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Infection Risk Reduction Program on Pathogens in High School and Collegiate Athletic Training Rooms


Abstract and Figures

Background Athletic training rooms have a high prevalence of bacteria, including multidrug-resistant organisms, increasing the risk for both local and systematic infections in athletes. There are limited data outlining formal protocols or standardized programs to reduce bacterial and viral burden in training rooms as a means of decreasing infection rate at the collegiate and high school levels. Hypothesis Adaptation of a hygiene protocol would lead to a reduction in bacterial and viral pathogen counts in athletic training rooms. Study Design Cohort study. Level of Evidence Level 3. Methods Two high school and 2 collegiate athletic training rooms were studied over the course of the 2017-2018 academic year. A 3-phase protocol, including introduction of disinfectant products followed by student-athlete and athletic trainer education, was implemented at the 4 schools. Multiple surfaces in the athletic training rooms were swabbed at 4 time points throughout the investigation. Bacterial and viral burden from swabs were analyzed for overall bacterial aerobic plate count (APC), bacterial adenosine triphosphate activity, influenza viral load, and multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). Results Overall bacterial load, as measured by APC, was reduced by 94.7% (95% CI, 72.6-99.0; P = 0.003) over the course of the investigation after protocol implementation. MRSA and VRE were found on 24% of surfaces prior to intervention and were reduced to 0% by the end of the study. Influenza was initially detected on 25% of surfaces, with no detection after intervention. No cases of athletic training room–acquired infections were reported during the study period. Conclusion A uniform infection control protocol was effective in reducing bacterial and viral burden, including multidrug-resistant organisms, when implemented in the athletic training rooms of 2 high schools and 2 colleges. Clinical Relevance A standardized infection control protocol can be utilized in athletic training rooms to reduce bacterial and viral burden.
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While musculoskeletal injuries represent the most
commonly reported health risks during athletic
participation, more recent attention has been paid to
the high risk of infection among athletes. The athletic training
room represents a shared environment involving close contact
among athletes and, in the presence of poor hygiene and
contamination, can predispose athletes to infection. Several
studies and surveys have documented the presence of high
bacterial burden in both high school and collegiate training
room facilities.6,14,19 Furthermore, high rates of multidrug-
resistant organisms, such as vancomycin-resistant enterococcus
(VRE) and methicillin-resistant Staphylococcus aureus (MRSA),
877865SPHXXX10.1177/1941738119877865LaBelle et alSports Health
Infection Risk Reduction Program on
Pathogens in High School and Collegiate
Athletic Training Rooms
Mark W. LaBelle, MD,†‡ Derrick M. Knapik, MD,†‡ James W. Arbogast, PhD,§ Steve Zhou, PhD,||
Lisa Bowersock, MS, Albert Parker, PhD, and James E. Voos, MD*†‡
Background: Athletic training rooms have a high prevalence of bacteria, including multidrug-resistant organisms,
increasing the risk for both local and systematic infections in athletes. There are limited data outlining formal protocols or
standardized programs to reduce bacterial and viral burden in training rooms as a means of decreasing infection rate at the
collegiate and high school levels.
Hypothesis: Adaptation of a hygiene protocol would lead to a reduction in bacterial and viral pathogen counts in athletic
training rooms.
Study Design: Cohort study.
Level of Evidence: Level 3.
Methods: Two high school and 2 collegiate athletic training rooms were studied over the course of the 2017-2018
academic year. A 3-phase protocol, including introduction of disinfectant products followed by student-athlete and athletic
trainer education, was implemented at the 4 schools. Multiple surfaces in the athletic training rooms were swabbed at 4
time points throughout the investigation. Bacterial and viral burden from swabs were analyzed for overall bacterial aerobic
plate count (APC), bacterial adenosine triphosphate activity, influenza viral load, and multidrug-resistant organisms such as
methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).
Results: Overall bacterial load, as measured by APC, was reduced by 94.7% (95% CI, 72.6-99.0; P = 0.003) over the course
of the investigation after protocol implementation. MRSA and VRE were found on 24% of surfaces prior to intervention and
were reduced to 0% by the end of the study. Influenza was initially detected on 25% of surfaces, with no detection after
intervention. No cases of athletic training room–acquired infections were reported during the study period.
Conclusion: A uniform infection control protocol was effective in reducing bacterial and viral burden, including multidrug-
resistant organisms, when implemented in the athletic training rooms of 2 high schools and 2 colleges.
Clinical Relevance: A standardized infection control protocol can be utilized in athletic training rooms to reduce bacterial
and viral burden.
Keywords: infection, athletic training room, bacteria, MRSA
From Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, University Hospitals Sports Medicine Institute, Cleveland, Ohio,
§GOJO Industries, Inc, Akron, Ohio, ||Microbac Labs, Inc, Sterling, Virginia, and Center for Biofilm Engineering, Montana State University, Bozeman, Montana
*Address correspondence to James E. Voos, MD, Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH
44106 (email:
The following authors declared potential conflicts of interest: J.W.A. is a scientist with GOJO Industries, Inc; L.B. and A.P. received payment and fees from GOJO Industries,
Inc; and J.E.V. is a consultant from Arthrex and received royalties from Stryker, Arthrex, and Linvatec. This research was supported by GOJO Industries.
