Cutaneous community-acquired methicillin-resistant Staphylococcus aureus infection in participants of athletic activities.

Objectives: Cutaneous community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) has been identified in otherwise healthy individuals either with or without methicillin-resistant S. aureus (MRSA)-associated risk factors who participate in athletic activities. The purpose of this study was to describe the clinical features of CAMRSA skin infection that occurred in university student athletes, evaluate the potential mechanisms for the transmission of MRSA infection of the skin in participants of athletic activities, and review the measures for preventing the spread of cutaneous CAMRSA infection in athletes.

Methods: A retrospective chart review of the student athletes from the University of Houston whose skin lesions were evaluated at the Health Center and grew MRSA was performed. The clinical characteristics and the postulated mechanisms of cutaneous MRSA infection in the athletes were compared with those previously published in reports of CAMRSA skin infection outbreaks in other sports participants.

Results: Cutaneous CAMRSA infection occurred in seven student athletes (four women and three men) who were either weight lifters (three students) or members of a varsity sports team: volleyball (two women), basketball (one woman), and football (one man). The MRSA skin infection presented as solitary or multiple, tender, erythematous, fluctuant abscesses with surrounding cellulitis. The lesions were most frequently located in the axillary region (three weight lifters), on the buttocks (two women), or on the thighs (two women). The drainage from all of the skin lesions grew MRSA, which was susceptible to clindamycin, gentamicin, rifampin, trimethoprim/sulfamethoxazole, and vancomycin; five of the isolates were also susceptible to ciprofloxacin and levofloxacin. All of the bacterial strains were resistant to erythromycin, oxacillin, and penicillin. The cutaneous MRSA infections persisted or worsened in the six athletes who were empirically treated for methicillin-sensitive S. aureus at their initial visit. Complete resolution of the skin infection occurred after the abscesses had been drained and the athlete had been treated with systemic antimicrobial therapy for which the bacterial strain was susceptible.

Conclusions: Cutaneous CAMRSA infection typically presents as an abscess, with or without surrounding cellulitis, in otherwise healthy participants of athletic activities who have or do not have MRSA-associated risk factors. Athletes who have MRSA skin infections include weight lifters and team members from competitive sports such as basketball, fencing, football, rugby, volleyball, and wrestling. Bacterial culture of suspected infectious skin lesions should be performed to establish the diagnosis of cutaneous MRSA infection and to determine the antibiotic susceptibility of the bacterial isolate. Treatment of cutaneous MRSA infection involves drainage of the abscess (either spontaneously or after incision) and appropriate systemic antimicrobial therapy. Direct skin-to-skin physical contact with infectious lesions or drainage, skin damage that facilitates the entry of bacteria, and sharing of infected equipment, clothing, or personal items may result in the acquisition and transmission of MRSA infection in participants of athletic activities. Earlier detection and topical treatment of the athlete's skin wounds by their coaches, avoidance of contact with other participants' cutaneous lesions and their drainage, and good personal hygiene are measures that can potentially prevent the spread of cutaneous MRSA infection in participants of athletic activities.

Key Words: abscess, athletes, cellulitis, community acquired, cutaneous, infection, methicillin resistant, participants, skin, sports, Staphylococcus aureus 

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Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is a global problem whose incidence continues to increase. (1-3) Cutaneous CAMRSA infections usually present as an abscess and cellulitis. (4-6) Skin infections caused by CAMRSA are more frequently being identified in otherwise healthy individuals who participate in athletic activities, including team members from competitive sports such as fencing, football, rugby, volleyball, and wrestling. (7-10) Cutaneous CAMRSA infections developed in seven students who participated in athletic activities at the University of Houston. The clinical features of their skin infections are described and the previously reported characteristics of cutaneous CAMRSA infections in competitive sports teams members are summarized. Potential mechanisms for the transmission of skin infections caused by CAMRSA in sports participants are reviewed, and possible measures to prevent the spread of cutaneous CAMRSA infection in athletes are discussed.

