Jan 29, 2015Searching for Answers
From locker rooms to hospital rooms, MRSA continues to threaten athletes’ health and safety. In this Q&A, an infectious disease expert sorts fact from fiction and explains how to minimize the risk.
With Jeff Hageman
If you keep up on the news about methicillin-resistant Staphylococcus aureus (MRSA), it’s a good bet you’ve seen at least a few quotes from Jeff Hageman, MS, Assistant Director for Antimicrobial Resistance at the Centers for Disease Control and Prevention (CDC). With over 10 years at the CDC, Hageman, an epidemiologist, is one of the world’s foremost experts on MRSA and other staph infections.
Hageman’s duties include directing lab research, conducting outbreak-control measures, and evaluating and implementing prevention and intervention strategies. He’s done field investigations and technical consultations with high schools, NCAA institutions, and pro sports teams and associations, as well as the U.S. military and state and federal prisons.
The work Hageman does at the CDC leads directly to guidelines and recommendations for the prevention and containment of MRSA, staph, and other types of infection. In this conversation with Training & Conditioning, Hageman explains how MRSA poses a threat in many different settings, and shares his expertise and advice on how to keep athletes safe.
T&C: MRSA in healthcare facilities, especially hospitals, has been in the news lately. Why do so many hospitals struggle with MRSA?
Hageman: Hospitals have been battling MRSA for several years, so it’s not exactly a recent development, but now there’s heightened attention to it and there has been a greater focus on prevention. Ten years ago, most people thought certain infections were inevitable–no matter what we did, some hospital patients were going to get staph and MRSA. But there’s been a paradigm shift, and people now realize that we can control MRSA and prevent new infections.
How are MRSA infections typically transmitted in hospitals?
For one thing, people aren’t usually hospitalized unless they are very sick, so they’re often at higher risk for infections in the first place because their immune systems are weakened. And one out of every three people carry staph bacteria on their skin (though that doesn’t mean they’re infected), so over 30 percent of patients and visitors bring staph into the hospital on any given day.
Any break in the skin can become an infection site, whether it’s a visible abrasion or a micro-abrasion caused by something like shaving or putting in a catheter. All that needs to happen is for bacteria to get into the skin opening. Staph and MRSA are usually transmitted in hospitals by nurses, doctors, and others picking it up on their hands while working with someone, then having a lapse in hand hygiene and passing the bacteria to another patient.
Athletes often worry about the risk of infection after surgery. How does MRSA typically get into a surgical wound?
For joint surgeries, which are common among athletes, staph doesn’t have to get in at the time of the surgery, particularly if foreign material is implanted. If you have pins or plates put into a knee or hip, for instance, staph can get in some time later through a break in the skin, and once it enters the bloodstream, it typically finds those pieces of foreign material. It can then bind to them and cause infection after the fact.
Overall, the risk of surgical infection is quite low. Everyone sees the headlines when a high-profile athlete gets infected after surgery, but there are roughly 27 to 30 million surgical procedures in the U.S. each year, and only 300,000 surgery-related infections–that’s only about one percent. For orthopedic procedures that athletes typically undergo, the infection rate is even lower.
What can someone do to limit the risk of contracting MRSA or another infection when visiting a hospital?
Patients undergoing surgery should receive instructions on staph prevention prior to their procedure. They’ll often be prescribed an antibiotic before the surgery, which they should always take according to the doctor’s instructions. Another control practice is using an antimicrobial or antiseptic agent on the surgical site for several days before the procedure, which will decrease the amount of bacteria on the surface of the skin. The most important advice is to closely follow all pre-op instructions.
What happens when MRSA gets into a surgical wound?
Surgical-site infections are broken down into several categories. Some are very superficial and don’t go beyond the skin surface, and others involve deep organ and tissue infection. The superficial infections tend to be less severe, while the deep infections that get into a joint can be more traumatic and damaging, especially when foreign material is involved. It can often result in having to redo the surgery, taking out the original material and putting in new material.
MRSA infections cause a heightened inflammatory response, which leads to tissue destruction. In joints, where white blood cells don’t penetrate the area well, the destruction can be severe. Many bacteria, including staph and MRSA, secrete toxins that can further break down tissue and bone.
