Health Advisory
COMMUNITY-ACQUIRED METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (CA-MRSA)

DPH has been alerted of Staphylococcus aureus infections, some of which are confirmed Community Acquired Methicillin Resistant (MRSA), apparently transmitted among school sports teams, primarily wrestlers. DPH is currently working with the Department of Education to further characterize the problem and implement control measures.

Healthcare providers are advised that DPH issued the following recommendations to the Department of Education. These recommendations are in the process of being implemented. Further, healthcare providers are urged to manage undiagnosed lesions suspected of being Staphylococcus aureus infections, among patients who participate in school athletic programs, as MRSA until culture confirmation is received.

Recommendations for Management of Rash Illnesses / Skin Lesions
-Sports Teams / Athletes-

1. Initial Screening
   • All athletes/sports team members should be assessed daily for the presence of rash illnesses and/or skin lesions. This can be conducted by the coach and/or athletic director.
   • Any individual that exhibits a rash illness and/or skin lesion should be referred to the school nurse/wellness center provider or primary care physician.
   • Rash illnesses, skin lesions, draining wounds or uncultured wounds/lesions should be treated as a potential MRSA infection---culture collected and treatment initiated immediately.
2. Culture collection / Treatment
             Collection of culture:
   • Utilize standard precautions for collecting and handling all specimens.
   • Whenever possible, collect culture specimens prior to administration of antimicrobial agents.
   • Deliver all specimens to the laboratory as soon as possible after collection. Specimens for bacterial culture should be transported at room temperature.
   • Specimens should be contained in tightly sealed, leakproof containers and transported in sealable, leakproof plastic bags.
   • Abscess – Tissue or aspirates are always superior to swab specimens. Remove surface exudates by wiping with sterile saline or 70% alcohol. Aspirate with needle and syringe. For superficial ulcers, cleanse surface with sterile saline and collect material from below the surface. Cleanse rubber stopper of transport device with alcohol; push needle through septum and inject all abscess material on top of agar. It a swab is used, pass the swab deep into the base of the lesion to firmly sample the fresh border. Specimens should be received at the laboratory as soon as possible.
   • Superficial ulcers – Cleanse surface with sterile saline and collect material from below the surface. Cleanse rubber stopper of transport device with alcohol; push needle through the septum and inject all abscess material on top of agar. If a swab must be used, pass the swab deep into the base of the lesion to firmly sample the fresh border. Specimens should be received at the laboratory as soon as possible.
   • Other dermal lesion – Obtain either a small biopsy of skin or drainage from the infected site after debriding the surface and cleansing with sterile saline. Cleanse rubber stopper of transport device with alcohol; push needle through the septum and inject all abscess material on top of agar. If a swab must be used, pass the swab deep into the base of the lesion to firmly sample the fresh border. Specimens should be received at the laboratory as soon as possible.
   • Further questions may be referred to the Division of Public Health Laboratory (Microbiology department): 302-223-1520.
     Antimicrobial therapy:
   • MRSA bacteria are resistant to many types of antibiotics and it is important to make sure that a culture from the infected area is obtained.
   • Laboratories can do sensitivity testing to find out which antibiotics will be effective in killing the bacteria. This will ensure that the correct antibiotic is given for the treatment of the infection.
   • Trimethoprim/Sulfamethoxazole (TMP-SMX) is considered the drug of choice. Recommended dosage: 160mg/800mg twice daily x 10-14 days.
   • For individuals with sulfa allergies, Doxycycline/minocycline 100mg twice daily x 10-14 days is an acceptable alternative.
   • Rifampin is useful as adjunctive therapy (with TMP-SMX or Doxycycline), but does have the potential for significant toxicity and drug interactions.
3. Reporting
   • Each facility should introduce an internal policy to assure that all rash illnesses and/or skin lesions are reported and evaluated by a healthcare provider.
