By Greg Scholand

Greg Scholand is an Assistant Editor at Athletic Management.

Jon Cochran, a senior guard on Stanford University's football team, is 6-foot-6 and weighs over 300 pounds. Methicillin-resistant Staphylococcus aureus, also known as MRSA, is a bacterium too small to be seen by the naked eye. But when the two butted heads this season, MRSA won, sending Cochran to the hospital and sidelining him for two games.

Cochran was one of a handful of Stanford football players infected during a MRSA outbreak this past fall, an albatross that contributed to the team's dismal 1-11 season. However, the experience gave the athletic department a hands-on emergency lesson in managing infectious disease.

"It was amazing how quickly the infection would hit somebody," says Charlie Miller, Stanford's Head Athletic Trainer for Football. "Our doctors would look at a tiny lesion and say, 'All right, let's keep an eye on it.' By the next day, it became something really significant. You could be doing all the right things to protect yourself and still get hit."

If MRSA isn't on your department's radar screen yet, it should be. It can strike anywhere, and if not properly dealt with, the effects can be devastating. Programs that have faced this microscopic menace agree that vigilance, communication, and common-sense preventive measures are the keys to keeping your athletes safe.

BACTERIAL BACKGROUND
It has been almost 10 years since MRSA first appeared in an athletic setting, and in that time, it has cropped up everywhere from elementary school gyms to NFL locker rooms. In 2003, it made national headlines when a football player at Lycoming College died of a bloodstream infection linked to MRSA bacteria. But while more and more team physicians and athletic trainers are aware of the risks, an outbreak still often catches programs by surprise.

What exactly is MRSA, and why is it so dangerous? For years, the antibiotic methicillin (a synthetic form of penicillin) was a standard treatment for staph infections, which were common in hospitals and nursing homes but rarely seen in the general public. Over time, some staph bacteria developed resistance to methicillin, and decades of doctors overprescribing antibiotics made the problem worse. Today, methicillin is no longer prescribed to treat infections, but the term "methicillin-resistant" is still used to describe staph strains that are immune to many common antibiotics.

Because MRSA bacteria are harder to kill, the infections must be treated more carefully than ordinary staph cases (methicillin-susceptible Staphylococcus aureus, or MSSA). If someone with MRSA is prescribed a standard antibiotic, like penicillin or amoxicillin, the bacteria won't be killed and the infection can spread and grow more serious. Untreated MRSA can lead to organ damage, bloodstream infections, pneumonia, or, in extreme cases, necrotizing fasciitis (commonly known as flesh eating bacteria). However, if a diagnosis is made quickly, MRSA can be treated fairly easily using special antibiotics.

"The real key to controlling MRSA is identifying it as quickly as possible," says Jeff Hageman, an epidemiologist specializing in staph infections at the Centers for Disease Control and Prevention (CDC). "The standard treatment procedures and drugs are very effective, and the severe cases are usually the result of an infection not being recognized early enough."

A MRSA infection typically begins as a skin lesion containing a pustule, so it is often mistaken for a pimple, ingrown hair, or spider bite. As it develops, it expands and can present with painful discoloration and swelling, running sores, boils, and sometimes serious tissue damage.

Various forms of Staphylococcus bacteria--and to a lesser extent MRSA--are all around us. The CDC estimates that between 25 and 30 percent of the U.S. population is "colonized" with staph, meaning the bacteria currently live on their skin, in their nasal passages, or elsewhere on their body. Of those people, only about one percent carry a MRSA strain. The colonized almost never find out they are inhabited with staph, and most show no symptoms.

In athletic settings, infection usually occurs when a colonized person's bacteria come into contact with a cut, scrape, or other open wound. Sports involving frequent body-to-body contact, such as football and wrestling, pose the greatest risk since any small break in the skin can become an infection site. But the danger extends to locker rooms as well--MRSA can be spread when athletes share towels, razors, or even bars of soap.