If the symptoms of an infection aren’t recognized early and appropriate steps aren’t taken, the impact can be devastating. Once staph and MRSA are inside the body and reach the bloodstream, they can travel anywhere, leading to complications like pneumonia. If the bacteria get into the bone, they’re very difficult to remove. Though it’s rare, in advanced cases, limb loss and death are possible.
What are the early signs of an infection?
Usually, the signs of a MRSA infection include fever, pain at the site, redness or other discoloration, and increased drainage or production of pus from the area. After surgery, discharge instructions should include a complete list of symptoms to watch out for. If a patient doesn’t receive that information, they should ask their physician about it.
Once an infection is identified, how is it treated?
The first step is usually draining and cleaning the infection site. Sometimes this can clear all the bacteria out of the area. Then the patient will often receive a special type of antibiotic that MRSA is not resistant to.
Depending on the type of infection, its location, and how early it’s caught, it may take a long course of antibiotics to completely get rid of it. But the good news is that we’re not running out of antibiotics that kill MRSA bacteria. It’s just a matter of a physician identifying the infection as drug-resistant and writing an appropriate prescription.
What other settings outside of athletic facilities pose the greatest risk to athletes?
People can get infections virtually anywhere–it’s difficult to pinpoint high-risk areas. Institutional and closed-group settings, such as prisons, have a lot of problems with MRSA, but hopefully athletes don’t find themselves there. Any place where a lot of people are present, a lot of bacteria will be there as well.
Athletic trainers should understand that when an athlete gets a staph infection, they might not have picked it up in the athletic setting. So while it’s important to raise awareness and make sure there are no other active infections on the team, they also need to ask the athlete about personal contacts–roommates, girlfriends, boyfriends, family members, and close friends. If one of those people has an active infection, they might be continually introducing it to the athlete, so it won’t go away. And with each subsequent infection, there is always the risk of spreading it among the team.
What should all athletes know about protecting themselves from MRSA and staph infections in their daily lives?
If I had to choose one thing, it would be signs and symptoms: what MRSA looks like and how to recognize a possible infection. Without that knowledge, treatment of infections will be delayed and there’s increased likelihood of transmission within the team environment.
Some teams distribute fact sheets to their athletes listing symptoms to watch out for and stressing the importance of seeking medical help immediately. We’ve worked with several national sports associations, like the NCAA, to create educational posters and other materials that are disseminated to schools. It’s important for athletes to understand that MRSA can take several forms–there’s quite a spectrum of how these infections can look.
It’s also extremely important for athletes to learn about and practice good hygiene habits. They should wash their hands after touching frequently used items in the weightroom and at practice. They should never share towels, razors, soap, or other toiletries. And showering is important after practices, workouts, and games. Even if someone comes into contact with MRSA or staph and gets it on their skin, it doesn’t cause an infection instantly. If they wash it off the skin surface, it doesn’t have a chance to infect tissue.
Another step is to prevent skin abrasions, since these are common entryways for MRSA bacteria. Many sports carry an inherent risk of abrasions, particularly contact sports like football and wrestling. Using equipment and apparel to protect exposed areas of the body helps prevent breaks in the skin.
If an athlete does have a skin abrasion, they should make sure to keep it clean and cover it with a bandage right away. Athletic trainers should have wound care supplies and anti-infection wound dressings on hand. And in all cases, athletes should keep the wound covered until it has healed completely. In addition to limiting person-to-person transmission, keeping a wound covered prevents staph from spreading to other body parts.
What specific cleaning products are most effective against MRSA and other bacteria?
The CDC has put fact sheets on our Web site to address this question. [See the “Resources” box below for a link.] We recently posted one about environmental management of MRSA, with information on laundry and surface cleaning and disinfection. In many cases, basic cleaning with soap, water, and detergent are sufficient to remove MRSA and staph from a surface. But with any product, it’s important to follow the instructions on the label.
If you’re using a disinfectant, it should be registered with the Environmental Protection Agency (EPA)–there should be an EPA number listed on the label. That label ensures there is data to support the effectiveness of the product.
For most cleaning applications, it’s not so much what you use, but using it properly and following a regular cleaning routine. For example, athletic training room equipment should be cleaned after each use. You can never create a completely sterile environment because bacteria spreads whenever people touch surfaces, but good cleaning habits can go a long way in reducing risk.