   • Participants should be excluded from further participation until evaluation and treatment by a healthcare provider. (Note: If referring a student athlete to their primary care physician, it is advisable to send culture/treatment recommendations)
   • By communicable disease regulation, MRSA is reportable to DPH. Primary care physicians, Wellness Center providers and school nurses are all obligated to report under this regulation (888-295-5156).
   • School nurses are responsible for conducting passive/active surveillance for the presence of any communicable disease and report unusual findings to DPH Epidemiology (888-295-5156). This includes suspected outbreaks among athletic teams, etc.
4. Exclusion and Return
   • Any athlete/sports team member presenting to the coach/school nurse and/or Wellness Center with any type of rash illness and/or skin lesion should be excluded from further athletic activity. This includes, but is not limited to, practices/games/matches involving person-to-person contact and use of any shared athletic equipment (i.e., weight room equipment, wrestling mats, and protective gear).
   • All rash illnesses and/or skin lesions should be treated as a potential MRSA infection, cultured, and appropriate antimicrobial therapy instituted.
   • If MRSA is culture-confirmed, at a minimum, the athlete/sports team member should be excluded for 48 hours after antimicrobial therapy was begun. However, clinical assessment is paramount to determine if the participant’s return is appropriate for his/her specific sport. As a general rule, participant’s who have culture-confirmed MRSA should be excluded until their rash/skin lesion is fully dry and healed.
   • If the healthcare practitioner chooses not to culture the rash and/or skin lesion, the participant should not return until their rash/skin lesion is fully dry and healed.
5. Rescreening Process for Culture-confirmed MRSA
   • Any participant with culture-confirmed MRSA shall be rescreened by the school nurse and/or Wellness Center provider (if available) prior to returning to sporting activities.
   • This screening should occur whether or not the participant has received a note from his/her Primary Care Provider stating he/she may return.
   • As a general rule, participant’s who have culture-confirmed MRSA should be excluded until their rash/skin lesion is fully dry and healed.
6. Prevention Strategies
             Personal hygiene:
   • Handwashing is the single most important behavior in preventing infectious disease. Encourage frequent handwashing with warm water/soap during the course of practices/games/matches.
   • When hand-washing facilities are not readily available, provide alcohol-based sanitizers and encourage frequent use.
   • Do not share personal care items (i.e., towels, soap, razors, and water bottles). This includes sideline towels and drinking reservoirs.
   • Encourage all participants to shower as soon as possible after direct contact sports using a clean, dry towel.
   • Do not share any topical preparations (i.e., ointments, salves, antibiotic creams)
   • Laundry: Wash towels, uniforms, etc. and any other soiled items using hot water, ordinary detergent, and dry on the hottest cycle after each use. Prewash or rinse any item that has been contaminated with body fluids. Laundry should be contained in an impervious container or sealed plastic bag for transport home.
     Environmental sanitation:
   • Establish and enforce routine cleaning schedules for all athletic areas or equipment (i.e., shared protective gear, weight rooms, locker rooms, wrestling mats, etc.)
   • Locker rooms and weight rooms should be cleansed at least once weekly using a commercial phenol-containing disinfectant, or a fresh mixture of 1:100 bleach solutions (1 tablespoon bleach in one quart of water).
   • If a single case of MRSA is diagnosed, cleaning should be increased to at least twice weekly.
   • Shared athletic equipment (i.e., wrestling mats, protective gear, etc.) should be cleansed after each use using a commercial phenol-containing disinfectant, or a fresh mixture of 1:100 bleach solution (1 tablespoon bleach in one quart of water).

To view the DPH fact sheet regarding CA-MRSA and Staphylococcus aureus among sports teams and/or athletes, please go to: http://www.dhss.delaware.gov/dhss/dph/files/mrsa.pdf

To view CDC’s general CA-MRSA fact sheets, please go to: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html

Please contact Delaware Division of Public Health at 1-888-295-5156 with any questions or concerns related to these recommendations.