AN OUNCE OF PREVENTION
Strategies for warding off MRSA range from the basic, like using the right kind of soap in locker room showers, to the high-tech--one company offers a metal box that attaches to a wall and constantly filters the air in the room. But experts agree a major piece of the puzzle is simply practicing good hygiene.

"Athletes can do a lot to minimize their exposure to MRSA just by following standard cleanliness rules," says A.J. Duffy III, Head Athletic Trainer at Widener University and former President of the Pennsylvania Athletic Trainers' Association. "That means washing their hands regularly with antibacterial soap. It also means showering immediately after practice--athletes shouldn't change their clothes and head back to their dorm room to shower, though many prefer to do that."

Basic hygiene standards should apply to uniforms and equipment as well. "One thing we know is that bacteria love damp, moist environments, which means protective equipment is a potential danger area," Duffy says. "How many times do you see athletes finish practice and throw their pads in a bag or locker instead of letting them dry out? It's a simple step, but it can make a very big difference."

Almost anything athletes touch on a daily basis--weightroom equipment, towels and washcloths, locker room benches, jerseys--can be a conduit for MRSA bacteria. Since it's impossible to clean every surface daily, it helps to identify the most frequently contacted spots in your facilities (for instance, locker room doorknobs, treatment tables, and shower areas) and single them out for more frequent cleaning.

Mike Goforth, Head Athletic Trainer at Virginia Tech, says his staff's close attention to cleanliness in the athletic training room sets an example that athletes take home with them. "We're real sticklers with hand washing procedures," Goforth says. "All the research says keeping your hands clean is one of the most important things you can do to prevent infection, so we're extremely diligent about that."

Hand washing is also now a major focus at Stanford, where Miller brings bottles of an alcohol-based hand sanitizer out to the field for every football practice. "Each athlete does a waterless hand washing as practice ends before they head to the locker room," Miller explains. "We have keypad locks on our doors, and since athletes will be touching those when they go back inside, we want them to disinfect themselves first. During practice, they touch the ball, wipe sweat off their faces, and make contact with one another, so we want their hands to be clean."

No detail is overlooked--not even the athletes' gloves. "We also provide a spray disinfectant at every practice for anyone who wears gloves on the field," Miller says. "Bacteria can thrive on players' sweaty gloves, so as they walk into the locker room we instruct everyone to spray their gloves down."

Inside the locker room, Stanford installed liquid soap dispensers in all its showers to prevent athletes from sharing bar soap, which provides an ideal growing environment for MRSA bacteria. "Nothing our athletes use in the locker room is shared--everyone keeps their own razors, towels, nail clippers, and whatever else they need," says Miller. "We make sure the athletes are following that policy."

Some programs are also looking to technology to boost their prevention efforts. Last year at Virginia Tech, Goforth's department hired a company to spray the Hokies' synthetic turf fields, wrestling mats, saunas, and other areas with a special antimicrobial coating made of spear-shaped molecules that pierce MRSA and other microbes to kill them without chemicals. Several athletic departments have turned to air purifiers that claim to remove harmful bacteria from locker rooms and other common areas. And in the NFL, the Washington Redskins went high-tech with MRSA prevention by equipping their whirlpools with a filtering system that uses ultraviolet light.

"There are many products out there making bold claims, and it's important to do your homework before investing in any of them," says the CDC's Hageman. "Some are backed up by research and registered with the Environmental Protection Agency to prove they'll do what they say, and others are not as responsible. For teams with very limited resources, the most important thing they can do is make sure everyone is aware of the dangers and knows how to protect themselves."

EDUCATION IS KEY
Well-informed athletes are the best line of defense against outbreaks, so the most proactive programs place heavy emphasis on MRSA-related education. The programs' message is extremely simple--when in doubt, get it checked out--but it can be delivered in many different ways.

