1. MRSA Infections on Campus: Focus on Athletes
Prevention Strategies
Richard D. Miller, Ph.D.

2. MRSA Infections in Athletes
MRSA, a strain of antibiotic-resistant staphylococcus once confined to hospitals is striking athletes at an alarming rate and with dire consequences
High school, college and professional athletes
Methicillin-Resistant Staphylococcus Aureus
Sports Illustrated Feb 28, 2005

3. Sports Illustrated Feb 28, 2005

4. MRSA is not just in athletics!

5. X ? 1980s Late 90s- 2000s Prior to MRSA
Staphylococcus – a common human pathogen
Common community and hospital infections
Vary from mild, superficial skin to serious invasive life-
threatening infections
Had developed moderate antibiotic resistant
now called MSSA (methicillin-sensitive S. aureus)
1980s
Late 90s- 2000s
MRSA – hospitals only
MRSA- community X ?
Moderate antibiotic resistant
More virulent (aggressive/invasive,
i.e. more dangerous) than normal staph
More likely to lead to hospitalization
Extreme antibiotic resistant
Life-threatening because of
immuno-compromised patients

7. MRSA Infections
N Engl J Med (2006) - MRSA infections are now the most common cause of skin and soft tissue infections treated at emergency departments. S. aureus caused 76%, and of these, 78% were MRSA.
2007 CDC study (2005 data) – estimated 90,000 cases of invasive MRSA in U.S., with 19,000 deaths (17,000 deaths from AIDS in 2005)

8. Many additional outbreaks in multiple sports including football, rugby, wrestling, soccer, volleyball, baseball, and even fencing
Single cases and multiple case outbreaks are widespread at the high school, college and professional levels.

9. MRSA cases in athletes Unreported Cases Reported Cases
Considering that most schools and teams would not want cases made public, the ones that we know about are likely to be just the tip of the iceberg.

10. Why Athletes?
General
Athletes are part of the community, and are part of the increase in community-associated (CA)-MRSA infections
Specific
Athletes may have direct skin contact with other athletes as part of their sport. (aids disease transmission)
Athletes may have contact with equipment and surfaces contacted by other athletes (aids disease transmission)
Athletes may have skin abrasions as part of their sport (essential for initiation of infection)

11. Skin Abrasions
Required!
MRSA
Colonization, no disease
Normal Skin

12. Skin Abrasions
Required!
MRSA
Major abrasions
wound
Disease

13. Skin Abrasions Required! Major abrasions Most often recognized
Athletes seek medical attention
Often treated before they become infected

14. Skin Abrasions
MRSA
Minor scratches, abrasions, and hair follicle infections
Hair follicle
Disease

15. Skin Abrasions Minor scratches, abrasions, and folliculitis
Often not recognized
Athletes think they are not serious enough to seek medical attention.
Many MRSA infections begin as apparent “spider bites”

16. Skin Abrasions Minor scratches, abrasions, and folliculitis
Often not recognized
Athletes think they are not serious enough to seek medical attention.
Many MRSA infections begin as apparent “spider bites”
Infections progress rapidly to absesses, invasive cellulitis, even necrotizing fasciitis, and septicemia

17. Carriers Provide a reservoir and promote transmission of MRSA and other Staph infections
Staph Carriers
30% of population carry as Staph. aureus as normal flora in the nose or rectum (no symptoms!!)
Months-to-years (half-life of 40 months)

18. Carriers Provide a reservoir and promote transmission of MRSA and other Staph infections
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum No symptoms!!
Months-to-years (half-life of 40 months)

19. Transmission of MRSA in the Athletic Environment
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands

20. Transmission of MRSA in the Athletic Environment
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands ● ● ● ● ● ● ● ●

21. Transmission of MRSA in the Athletic Environment
MRSA Carriers (or Infections)
1-5% of population carry as normal flora in the nose
Spread to face and hands ● ● ● ● ● ● ● ●

22. Transmission of MRSA in the Athletic Environment
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands
Transmission to others by direct skin contact

23. Transmission of MRSA in the Athletic Environment
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands
Transmission to others by direct skin contact
Break in skin leads to infection ▲

24. Transmission of MRSA in the Athletic Environment
MRSA Carriers (or Infections)
1-5% of population carry as normal flora in the nose
Spread to face and hands
Break in the skin leads to infection
Carrier has the highest risk of infection because of the high level of skin contamination ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

25. Transmission of MRSA in the Athletic Environment
Shared Facilities
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands
Transmission to others via contaminated environmental surfaces
MRSA can live for days or even weeks on surfaces