Should an athlete with a MRSA infection be kept from participating in their sport?
If the infection site can be kept covered, the athlete might be allowed to participate, especially in non-contact sports. It depends on where the infection is and whether there’s a risk of spreading MRSA bacteria to others. If it’s on a body area that’s hard to keep covered and there’s potential for drainage or other matter from the wound to get on surfaces or other people, it’s best to exclude the athlete from participation.
Wound coverage in contact sports is a major challenge. In football, for instance, an infection on an athlete’s arm might be bandaged before a game, but between sweat, contact with the ground, and contact with other players, that bandage might come loose or fall off during play. That can even happen in sports with limited person-to-person contact like soccer. If a wound has the potential to become uncovered, that athlete should sit out until it has completely healed.
We also recommend that athletes with active infections not use whirlpools or other therapy pools. In fact, that goes for anyone with a skin abrasion, because staph can survive in water. People with abrasions open themselves up to infection by getting into a common-use pool.
A few college teams that have struggled with MRSA have considered using antibiotics preventatively. Is that a good idea?
For MRSA prevention, there’s no evidence to support that practice. Furthermore, we know that overuse of antibiotics leads to new bacteria that are drug-resistant, so you could actually do a lot of harm by using antibiotics indiscriminately.
When the CDC investigated an outbreak among the St. Louis Rams in 2003, we found that the players received 10 times the amount of antibiotics that the general population in the same age group received. Heavy antibiotic use could have been one reason why that team was more susceptible to a MRSA outbreak.
What misconceptions persist about MRSA and the risk of transmission?
One is the idea that MRSA isn’t treatable. People call it a “superbug,” and the only cases that make news are the tragic ones, and that creates a sense of alarm about MRSA. But in reality, an infection isn’t cause for panic–just a fast response. It is treatable, especially when it’s only a skin infection, which most cases are. The earlier it’s treated, the better the outcome, so the key is being well-educated.
Another misconception is that good prevention is just about having the best resources–that’s not the case. In the NFL, for instance, they have the best physicians, great athletic training facilities, and all the latest technology, but athletes still get infections. The truth is that anyone can get infected, and everyone has access to the basic prevention tools: soap and water, showers, good hygiene habits, and awareness of what to look for.
What common mistakes might an athlete or athletic trainer make regarding infection control?
When someone receives antibiotics, it’s common for them to stop taking the medication when their symptoms resolve. Antibiotics control bacteria so the body can catch up and eliminate it, but if you stop taking them too soon, your body won’t kill the bacteria. Unless a physician tells the athlete to stop taking the antibiotics, he or she should always complete the course.
For athletic trainers, a common error might be not taking a proactive approach to identifying infections. Any time a skin problem looks suspicious, the athlete should be referred to a physician who can perform any needed tests and make a diagnosis. Athletic trainers also need to follow up with athletes who have MRSA infections, to ensure they are healing properly and practicing good hygiene and wound care.
What is the latest news in the fight against MRSA?
Things are pretty much as they’ve always been. Methods for preventing skin infections today are no different than they were 10 years ago, but we need to be more vigilant about following them. It’s up to the athletes to follow through with proper precautions, and it’s up to athletic trainers and coaches to promote good hygiene and awareness.
At one college I consulted with, athletes weren’t showering after practice, and when we talked to some of them, we figured out the reason: They didn’t think the shower room floor was sanitary, and they didn’t want to go in with bare feet. So the school included shower shoes as part of its uniform handout. Sometimes, it’s just a matter of taking simple steps to create a culture of awareness about the risk.
www.cdc.gov/MRSA The Centers for Disease Control and Prevention offers extensive information on preventing and managing MRSA outbreaks.
www.ncaa.org/health-safety Click on “Skin Infection Prevention” for information from the NCAA. This Web site includes the association’s sports medicine guidelines for skin infections, along with downloadable educational materials for coaches and athletes.
www.training-conditioning.com/mrsa.html Visit our Web site to download free posters that can help educate everyone in your athletic program about the risk of MRSA and how to protect themselves. You can also find past MRSA articles from T&C.