Materials and Methods

Patients

Patients included student athletes of the undergraduate and graduate schools who were self-referred, or referred from the Athletic Department, to the health center services at The University of Houston, Houston, TX, for the care of their cutaneous lesions. The charts of student athletes evaluated between August 2002 and February 2004 whose bacterial culture of their skin grew methicillin-resistant S. aureus (MRSA) were reviewed.

Bacterial cultures

Bacterial cultures from the lesional site of the draining (either spontaneously or after incision of the skin lesion) serosanguinous pus were performed. The inoculated cotton applicator tip was transferred in transport media (Amies, Colpan Diagnostics, Corona, CA) to a laboratory (Laboratory Corporation of America, Houston, TX). Susceptibility testing of the S. aureus isolates was performed with the use of the VITEK system (Biomerieux, Hazelwood, MO). The samples were inoculated onto VITEK Gram-positive susceptibility cards and incubated inside the VITEK Reader/Incubator at 35[degrees]C for 8 hours. An optical scanner measured the attenuation of light in each of the inoculated wells of the Gram-positive susceptibility card on an hourly basis and determined the extent of bacterial growth, which was expressed as a change in the turbidity and the color in the wells. With this information, the system's software was able to calculate the minimal inhibitory concentration for each antimicrobial in the card. To confirm methicillin resistance, a direct inoculum of bacterial colonies equivalent to 0.5 McFarland standard was inoculated onto an agar plate containing 6 [micro]g/mL of oxacillin and Mueller-Hinton agar supplemented with NaCl (4% wt/vol; 0.68 mol/L) and incubated for 24 hours at 35[degrees]C; detection of more than 1 bacterial colony or a light film of growth confirmed oxacillin/methicillin resistance.

Results

Seven student athletes, four women and three men ranging in age from 19 years to 25 years (median, 20 years), presented for the evaluation and treatment of MRSA culture-positive cutaneous infections (Table 1). (11) Three of the students participated in weight lifting at the same recreation center; two of these individuals were also physical fitness trainers. Two of the women were members of the varsity volleyball team, and both of them had initially interpreted their lesions to be secondary to an insect bite; in addition, a third member of their team had a similar-appearing skin infection that was evaluated and treated elsewhere. One student was a member of the men's varsity football team and one was on the women's varsity basketball team. Two of the students had received systemic antibiotics for either a urinary tract infection (one of the volleyball players) or skin infection (one of the weight lifters) within the preceding year--a risk factor that has been associated with the possible development of MRSA infection.

The cutaneous MRSA infections presented as either a solitary or multiple tender, erythematous, fluctuant abscesses with surrounding cellulitis (Fig. 1). The most frequent location was the axillary region in all three weight lifters (Figs. 2 and 3). The buttocks (two women) and thighs (two women) were also more common sites of infection; in addition to lesions at these sites, the basketball player also had an abscess on her labia majora. Skin infection also appeared on the face of one of the volleyball players and the great toe (presenting as onychocryptosis with an associated acute paronychia) of the football player (Table 1).

At least one lesion was cultured from each of the students. All of the bacterial strains of S. aureus were reported to be resistant to erythromycin, oxacillin (and therefore also methicillin), and penicillin; the isolates from both male weight lifters were also resistant to ciprofloxacin and levofloxacin. The S. aureus cultured from all of the students was susceptible to clindamycin, gentamicin, rifampin, trimethoprim/sulfamethoxazole, and vancomycin; the strains from five of the students were also susceptible to ciprofloxacin and levofloxacin. Polymicrobial cutaneous infection was demonstrated in two of the students: the concurrent presence of either group B or group G [beta]-hemolytic Streptococcus in the basketball player and football player, respectively.

[FIGURE 1 OMITTED]

The abscesses had spontaneously ruptured and were draining purulent serosanguinous pus at the initial evaluation of both volleyball players and one of the weight lifters (Table 1). Similarly, pus could be expressed after gentle pressure to the lateral nail fold of the football player's toe. Incision and drainage of the inflamed fluctuant nodules was performed during the initial visit of the other students.