DOI: 10.1177/1941738119877865
© 2019 The Author(s)
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LaBelle et al
have been documented to exist within training rooms.7,9 While
MRSA is highly publicized because of its propensity to cause
localized soft tissue infections, MRSA is also a potential source
of bacteremia, pneumonia, and urinary tract infections.16,18 Such
infections have been associated with significant morbidity, with
up to 70% of patients acquiring MRSA infections requiring
hospitalization and intravenous antibiotics.18
The prevention, containment, and treatment of MRSA
infections continues to be challenging in collegiate and high
school athletes, especially contact sport athletes. Of 21 infection
outbreaks in competitive athletes over a 5-year period, 1 in 3
were caused by MRSA.4 A recent survey reported the incidence
of MRSA infections as 26.8 per 10,000 athletes in 2015-2016 and
20.3 per 10,000 athletes in 2016-2017.1 Infection incidence was
highest in contact sport athletes, such as wrestlers and football
players, with incidence rates of 248 per 10,000 and 71 per
10,000, respectively.1 Additional studies have confirmed higher
rates of nasal carriers of methicillin-sensitive Staphylococcus
aureus and MRSA in contact sport athletes when compared with
the general population,7 with the athletic training room serving
as a likely transmission source. Montgomery etal13 sampled 10
athletic training rooms in secondary schools in rural
communities and reported that 46% of surfaces tested positive
for MRSA. Additionally, the National Wrestling Coaches
Association found high bio-burdens of bacteria, particularly skin
and respiratory bacteria, on collegiate wrestling mats.22 After
implementation of a standardized cleaning protocol, the authors
reported a 76% reduction in bacterial load using residual
disinfectants in comparison with nonresidual cleaners.22 Given
the high frequency of MRSA exposure in collegiate and high
school athletes, infection control and decontamination protocols
warrant further investigation to examine the extent to which
implementation decreases the risk of illness.1,10
Professional athletic leagues maintain high standards for hygiene
within athletic facilities based on national and international
guidelines. Standardized protocols have been outlined by the
Centers for Disease Control and Prevention (CDC)2,3 and the
World Health Organization (WHO)20,21 to establish best practices
for hand hygiene and infection control. The National Football
League uses the model outlined by the Duke Infection Control
Outreach Network (DICON) to apply CDC and WHO infection
control principles throughout the league.11 The National Collegiate
Athletic Association publishes a sports medicine handbook to
outline CDC guidelines for hygiene and wound care in athletic
training rooms.15 In contrast, it is difficult to replicate and
implement standardized protocols at the high school level because
of limited resources and trained personnel.
Despite the known potential for infection in the athletic
training room, there remains a lack of knowledge among
athletes, parents, and athletic trainers about best practices to
limit the spread of infection. A survey of collegiate and high
school athletic trainers found that that while the majority of
athletic trainers were aware of the risks of MRSA, 35% of athletic
trainers reported performing inadequate hand hygiene while
being unaware of proper disinfectant solutions.8 As such, while
guidelines for infection management exist, many student-
athletes and athletic trainers at the collegiate and high school
levels need further training and a better understanding of
effective infection control protocols.
The purpose of this investigation was to examine the
outcomes of a year-long quality improvement study aimed at
reducing bacterial and viral burden in athletic training rooms at
the collegiate and high school levels by creating an infection
control protocol consisting of hand hygiene solutions, surface
disinfectants, athletic trainer education, and student-athlete
Study Design
The institutional review board reviewed the protocol and
designated the investigation a quality improvement study prior
to study initiation. There were 2 suburban high schools and 2
suburban colleges selected for inclusion in the investigation.
These schools were representative of the surrounding
community and agreed to participate after discussion and
approval from athletic trainers and athletic directors.
Bacterial swabs of high-touch surfaces were obtained at 4
separate time points during the academic year. Baseline samples
were taken at the start of the school year in September 2017
(time 0). Subsequent samples were obtained in November 2017
(time 1), February 2018 (time 2), and May 2018 (time 3) to
correspond with infection control interventions. Sampled
surfaces included water bottle lids, water cooler nozzles,
training room benches, front door handles, and drawer/cabinet
handles. The number of surfaces was proportional to the size of
the athletic training room, ranging from 24 to 28 samples at
each facility, and varied in total quantity from visit to visit
because of availability (eg, if no water bottles were clean and
ready to use by athletes, no samples were obtained).
An infection control program was formulated based on CDC
and DICON guidelines.2,3,12,20,21 Key components included
utilization of disinfectant products with rapid, broad-spectrum
antimicrobial efficacy for skin and surfaces, teaching athletic
trainers principles of infection control and proper use, and
educating student-athletes on hygiene measures. An alcohol-
based hand sanitizer (PURELL Foam Handwash; GOJO
Industries Inc) was selected along with an antimicrobial spray
for hard surfaces (PURELL Surface Spray; GOJO Industries Inc).
Educational components involved distribution of electronic and
paper educational tools, presented to the athletic trainers,
coaches, athletes, and parents at each of the 4 schools.
Informative posters were placed around the training rooms and
locker rooms to reinforce concepts of proper hand hygiene and
infection awareness. Each athletic training room was equipped
with written guidelines, and daily checklists were provided to
athletic trainers to ensure compliance.
