STATE OF WEST VIRGINIA
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Bob WisePaul L. Nusbaum
Governor Secretary
H E A L T H A L E R T
DATE:September 23, 2004
TO:Physicians
Local Health Departments
Regional Epidemiologists
School Nurses
FROM:Infectious Disease Epidemiology Program
West Virginia Department of Health and Human Resources
RE:Outbreaks of Community Acquired Methicillin Resistant Staphylococcus aureus (CA-MRSA) in high school football players
Since the beginning of the school year, the Infectious Disease Epidemiology Program has received reports of skin infections in members of two high school football teams.
High School A: A 16-year-old football player on the first team noted symptoms on 8/15/2004 and presented to a local emergency room the following day with a knee wound. Culture of the wound grew methicillin resistant Staphylococcus aureus (MRSA). A 15-year-old teammate, who had been symptomatic with an ankle wound since 8/5/2004 was subsequently cultured on 8/19/2004 and also was found to have MRSA. Their coach had an infected hair on 8/3/2004, which progressed to cellulitis with an abscess. A culture taken 8/6/2004 was positive for MRSA. The coach was treated initially with a variety of oral antibiotics, but ultimately required intravenous vancomycin. After discussion with staff from the local health department and hospital, the high school instituted environmental cleaning of the locker rooms, and every student on the team was examined for skin lesions. No further cases were identified. Information on personal hygiene and MRSA control was shared with students and parents.
Bureau for Public Health
Division of Surveillance and Disease Control
Infectious Disease Epidemiology
Room 125, 350 Capitol Street
Charleston, West Virginia 25301-3715
(304) 558-5358 or 1-800-423-1271
Health Alert
September 23, 2004
Page 2
High School B: On 9/7/2004 the local health department was notified to evaluate several football players with ‘spider bites.’ Four football players with suspicious skin lesions were identified. One of these individuals had a severe cellulitis at the time of
report and had been treated for several days with intravenous ceftriaxone without improvement. Public health officials recommended cultures for all football players with lesions and local care, including incision and drainage, as clinically indicated. The football player with severe cellulitis required incision and drainage and packing of his
wound. Intravenous levofloxacin was added to his regimen, and he has since recovered. Ultimately, a total of three individuals on the team had lesions that were culture-positive for MRSA. The school instituted environmental cleaning of locker rooms, and sent information home on MRSA with all students. All teams that had played High School B during the previous two weeks were notified. High Schools A and B had not played each other at all during the season.
Outbreaks of CA-MRSA among high school sports teams (fencers, football players, wrestlers) were first reported in the MMWR, volume 52, pg 793(2003). Outbreaks of CA-MRSA have also been reported in a variety of correctional institutions and in close-knit family and social groups in West Virginia. Skin lesions associated with this condition have often been misdiagnosed as ‘spider-bites,’ on initial presentation. Often, cultures of these lesions are not obtained, leading to delays in institution of appropriate antimicrobial therapy. The strain circulating in West Virginia has been susceptible to trimethoprim-sulfamethoxazole in most cases, and this antibiotic has been used successfully for oral treatment. Physicians should now consider the possibility of MRSA in evaluation of any skin lesion, even in the ambulatory care setting.
The Infectious Disease Epidemiology Program is following this situation and encourages reporting of outbreaks to the local health department, as required by law.
Recommendations for School Athletic Teams (MMWR, Vol. 52, pg 793 (2003):
Cover all wounds. If a wound cannot be covered adequately, consider excluding players with potentially infectious skin lesions from practice or competitions until the lesions are healed or can be covered adequately.
Encourage good hygiene, including showering and washing with soap after all practices and competitions.
Ensure availability of adequate soap and hot water.
Discourage sharing of towels and personal items (e.g., clothing or equipment).
Establish routine cleaning schedules for shared equipment.
Health Alert
September 23, 2004
Page 3
Train athletes and coaches in first aid for wounds and recognition of wounds that are potentially infected.
Encourage athletes to report skin lesions to coaches and encourage coaches to assess athletes regularly for skin lesions.
Recommendations for Physicians:
Maintain a low threshold for culturing infected skin lesions.
Maintain a low threshold for obtaining blood cultures on potentially bacteremic patients with skin infections.
Local care (incision and drainage, debridement) is the mainstay of treatment for localized skin lesions.
Empiric antibiotic therapy, if needed, should be initiated in accordance with locally available antibiogram data and adjusted according to antibiotic susceptibilities when available.
Physicians should familiarize themselves with the principles of judicious use of antibiotics. Information is available on our website at: Overuse of oral antibiotics for viral upper respiratory infections is extremely common and may contribute to increased incidence of resistant infections such a CA-MRSA. Educational materials for your patients on the problem of antibiotic overuse are available by calling 800-423-1271.
Recommendations for Local Health Departments:
Work with schools, jails and health care providers to raise awareness of CA-MRSA – a serious emerging public health concern in our state. Share this alert and other information with anyone who needs to know.
Work with schools, providers and community groups to increase awareness of the problem of antibiotic overuse. Please contact Mary A. Myers at 800-423-1271 for information on the GET SMART campaign, the school program and other education and outreach programs available for use in your community, or see the information on our website at Encourage your regional epidemiologist to get involved.
Report outbreaks of CA-MRSA to the Infectious Disease Epidemiology Program using investigation forms in the reportable disease protocol manual.