Sports & Infection
Loreen A. Herwaldt, MD
Professor
Hospital Epidemiologist

May 28, 2005 - Larson Conference Room

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Outbreaks Among Athletes
Football
MRSA/MSSA
Group A strep
Norwalk, Coxsackie, & Echo viruses
Measles/Mumps
Flu-like illness
Rugby
Herpes
Group A strep
Wrestling
MRSA
Herpes
Trichophyton
Measles
Basketball
Measles
Chickenpox
Flu-like illness
Fencers
MRSA

Defining Community Acquired MRSA (CA-MRSA)
Patient:
Had a culture positive for MRSA w/in 48 hours of admission
Was not: hospitalized, in a nursing home, in hospice care, undergoing dialysis
Did not have: surgery, or a permanent indwelling catheter or other medical device that passes through the skin

CA-MRSA Outbreaks
1997-1999 in North Dakota & Minnesota
4 deaths in children w/out risk factors for MRSA
2 had respiratory symptoms and 2 had a more disseminated picture
All 4 patients were initially treated with a cephalosporin antibiotic
All 4 isolates had the mecA gene and were different by greater than 10 bands from the nosocomial MRSA isolates from area hospitals

MMWR August 1999;48:707-10.
CA-MRSA Outbreaks
1988-1990: 8 children were hospitalized with CA-MRSA
1993-1995: 35 children were hospitalized with CA-MRSA
19/25 CA-MRSA isolates were susceptible to at least 2 non -lactam drugs

JAMA 1998;279:593-8.
CA-MRSA Outbreaks
Increased incidence of MRSA in correctional facilities: Georgia, California, & Texas, 2001-2003
Los Angeles prison facilities had 921 MRSA skin infections in 2002
Risk factors included: previous antimicrobial use, self-draining of boils, skin laceration, sharing soap, recent arrival at the prison
MMWR 2003;52:992-6.
CA-MRSA Outbreaks

Fencers in Colorado
Possible source: sensor wires worn under the clothes are shared and not routinely washed


MMWR 2003;52:793-5.



General Comments about CA-MRSA Outbreaks
Outbreaks in US, Canada, Europe, Finland, Saudi Arabia, India, Asia, Australia, New Zealand
Often in clusters among persons who have close contact with each other
Often in young, previously healthy patients
Infections:
Primarily skin infections, some necrotizing
Necrotizing pneumonias with high mortality

General Comments about CA-MRSA Outbreaks
CA-MRSA vs. HA-MRSA
Fewer co-resistances (often <=2 other classes)
Different PFGE patterns than those seen in usual HA-MRSA
Different SCCmec element (type IV)
Carry Panton-Valentine leukocidin genes


Panton-Valentine Leukocidin (PVL)
Bicomponent toxin directed against cell membranes
Lytic activity against PMNs, monocytes & macrophages of humans and rabbits
Cause skin/soft tissue infection & severe, necrotizing pneumonia
Detected in <5% of S. aureus in a general hospital population

A Clone of Methicillin-Resistant Staphylococcus aureus among Professional Football Players
S. V. Kazakova & a cast of thousands
NEJM 2005;352:468-75
Case Definition
Any skin or soft-tissue infection:
In a player or staff member of the St. Louis Rams
During the 2003 football
season
MRSA was isolated from culture
The Outbreak
Who: 5/58 (9%) Rams football players—4 linemen & 1 linebacker
What: Infected boo boos on elbows, forearms, & knees became large (5-7 cm) abscesses
Where: St. Louis (dah)
When: 8-11/2003


Outcomes
5/5 required incision & drainage
3/5 had recurrent infections
0/5 hospitalized
3/5 missed 1, 4, 12 days of “work” (practice and games)
5/5 received 3 oral agents (cephalexin, TMP-sulfa, rifampin)
2/5 received IV abx before oral agents


Investigations
Observed during training & competition :
On-field activities
Off-field activities
Hygiene practices
Did retrospective cohort study to identify risk factors
Cultured all players, staff, & environment
Did molecular typing: PFGE & PCR for SCC mec IV & pvl
Results
2-3 turf burns per week; worse on artificial turf
Trainers provided wound care but didn’t do hand hygiene
Players shared towels
Players didn’t shower before using whirlpool
Weight-training & therapy equipment were not cleaned routinely

Results—Antimicrobial Use
Players on average took 2.6 antimicrobial prescriptions/year; 10 times more than men the same age in the general population
60% of players took antimicrobials during the 2003 season
Results--Laboratory
MRSA isolates were:
Resistant to macrolides
D-test negative
PFGE-type USA300-0114
SCCmec IVa positive
pvl positive


Interventions
Installed wall-mounted chlorhexidine soap dispensers
Changed local wound care
Prescribed antimicrobial agents for MRSA
Performed surveillance for skin infections
Only 1 infection occurred after interventions started

Recurring Methicillin-resistant Staphylococcus aureus Infections in a Football Team
DM Nguyen, L Mascola, E Bancroft
EID, April 2005
http://www.cdc.gov/ncidod/EID/vol11no04/04-1094.htm

The Outbreak
Who: 11/107 (10%) football players
What: 7/11 boils, 2/11 insect bite, 2/11 folliculitis; 4 players hospitalized
Where: A college or university in Los Angeles County, CA
When: 8/5-9/5/2003
Note: 2 players were hospitalized for MRSA infections in 8/2002