The infection control program was implemented in 3 phases
throughout the year to track changes in bacterial and viral load.
Phase 1 (between time 0 and time 1) involved installation of
products at the point of care in athletic training rooms. Phase 2
(between time 1 and time 2) involved the initiation of
educational interventions with the placement of posters and
checklists. Posters featuring athletes following CDC protocols
were designed by the research team and placed throughout the
training room and locker room (see Appendix 1, available in the
online version of this article). Checklists were provided in each
training room for reference by the athletic trainer, reminding
him or her to use surface and hand disinfectants daily. Phase 3
(between time 2 and time 3) involved targeted educational
materials distribution. Athletic trainers distributed informational
slides to each coach, which were then shared with the athletes.
Additional educational emails/handouts were given to parents
and athletes. Figure 1 outlines the study design. Athletic trainers
were required to record and report any incidence of infection
noted during the study period.
Specimen Collection and Analysis
Sampling occurred on weekdays at peak times of athlete
presence in the training rooms, generally between 3:00 pm and
7:00 pm. After swab collection, specimens were transported to an
approved laboratory and maintained under refrigeration until
testing for total and specific microorganisms. Overall cleanliness
was quantified by aerobic plate count (APC), while adenosine
triphosphate (ATP) assays using CHARM (novaLUM II ATP
Detection System; Charm Sciences) and Hygiena (SystemSURE
Plus) systems were performed for microbial testing. Samples
were also assessed for presence or absence of MRSA, VRE,
Enterococcus, and Staphylococcus subspecies. Additional surface
samples for influenza were obtained in November 2017 (time 1)
and February 2018 (time 2). Appendix 2 (available online)
contains the microbiology and assay details.
Statistical Analysis
R (version 3.4.3) and Minitab (version 18) software packages
were both used for statistical analysis. Linear models were fit
using the lme4 package in R. Individual value, residual, and
normal probability plots were used to assess model assumptions
and check for outliers. All statistically significant results were
reported, with significance set at P < 0.05. To determine
percentage reduction and statistical significance over time for
ATP and APC results, mixed-effects linear regression models
were used. Models included fixed effects for each surface tested
and whether the sample came from a high school or a college,
with random effects for facility and the date the sample was
To determine the percentage reduction and statistical
significance following each study phase, additional models were
created with an added fixed effect for if the sample was taken
before or after each intervention. The data were then split by
high schools and colleges to determine percentage reduction
and statistical significance within each of those categories
separately. Models using these split data sets were structured
like the previously described mixed-effects regression models,
but without the fixed effect for whether the sample was taken at
a high school or college. Comparisons between time periods for
Figure 1. Overview of study design. The above sampling periods are noted in the boxes, with each intervention phase initiated
between samples.
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LaBelle et al
microbiological species tested for presence or absence were
completed using Bayesian analysis. Analysis was performed
using the average of beta posteriors for each school and a
noninformative beta prior.
There were no reported infections in student-athletes
throughout the study period. A steady decline in APCs was
observed at all 4 test locations after implementation of phase 1
in November 2017 to the conclusion of the investigation in May
2018 (Table 1). After implementation and completion of the full
quality improvement program, no VRE- or MRSA-positive
samples were detected. A steady decline in mean logAPC (in
colony-forming units per gram) values for both colleges and
high schools over the course of the sampling period was
appreciated (Figures 2 and 3). No samples tested positive for
Escherichia coli during the investigation, while few samples
were positive for coliforms.
Percentage reductions from pre- to postintervention (time 0 to
aggregate of time 1 through time 3) are shown in Table 2 for
APC and ATP measures. Bacterial load, as measured by APC,
was reduced by 94.7% (95% CI, 72.6%-99.0%; P = 0.003) from
time 0 to the end of the study. When measured using the
Hygiena ATP meter, there was a statistically significant reduction
in bacterial burden across all schools and surfaces by 60.2%
(95% CI, 0.92%-84.0%; P = 0.048). When analyzing high schools
and colleges separately, there was a statistically significant
reduction in APC measurements from pre- to postintervention of
96.3% for high schools (95% CI, 79.9%-99.3%; P < 0.001) and
92.2% for colleges (95% CI, 33.3%-99.1%; P = 0.029). There was
no significant difference for ATP testing when comparing pre- to
postintervention in high schools or colleges.
Influenza was detected on 25% of the surfaces initially with
195 viral particles on each contaminated site, which included
front door handles (college A, 195 viral particles; high school A,
218 viral particles), drawer handles (high school A, 293 viral
particles), water bottle lids (college A, 462 viral particles), and
water cooler nozzles (college A, 222 viral particles). Influenza
was not detected during the February sampling after
implementation of program education.
As a shared environment, athletic training rooms act as a
source for the spread of infection. Although DICON has served
as a blueprint for infection control in the National Football
League, there are limitations on the implementation of such
programs at the high school and collegiate levels because of
limited resources and personnel. To decrease bacterial and viral
burden within the training room, this investigation sought to
provide practical, feasible resources aimed at educating athletic
trainers and student-athletes to minimize infection risk and
Phase 1 of our study involved the introduction of hand
hygiene and surface disinfectant solutions into the athletic
training room. This resulted in a modest, albeit nonsignificant,
reduction in overall bacterial burden, with a slight increase in
the amount of MRSA and VRE detected in the training rooms.
