshimer said clinical presentations include abscesses, tissue destruction, folliculitis, furuncles and carbuncles. Some lesions may be mistakenly diagnosed as spider bites.
Treatment can be tricky, however.
“Bacteria have developed ways to be resistant to … common antibiotics,” like Keflex (cephalosporin; Eli Lilly), making them harder to treat than some common infections, Dorshimer said during a joint AOSSM and American Academy of Orthopaedic Surgeons (AAOS) press conference held prior to the meeting.
Genetically different from health care-associated MRSA, CA-MRSA genetic subtypes seem to promulgate future transmission of resistance between organisms. Such genetic modification may explain why the number of CA-MRSA cases seems to be escalating, Weber explained.
More prevalent
The Centers for Disease Control and Prevention (CDC) reported at least three U.S. strains of CA-MRSA that are now more prevalent. Some have cytotoxins that create destructive holes in leukocytes, which lead to skin infections commonly seen in athletes.
Halting the spread of CA-MRSA in gyms and locker rooms is critical.
According to Dorshimer, some CA-MRSA infections are straightforward to treat but are more problematic once in the bloodstream where they can lead to hepatitis, osteomyelitis, fasciitis, sepsis or possibly death.
Athletes are at greater risk for exposure to the bacteria from shared equipment and mats. There are also more avenues by which they can contract an infection, from abrasions or cuts they get from their equipment to coming in contact with others. Opportunities for staph-transmitting athlete-to-athlete contact are also more frequent.
Identification
“We recommend more cultures,” to monitor MRSA prevalence and select appropriate antibiotics, Weber said. “Make sure you are culturing anything that has pus or is already draining.”
CDC officials suggest culturing lesions in cases of recurrent skin infection, advanced infection or when antibiotics fail, which also helps identify the strain in question.
If antibiotics are indicated, it is the physician’s job to ensure they are used appropriately and in combination with good skin-care practices, both of which are critical since athletes are often exposed to several “communities” and can be exposed to MRSA with different antibiotic-resistant patterns, Weber said.
Lesion management
“In wound management … inspect athletes with suspicious lesions often,” but wear gloves when doing this, Dorshimer said. “When it is not healing in a timely fashion … get more suspicious for the presence of MRSA.”
He recommended circling and measuring suspicious lesions and re-measuring them every day to see if they have grown. To encourage draining, cover wounds with warm compresses or open them surgically or with a scalpel. Then manage the athlete with oral or timed intravenous antibiotics, Dorshimer said
The antibiotics prescribed should be dictated by the organism’s susceptibility profile from culture results, according to the CDC Web site. Among antibiotics indicated for CA-MRSA, Bactrim (sulfamethoxazole and trimethoprim) has shown effectiveness and some evidence suggests chlorhexidine baths alone or in combination with other treatments can help decrease skin carriage, Weber said.
Return to play
“The key is early treatment and identification. If you have a skin infection the first thing you should keep in mind in your differential is MRSA,” Weber noted.
Dorshimer urged orthopedists to take part in return-to-play decisions. National Collegiate Athletic Association guidelines for MRSA infection state players can return after 72 hours of antibiotics and 2 days without a new lesion, he said.
Weber’s sports program benefitted greatly from having an infectious disease specialist inspect the facility’s training and locker rooms and make recommendations to minimize the teams’ CA-MRSA risk. She encouraged others to do likewise.
“The message to our athletes and our coaches is that antibiotics should be used appropriately and not for viruses,” she said.
For more information:
- Gary W. Dorshimer, MD, FACP, is program director of the primary care/sports medicine fellowship at the University of Pennsylvania Healthcare System, head team physician for the Philadelphia Flyers and team internist for the Philadelphia Eagles. He can be reached at Delancey Medical Associates, 727 Delancey St., Philadelphia, PA 19106; 215-829-3523; e-mail: gadors@pahosp.com.
- Kathleen M. Weber, MD, MS, is program director of the primary/sports medicine fellowship at Rush University Medical Center and the internist/sports medicine physician for the Chicago Bulls and Chicago White Sox. She can be reached at Rush University Medical Center, 1725 W. Harrison, Suite 1063, Chicago, IL 60612; 312-942-4301; kweber@rushortho.com. She received research support from Genzyme and is a paid consultant to Coldmoji.
References:
- Dorshimer GW. Sport savvy: Battling injuries and infections in athletes of all ages: Wiping out MRSA infections in the athlete. AOSSM and AAOS. http://www.sportsmed.org/tabs/newsroom/AnnouncementDetails.aspx?DID=516. Accessed June 25, 2008.
- Weber KM. American Medical Society for Sports Medicine Exchange Lecture: The current status of MRSA infection in the athlete. Presented at the American Orthopaedic Society for Sports Medicine 2008 Annual Meeting. July 10-13, 2008. Orlando, Fla.