Skin Infections In Athletics PowerPoint Presentation

Slide 1 -

Skin Infections In Athletics W. Randy Martin, MD Infectious Disease Consultant Director, Sutter Roseville Wound Clinic

Slide 2 -

Skin Infections The skin always has some amount of bacteria, fungus, and viruses living on it Skin infections occur when there are breaks in the skin and the organisms have uncontrolled growth

Slide 3 -

How Infectious?? It is more important to understand the potential for infection rather than placing a name on a skin problem The priority is the health of the athlete When in doubt, err on the side of safety and well-being

Slide 4 -

Problem Skin Lesions Always worry about lesions that have an irregular border Worry about raised skin lesions Worry about “wet” or “moist” lesions

Slide 5 -

Problem Skin Lesions Worry about skin lesions that have different colors within the lesion Bright red colored lesions are more of a problem compared to faded lesions Lesions that are warmer compared to other skin are more likely to be infected.

Slide 6 -

Problem Skin Lesions Patterns of skin lesions help determine how infectious the lesions have become Inflammation and irritation around the skin lesions increase the chance the lesions are infectious

Slide 7 -

Problem Skin Lesions An athlete with a prior history of infectious skin lesions has a higher risk of recurrent skin infections Skin abrasions increase the risk of skin infection. The deeper or more traumatic the break in the skin, the higher the risk for a subsequent infection

Slide 8 -

Expertise The more experienced a medical person has with skin lesions, the better the medical evaluation An physician experienced with skin lesions and infections is better than one with limited experience Legally the experienced matside physician evaluation is more important compared with a prior outpatient evaluation

Slide 9 -

Expertise In some situations an experienced athletic trainer or referee may have more expertise compared to a physician who has limited experience – but this problem is difficult to objectively document The best situation is qualified physicians, trainers and referees working together for the benefit of the athletes.

Slide 10 -

Skin Infections - Highlights Bacteria (can be cured) Staphlococcus including MRSA & Impetigo Streptococcus Fungal (can be cured) Ringworm Viral (can’t be cured but can be treated) Herpes Warts Molluscum contagiosum

Slide 11 -

Skin Infections The right antibiotic is required to cure a specific bacterial skin infection Antibiotics for bacteria will not improve fungal or viral infections Bacterial infections can be the fastest growing infections and for this reason are the most easily spread among athletes

Slide 12 -

Skin Infections The faster the bacteria grows, the more likely the correct antibiotic will cure the infection. Herpes gladitorium (Herpes simplex) responds the best to antiviral medication. Other virus infections are relatively resistant to current medications

Slide 13 -

Examples of Staph Infections www.spapex.org/spapex/ impetigobulloso.jpg

Slide 14 -

Staph Infection

Slide 15 -

Chronic folliculitis due to Staphylococcus aureus infection

Slide 16 -

Folliculitis Inflammation of hair follicle Frequently caused by infection Physical injury can cause problem Painless or tender pustule

Slide 17 -

What is MRSA? The official name is Methicillin resistant Staphylococcus aureus. It is a “Staph” infection “Staph” and “Strep” bacteria often cause skin infections. MRSA is resistant to many of the traditional “Staph” antibiotics

Slide 18 -

MRSA In Sports 1984 - rugby team in London 1986 - outbreak of boils in football and basketball Kentucky 1993 - 1st case of MRSA in a wrestling team in Vermont 2002 - 03 – MRSA boom!!! -Los Angeles county: athletes & county jail -Colorado, Indiana, and Pennsylvania – fencers, football, & wrestlers 2004 - 05 – high school, college, professional football and basketball

Slide 19 -

MRSA Typically presents with an abscess May or may not have surrounding cellulitis Athlete may or may not have risk factors for infection

Slide 20 -

MRSA Sports who have athletes develop infections include weight lifting, basketball, baseball, canoeing, fencing, football, rugby, running (cross-country), soccer, softball, volleyball, and wrestling

Slide 21 -

How Do MRSA Infections Occur? Touching someone’s MRSA-infected skin Touching surfaces that have MRSA on them, like doorknobs and light switches Sharing personal hygiene items (bar soap, towels, razors) Overusing antibiotics, stopping them early, or missing doses

Slide 22 -

MRSA

Slide 23 -

How is MRSA treated? By a healthcare provider who may: Drain the infection and/or Give the correct antibiotic and/or Help reduce the amount of bacteria on the skin.