"I've learned to not assume athletes will recognize dangers on their own," says Goforth. "We recently had an athlete with a wound on his knee who didn't tell anyone for six days--it was ulcerated by the time we treated him. Here's a college athlete with a hole in his knee, and he didn't say anything. Luckily it wasn't MRSA, but it could have been. We need to constantly reinforce the message about getting every cut, scrape, pimple, and spider bite checked out and not leaving anything to chance."

Whether it's at preseason team meetings, during physicals, or in the athletic training room, Goforth and his staff take every opportunity to talk about MRSA and keep it in the front of athletes' minds. "The more ways they're hearing about it, the better," he says. "We're even looking into purchasing a big flat-screen TV to use as a rotating message board for sports medicine topics. If we're flashing pictures up there of untreated MRSA cases and showing how bad it can get, that will grab their attention."

Indeed, while they're not for the squeamish, photos of MRSA infections can make for a very powerful warning. "We hung up a poster in the football locker room that showed some extreme cases, and it definitely had shock value--which in this case is a good thing," says Stanford's Miller. "The guys kept asking us to flip the poster around. They said, 'Look, we've got it, okay? We don't need to see these pictures every time we go in and out!' But there's no doubt it raised their awareness."

Another effective technique is to discuss playing time. At Stafford (Texas) High School, Athletic Trainer David Edell talks to athletes about teammates who were sidelined with MRSA. "When I say to a team, 'See this guy? He didn't practice yesterday because he's got an infection, and he won't be playing this week,' that hits home for them more than anything else," Edell says. "When it's someone they know, a teammate they can relate to, they're going to remember it and think to themselves, 'Could that be me?'

"Above all, athletes want to participate," Edell continues. "The thought of having their season ended by something that's preventable means more than any other warning or lecture they'll get from me, their coaches, or anyone else."

Athletes' parents, too, should be part of the education process. The message is still very simple--parents should encourage their children to practice good hygiene and report any suspicious skin problem, no matter how minor. But MRSA is something many parents will be hearing about for the first time.

"We conduct a parents' meeting at the beginning of our sports seasons, where we explain what MRSA is and talk about how they can help their children protect themselves," says Tanya Dargusch, Head Athletic Trainer at Washington Township (N.J.) High School, where two football players were infected with MRSA last fall. "For one thing, we're easing any fears parents may have--we always stress that if it's caught early, it can be treated and isn't a major problem. But I make clear it's something everybody needs to be aware of and concerned about."

Especially in high school settings, parents can play a key role in helping their children avoid MRSA. "It's mostly simple things like making sure uniforms get washed, or telling kids to wear their wrestling shoes only on the mats so they're not bringing germs and bacteria from outside into the competition area," Dargusch says. "And we always open it up to questions so parents' individual concerns can be addressed.

"Parents always tell us how much they appreciate being educated and say they're glad we are so proactive about their children's safety," continues Dargusch. "And if they have any concerns during the season, they know they can always come to us."

HANDLING AN OUTBREAK
Even with the best education and prevention programs in place, your athletic department can still get hit with MRSA. And with any outbreak comes a slew of decisions to be made, from how you halt the spread to how you communicate with students, parents, other schools, and even your local media.

On the medical side, it's important to tap into outside resources as soon as possible. When Stanford's outbreak began last fall, the athletic department called on team physicians and infectious disease specialists from the Stanford Hospital & Clinics to take the lead in developing a plan of action.

"The hospital immediately helped us decide what to do," says Miller. "Any wound that was even remotely suspicious was cultured and tested, and anyone who came up positive had their wounds treated and received antibiotics that would kill the bacteria."

The next step was decolonizing the infected players to prevent them from re-infecting themselves or others during and after treatment. "We had those players shower using Hibiclenz soap, which specifically targets MRSA and other bacteria on the skin," Miller explains. "And to decolonize their nasal passages, we gave them Bactroban ointment to coat the inside of their nostrils with."

As a further precaution, the MRSA-positive athletes showered away from the rest of the team in a private bathroom, and their uniforms and other laundry were washed separately. According to the CDC's Hageman, normal washing with hot water and detergent will usually kill any bacteria found on clothing, but with an outbreak already under way, Stanford's athletic department left nothing to chance.