Anecdotally, it was observed that while resources were now
Table 1. Bacterial results summary
School Measure
Mean Results (All Surfaces)
September 2017 November 2017 February 2018 May 2018
College A Micro (CFU APC) log mean
2.127 2.393 1.512 1.271
No. of MRSA + VRE hits 2/12 (16.7%) 2/12 (16.7%) 1/8 (12.5%) 0/8 (0%)
College B Micro (CFU APC) log mean
4.467 3.058 2.635 1.987
No. of MRSA + VRE hits 3/14 (21.4%) 1/13 (7.7%) 1/13 (7.7%) 0/8 (0%)
High school A Micro (CFU APC) log mean
3.836 4.263 2.232 2.457
No. of MRSA + VRE hits 4/12 (33.3%) 6/11 (54.5%) 1/13 (7.7%) 0/5 (0%)
High school B Micro (CFU APC) log mean
4.780 3.597 2.457 2.573
No. of MRSA + VRE hits 3/12 (25%) 3/12 (25%) 1/12 (8.3%) 0/7 (0%)
APC, aerobic plate count; CFU, colony-forming unit; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococcus.
available, many student-athletes were not consistently utilizing
them. The authors suspect that athletic trainers and athletes
were not adequately educated on principles of infection control
in the training room, similar to the findings reported by
Kahanov etal,8 in which 35% of athletes were noncompliant
with hand hygiene while many athletic trainers were unaware
of how to properly disinfect surfaces for MRSA.
The next 2 phases of this investigation focused on education
to address this gap in understanding and compliance with the
use of disinfectants. Phase 2 involved the addition of posters
Figure 3. Mean logAPC (in CFU/g) values for all colleges and high schools separately for each sampling period, pooled across all
surface types. APC, aerobic plate count; CFU, colony-forming unit; HS, high school.
Figure 2. Mean logAPC (in CFU/g) values for all schools for each sampling period, pooled across all surface types. APC, aerobic plate
count; CFU, colony-forming unit.
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LaBelle et al
and checklists in the training rooms to raise awareness by
focusing on hygiene as a crucial element to ensure athlete
health. Phase 3 involved direct education of the athletic trainers,
coaches, and student-athletes. After these phases, there was a
significant improvement in bacterial and viral burdens within
the training rooms, indicative of the effectiveness of education
in decreasing bio-burden and the potential risk of infection.
Schools had a cumulative MRSA rate of 24% (12/50 surfaces)
prior to intervention, lower than the 46% rate of surface MRSA
infections in the 10 training rooms sampled by Montgomery
etal.13 After implementation of the final phase of our study,
both MRSA and VRE were no longer detected in any of the 4
training rooms. These findings are consistent with those
reported by Oller etal,14 who reported the presence of MRSA
on 31% of surfaces in a single Division II collegiate locker room
and weight room, followed by complete elimination after
implementation of an infectious control protocol. The protocol
employed by Oller etal involved education of custodial staff
and student-athletes, focusing on proper use of disinfectants by
the custodial staff.14 Instead, our protocol empowered the
student-athletes to use hand and surface disinfectants after each
training room encounter.
In addition to the quantification of bacterial burden, this
investigation represents the first study to our knowledge
tracking influenza burden in athletic training rooms. Pope and
Koenig17 outlined the risk that influenza poses in the athletic
training room, but no sampling or interventions were
performed. Meanwhile, the detrimental respiratory effects of
influenza, along with other respiratory tract infections, have
been well documented.12 It is important to note that this portion
of the study in which influenza samples were obtained
(November and February) occurred across phase 2, after the
initiation of student-athlete education, which was felt to be
optimal as schools had both disinfectant products distributed
and some educational material implemented. There were
limitations, however, given the high degree of variability
inherent to the influenza virus,5 even during the winter season.
Additional data points between November and February would
have been beneficial to better trend the changes in influenza
burden; however, resource constraints limited our sample size
and sampling frequency.
The implementation of a standardized infectious control
protocol revolving around student-athlete and athletic trainer
education effectively eliminated multidrug-resistant bacteria and
influenza while significantly lowering overall bacterial and viral
burden in high school and college athletic training rooms.
Future investigations tracking pathogen incidence and
transmission in additional schools are warranted to further
evaluate the efficacy of this protocol and its effects on infection
incidence and outcomes at other institutions in different
geographic areas.
The authors recognize Stephanie Bock and Chelsea Conley for
their help in sample collection, and John N. Rapko, PhD, for his
Table 2. Percentage reduction pooled across schools as noted and all surfaces
% Reduction 95% CI P
All schools
Charm ATP 36.3 –39.7%, 75.6% 0.321
Hygiena ATP 60.2 0.92%, 84.0% 0.048a
APC 94.7 72.6%, 99.0% 0.003a
High schools only
Charm ATP 51.4 –58.9%, 90.3% 0.305
Hygiena ATP 63.3 –63.1%, 95.0% 0.255
APC 96.3 79.9%, 99.3% <0.001a
Colleges only
Charm ATP 17.0 –77.2%, 84.3% 0.774
Hygiena ATP 62.3 –20.7%, 88.8% 0.090
APC 92.2 33.3%, 99.1% 0.029a
APC, aerobic plate count; ATP, adenosine triphosphate.
aStatistically significant reduction.
help in data handling and analysis of the ATP meter science.
