By Janet Cromley, Los Angeles Times Staff Writer
These days, USC's football players might seem more like fussy disciples of the TV detective Monk than scrappy athletes. They use paper towels on the practice field and at games, and they shower before setting foot in the training room. Their laundry is washed at a constant 140-degree temperature, which is regularly monitored. Portable cold therapy tubs are drained and cleaned after each use, and the team brings its own soap to away games.
That's because while racking up wins in the 2003 and 2004 seasons, the players and trainers were also facing down a different type of adversary -- a potential killer known as MRSA, methicillin-resistant staphylococcus aureus.
S. aureus is a common strain of bacterium, often found on the skin and in nasal passages, that can cause infection if it enters the body through a cut or scrape. Although it can be easily treated with antibiotics, methicillin-resistant strains don't respond as readily to common antibiotics and thus can be difficult to eradicate once infection takes hold.
The strain of MRSA that infected the USC athletes was a community-acquired strain, as opposed to a hospital-acquired strain, which means that it occurred in otherwise healthy people who hadn't been hospitalized. The bacterium, which can lead to disfiguring skin infections, is generally passed along through skin-to-skin contact but can linger in showers, on towels and on exercise equipment.
The Trojans' MRSA battle -- two hospitalizations in 2002, followed by 11 confirmed cases as well as six suspected cases in 2003 -- was highly publicized at the time. By 2004, though, MRSA at USC was a nonstory.
Why? Because as USC nears the midpoint of the 2007 season as one of the top 10 winningest Division 1 schools in history, it is also winning the MRSA battle. In the 2004 season through this year, the football team has logged only two cases in total.
USC's response to the MRSA outbreak has been quite extraordinary, says David Klossner, NCAA director of education services. "Their staff recognized the situation, took steps to eradicate spreading of the infection and added monitoring measures on a scale that was not commonly found in the athletics setting."
The story of what USC did to fight MRSA is a valuable lesson and a cautionary tale not only for those who play team sports but also for anyone who has swapped sweat on a community exercise machine.
Caught off guard in 2002The year 2002 was a bad one for CA-MRSA infections. "In 2002, we investigated four outbreaks of community MRSA, which included USC," says Elizabeth Bancroft, medical epidemiologist with the L.A. County Department of Public Health.
"We also investigated an outbreak in a newborn nursery, among men who have sex with men and at the L.A. County Jail, which is still the largest facility outbreak reported in the nation," she says.
Caught off guard by the outbreaks, the Health Department scrambled to get the word out, issuing fact sheets to consumers and medical professionals on how to prevent the spread of the bacterium, documenting the outbreaks in medical newsletters and journals and initiating surveillance programs at county hospitals. The National Collegiate Athletic Assn. also stepped up to the plate, developing educational outreach programs for coaches and trainers involved in team sports. "We took a look at the problem and knew it wasn't going away," Klossner says.
Following the outbreaks at USC, which occurred at about the same time as outbreaks at a fencing club in Colorado and among high school wrestlers in Indiana, the NCAA launched a series of initiatives. It created a MRSA website to educate players and coaches, updated its sports medicine guidebook, which is available online, and sent prevention posters to its member institutions.
The state of fitness centersFitness centers, on the other hand, have not exactly rallied to the cause.
If health clubs are doing anything extra to curb MRSA transmissions, they're not talking about it. Officials at Bally Total Fitness, the Sports Club/LA, Gold's Gym and Crunch Fitness either didn't return repeated calls or declined to comment. But in fairness, no one really knows what danger fitness clubs may pose in the transmission of the bacterium.
Although health officials assume that some cases are transmitted through communal use of equipment and towels, it's nearly impossible to prove that because of the long incubation period of the bug. "People will call us at the Health Department, and say, 'I know I got this skin infection because I went to this gym,' but it's almost impossible to know for certain," says Bancroft. "It could be that they were exposed through their child at school." Cedric Bryant, chief science officer for the American Council on Exercise, acknowledges that there's a reasonable danger of contracting something in a gym. "A set of dumbbells can be a hotbed for common bacteria as well as the handrails on the aerobic equipment, bikes and stair climbers." Nevertheless, he says, "you don't want to be a germaphobe, but following basic hygenic principles should minimize the risk."