Slide 24 -

Recurrent Infections MRSA skin infections recur at a high rate Skin surface and fomite colonization appear to be as important as nasal colonization Alcohol-based disinfectants may be superior to detergent-based formulations

Slide 25 -

Stop Spreading MRSA! Wash your hands often with warm, soapy water Use 60% alcohol- based hand sanitizer when soap and water are not available Shower immediately after practice and matches

Slide 26 -

Stop Spreading MRSA! Do not share personal hygiene items (bar soap, towels, razors) or clothing Wear practice clothes/ uniforms only once, wash with soap and hot water, dry in hot dryer Cover all wounds with a clean, dry bandage taped on all four sides

Slide 27 -

Stop Spreading MRSA! Avoid contact with other people’s skin infections Report skin infections to coach/ trainer/ nurse Clean and disinfect athletic/wrestling gear and practice surfaces (mats, benches, weight lifting equipment) after each use

Slide 28 -

Stop Spreading MRSA! Do not let wrestlers practice with potentially contagious wounds, even if covered, and consider use of this rules for all contact sports

Slide 29 -

Returning To Athletics Should be kept out of competition until wounds are completely healed Recurrent infections can be prevented by chlorhexidine body washes daily for three days and then three times per week. Nasal carriage of MRSA can be treated with intranasal povidine-iodine or mupirocin.

Slide 30 -

Impetigo Can develop on any exposed skin surface after skin-to-skin contact in sports. Topical mupirocin may be used with the possible addition of oral antibiotics, such as a second-generation oral cephalosporin Athlete may return to competition after five days of therapy if the lesions have become crusted.

Slide 31 -

General Treatment of Bacterial Infections with Antibiotics You need to take the right medicine. Antibiotics are not all the same. Even if you start to feel better, you need to take all of the pills, to help the infection go away. Taking a few pills will not kill all of the bacteria, and may make the ones that remain stronger.

Slide 32 -

Treatment with Antibiotics(cont) Antibiotics work by killing the bacteria in skin infections. The bacteria that are normally on your skin can become resistant to antibiotics if you take them when you don’t really need them.

Slide 33 -

Treatment with Antibiotics(cont) Go back to the doctor if you are taking your antibiotics and are not getting better after two or three days of treatment. You may need a different kind of antibiotic.

Slide 34 -

Ringworm (fungus) Also known as Tinea corporis (fungus) Common among wrestlers Treatment should include a topical agent (such as clotrimazole twice a day for three weeks) as well as an oral antifungal agent (such as fluconazole for three weeks). May return to competition after five, but ideally after 10 days of treatment

Slide 35 -

Ringworm

Slide 36 -

Treatment of Ringworm Be sure to take the anti-fungal medicine for the full duration of time. Failure to do so may result in the ringworm returning.

Slide 37 -

Herpes Gladitorium (viral) Also known as Herpes simplex Relatively common. Well-defined grouped vesicles are diagnostic. Symptoms may include fever, chills, and headache

Slide 38 -

Herpes Gladitorium

Slide 39 -

Herpes Infection Of Finger

Slide 40 -

Herpes Infections Herpes infections are associated with nerve endings and are never completely killed in the body Herpes skin infections are the same as sexually transmitted herpes infections – same organism and they recur during times of stress and illness

Slide 41 -

Herpes Infections Herpes infections can be transmitted from a carrier to another athlete without any visible skin lesions being present Only approximately 20% of people infected with herpes ever experienced skin lesions

Slide 42 -

Herpes Infections Potential signs and symptoms of active herpes infections – without skin lesions Itchiness Pain, especially nerve pain Enlarged lymph nodes Fever

Slide 43 -

Problematic Herpes Recurrent infections in the same athlete Infections in multiple athletes on the same team Multiple athletes fighting the “crud” with fever, fatigue, enlarged lymph nodes May consider chronic suppressive antiviral medication especially during critical times of the competitive season

Slide 44 -

Treatment For Herpes Gladitorium Treatment with either acyclovir, valcyclovir, or famciclovir for 10 days Wrestling can be resumed four to seven days after start of treatment if vesicles have resolved.