Definitive systemic antimicrobial therapy was only received by the basketball player on her first visit. All of the other students were initially given an oral antibiotic that would provide adequate coverage for methicillin-susceptible S. aureus (MSSA). Their skin infections either persisted or progressed, and the systemic antibiotic was changed to either monotherapy with trimethoprim/sulfamethoxazole for five of the students or combination therapy with clindamycin and rifampin for the football player (Table 1).

The students were also treated with adjuvant topical therapy (Table 1). Mupirocin (2%) ointment was applied intranasally three times daily to treat possible bacterial colonization at that site; also, the infectious lesions were treated with the antibiotic ointment after each cleaning. In addition, several of the students bathed the involved areas of skin with an antibacterial agent each day. They used povidone-iodine liquid soap (at either a 7.5% or 10.0% concentration) or 4% chlorhexidine gluconate liquid detergent.

[FIGURE 2 OMITTED]

Complete resolution of the student's cutaneous MRSA infection occurred after the abscesses had been drained (either spontaneously or after incision) and treatment with a definitive systemic antimicrobial therapy (for which the bacterial strain was susceptible) had been received. The MRSA skin infection recurred in one of the male weight lifters. He was retreated, and his infection resolved completely without any subsequent episodes.

[FIGURE 3 OMITTED]

Discussion

Infections caused by CAMRSA have been observed within many cities throughout the United States and within many countries throughout the world. (6,12-14) Bacterial strains of CAMRSA are distinctly unique, particularly in comparison to those associated with hospital-acquired MRSA infections. (15,16) CAMRSA isolates not only have a type IV staphylococcal chromosomal (SCCmec) cassette on which the mecA gene that encodes for methicillin resistance is encoded but also have a leukocyte-killing toxin. (1,2,15,16) This toxin, which is encoded by the Panton-Valentine leukocidin locus, is the feature that gives CAMRSA bacterial strains their predilection for causing skin infections. (2,17-19) Currently, cutaneous CAMRSA infection is an emerging clinical problem of epidemic proportion. (3)

CAMRSA skin infection often affects individuals without MRSA-associated risk factors. (6,12,14,16) Recently, cutaneous infections caused by CAMRSA have been increasingly observed in competitive sports participants. (7-10) The activities in which the participating athletes acquired community-acquired infectious skin lesions, from which MRSA was cultured, were characterized by close physical contact, shared equipment, or both.

A community outbreak of MRSA between January 1993 to February 1994 in southern Vermont involved 7 of the 32 members of the high school wrestling team and 6 nonwrestlers who had some connection with the high school. None of these individuals had underlying risk factors for MRSA infection. Six of the wrestlers had MRSA culture-positive infectious lesions (either an abscess or boils) located on their lower extremities (four team members) or forearms (two team members); the final team member was colonized with MRSA that was cultured from his nares. The members of the wrestling team typically participated in wrestling practice with their arms and legs uncovered for 2 hours per day, 6 days per week. In addition to direct skin contact with infected or colonized wrestlers, transmission of MRSA infection may also have been facilitated secondary to contact with bacteria-inoculated shared equipment such as the wrestling mat, because the wrestlers frequently received mat burns to their extremities. (7)

In December 1996, 25% of the members of a United Kingdom rugby team presented with large abscesses located at various sites including their upper arms, back, neck, and face. The five affected players were all forwards, who had competed together in a match against a touring team from the South Pacific 10 days earlier; therefore, prolonged periods of close physical contract, rather than shared equipment or facilities, was favored as the mechanism of bacterial transmission. A [beta]-lactam antibiotic was initially prescribed, and their infectious lesions did not respond. Cultures from the abscesses grew MRSA; in addition, this bacteria was also cultured from the nares of one of these players. None of the 15 asymptomatic team members were colonized with MRSA. Subsequently, the MRSA infection in the five affected players responded well after receiving antimicrobial treatment to which their bacterial isolates were sensitive--either erythromycin or clarithromycin. (8)