26. Transmission of MRSA in the Athletic Environment
Towels
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands
Transmission to others via contaminated environmental surfaces
Break in skin leads to infection

27. Transmission of MRSA in the Athletic Environment
Equipment of the sport
MRSA Carriers
1-5% of population carry as normal flora in the nose or rectum
Spread to face and hands
Transmission to others via contaminated environmental surfaces
Break in skin leads to infection

28. Flow Diagram of MRSA Transmission
Different person
MRSA from Nose or Disease
MRSA on Skin
MRSA on Shared Athletic or Healthcare Surfaces
MRSA in Nose
MRSA on Skin
Skin Trauma
MRSA in Wound
MRSA Disease

29. Control of MRSA Transmission?
Application of HACCP Critical Control Points
MRSA from Nose or Disease X
MRSA on Skin
Handwashing/Showering
MRSA on Shared Athletic or Healthcare Surfaces X
Wound Care
Disinfection X X X
MRSA in Nose
MRSA on Skin
Skin Trauma
MRSA in Wound
MRSA Disease
Decolonization
Handwashing/Showering

30. MRSA Infection Control Program
- Written
MRSA Infection Control
Independent help and validation
Eliminating Carriers
Personal hygiene
Environmental cleaning
Decolonize
Wound care
Educational Awareness

31. Univ. Georgia MRSA Program
Former Chair, College and University Athletic Trainer’s Committee of the National Athletic Trainers Association (NATA)
Major address at the 2006 NATA Annual Meeting in Atlanta, GA
“Antibiotic Resistant Staph Infections:
MRSA and Beyond”
Described the Comprehensive MRSA Control Program in place at Univ. of Georgia football program.
Ron Courson
Director of Sports Medicine
University of Georgia

32. MRSA Infection Control Program
Environmental Cleaning and Microbiological Validation
Eliminating Carriers
Decolonize
Wound care
Educational Awareness

33. Personal Hygiene and Management of Staph or MRSA Infections
Encourage good hygiene, including showering and washing with soap after all practices and competitions
Ensure availability of adequate soap and hot water
pump soap dispensers with antibacterial soap; no bar soap
waterless hand disinfectant dispensers
Aggressively cover all wounds
if wound cannot be covered adequately, consider excluding players with potentially infectious skin lesions from practice and/or competition until lesions are healed or can be covered adequately
Identify MRSA infections when it occurs
bacitracin

34. Comprehensive Cleaning/Disinfection Program
Initial Microbiological assessments of the football complex
Locker room
Treatment room
Strength room
Analysis for: MRSA, MSSA, other bacteria and fungi
Cleaning and disinfection of facility- supervised with training of all personnel, including housekeeping staff
Follow-up microbial sampling to validate the effectiveness

35. Don’t believe your eyes!
What appeared to be clean visually was often highly contaminated microbiologically, including MRSA!

36. MRSA Carrier Decolonization
Decolonization has been successful in athletic populations
Carriers have the highest risk for MRSA infections-from their own nose and skin!!
Sports medicine personnel may also be carriers
Reduce infection rates?

37. 850 bed organization, 40,000 annual admissions
universal surveillance with decolonization and isolation
large reduction in MRSA disease compared to baseline
during admission and 30 days after discharge

38. Getting Started with your MRSA Program
Keep it simple and cost effective!
Written Infection Control Program
Education of students and staff about MRSA and their roles in prevention (for example):
Students – personal hygiene, observing for wounds
Medical staff – wound management, surface disinfection
Training staff – towel use and laundry, equipment disinfection
Housekeeping – proper disinfectants and cleaning techniques
Response to MRSA cases
Identifying breaches in infection control program
Environmental monitoring
Identification of carriers
notification?

39. MRSA Infection Control Programs- More than just MRSA

40. MRSA Infection Control Programs- More than just MRSA
MRSA and other skin/tissue infectons
Respiratory diseases
Athlete’s foot, ringworm fungus skin infections

41. Infectious Diseases in Athletes
MRSA Infection Control Program
☺Benefits☺
MRSA and other skin/tissue infectons
Overall health - both students and staff
More than just MRSA- other infections!
Best athletic performance
Recruiting advantage with parents
Respiratory infections
Athlete’s foot fungus
Liability protection

43. Infectious Diseases in Athletes
MRSA Infection Control Program
☺Benefits☺
Best athletic performance
Liability protection
Help promote the good – protect from the bad

44. Thank you!