Cutaneous community-acquired methicillin-resistant Staphylococcus aureus infection in participants of athletic activities.Objectives: Cutaneous cutaneous /cu·ta·ne·ous/ (ku-ta´ne-us) pertaining to the skin.
Of, relating to, or affecting the skin.
Pertaining to the skin. community-acquired methicillin-resistant Staphylococcus aureus methicillin-resistant Staphylococcus aureus Methicillin-aminoglycoside resistant Staphylococcus aureus, MRSA An organism with multiple antibiotic resistances–eg, aminoglycosides, chloramphenicol, clindamycin, erythromycin, rifampin, tetracycline, (CAMRSA) has been identified in otherwise healthy individuals either with or without methicillin-resistant S. aureus The aureus (pl. aurei) was a gold coin of ancient Rome valued at 25 silver denarii. The aureus was regularly issued from the 1st century BC to the beginning of the 4th century AD, when it was replaced by the solidus. (MRSA MRSA Methicillin-resistant Staphylococcus aureus. See MARSA. )-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 Skin Lesions Definition
A skin lesion is a superficial growth or patch of the skin that does not resemble the area surrounding it.
Skin lesions can be grouped into two categories: primary and secondary. were evaluated at the Health Center and grew MRSA was performed. The clinical characteristics and the postulated pos·tu·late
tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates
1. To make claim for; demand.
2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument.
3. 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 weight·lift·er or weight lift·er
One who lifts heavy weights for exercise or in an athletic competition.
weight lifter n → levantador(a) m/f de pesas (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 erythematous
characterized by erythema. , fluctuant abscesses with surrounding cellulitis Cellulitis Definition
Cellulitis is a spreading bacterial infection just below the skin surface. It is most commonly caused by Streptococcus pyogenes or Staphylococcus aureus. . The lesions were most frequently located in the axillary ax·il·lar·y
Relating to the axilla.
Located in or near the armpit.
Mentioned in: Mastectomy
of or pertaining to the armpit. region (three weight lifters), on the buttocks buttocks /but·tocks/ (but´oks) the two fleshy prominences formed by the gluteal muscles on the lower part of the back. (two women), or on the thighs (two women). The drainage from all of the skin lesions grew MRSA, which was susceptible to clindamycin, gentamicin gentamicin /gen·ta·mi·cin/ (jen?tah-mi´sin) an aminoglycoside antibiotic complex isolated from bacteria of the genus Micromonospora, , rifampin rifampin (rĭfăm`pĭn), antibiotic used in the treatment of tuberculosis. It is also used to eliminate the meningococcus microorganism from carriers and to treat leprosy, or Hansen's disease. , trimethoprim/sulfamethoxazole, and vancomycin vancomycin (văn'kōmī`sĭn), antibiotic resembling penicillin in the way it acts. It is derived from the bacterium Streptomyces orientalis, which was isolated from soil of India and Indonesia. ; five of the isolates were also susceptible to ciprofloxacin ciprofloxacin /cip·ro·flox·a·cin/ (sip?ro-flok´sah-sin) a synthetic antibacterial effective against many gram-positive and gram-negative bacteria; used as the hydrochloride salt.
n. and levofloxacin. All of the bacterial strains were resistant to erythromycin erythromycin (ĭrĭth'rōmī`sĭn), any of several related antibiotic drugs produced by bacteria of the genus Streptomyces (see antibiotic). , oxacillin oxacillin /ox·a·cil·lin/ (ok?sah-sil´in) a semisynthetic penicillinase-resistant penicillin used as the sodium salt in infections due to penicillin-resistant, gram-positive organisms. , 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 antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al)
1. killing microorganisms or suppressing their multiplication or growth.
2. an agent with such effects. therapy for which the bacterial strain was susceptible.
Conclusions: Cutaneous CAMRSA infection typically presents as an abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling. , 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 incision /in·ci·sion/ (in-sizh´un)
1. a cut or a wound made by cutting with a sharp instrument.incis´ional
2. the act of cutting.
1. ) 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 personal hygiene person n → Körperhygiene f 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 methicillin /meth·i·cil·lin/ (meth?i-sil´in) a semisynthetic penicillin highly resistant to inactivation by penicillinase; used as the sodium salt.
n. resistant, participants, skin, sports, Staphylococcus aureus Staphylococcus au·re·us
A bacterium that causes furunculosis, pyemia, osteomyelitis, suppuration of wounds, and food poisoning.