An outbreak of MRSA culture-positive skin and soft tissue infections involved 10 members of a Pennsylvania college football team during September and October 2000. Hospitalization was required for 70% of these players to treat their infection. The bacterial isolates from all of the athletes had indistinguishable pulsed-field gel electrophoresis patterns. Shaving and turf burns resulting in trauma to the skin and sharing of unwashed bath towels were suspected as potential risk factors for transmission of MRSA infection. (10)

The University of Houston varsity football player presented in August 2002 with onychocryptosis and an acute paronychia of his right great toenail. Bacterial culture of the pus expressed from his erythematous and tender nail fold grew not only MRSA but also group G [beta]-hemolytic Streptococcus. His spontaneously draining toe infection continued to worsen after starting treatment with cephalexin. Subsequently, his cutaneous infection completely resolved after he was treated with clindamycin and rifampin. The source of his infection was not identified.

In California, the Los Angeles County Department of Health Services investigated the circumstances regarding two members of a college football team who were hospitalized for MRSA skin infection within the same week during September 2002. The pulsed-field gel electrophoresis patterns of the bacterial isolates from both players were indistinguishable. Surgical debridement and skin grafts were required to treat one of the player's cutaneous infection. Potential causes for transmission of MRSA included frequent skin trauma, prolonged covering of the cutaneous wounds, and shared items among the team members such as balms and lubricants. (9,10)

In January 2003, cutaneous MRSA infection was diagnosed in two wrestlers on an Indiana high school team. Hospitalization was not required. The sharing of items--instead of direct contact--was favored as the source of bacterial transmission because the two boys were not in the same weight group and had never wrestled each other. (10)

MRSA infection occurred in 4 of 70 members (6%) of a Colorado fencing club and one household contact of a fencer between July 2002 and February 2003. MRSA was confirmed by culture for three of these individuals. Cutaneous infection in four of the patients presented as a single abscess or multiple abscesses that were most commonly located on the lower extremities and abdomen; two of these individuals required hospitalization to receive intravenous antibiotics. Paraspinal myositis with bacteremia, requiring hospitalization, developed in the fifth patient. All of the patients recovered from their infection; however, similar episodes of antimicrobial-treated infection had previously occurred in two of the patients with subsequently culture-confirmed MRSA. The mode of MRSA transmission was not determined. The infected fencers reported that they did not share their clothing, masks, and weapons; however, it is possible that they unknowingly used the same sensor wires, a piece of equipment that is worn under their uniform to record when an opponent's weapon has touched them, which is usually shared by club members and that is not cleaned on a routine schedule. (10)

Possible risk factors for the acquisition and transmission of MRSA infection in athletes include physical contact (enabling direct skin-to-skin transmission of MRSA), skin damage (resulting in nonintact epithelium that facilitates the entry of pathogens at that location), and sharing of equipment or clothing (providing a vehicle for bacterial transmission if they have not been cleaned or laundered between users). (7-10) The mode of MRSA transmission for the sports participants in this study potentially includes some or all of these factors. During volleyball team practice and competition, transmission of MRSA may have resulted from incidental skin-to-skin contact between the team mates; alternatively, or in addition, acquisition of MRSA may have possibly resulted from cutaneous injury secondary to nonintentional frictional contact of the player's skin with the wooden court. All of the weight lifters exercised at the same recreation center and had cutaneous MRSA lesions that were located in a similar distribution; therefore, shared use of the same equipment (such as the bench press) may be the source of transmission of their skin infection.

Treatment of cutaneous CAMRSA infection requires drainage of the abscess (either spontaneously or after incision), considering--and optimally confirming by culture--the diagnosis of MRSA infection, and treatment with systemic antimicrobial therapy to which the bacterial isolate is susceptible. (3,9) The basketball player in this study presented with multiple abscesses. At her initial visit, the surface of her nondraining infectious lesions was cultured for bacteria and she received empiric treatment with an antibiotic to which her culture-positive MRSA strain was susceptible. However, when she returned for follow up 10 days later, her left thigh abscess was still tender and fluctuant (Fig. 1); the lesion was incised and the antibiotic susceptibility of the MRSA culture-positive pus that was drained was identical with that of her original bacterial culture. After an additional 2 weeks of double-strength trimethoprim/sulfamethoxazole twice daily, all of her infectious skin lesions had completely resolved. Therefore, even if a patient is receiving systemic antibiotic treatment to which their MRSA strain is susceptible, their cutaneous infection will not resolve--and will remain unchanged or progress--until the infectious abscess has been drained.

