Open Letter to Ohio Wrestling Association,
As a dermatologist, I have recently uncovered an ‘easily treatable’ form of methicillin-resistant Staphylococcus aureus (MRSA) in two wrestlers from the same school with open skin sores. I credit the high school wrestling coach, Brian Buck at Maumee High, for finding the cases and sending them for treatment. The sensitivities of this form of MRSA may be important to other physicians and coaches attending to treating such patients in our neck of the woods.
To begin with, the reported incidence of MRSA ranges from 7 to 60 % of the population.1,2,3 A higher incidence is seen in hospital care workers and their families. In one study of 231 wrestlers and 8 officials, the incidence of MRSA was less than a percent about the normal population.4 There are at least three ‘types’ of MRSAnamely healthcare-associated, community-associated and livestock-associated. Each of these has a range of different clones, clinical features, molecular biology, antibiotic susceptibility and treatment. In some individuals, MRSA infections can be serious and can cause significant morbidity and mortality.5
MRSA is known to cause skin and soft tissue infections such as cellulitis, necrotizing fasciitis, and diabetic foot ulcers.5 Such infections can be multidrug-resistant leading to frequent recurrence, hospitalization, and mortality.2
A bacterial culture collected on 12/11/23 from a skin wound from a wrestler on a high school wrestling team revealed MRSA resistant to cefazolin and oxacillin; but sensitive to clindamycin, doxycycline, trimethoprim-sulfamethoxazole, and intravenous vancomycin. This was followed by another wrestler on the same team also growing MRSA from a skin wound on 1/18/24. This strain of MRSA had the same exact sensitivities. Both wrestlers were treated successfully with doxycycline 100 mg bid and Bactrim DS bid for a week and application of Neosporin ointment. Since both bacteria had the same exact sensitivities, it could be inferred that it is the same strain of MRSA. Of note, on 1/25 /24 and 1/26/24, two other wrestlers from the same school had superficial abrasions swabbed for bacterial culture (results pending). In the interim, I opted to treat both competitors in the same fashion as the other two earlier classmates with combination of oral antibiotics.
No other screening for active surveillance was initiated, but could include testing for PCR MRSA, or cultures of nares, oropharynx, or perineum.
This organism is probably in the normal flora of many wrestlers in the Toledo area. Given the high incidence of MRSA in the general population (that includes wrestlers) there is no need to institute strict contact precautions especially considering the benign list of antibiotics useful to eradicate the infection. The sensitivities of the strain of MRSA in our patients might be important information for other health professionals and the Ohio State Athletic Association treating abrasions, scrapes, cuts, and cellulitis in wrestlers in Northwest Ohio.
These cases have allowed the high school coach, his team, and myself to review several safety issues related to wrestling. I start with the conclusion of a study of two 15-college wrestling invitational meets evaluating 231 wrestlers and 8 officials. 4 They concluded under key points (taken verbatim):
Best-practice recommendations to minimize the spread of skin infections via wrestling mats are that all wrestlers should receive annual influenza vaccinations, all mats should be mopped backward with a residual disinfectant, and all wrestlers must use alcohol-based hand-sanitizing gel before each bout.
The incidence of respiratory bacteria on the mats was high.
Residual disinfectants had long-term bacteria-killing action.
Backward mopping of mats reduced the occurrence of soil bacteria.
Using an alcohol-based hand-sanitizing gel reduced bacterial load on the hands
We have also reviewed the cleaning of wrestling mats as bacteria and germs can inhabit there. The present guide to disinfecting wrestling mats includes:
· Step 1: Clear the Mat Before you start with the wrestling mat cleaning solution, ensure you remove any loose dirt or debris.
· Step 2: Apply the Disinfectant Whether you’re using a spray or wipe, apply the wrestling mat disinfectant evenly across the surface.
· Step 3: Allow the disinfectant to sit for the recommended time. …
· Step 4: Wipe Down and Air dry
We also addressed the effectiveness of body wipes as an adjunct to reducing skin infections. This has been investigated minimally in the literature.6 KS Skin creme and CLN sport wash are two examples. It is my feeling that in the case of MRSA in which antibiotics can rectify the problem, the natural body bacteria on the skin surface should remain intact as much as possible. Eliminating the bulk of the normal bacterial flora with wipes means there are going to be considerable spots for recolonization. Thus, using a disinfectant to the skin would greatly reduce the natural flora, possibly making it easier for stray MRSA organism to recolonize in a team situation.
References cited include:
1. Sabbagh P, Riahi SM, Gamble HR, Rostami A. The global and regional prevalence, burden, and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV-infected people: A systematic review and meta-analysis. Am J Infect Control. 2019 Mar;47(3):323-333. [PubMed]
2 Khan TM, Kok YL, Bukhsh A, Lee LH, Chan KG, Goh BH. Incidence of methicillin resistant Staphylococcus aureus (MRSA) in burn intensive care unit: a systematic review. Germs. 2018 Sep;8(3):113-125. [PMC free article] [PubMed]
3. Ko JH, Moon SM. Evaluation of Methicillin-Resistance Rates among Community-associated Staphylococcus aureus Infections in Korean Military Personnel. J Korean Med Sci. 2018 Sep 24;33(39):e250. [PMC free article] [PubMed]
4. Young LM, Motz VA, Markey ER, et al. Recommendations for best disinfectant practices to reduce the spreaad of infection via wrestling mats. Journal of Athletic Training 2017;52:82-8.
5. Siddiqui AH, Koirala J. Methicillin-resistant Staphylococcus aureus. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
2023 Apr 2.
6. Anderson BJ. . Effectiveness of body wipes as an adjunct to reducing skin infections in high school wrestlers. Clin J Sport Med. 2012; 22 5: 424– 429. [PubMed]
Sincerely,
Craig G, Burkhart, MD, MPH, Dermatologist at 5600 Monroe Street, Suite 106B, Sylvania, Ohio
Brian Buck, ME, Varsity Wrestling Coach, Maumee High