Health Update
RECOMMENDATIONS FOR MANAGEMENT OF SUSPECT STAPHYLOCOCCUS INFECTIONS AMONG SPORTS TEAMS/ATHLETES-REVISED

DPH has been working closely with Department of Education regarding management of Staphylococcus aureus infections, some of which are culture confirmed Community Acquired Methicillin Resistant (CA-MRSA), transmitted among school sports teams. In order to further characterize the problem and implement control measures, our original recommendations have been revised.

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 Suspect Staph Infections
-Sports Teams / Athletes-
February 23, 2006

1. Initial Screening
2. Culture collection / Treatment
   • Collection of culture
   • Antimicrobial therapy
3. Reporting
4. Exclusion and Return
5. Reevaluation Process for Culture-confirmed MRSA
6. Prevention Strategies:
   • Personal hygiene
   • Environmental sanitation

These recommendations were developed in the sole context of sports teams and student athletes, which constitute a high risk group for transmission of Staphylococcus aureus and Methicillin Resistant Staphylococcus aureus (MRSA) infections. These recommendations would not necessarily be applicable in a general community setting.

Initial Screening

• All athletes/sports team members should be assessed daily for the presence of suspect Staph infections. This can be conducted by a qualified healthcare provider.
• Any individual that exhibits a suspect Staph infection should be referred to the school nurse/wellness center provider or other qualified healthcare provider.
• Suspect Staph infections or uncultured wounds/lesions should be treated as a potential MRSA infection---culture should be collected and treatment initiated immediately.
• More serious infections (i.e., abscesses) may require incision and drainage. These individuals should be referred out to a physician. In these cases, proper drainage of the infection can be more important than antibiotic therapy.
• Suspect Staph infections consist of, but are not limited to: pustules of any type, abscesses, furuncles, carbuncles, folliculitis, impetigo, and cellulitis.

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.
• 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 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.
• 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. If 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.
• 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.
• Some physicians may choose to treat with topical antibiotics and wound care. However, physicians are encouraged to perform incision and drainage on all appropriate lesions and send for culture, even if oral antibiotics are not being considered for treatment. The antibiogram information obtained from the culture can guide subsequent antibiotic therapy should the patient not respond to topical antibiotics and wound care.

Reporting

• Each facility should introduce an internal policy to assure that all suspect Staph infections are reported and evaluated by a qualified healthcare provider.
• Participants should be excluded from further participation until evaluation and treatment by a qualified healthcare provider. (Note: If referring a student athlete to their primary care physician, it is advisable to send culture/treatment recommendations.)
• According to Delaware Communicable Disease Regulations, 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.

Exclusion and Return

• Any athlete/sports team member presenting with a suspect Staph infection should be excluded from further athletic activity. This applies to any activity involving person-to-person contact and use of any shared athletic equipment (i.e., weight room equipment, wrestling mats, and protective gear).
• All suspect Staph infections should be treated as a potential MRSA infection, cultured, and appropriate antimicrobial therapy instituted.
• If the participant is evaluated by a healthcare provider who chooses to treat with topical medications and wound care, the participant should continue to be excluded until they are clear of any moist, exudative or draining lesions.
• 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, participant should be reevaluated as detailed below prior to return to play. As a general rule, participant’s who have culture-confirmed MRSA should be excluded until they are clear of any moist, exudative or draining lesions.
• Dermatologic conditions that are not suspect Staph infections (or other communicable condition) can be covered by a bandage made of nonpermeable material that will withstand the rigors of competition. These participants should not be excluded.
• Under no circumstances shall a participant with a suspect or confirmed Staph infection be allowed to participate until they are clear of any moist, exudative or draining lesions.

Reevaluation Process for Culture-confirmed MRSA

• Any participant with culture-confirmed MRSA shall be reevaluated by visual inspection by a qualified healthcare provider prior to returning to sporting activities.
• Upon reevaluation (48 hours), if the participant’s infection has not improved, consider reevaluation at 72 hours or refer out to a physician.

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.
• Consider installation of liquid shower soap dispensers and use an antibacterial soap such as Safeguard.
• Do not share any topical preparations (i.e., ointments, salves, antibiotic creams).
• Discourage practice of body shaving among male athletes.
• Laundry: Wash towels, uniforms, etc. and any other soiled items using hot water, ordinary detergent, and dry using normal drying cycle. 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. All items should be laundered after each use.
• After laundering, all items should be dried completely before being reused.

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 solution (1 tablespoon bleach in one quart of water).
• If a single case of MRSA is diagnosed, or an outbreak of Staph infections occurs, 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).

Whirlpool equipment should be sanitized following the manufacturer’s recommendations. Participants with suspect Staph infections and/or MRSA infections should be excluded from the use of whirlpool equipment.

To contact DPH about this Health Advisory, call 1-888-295-5156. This number is answered during normal business hours, and during non-business hours for emergencies.