We also acknowledge ATL (Advanced Testing Labs) and Phil
Geis, PhD, for execution of all microbiology testing and in
writing the microbiology methods appendix.
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... An infection control protocol involving introduction of disinfectant products and education may be effective in reducing bacteria, drug-resistant bacteria, and viral burden in training facilities. Through the introduction of an infection protocol in high school and collegiate training rooms, LaBelle et al. were able to reduce overall bacterial load by 94.7% and drug-resistant organisms (MRSA and vancomycin-resistant Enterococcus) and influenza by 100% [9]. Similar approaches applied in rock climbing facilities would likely be beneficial in reducing the bacterial load as well. ...
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Currently, investigations on the microbiota of sports centers and related facilities have been carried out in some countries, which showed that Microsporum gypseum, Trichophyton mentagrophytes and T. tonsurans are important dermatoprotofungi. In China, some research on athletes and sports equipment between the fungal community and public health has made some interesting achievements. However, the bacterial group among them has not been reported. Therefore, The aim of this study was to uncover (I) gymnastic equipment is there potential pathogenic factors and (ii) is there any difference in the biomarker of bacterial in different types of gymnastic room? The samples were collected from the gymnastics halls of one university in western China and main sports equipment, including gymnastics carpets, moving barres, hoops and balls, as well as wall bars, parallel bars and horizontal bars. The 16S rDNA of all the samples was sequenced, and the analyses were performed using FaproTax, Bug base function prediction and Line Discriminant Analysis (LDA) Effect Size. A 16S rDNA sequence analysis revealed abundant bacterial species biodiversity on gymnasts and apparatuses from two gymnastics halls at a university in western China. An analysis using the FaproTax and Bugbase functional prediction platforms showed that there were some opportunistic pathogens on the athletes and equipment from the Rhythmic Gymnastics (RG) and Artistic Gymnastics (AG) halls, such as Staphylococcus and Corynebacteiaceae. Infectious agents associated with cancer induction and development, such as Ruminococcaceae, Veillonellaceae and Moraxellaceae, as well as microbial toxin producers with a potential impact on human health, were also detected. According to a line discriminant analysis (LDA effect size), the bacterial biomarker groups of the two gymnasiums were different at the phylum-genus level: for RG, Erysipelatoclostridium, Lachnospiraceae and Bacteroidales, while for AG, Rhizobiales. Based on the results of the investigation, we suggest that more comprehensive consideration should be given to indoor microbial biodiversity and related public health problems in school gymnasiums.
... Therefore, it is necessary to elucidate in detail the role of exposure to airborne bacteria and viruses in various sports activities. Fortunately, the situation is starting to change, and researchers are focusing their activities on this topic [17]. ...
... В местах проведения тренировок должны быть развешены постеры о правилах гигиены и проведен инструктаж на данную тему. Внедрение соответствующих протоколов в американских колледжах и школах позволило за 5 мес снизить бактериальную контаминацию на 94,7% и полностью исключить присутствие вируса гриппа на ручках дверей, ящиков, крышках бутылок и форсунках кулеров [12]. Это свидетельствует об эффективности профилактики предметно-контактных способов заражения. ...
Rapid hygiene monitoring tests based on the presence of ATP have been widely used in the food industry to ensure that adequate cleanliness is maintained. In this study, the practical applications and limitations of these tests and recent technological progress for facilitating more accurate control were evaluated. The presence of ATP on a surface indicates improper cleaning and the presence of contaminants, including organic debris and bacteria. Food residues are indicators of insufficient cleaning and are direct hazards because they may provide safe harbors for bacteria, provide sources of nutrients for bacterial growth, interfere with the antimicrobial activity of disinfectants, and support the formation of biofilms. Residues of allergenic foods on a surface may increase the risk of allergen cross-contact. However, ATP tests cannot detect bacteria or allergenic proteins directly. To ensure efficient use of commercially available ATP tests, in-depth knowledge is needed regarding their practical applications, methods for determining pass-fail limits, and differences in performance. Conventional ATP tests have limitations due to possible hydrolysis of ATP to ADP and AMP, which further hinders the identification of food residues. To overcome this problem, a total adenylate test was developed that could detect ATP+ADP+AMP (A3 test). The A3 test is suitable for the detection of adenylates from food residues and useful for verification of hygiene levels. The A3 test in conjunction with other methods, such as microorganism culture and food allergen tests, may be a useful strategy for identifying contamination sources and facilitating effective hygiene management. Highlights:
Objectives Skin and soft tissue infections commonly affect athletes and can lead to cluster outbreaks if not managed appropriately. We report the findings of an investigation into an outbreak of community-acquired Staphylococcus aureus infection in an Australian professional football team. Design Retrospective cross-sectional study. Methods Nose, axilla, groin and throat swab were collected from 47 participants. MRSA and MSSA isolates underwent antibiotic susceptibility testing, binary typing and whole genome sequencing. Infection control practitioners (ICPs) investigated the training grounds for risk factors in the transmission of S. aureus. Results Almost half of the participants (n = 23, 48.9%) were found to be colonised with MSSA. An outbreak cluster of MRSA ST5 closely related to the fusidic acid-resistant New Zealand NZAK3 clone was identified in a group of four players. MSSA ST15 and MSSA ST291 strains were found to have colonised and spread between two and five players, respectively. All participants were advised to undergo decolonisation treatment consisting of 4% chlorhexidine body wash and mupirocin nasal ointment for ten days. The ICP team identified several unhygienic practices within the club’s shared facilities that may have played a role in the transmission of S. aureus. Conclusions We report for the first time a community-associated S. aureus outbreak involving the highly successful fusidic acid-resistant MRSA ST5 clone in a professional football club associated with inadequate hygiene procedures. Management and prevention of S. aureus relies heavily on hygiene education and adherence to personal and environmental hygiene practices and policies.