Case Definition
Team A members with MRSA culture-confirmed skin or soft tissue infections (SSTI), or
Team A members with SSTIs presumably caused by the USA 300 strain between 8/5 & 9/5/2003
Investigations
Reviewed trainer’s treatment log
Cultured nares of team members
Case control studies to assess risk factors for:
Infection
Nasal carriage
Molecular typing

Results
Risk factors for infection
Shared bars of soap with teammates 5/10; OR = 15.0; p = 0.005
Had preexisting cuts or abrasions 10/10; OR = undefined; p = 0.02
Risk factors for nasal carriage
Had locker close to an infected teammate 4/5; OR 60.0; p = 0.001
Shared towels with teammates 3/5 OR = 46.5; p = 0.005
Lived in dorm, frat, on campus housing 5/5; OR = undefined; p = 0.003

Intervention
Aftermath
4 more infections from 10/20-11/9/2003
Chin abscess (LM, shared soap with his room mate who was a case),
Elbow boil (LM, his second infection),
Folliculitis (QB, had another relapse),
Gluteal boil (TE)
PFGE pattern for 3 isolates = A
0/28 nares cultures from staff
During a game student trainers reused towels between players & players shared towels
Switched to single use towels on sidelines

A High-Morbidity Outbreak of MRSA among Players on a College Football Team, Facilitated by Cosmetic Body Shaving and Turf Burns
EM Begier, & a cast of thousands
CID 2004;39:1446-53
Case Definition
A culture-confirmed MRSA cellulitis or skin abscess diagnosed in a player during the period from 8/6-10/1/2003
The Outbreak
Who: 10 /100 college football players
What: Skin abscess (9) or cellulitis (4); Where: College or university in Connecticut
When: 8/6-10/1/2003

Outcomes
2 players required hospitalization
Outpatient required median of 10 days of frequent visits for wound care
Sites of infection:
Elbow = 4
Thigh and hip = 2
Chin, forearm, wrist, knee, tibial plateau = 1
Investigations
Nasal culture survey
Contacted hospital labs to find other cases
Interviewed trainers, coaches, infected players
Retrospective cohort study by face to face questionnaire
Results
Isolates from 9/10 infected players were USA 300 strain, SCCmec IVa, PVL positive
No other players or staff were colonized
Attack rate highest among corner backs (50%) & wide receivers (33%)
Results
Player position:
Wide receiver—RR = 11.7 (2.4-56.8); p = 0.004
Cornerback—RR = 17.5 (3.8-81.0); p = 0.001
Turf burns—RR = 7.2 (0.3-16.6); p = 0.038
Body shaving: RR = 6.1 (1.7-22); p = 0.004
Players at high risk positions  their risk if they had turf burns or they shaved their bodies
Results
Trend toward increased risk of infection w/elbow pads
Risk of infections at covered sites  significantly as use of the cold whirlpool increased
Sharing personal items was infrequent
No soap in showers
Temp of water used to wash towels was 44.4° C not 71° C; no chlorine used
Interventions
Case players could not play until wounds healed
Players required to cover open wounds during play
Players should shower, clean & dress cuts & turf burns ASAP
Whirlpool must be emptied, disinfected, refilled after each use
Antibacterial soap dispensers installed in shower
Towels should be washed in water hotter than 71° C
Surveillance Study in Iowa
15 participating centers:
Were chosen based on geographic location, population distribution & hospital-bed size.
Account for over half of acute-care hospital discharges in Iowa.
Submitted the first ten consecutive isolates of S. aureus during each quarter between July 1998 and June 2001.
Distribution of MRSA in Iowa
Proportion of MRSA Carrying PVL Gene
Healthcare-associated vs Community-acquired MRSA
Geographic Distribution of 17 PVL+ CA-MRSA in Iowa
SCCmec IV, PVL+ MRSA
15 were community-acquired:
12/15 caused skin and soft tissue infections
All 15 had < 2 co-resistances
2 were healthcare-associated
1 nosocomial, 0 co-resistances
1 LTCF associated, bloodstream infection in a 70 year old
Most were USA400 (MW2, Minnesota cluster)

Conclusion
MRSA carrying SCCmec IV and PVL have been present throughout Iowa since at least the late 1990’s
Though largely confined to community acquired MRSA, these organisms have also caused healthcare-associated disease
Further surveillance is indicated
Future Directions
Repeat statewide surveillance program
Risk factors for CA-MRSA
Characterize MRSA in LTCF and acute care environment
Survey high school, college, university athletics departments to estimate extent of the problem in Iowa schools
What Did We Learn?
CA-MRSA is Ram tough
Football players get down & dirty; they go to ground
Don’t let your kid:
Play lineman, linebacker, wide receiver, or cornerback
Share towels or a poorly maintained whirlpool
Shave body parts other than his face
Shower without soap






Recommendations
Do surveillance for skin infections
Culture all skin infections
Restrict players with skin infections
Use chlorhexidine or hexachlorophene for showers
Don’t share towels, soap bars, drink bottles
Wash towels, etc at adequate temp. (> 71° C)
Recommendations
Trainers should practice good hand hygiene
Maintain whirlpools appropriately
Clean environment, athletes’ equipment, exercise/therapy equipment regularly
Encourage immediate showering and care for open wounds
Discourage body shaving