Not only the people who coach athletes but also the physicians who treat sports participants should be aware that skin infections in these individuals may be caused by MRSA. (8,9) Therefore, at the initial office visit, performing a bacterial culture of an athlete's cutaneous lesions that are suspected to be secondary to S aureus is recommended. (3,6,9) However, because MSSA skin infection is still more common in the community than MRSA in an otherwise healthy sports participant without MRSA-associated risk factors, it is not uncommon for that athlete to be treated with antibiotics that cover MSSA. (3) Subsequently, similar to the currently reported sports participants and to the previously described athletes with cutaneous MRSA infections, the MRSA skin infection that is being treated for MSSA will usually persist or worsen. (6) Hence, unresolved or progressing cutaneous infection suspected to be caused by S. aureus and initially treated with therapy directed toward MSSA should prompt the physician to culture the patient's lesion for bacteria, if not already done, and to change their antibiotic to a systemic antimicrobial to which the MRSA isolate is likely to be susceptible, such as trimethoprim/sulfamethoxazole or clindamycin--either alone or in combination with rifampin. (3,7)

The treatment of cutaneous MRSA infection should also include topical treatment to the infectious lesion and to potential sites of bacterial colonization such as the nares. (3,20-22) Most of the athletes in this study applied mupirocin (2%) ointment, at least three times each day for a minimum of 7 to 10 days, intranasally and to their skin lesions after cleaning and/or soaking them in warm water. Daily bathing of the infectious lesions and the surrounding area with an antibacterial liquid soap or detergent is also helpful for treating MRSA infection and colonization. (3,20-22) Several of the athletes in this study were treated daily with either povidone-iodine (7.5% or 10.0%) liquid soap or 4% chlorhexidine gluconate liquid detergent while concurrently receiving systemic antimicrobial therapy. After their cutaneous MRSA infection resolved, they tapered the frequency of bathing with the antibacterial agent every 2 weeks starting with every other day (three times weekly) and decreasing to every third or fourth day (twice weekly) before stopping.

There are several measures that can be incorporated to prevent the spread of skin infections, such as those caused by MRSA, in sports participants. (7-10) Players should avoid contact with other participant's cutaneous lesions and their drainage. (7,10) Therefore, an individual with skin wounds should not permit these lesions to be exposed; ideally, they should be completely covered. The possible exclusion from practice or competition of participants in athletic activities with potentially infectious unhealed cutaneous lesions that cannot be covered should be considered. (8)

Good hygiene is essential. (9,10) This not only includes showering with soap and hot water after practice and competition but also not sharing clothing (such as towels) or personal items. (8) In addition, there should be an established schedule for the routine cleaning of the equipment that is regularly shared by participants. (7-9)

Coaches and sports players should actively participate in the detection and preliminary treatment of the athlete's skin lesions. Coaches should regularly inspect their players for cutaneous lesions and participants should report new wounds to their coaches. (8,10) In addition, both the coaches and the participants should receive training about cutaneous wounds. (10) This should not only consist of education on how to recognize potentially infected skin lesions but also include first aid instruction for these wounds. (10)