Objectives Full-contact football-code team sports offer a unique environment for illness risk. During training and match-play, players are exposed to high-intensity collisions which may result in skin-on-skin abrasions and transfer of bodily fluids. Understanding the incidence of all illnesses and infections and what impact they cause to time-loss from training and competition is important to improve athlete care within these sports. This review aimed to systematically report, quantify and compare the type, incidence, prevalence and count of illnesses across full-contact football-code team sports. Design/methods A systematic search of Cochrane Library, MEDLINE, SPORTDiscus, PsycINFO and CINAHL electronic databases was performed from inception to October 2019; keywords relating to illness, athletes and epidemiology were used. Studies were excluded if they did not quantify illness or infection, involve elite athletes, investigate full-contact football-code sports or were review articles. Results Twenty-eight studies met the eligibility criteria. Five different football-codes were reported: American football (n = 10), Australian rules football (n = 3), rugby league (n = 2), rugby sevens (n = 3) and rugby union (n = 9). One multi-sport study included both American football and rugby union. Full-contact football-code athletes are most commonly affected by respiratory system illnesses. There is a distinct lack of consensus of illness monitoring methodology. Conclusions Full-contact football-code team sport athletes are most commonly affected by respiratory system illnesses. Due to various monitoring methodologies, illness incidence could only be compared between studies that used matching incidence exposure measures. High-quality illness surveillance data collection is an essential component to undertake effective and targeted illness prevention in athletes.
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Staphylococcus genus is a Gram-positive coccus normally associated with skin and mucous membranes of warm-blooded animals. It is part of the commensal human microflora, or found in animals, or contaminating surfaces in the community and hospital settings. Staphylococcus aureus is the most pathogenic species belonging to this genus, as it possesses a collection of virulence factors that are expressed solely to evade the immune system. The increase in the misuse of antimicrobial agents predisposed S. aureus to develop antibiotic resistance, including the resistance to methicillin which led to the emergence of Methicillin-Resistant S. aureus (MRSA). MRSA is considered one of the most dangerous nosocomial pathogens causing many hard to treat infections in hospitals and was named as Hospital Associated MRSA (HA-MRSA). Over the past 20–25 years, MRSA was isolated from community settings and thus Community Associated MRSA (CA-MRSA) has emerged. Inside hospitals, MRSA has been isolated from fomites in contact with patients, as well as staff’s protective and personal items. This review highlights the worldwide prevalence of MRSA on fomites within the contexts of hospital and community settings.
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Context: At the request of the National Wrestling Coaches Association and the head wrestling coach at our university, we conducted a study of infection transmission in collegiate wrestlers. Objective: To examine disinfectant effectiveness and develop best-practice guidelines for minimizing the spread of skin infections via wrestling mats. Design: Controlled laboratory study and crossover study. Setting: Laboratory and two 15-college wrestling invitational meets. Patients or other participants: A total of 231 collegiate wrestlers and 8 officials. Intervention(s): In the laboratory-based part of the study, we measured the bacterial load of mats disinfected with 10% bleach, OxiTitan, Benefect, eWater, and KenClean and inoculated with Staphylococcus epidermidis (strain ATCC 12228) at a concentration of 6.5 × 10(4) bacteria/cm(2). In the empirical part of the study, we used these disinfectants during 2 invitational meets and measured mat and participant bacterial load during competition. Participants were swabbed at weigh-in and after their last bout. Mat bacterial load was monitored hourly. Main outcome measure(s): We determined total colony counts and species. Results: With controlled testing, we observed that products claiming to have residual activity reduced bacterial load by 63% over the course of competition compared with nonresidual agents. Only 4 of 182 participating wrestlers tested positive for methicillin-resistant Staphylococcus aureus , which is the normal population occurrence. The predominant species on mats were skin bacteria ( Staphylococcus epidermidis ) and substantial levels of respiratory bacteria ( Streptococcus pneumonia ), as well as several soil species and a surprisingly low incidence of fecal bacteria ( Escherichia coli ). Disinfectant effectiveness during the meets was consistent with controlled study findings. Cleaning mats with residual disinfectants reduced the average bacterial load by 76% compared with nonresidual cleaners. Using a footbath did not reduce the bacterial load compared with a bleach-cleaned mat, but using alcohol-based hand gel reduced it by 78%. Conclusions: Best practices based on these data include backward mopping of the mats with a residual disinfectant pulled behind the cleaner, allowing mats to dry before walking on them, having wrestlers use hand gel before each bout, and strongly recommending that all wrestlers receive annual influenza vaccinations.