Staphylococcus aureus Staphylococcus pyogenes
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 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 from the lesional site of the draining (either spontaneously or after incision of the skin lesion Skin Lesions can include moles, cysts, warts or skin tags. Most are benign but are sometimes removed if they are painful, unsightly or restrict movement. Surgical removal is the most common treatment for most skin lesions. ) serosanguinous pus pus, thick white or yellowish fluid that forms in areas of infection such as wounds and abscesses. It is constituted of decomposed body tissue, bacteria (or other micro-organisms that cause the infection), and certain white blood cells. were performed. The inoculated cotton applicator ap·pli·ca·tor
An instrument for applying something, such as a medication.
n a device for applying medication; usually a slender rod of glass or wood, used with a pledget of cotton on the end. 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 See scanner. measured the attenuation Loss of signal power in a transmission.
The reduction in level of a transmitted quantity as a function of a parameter, usually distance. It is applied mainly to acoustic or electromagnetic waves and is expressed as the ratio of power densities. 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 Bacterial growth
The processes of both the increase in number and the increase in mass of bacteria. Growth has three distinct aspects: biomass production, cell production, and cell survival. , which was expressed as a change in the turbidity turbidity /tur·bid·i·ty/ (ter-bid´i-te) cloudiness; disturbance of solids (sediment) in a solution, so that it is not clear.tur´bid
The cloudiness or lack of transparency of a solution. and the color in Verb 1. color in - add color to; "The child colored the drawings"; "Fall colored the trees"; "colorize black and white film"
color, colorise, colorize, colour in, colourise, colourize, colour 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 inoculum /in·oc·u·lum/ (-ok´u-lum) pl. inoc´ula material used in inoculation.
n. pl. of bacterial colonies equivalent to 0.5 McFarland standard was inoculated onto an agar plate An agar plate is a sterile Petri dish that contains a growth medium (typically agar plus nutrients) used to culture microorganisms. Selective growth compounds may also be added to the media, such as antibiotics. 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 Adv. 1. for 24 hours - without stopping; "she worked around the clock"
around the clock, round the clock at 35[degrees]C; detection of more than 1 bacterial colony or a light film of growth confirmed oxacillin/methicillin resistance.
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 weight lifting, international sport, also a training technique for athletes in other sports. From the earliest times men have lifted weights as a test of strength. 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 urinary tract infection (UTI),
n infection in one or more of the structures that make up the urinary system. Occurs more often in women and is most commonly caused by bacteria. (one of the volleyball players This is a list of top international volleyball players.
: Top - 0–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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 labia ma·jo·ra
The two outer rounded folds of adipose tissue that lie on either side of the vaginal opening and that form the external lateral boundaries of the vulva. . 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 paronychia /par·onych·ia/ (par?-ah-nik´e-ah) inflammation involving the folds of tissue around the fingernail.
Inflammation of the tissue surrounding a nail. ) 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 streptococcus (strĕp'təkŏk`əs), any of a group of gram-positive bacteria, genus Streptococcus, some of which cause disease. in the basketball player and football player, respectively.
[FIGURE 1 OMITTED]
The abscesses had spontaneously ruptured and were draining purulent pu·ru·lent
Containing, discharging, or causing the production of pus.
Consisting of or containing pus
Mentioned in: Lacrimal Duct Obstruction
containing or forming pus. 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 nail fold
A fold of hard skin overlapping the base and sides of a fingernail or toenail. of the football player's toe. Incision and drainage Incision and drainage is a minor surgical procedure to release pus or pressure built up under the skin, such as from an abscess or boil. It is performed by treating the area with an antiseptic, such as iodine based solution, and then making a small incision to puncture the skin of the inflamed fluctuant nodules Nodules
A small mass of tissue in the form of a protuberance or a knot that is solid and can be detected by touch.
Mentioned in: Leprosy 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 MSSA Methicillin-Sensitive Staphylococcus Aureus
MSSA Microscopy Society of Southern Africa
MSSA Maryland Saltwater Sportfishermen's Association
MSSA Military Selective Service Act
MSSA Mid-South Sociological Association
MSSA Minnesota Social Service Association ). 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 adjuvant /ad·ju·vant/ (aj?dbobr-vant) (a-joo´vant)
1. assisting or aiding.
2. a substance that aids another, such as an auxiliary remedy.