Another step was eliminating potential MRSA transmission sites, and that meant getting rid of the cloth couches in the locker rooms. "We had no reason to believe the couches were the culprit, but we decided to be safe and replace them with vinyl ones that could be cleaned more easily," says Miller. "We were just trying to isolate and eliminate anything that could possibly be contributing to the spread of bacteria."

At Washington Township High, as soon as the first case was confirmed, Dargusch and Assistant Principal for Athletics Kevin Murphy partnered with other school employees to prevent a broader outbreak. "Our school's director of operations, who oversees the custodians, helped us find a cleaning solution that would be effective against MRSA, and we went through the whole building with it," explains Murphy. "We began by disinfecting the locker rooms, the weightroom, bathrooms, showers, and common areas athletes use regularly. Then, over Thanksgiving break, our custodians went all over the school wiping down door handles, doorknobs, windows, lockers, and anything else student-athletes may touch throughout the day. We wanted to cover as much ground as possible to prevent the infection from spreading."

Communication was also at the top of Murphy's priority list. "I called the athletic directors at schools we had competed against or would be competing against, particularly in contact sports," he says. "We have very open lines of communication about everything, but this warranted special attention just to make sure they knew what to be looking for. You certainly don't want it to spread to another school and have someone there be caught off-guard."

In addition, Murphy sent a letter home with each athlete explaining that MRSA had shown up at the school and reminding parents how they could help keep their children safe. He worked with the district's community relations director to put the same information on Washington Township High's Web site, along with links to more in-depth MRSA information from the CDC and the New Jersey Department of Health.

Since the school was so proactive in its response, local media coverage of the situation was no problem for Murphy. "With a story like this, it's always possible a newspaper can take it and jump to an alarmist conclusion," he says. "But we put out so much material that we basically did the reporting for them. The local paper's story about MRSA in our school was taken almost verbatim from our Web site--all they did was put a byline on it. By handling things the way we did, we controlled the message received by the public and made sure there was accurate, quality information out there."

When Stanford's outbreak reached local media, the athletic department focused on protecting athletes' privacy. "We're very careful when it comes to HIPAA and FERPA regulations, so that guided our decisions about what information to put out," says Gary Migdol, Stanford's Assistant Athletic Director for Media Relations. "We did not have an announcement or write a press release to explain the details of our MRSA outbreak. Our head coach answered limited questions as they arose about football players who were out, and that was all--he would just say someone was out because of a staph infection, and leave it at that. Our athletes sign a release that allows us to disclose certain health information related to their playing status, so we basically just followed our policy."

When reporters wanted to know more, Stanford let the athletes themselves decide how much to reveal. "For any questions about what the infection was like or what body parts were affected, we told the players it was up to them whether they wanted to talk about their situation with the media, and a few did," Migdol says.

Beyond that, Stanford made sure the public saw how much the athletic department was committed to treating and protecting its student-athletes. "We certainly wanted to get the word out that we were doing everything we could," Migdol explains. "We talked about all the precautions we were taking--cleaning our facilities, separating the laundry, installing soap dispensers, removing the locker room couches, and other things like that. Our top priority through the whole process was protecting our student-athletes, so that was the message we presented to the media and the public."

SUPPORTING ROLE
As an athletic administrator, the best way you can help keep your program safe from MRSA is to provide complete support for those in charge of caring for your athletes. From making sure coaches know how to talk about prevention to helping your athletic training staff muster its resources in case of an outbreak, administrators can play a crucial role.

"We have an excellent medical team here, and they're the experts," says Migdol. "On the administrative side, our job was just to listen to what they needed and respond to their requests. If they said our department should be doing X, Y, and Z to help protect our athletes, that's what we did."

Miller's final piece of advice is to maintain constant vigilance. "You should never assume that it can't happen to your program," he warns. "It's easy to say, 'We've been careful, it will hit someone else.' But the truth is, you could always be next."