Conclusion

Cutaneous CAMRSA infection is more frequently being observed in athletic participants, including weight lifters and team members from competitive sports such as basketball, fencing, football, rugby, volleyball, and wrestling. The infectious lesions usually occur in otherwise healthy athletes--many of whom do not have any MRSA-associated risk factors. The MRSA skin lesions typically present as one or more abscesses, with or without surrounding cellulitis; they are often erythematous, tender, and fluctuant. This infection is contagious and may affect not only the athletes but also their household contacts. Therefore, in addition to establishing the diagnosis of the infectious cutaneous lesion and appropriately treating the MRSA skin infection, it is also important to prevent additional transmission of the causative bacteria. The diagnosis of cutaneous MRSA infection should be considered when skin lesions suspected to be caused by S. aureus and initially treated with antimicrobials to which MSSA is susceptible persist or worsen. Bacterial culture of the lesion should be performed to establish the diagnosis of cutaneous MRSA infection and to determine the antibiotic susceptibility of the bacterial isolate. Treatment of cutaneous MRSA infection involves drainage of the abscess (either spontaneously or after incision) and appropriate systemic antimicrobial therapy. Many stains of CAMRSA are susceptible to trimethoprim/sulfamethoxazole or clindamycin or both; therefore, either of these antibiotics may be used alone or in combination with rifampin for the treatment of CAMRSA skin infection. One or more of the following factors may result in the acquisition and transmission of MRSA infection in athletes: direct skin-to-skin physical contact with infectious lesions or drainage, skin damage that facilitates the entry of bacteria, and sharing of infected equipment, clothing, or personal items. Measures that can potentially prevent the spread of cutaneous MRSA infection in participants of athletic activities include earlier detection and topical treatment of athletes' skin wounds by their coaches, avoidance of contact with other participants' cutaneous lesions and their drainage, and good personal hygiene.

Table 1. Characteristics of cutaneous community-acquired
methicillin-resistant Staphylococcus aureus infections in university
student athletes (a)

       Age                       MRSA
Case   R-S   Sport               RF       Lesion site(s)

1      19 y  Varsity basketball  None     Left anterolateral thigh
       B-F                                Left buttock
                                          Left labia majora
2 (c)  19 y  Varsity volleyball  None     Left posterior thigh
       W-F
3      20 y  Varsity volleyball  Yes (e)  Left buttock
       B-F                                Left chin
4      25 y  Weight lifting (f)  None     Left arm (g)
       B-F
5 (h)  19 y  Weight lifting      None     Right axillae
       B-M
6 (c)  22 y  Varsity football    None     Right great toe (i)
       B-M
7 (j)  24 y  Weight lifting (f)  Yes (k)  Left flank (g)
       H-M                                Right flank (g)

       Lesion            Initial                  Definitive
Case   morphology        treatments (b)           treatments (b)

1      Abscess and       TMP/SMZ X 10 d           Incision and drainage
         cellulitis      Bactroban ointment       TMP/SMZ X 14 d
                                                  Bactroban ointment
                                                  Povidone-iodine soap
2 (c)  Abscess (d) and   Cephalexin X 2 d         TMP/SMZ X 10 d
         cellulitis                               Bactroban ointment
3      Abscess (d) and   Ceftriaxone X 2 d        TMP/SMZ X 14 d
         cellulitis      Cephalexin X 14 d        Bactroban ointment
4      Abscess and       Incision and drainage    TMP/SMZ X 8 d
         cellulitis      Cephalexin X 1 d         Bactroban ointment
                         Bactroban ointment       Chlorhexidine
                         Chlorhexidine detergent  detergent
5 (h)  Abscess and       Incision and drainage    TMP/SMZ X 15 d
         cellulitis      Cephalexin X 7 d         Bactroban ointment
                                                  Povidone-iodine soap
6 (c)  Abscess (d) and   Cephalexin X 7 d         Clindamycin X 14 d
         cellulitis (i)                           Rifampin X 14 d
7 (j)  Abscess (d) and   Cephalexin X 7 d         TMP/SMZ X 24 d
         cellulitis      Bactroban ointment       Bactroban ointment
                         Povidone-iodine soap     Povidone-iodine soap