3. topical therapy (Table 1). Mupirocin (2%) ointment ointment /oint·ment/ (oint´ment) a semisolid preparation for external application to the skin or mucous membranes, usually containing a medicinal substance.
n. was applied intranasally three times daily to treat possible bacterial colonization at that site; also, the infectious lesions were treated with the antibiotic ointment antibiotic ointment Any of a number of topical antibacterial ointments or creams after each cleaning. In addition, several of the students bathed the involved areas of skin with an antibacterial antibacterial /an·ti·bac·te·ri·al/ (-bak-ter´e-al) destroying or suppressing growth or reproduction of bacteria; also, an agent that does this.
adj. agent each day. They used povidone-iodine liquid soap (at either a 7.5% or 10.0% concentration) or 4% chlorhexidine gluconate Chlorhexidine gluconate is a chemical antiseptic.  It kills (is bactericidal to) both gram-positive and gram-negative microbes, although it is less effective with some gram-negative microbes.  It is also bacteriostatic. liquid detergent Noun 1. liquid detergent - a detergent in liquid form
detergent - a cleansing agent that differs from soap but can also emulsify oils and hold dirt in suspension .
[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]
Infections caused by CAMRSA have been observed within many cities throughout the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. 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 staphylococcal
pertaining to Staphylococcus spp.
staphylococcal clumping test
used as a means of measuring the quantity of fibrinogen-split products in a sample of blood. 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 Panton-Valentine leukocidin
a nonhemolytic toxin produced by Staphylococcus aureus which kills segmented neutrophils and macrophages. 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 Colonized
This occurs when a microorganism is found on or in a person without causing a disease.
Mentioned in: Isolation 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 Noun 1. wrestling mat - a mat on which wrestling matches are conducted
gym mat, mat - sports equipment consisting of a piece of thick padding on the floor for gymnastic sports , 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 gel electrophoresis
Electrophoresis performed in a gel composed of agarose, polyacrylamide, or starch. 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 toenail /toe·nail/ (to´nal) the nail on any of the digits of the foot.
ingrown toenail see under nail.
n. . 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 cephalexin /ceph·a·lex·in/ (-lek´sin) a semisynthetic first-generation cephalosporin, effective against a wide range of gram-positive and a limited range of gram-negative bacteria; used as the base or the hydrochloride salt. . 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 The Los Angeles County Department of Health Services (DHS) in Los Angeles County's department providing public and personal health services to the over 10 million residents in the County. 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 Debridement Definition
Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds.
Debridement speeds the healing of pressure ulcers, burns, and other wounds. and skin grafts were required to treat one of the player's cutaneous infection. Potential causes for transmission of MRSA included frequent skin trauma Skin trauma is when the skin or multiple layers of epithelial tissues experience serious and altering physical injury. This can be in the form of cuts, burns, sickness or other injury. , 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 myositis
Inflammation of muscle tissue, often from bacterial, viral, or parasitic infection but sometimes of unknown origin. Most types destroy muscle and surrounding tissue. Bacteria may directly infect muscle (usually after injury) or produce substances toxic to it. with bacteremia bacteremia: see septicemia.
Presence of bacteria in the blood. Short-term bacteremia follows dental or surgical procedures, especially if local infection or very high-risk surgery releases bacteria from isolated sites. , 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 incised /in·cised/ (in-sizd´) cut; made by cutting. 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)
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 caus·a·tive
1. Functioning as an agent or cause.
2. Expressing causation. Used of a verb or verbal affix.
caus 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.
1. Said-Salim B. Mathema B, Kreiswirth BN. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen emerging pathogen Public health Any pathogen that ↑ incidence of an epidemic outbreak Examples Cryptosporidium, E coli O157:H7, Hantavirus, multidrug resistant pneumococci, vancomycin-resistant enterococci. See Emergent disease. . Infect Control Hosp Epidemiol 2003;24:451-455.
2. Vandenesch F, Naimi T, Enright MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence. Emerg Infect Dis 2003;9:978-984.
3. Cohen cohen
(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. PR, Grossman ME. Management of cutaneous lesions associated with an emerging epidemic: community-acquired methicillin-resistant. Staphylococcus aureus skin infections [commentary]. J Am Acad Dermatol 2004;51:132-135.
4. Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus: an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003;16:103-124.
5. Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J 2004;23:123-127.
6. Cohen PR, Kurzrock R. Community-acquired methicillin-resistant Staphylococcus aureus skin infection; an emerging clinical problem. J Am Acad Dermatol 2004;50:277-280.