Reducing risk of contracting MRSA at the gym and elsewhere is a simple matter of adopting common sense hygiene routines that can be found on the county's public-health website, says Bancroft. "None of these guidelines are rocket science," she says. "Wash your hands. Keep things clean. Follow directions. They're things you learned from your grandmother or in kindergarten."
The problem in generalIt's impossible to know just how many people contract MRSA each year because physicians and medical facilities aren't legally required to report it, but according to Bancroft, the numbers are soaring.
"Countywide, MRSA is the new normal for causing skin and soft-tissue infections," she says. "In fact, it's becoming one of the most prevalent causes of skin soft-tissue infection in emergency rooms." Bancroft believes that about 50% to 60% of people who come to the county emergency rooms with a skin infection have CA-MRSA, based on reports from local county hospitals. These figures vary 15% to 75% across the nation.
In addition, CA-MRSA -- which previously has been confined to the homeless, men who have sex with men, and prison inmates -- has effectively moved out of those risk areas, and now essentially anyone is at risk, says Dr. Paul D. Holtom, hospital epidemiologist for LAC+USC Medical Center and associate professor of medicine and orthopedics at USC Keck School of Medicine.
Holtom, who was consulted extensively on USC's MRSA outbreak, has seen CA-MRSA in basketball and volleyball players, but not to the extent that he's seen it in football players. "Why football players are vulnerable is not well explained," he says. "They have more scrapes on the field, but basketball players, for example, have a lot of physical contact too."
What USC didTo combat MRSA, USC developed and implemented an aggressive plan of attack based on Health Department guidelines that included eliminating towel sharing; using alcohol-based hand sanitizers; using 3% hexachlorophene (Phisohex) or 4% chlorhexidine, intermittently, in the shower soap dispenser; eliminating multiuse lotions and gels with pump dispensers; spraying equipment with disinfectant throughout the day; boosting water temperature in the laundry facility and increasing drying temperature of towels to 180-190 degrees; examining all suspicious lesions; and administering antibiotics to players who are colonized with CA-MRSA. This final move is somewhat controversial, as some public health officials fear the use of antibiotics in this context could increase resistance in the CA-MRSA bug.
Football players and other athletes who engage in vigorous exercise for 90 minutes or more, such as cyclists and swimmers in hard training, appear to be at greater risk for contracting CA-MRSA because of the exercise, says David C. Nieman, an exercise immunologist at Appalachian State University in Boone, N.C.
"The immune system of a marathon athlete after a race is very similar to what you'd see in an elderly person. But it's transient; it lasts about a day."
Nieman, who led a study of 2,300 L.A. marathoners in 1990 that showed a steep increase in upper respiratory tract infections among the athletes one week after the marathon, doesn't believe that fitness facilities are doing enough to educate staff and customers about the dangers of MRSA.
"All it's going to take is some fitness facility having an outbreak, and the whole fitness facility community is going to have to respond to that with improved prevention practices to keep it down."
Despite the precautions that USC took to control its MRSA outbreak, it's hard to say which changes were most responsible for the improvement.
Nevertheless, "it's a safe assumption that the measures USC took caused the decrease," says Holtom.
USC's head athletic trainer, Russ Romano, who spearheaded USC's effort to control MRSA, believes that all of the infection control measures USC undertook were important.
Certainly USC has set the bar higher for everyone else. After a recent talk on MRSA at a conference for athletic trainers, Romano was besieged with questions from coaches, trainers and educators.
"We still have to be very vigilant," he writes in an e-mail. "The problem is very prevalent in our community as well as all over the country. The battle is not over."
By Janet Cromley, Los Angeles Times Staff Writer