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Objective Athletes have a higher risk of infection with Staphylococcus aureus than the general population. Most studies in athletes have included primarily male contact sports participants and have not assessed S. aureus carriage over time. We aimed to examine the epidemiology and risk factors of S. aureus carriage in a cohort of male and female collegiate athletes. Study designWe conducted a prospective cohort study of 377 varsity collegiate athletes from August 2008 to April 2010. A baseline questionnaire ascertained risk factors for colonization. Nasal and oropharyngeal swabs were obtained at enrollment and monthly thereafter to detect S. aureus colonization. The primary outcome was S. aureus colonization, both with methicillin-susceptible and methicillin-resistant S. aureus, as defined by bacterial culture and molecular confirmation. Secondary outcomes were time to colonization with S. aureus and carriage profile, defined as non-carrier, intermittent carrier, or persistent carrier. ResultsOverall, 224 contact sports and 153 non-contact sports athletes were enrolled. Contact sports athletes had a higher risk of carrying S. aureus over time: They had higher odds of being colonized with MRSA (OR 2.36; 95 % CI 1.13–4.93) and they tended to carry S. aureus for longer periods of time (intermittent carriage OR 3.60; 95 % CI 2.02–6.40; persistent carriage OR 2.39; 95 % CI 1.21–4.72). Athletes engaged in contact sports also acquired S. aureus more quickly (HR 1.61; 95 % CI 1.02–2.55). Conclusions Staphylococcus aureus carriage was common in contact sports athletes. These findings suggest that efforts to prevent transmission of S. aureus among athletes should be focused on contact sports teams.
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Methicillin-resistant Staphylococcus aureus (MRSA) infections are increasingly common in athletic settings. The MRSA knowledge and infection-control practices of certified athletic trainers (ATs) and the cleanliness of the athletic training room are important factors in preventing MRSA infections. To assess knowledge of MRSA and the use of common disinfectants among ATs and to explore their infection-control practices. Cross-sectional study. High school and collegiate athletic training rooms. A total of 163 ATs from National Collegiate Athletic Association Divisions I, II, and III and high schools, representing all 10 National Athletic Trainers' Association districts. Frequencies, analyses of variance, and χ(2) tests were used to assess current practices and opinions and relationships between factors. Methicillin-resistant Staphylococcus aureus was perceived as a national problem by 92% of respondents; 57% perceived MRSA as a problem in their practice setting. Most respondents had treated general infections (88%), staphylococcal infections (75%), and MRSA infections (57%). Male sex was associated with treating all 3 types of infections (χ(2) test, P < .05). Noncurriculum education was associated with a lack of recognition of environmental issues as risk factors and with the use of isopropyl alcohol for disinfection (χ(2) test, P < .05). For example, 10% of respondents did not recognize that contaminated whirlpools can be a source of MRSA infection. Respondents also incorrectly identified effective cleaning solutions. Thirty percent of respondents cleaned their hands frequently or sometimes before treating each athlete and 35% cleaned their hands sometimes, occasionally, or never after seeing each athlete. The majority of ATs were informed about MRSA and made correct disinfection choices. However, improvements are still needed, and not all ATs were using proper disinfection practices.
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Methicillin-resistant Staphylococcus aureus (MRSA) is a group of bacteria resistant to antibiotic treatment. Open abrasions, therapeutic whirlpools, treatment tables, locker rooms (LR), and athletic equipment are identified as potential areas of transmission in athletic training rooms (ATR) and LR facilities. To determine the prevalence of MRSA and to identify control measures in ATR and LR, the authors collected samples from nine surfaces at seven high schools over a four-month period. Initial analyses considered both suspected colonies and confirmed MRSA colonies with analyses of variance revealing significant differences of suspected colonies based on regular cleaning product and facility surface. Further results, however, focused on MRSA colonies as the primary variable, rather than suspected colonies. Results indicate a need for more effective cleaning products and schedules in LRs.
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Staphylococcus aureus is spread via direct contact with persons and indirect contact via environmental surfaces such as weight benches. Athletes participating in direct-contact sports have an increased risk of acquiring S aureus infections. To determine (1) potential environmental reservoirs of S aureus in football and wrestling locker rooms and weight rooms, (2) environmental bacterial status after employing more stringent cleaning methods, (3) differences in colonization rates between athletes and nonathletes, (4) exposed body locations where Staphylococcus was recovered more frequently, and (5) personal hygiene practices of athletes and nonathletes. Cross-sectional study. Locker room and strengthening and conditioning facilities at a National Collegiate Athletic Association Division II university. Collegiate football players and wrestlers, with nonathlete campus residents serving as the control group. Infection control methods, education of the custodial staff, and education of the athletes regarding the Centers for Disease Control and Prevention guidelines for infection prevention. Cultures were taken from the participants' noses, fingertips, knuckles, forearms, and shoes and from the environment. Before the intervention, from the 108 environmental samples taken from the football locker room and weight room, 26 (24%) contained methicillin-susceptible S aureus (MSSA) and 33 (31%) contained methicillin-resistant S aureus (MRSA). From the 39 environmental samples taken from the wrestling locker room and pit areas, 1 (3%) contained MSSA and 4 (10%) contained MRSA. The MRSA rates were different between the 2 locations according to a chi(2) test (P = .01). Seven MRSA isolates were recovered from football players and 1 from a wrestler; no MRSA isolates were recovered from the control group. The fingertip location of S aureus recovery from football players was significant when compared with both other locations in football players and fingertips in wrestlers and the control group (P < .05). Football players and wrestlers shared more personal items than the control group (P < .05). After the intervention, the football locker room and weight room samples were negative for S aureus. Intact strengthening and conditioning equipment, proper hygiene, and proper disinfection methods lowered both environmental and human S aureus recovery at 1 university.
