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MRSA Infections on Campus: Focus on Athletes Prevention Strategies Richard D. Miller, Ph.D. www.estechlab.com MRSA Infections in Athletes MRSA, a strain of antibioticresistant 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 Sports Illustrated Feb 28, 2005 MRSA is not just in athletics! Prior to MRSA Staphylococcus – a common human pathogen Common community and hospital infections Vary from mild, superficial skin to serious invasive lifethreatening infections Had developed moderate antibiotic resistant now called MSSA (methicillin-sensitive S. aureus) 1980s Late 90s- 2000s MRSA – hospitals only MRSA- community ? X • Extreme antibiotic resistant • Life-threatening because of immuno-compromised patients • Moderate antibiotic resistant • More virulent (aggressive/invasive, i.e. more dangerous) than normal staph • More likely to lead to hospitalization 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) 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. MRSA cases in athletes Reported Cases Unreported 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. 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) Skin Abrasions Required! MRSA Colonization, no disease Normal Skin Skin Abrasions Required! MRSA • Major abrasions wound Disease Skin Abrasions Required! • Major abrasions – Most often recognized – Athletes seek medical attention – Often treated before they become infected Skin Abrasions MRSA • Minor scratches, abrasions, and hair follicle infections Hair follicle Disease 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” 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 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) 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) 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 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 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 ● ● ● ● ● ● ● ● 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 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 ▲ 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 ● ● ● ● ● ● ● ● ● ● ● ● ● 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 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 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 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 Control of MRSA Transmission? Application of HACCP Critical Control Points MRSA from Nose or Disease MRSA on Skin X Handwashing/Showering MRSA on Shared Athletic or Healthcare Surfaces X Wound Care Disinfection MRSA in Nose X Decolonization MRSA on Skin X Skin Trauma Handwashing/Showering MRSA in Wound X MRSA Disease MRSA Infection Control Program - Written Independent help and validation MRSA Infection Control Eliminating Carriers Personal hygiene Environmental cleaning Wound care Educational Awareness Decolonize 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 MRSA Infection Control Program MRSA Infection Control Environmental Cleaning and Microbiological Validation Eliminating Carriers Wound care Educational Awareness Decolonize 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 bacitracin – 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 Comprehensive Cleaning/Disinfection Program Initial Microbiological assessments of the football complex Analysis for: MRSA, MSSA, other bacteria and fungi Cleaning and disinfection of facility- supervised with training of Follow-up microbial sampling to validate the effectiveness Locker room Treatment room Strength room all personnel, including housekeeping staff Don’t believe your eyes! What appeared to be clean visually was often highly contaminated microbiologically, including MRSA! MRSA Carrier Decolonization Carriers have the highest risk for MRSA infections-from their own nose and skin!! Sports medicine personnel may also be carriers Decolonization has been successful in athletic populations Reduce infection rates? 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 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 • • • notification? Identifying breaches in infection control program Environmental monitoring Identification of carriers MRSA Infection Control ProgramsMore than just MRSA MRSA Infection Control ProgramsMore than just MRSA MRSA and other skin/tissue infectons Respiratory diseases Athlete’s foot, ringworm fungus skin infections 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 Athlete’s foot fungus Liability protection Respiratory infections Infectious Diseases in Athletes MRSA Infection Control Program ☺Benefits☺ Best athletic performance Liability protection Help promote the good – protect from the bad Thank you!