7. Lindenmayer JM, Schoenfeld S. O'Grady R, et al. Methicillin-resistant Staphylococcus aureus in a high school wrestling team and the surrounding community. Arch Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine.
in·tern or in·terne
n. Med 1998;158:895-899.
8. Stacey AR, Endersby KE, Chan PC, et al. An outbreak of methicillin resistant Staphylococcus aureus infection in a rugby football team. Br J Sport Med 1998;32:153-154.
9. Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Outbreaks of community-associated methicillin-resistant Staphylococcus aureus skin infections: Los Angeles County, California Los Angeles County is a county in California and is by far the most populous county in the United States. Figures from the U.S. Census Bureau give an estimated 2006 population of 9,948,081 residents, while the California State government's population bureau lists a , 2002-2003. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 2003;52:88.
10. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus infections among competitive sports participants: Colorado, Indiana, Pennsylvania Indiana is a borough in Indiana County, Pennsylvania, United States, part of the Pittsburgh DMA. The population was 14,895 at the 2000 census. It is the county seat of Indiana County. , and Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. County, 2000-2003. MMWR Morb Mortal Wkly Rep 2003;52:793-795.
11. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin infection presenting as an axillary abscess with cellulitis in a college athlete. SKINmed 2005;4:115-118.
12. Gosbell IB, Mercer JL, Neville SA, et al. Non-multiresistant and multiresistant methicillin-resistant Staphylococcus aureus in community-acquired infections. Med J Aust 2001;174:627-630.
13. Dietrich DW, Auld auld
Adj. 1. auld - a Scottish word; "auld lang syne"
old - of long duration; not new; "old tradition"; "old house"; "old wine"; "old country"; "old friendships"; "old money" DB, Mermel I.A. Community-acquired methicillin-resistant Staphylococcus aureus in Southern New England New England, name applied to the region comprising six states of the NE United States—Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. The region is thought to have been so named by Capt. children. Pediatrics 2004;113:e347-e352. (http://www.pediatrics.org/cgi/content/full/113/4/e347).
14. Fang YH, Hsueh PR, Hu JJ, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children in northern Taiwan. J Microbiol Immunol Infect 2004;37:29-34.
15. Palavecino E. Community-acquired methicillin-resistant Staphylococcus aureus infections. Clin Lab CLIN LAB Clinical Laboratory / Klinisches Labor (Journal) Med 2004;24:403-418.
16. Naimi TS, LeDell KH, Como-Sabetti K, et al. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA JAMA
Journal of the American Medical Association 2003;290:2976-2984.
17. Diep BA, Sensabaugh GF, Somboona NS, et al. Widespread skin and soft-tissue infections due to two methicillin-resistant Staphylococcus aureus strains harboring the genes for Panton-Valentine leucocidin. J Clin Microbiol 2004;42:2080-2084.
18. Baggett HC, Hennessy TW, Rudolph K, et al. Community-onset methicillin-resistant Staphylococcus aureus associated with antibiotic use and the cytotoxin cytotoxin /cy·to·tox·in/ (si´to-tok?sin) a toxin or antibody having a specific toxic action upon cells of special organs.
n. Panton-Valentine leukocidin during a furunculosis furunculosis /fu·run·cu·lo·sis/ (fu-rung?ku-lo´sis)
1. the persistent sequential occurrence of furuncles over a period of weeks or months.
2. the simultaneous occurrence of a number of furuncles. outbreak in rural Alaska. J Infect Dis 2004;189:1565-1573.
19. Cohen PR. What caused this abscess and cellulitis? Diagnosis: Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) skin infection. Skin & Aging 2004;12:56-58.
20. Boyce JM. MRSA patients: proven methods to treat colonization and infections. J Hosp Infect 2001;48(Suppl A):S9-S14.
21. Semret M, Miller MA. Topical mupirocin for eradication of MRSA colonization with mupirocin-resistant strains. Infect Control Hosp Epidemiol 2001;22:578-580.
22. Kampf G, Kramer A. Eradication of methicillin-resistant Staphylococcus aureus with antiseptic antiseptic, agent that kills or inhibits the growth of microorganisms on the external surfaces of the body. Antiseptics should generally be distinguished from drugs such as antibiotics that destroy microorganisms internally, and from disinfectants, which destroy soap and nasal mupirocin among colonized patients: an open uncontrolled clinical trial. Ann Clin Microbiol Antimicrob 2004;3:9 (http://www.ann-clinmicrob.com/content/3/1/9).
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: email@example.com