(a) B, black; F, female, H, Hispanic; M, male; R, race; RF, risk factor;
S, sex; TMP/SMZ, trimethoprim/sulfamethoxazole; W, white.
(b) The agent, dosage, route of administration, and frequency of
administration for the initial and definitive treatments were as
follows: Bactroban ointment = applied topically thrice daily
intranasally and to the lesions for at least 10 to 14 days; Ceftriaxone
= ceftriaxone sulfate 250 mg intramuscularly each day; Cephalexin =
cephalexin 500 mg orally 4 times each day; Chlorhexidine detergent = 4%
chlorhexidine gluconate liquid detergent, used topically on the lesions
and surrounding area each day when bathing; Clindamycin = clindamycin
300 mg orally 4 times each day; Povidine-iodine soap = either 7.5% or
10% povidine-iodine liquid soap, used topically on the lesions and
surrounding area each day when bathing; Rifampin = rifampin 300 mg
orally twice each day; TMP/SMX = double strength trimethoprim/
sulfamethoxazole, orally twice each day. Initially, the liquid
antimicrobial agents (chlorhexidine detergent and povidine-iodine soap)
were used daily while the student was receiving systemic therapy; once
their infection resolved, the frequency of bathing with the agent was
tapered every 2 weeks starting with 3 times each week (every other day)
and decreasing to 2 times each week (every third or fourth day) before
stopping.
(c) Some of the clinical features of this student have previously been
described. (6)
(d) The abscesses of these students had spontaneously ruptured before
their initial evaluation; purulent serosanguinous pus was either
draining from the lesion or able to be expressed after gentle pressure
to the lesional area.
(e) The student had received systemic ciprofloxacin for the treatment of
a urinary tract infection within the prior year.
(f) The students were also physical fitness trainers.
(g) The location of the student's abscess and surrounding cellulitis was
adjacent to their axillae.
(h) Some of the clinical features of this student have previously been
described. (11)
(i) The student's skin infection clinically presented as an ingrown nail
of the right great toe (onychocryptosis) with an associated abscess and
cellulitis of that toe's lateral nail fold (acute paronychia).
(j) The student had a culture-confirmed recurrence of his cutaneous
infection within 2 weeks after completing the definitive systemic
antibiotic treatment for his initial episode. His recurrent bacterial
infection presented as an intact enlarging tender erythematous fluctuant
nodule with surrounding cellulitis in his right axillae; the lesion was
incised and drained, oral TMP/SMZ was taken for 25 days, and topical
Bactroban ointment and chlorhexidine detergent were used. The infection
resolved completely and there were no additional recurrences during the
next 5 months.
(k) The student had received systemic ciprofloxacin for the treatment of
a skin infection within the previous year.

Accepted February 14, 2005.

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RELATED ARTICLE: Key Points

* Cutaneous community-acquired methicillin-resistant Staphylococcus aureus infection typically presents as an abscess, with or without surrounding cellulitis, in otherwise healthy participants of athletic activities who have or do not have methicillin-resistant Staphylococcus aureus (MRSA)-associated risk factors.

* Athletes who have MRSA skin infections include weight lifters and team members from competitive sports such as basketball, fencing, football, rugby, volleyball, and wrestling.

* Bacterial culture of suspected infectious skin lesions should be performed to establish the diagnosis of cutaneous MRSA infection and to determine the antibiotic susceptibility of the bacterial isolate.

* Treatment of cutaneous MRSA infection involves drainage of the abscess and appropriate systemic antimicrobial therapy.

* Direct skin-to-skin physical contact with infectious lesions or drainage, skin damage that facilitates the entry of bacteria, and sharing of infected equipment, clothing, or personal items may result in the acquisition and transmission of MRSA infection in athletes.

* Earlier detection and topical treatment of the athlete's skin wounds by their coaches, avoidance of contact with other participants' cutaneous lesions and their drainage, and good personal hygiene are measures that can potentially prevent the spread of cutaneous MRSA infection in participants of athletic activities.

Philip R. Cohen, MD

From the Dermatologic Surgery Center of Houston and The Department of Dermatology, University of Texas-Houston Medical School, Houston, TX.

Reprint requests to Dr. Philip R. Cohen, 805 Anderson Street, Bellaire, TX 77401. Email: [e-mail]