Slide 45 -

Molluscum contagiosum Virus infection of skin Discrete, flesh‑colored, dome‑shaped papules

Slide 46 -

Covering Skin Lesions Covering skin lesions do not reduce infections! Infections penetrate dressings and the outer dressings have been shown to be contagious In the physical sport of wrestling, dressings slip and move around, are abrasive on the wound which increases infection potential

Slide 47 -

Disinfection Guidelines All hard environmental surfaces that may come in contact with body fluids should be cleaned (i.e., visible dirt removed) and sanitized (i.e., disinfected, or removal of bacteria) daily, if area is in use. Many commonly available cleaning products are effective against MRSA - a complete list of EPA-approved disinfectants for MRSA is available at www.epa.gov/oppad001/list_h_mrsa_vre.pdf. Refer to the manufacturer's directions for recommended contact times for various disinfectants. Always wear gloves when using disinfectants.

Slide 48 -

Disinfection Guidelines All floor and wall padding in athletic area(s) should be washed daily (if the athletic area is used) Separate mop heads/ buckets should be used for each activity area, locker room, and restroom. Mop heads and buckets should be cleaned regularly. (Washable micro-fiber heads or disposable mop cloths may be more convenient)

Slide 49 -

Disinfection Guidelines Towels/ linens laundered on premises should be washed with detergent at a minimum of 160 F and dried in a hot dryer.

Slide 50 -

Disinfection Guidelines CAUTION!! If clean athletic gear is dumped into a dirty laundry bag or gym bag, the gear immediately becomes a source of infection!

Slide 51 -

Wrestling Rooms and Mats Wall padding and benches should be wiped-down with an EPA-approved disinfectant such as a quaternary ammonium (quat) or 1:9 bleach solution after each practice and meet. Mat surfaces with small holes or tears should be repaired with mat tape. When mat sides are in poor condition, mats should be taped together for meets and for practice.

Slide 52 -

Wrestling Room and Mats Mat surfaces should be replaced promptly when there are large holes or surfaces are excessively worn. Both sides of the mats should be cleaned thoroughly before and after each use for practices and meets. In rooms with multiple 40x40 foot mats, it may not be practical to clean the mat underside everyday but this cleaning should be perform as frequent as possible.

Slide 53 -

Wrestling Room And Mats Mop heads and buckets should be washed regularly. Consider using a separate mop head/bucket specifically for cleaning mats.

Slide 54 -

Locker Rooms/ Shower Rooms Liquid, not bar, soap should be readily available and provided by wall dispensers close to sinks and next to showers. Safeguard or Dial brands are two of the more effective brands of soap Chlorhexidine is much more effective compared to soap in reducing infection

Slide 55 -

Locker Rooms/ Shower Rooms Soap dispensers should be checked regularly to ensure that soap is present Soap dispensers should have “unit” refills

Slide 56 -

Locker Rooms/ Shower Rooms Shower with soap or chlorhexidine (recommended) and water immediately after each practice, game, match, or other event. Use a clean, dry towel

Slide 57 -

Locker Rooms/ Shower Rooms All shower and locker room areas should be cleaned daily (if used) Towels should not be shared. If they are washed at school, they should be washed in soap and water at 160 F minimum and dried in a hot dryer.

Slide 58 -

Sports Equipment Whenever possible, equipment and clothing should not be shared. All shared equipment that comes in direct contact with the skin of an athlete (wrestling head gear, football helmets, and fencing wires) should be cleaned and sanitized after each use. Sports equipment (balls, racket grips, bats, gloves) should be cleaned regularly

Slide 59 -

Disinfectant A bleach solution of 1 part bleach in 9 parts water (e.g., 1 3/4 cups bleach to 1 gallon of water) will kill Staphylococcus aureus, as well as other (tougher to kill) disease-causing organisms such as norovirus and Clostridium difficile, and should be used when possible.

Slide 60 -

Disinfectant In situations where this is impractical, a more dilute solution (e.g., 1 part bleach in 64 parts water, such as 1/4 cup bleach in 1 gallon of water) may be used to disinfect surfaces that may be contaminated with S. aureus. However, it should be noted that bleach solutions more dilute than 1 part bleach in 9 parts water may not kill some disease causing organisms.

Slide 61 -

Disinfectant Another option is to use a 1 part bleach in 9 parts water solution, followed by a rinse with water to remove residual bleach. Bleach solutions should be mixed fresh daily to ensure effectiveness. Bleach solutions should NOT be used to sanitize hands or for cleaning wounds.

Slide 62 -

Disinfectants Make your own solution of bleach and water: Mix one tablespoon bleach into one quart of water in a spray bottle and label it “bleach solution.” Make it fresh each time you plan to clean because the bleach evaporates out of the water making it less effective Never mix bleach with other cleaners, especially ammonia.

Slide 63 -

Cleaning Frequency MRSA bacteria and other organisms can live on surfaces for days, weeks and months It is important to clean regularly. Clean daily frequently touched items and surfaces.

Slide 64 -

First Aid Include alcohol-based hand sanitizer (60% or greater) in coach’s first aid kit so that coaches/ trainers will always be able to sanitize hands before and after caring for each injured player when soap and water is not readily available.

Slide 65 -

First Aid Have disposable gloves readily available in first aid kit for use when caring for the scrapes and cuts of players. Use gloves once and then discard; wash hands or use hand sanitizer immediately after removing gloves. Scoops (not hands) must be used to take ice out of cooler to make ice packs for injuries. Scoops should be cleaned daily when in use and NOT stored in the ice container.

Slide 66 -

First Aid Single-use portions of antibiotics, salves, and other ointments should be removed from any larger dispensing unit prior to application. Any un-used product must NOT be returned to the original dispenser, but discarded.

Slide 67 -

First Aid Athletes should be prohibited from participating until wounds have healed-even if wounds are covered – if extensive skin-to-skin contact may occur (e.g., wrestlers). Athletes with potential skin infections should be referred to the team physician or their own medical provider. Culturing wounds that appear to be infected should be encouraged.

Slide 68 -

Other Skin Conditions

Slide 69 -

Hives A.k.a. Urticaria Formation of “wheals” Usually raised, red welts appear Multiple causes: Irritants Allergens Foods Medications Stress Pet dander Pollen Environments

Slide 70 -

Sunburn

Slide 71 -

Atopic Dermatitis (www.meddean.luc.edu/.../dermatology/ melton/poisivy1.jpg)

Slide 72 -

Atopic Dermatitis Poison Ivy Poison Oak Various chemicals Clothing Cosmetics Laundry detergents Food Jewelry

Slide 73 -

Psoriasis A chronic skin condition, not infectious

Slide 74 -

Verruca Vulgaris “common wart” Benign, hypertrophied areas of the skin Papilloma viruses Types common warts plantar warts

Slide 75 -

Key Points Athletes should be regularly encouraged to follow good hygiene practices, including frequent hand washing, showering immediately following each practice or competition, and NOT sharing “drinking” water bottles Do NOT touch other peoples’ skin infections. Any draining wound should be considered a potential skin infection

Slide 76 -

Key Points Do NOT share personal hygiene items (e.g., bar soap, razors, nail clippers, etc.), or topical ointments, antibiotics, deodorants, and salves. Promptly report abrasions, lacerations, or skin infections to a coach/ team trainer, or school nurse Cosmetic shaving should be discouraged

Slide 77 -

Key Points Athletes with open wounds should be discouraged from using whirlpools or common tubs. Individuals with scratches or open wound can infect others or become infected in this kind of environment. Wash practice clothes/ uniforms with soap and warm water and dry in a hot dryer after every use

Slide 78 -

Key Points Messages should be repeated regularly (e.g., weekly) and following any observed violations. Rewards for compliance (as well as potential penalties for non-compliance) may help to reinforce appropriate behaviors.

Slide 79 -

Key Points Visual aids (e.g., posters) should be present and located strategically to remind athletes, staff, and parents regarding proper behaviors Coaches and staff should be role-models for students and parents – they should strive to model correct behaviors.

Slide 80 -

Maximize Athletic Success!Minimize Risk of Infections!

Slide 81 -

Acknowledgements Center for Disease Control Tacoma-Pierce County Health Department Sutter Roseville Medical Center Infection Control Department Virginia Department of Health