Purpose: Although community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have reduced among inpatient populations, the incidence in athletics continues to range greatly dependent on the sport. Over the 2015-2016 and 2016-2017 school years, we assessed the annual CA-MRSA incidence, sport risk, referral practices, and management protocols or interventions among high school and intercollegiate athletics. Methods: This study targeted high school and intercollegiate athletic programs across the United States. For the 2015-2016 study, 269 athletic trainers completed a one-time questionnaire. In the 2016-2017 study, 217 athletic trainers reported data bimonthly during the academic year. Each questionnaire targeted demographic information, physician-confirmed CA-MRSA infection occurrence, and management of CA-MRSA infections and bacterial skin lesions. Results: The CA-MRSA infection incidence was 26.8 per 10,000 athletes (95% confidence interval [CI], 24-30) in 2015-2016 and 20.3 per 10,000 athletes (95% CI, 18-23) in 2016-2017. The CA-MRSA infection incidence was high in wrestling and football compared to the general student-athlete population. During the 2015-2016 study, the wrestling incidence rate was 248.3 per 10,000 (95% CI, 204-302); the football incidence rate was 71.0 per 10,000 (95% CI, 60-85). In the 2016-2017 study, the wrestling incidence rate was 100.0 per 10,000 (95% CI, 66-151); the football incidence rate was 81.8 per 10,000 (95% CI, 68-99). At least 23% of respondents denoted at least one physician-confirmed CA-MRSA infection within their populations (2015-2016, 39%, n=105; 2016-2017, 23.5%, n=51). In the 2015-2016 survey, respondents indicated that athlete education and environmental decontamination were the most utilized management steps (51.8%, n=582). Conclusion: Despite increased awareness of CA-MRSA, more educational efforts focusing on best practices and education are needed, especially with athletes and the medical community involved in their care.
The seasonalities of influenza-like illnesses (ILIs) and invasive pneumococcal diseases (IPDs) remain incompletely understood. Experimental evidence indicates that influenza-virus infection predisposes to pneumococcal disease, so that a correspondence in the seasonal patterns of ILIs and IPDs might exist at the population level. We developed a method to characterize seasonality by means of easily interpretable summary statistics of seasonal shape-or seasonal waveforms. Non-linear mixed-effects models were used to estimate those waveforms based on weekly case reports of ILIs and IPDs in five regions spanning continental France from July 2000 to June 2014. We found high variability of ILI seasonality, with marked fluctuations of peak amplitudes and peak times, but a more conserved epidemic duration. In contrast, IPD seasonality was best modeled by a markedly regular seasonal baseline, punctuated by two winter peaks in late December-early January and January-February. Comparing ILI and IPD seasonal waveforms, we found indication of a small, positive correlation. Direct models regressing IPDs on ILIs provided comparable results, even though they estimated moderately larger associations. The method proposed is broadly applicable to diseases with unambiguous seasonality and is well-suited to analyze spatially or temporally grouped data, which are common in epidemiology.
Background: Athletes are a vulnerable population for methicillin-resistantStaphylococcus aureus(MRSA) infection. We aimed to determine MRSA colonization in asymptomatic athletes and estimate the risk for subsequent MRSA infection. Methods: We searched the PubMed and EMBASE (to October 29, 2015) looking for studies on MRSA colonization among asymptomatic athletes. Results: The pooled prevalence of MRSA colonization among athletes was 6% [95%CI (1,13)], and it was higher in the US (8% [95%CI (2,17)]). USA300 was the most common strain detected (22%) and 62% and 36% of isolates were resistant to clindamycin and trimethoprim/sulfomethoxazole, respectively. Notably, the prevalence of MRSA colonization among collegiate athletes was higher and reached 13% [95%CI (4,25)]. Sports with the highest prevalence among collegiate athletes were wrestling with 22% [95%CI (0,85)], followed by football 8% [95%CI (3,15)] and basketball 8% [95%CI (0,28)]. The risk for MRSA skin and soft tissue infection within 3 months after documented colonization among MRSA-colonized athletes was significantly higher than non-colonized [RR=7.37, 95%CI (2.47,21.94)]. Decolonization treatment among colonized athletes decreased significantly the risk for infection [RRR=0.33, 95%CI (0.03,4.28)]. Conclusions: The prevalence of MRSA colonization among asymptomatic athletes is comparable to that among individuals with chronic illness. The prevalence is even higher among collegiate athletes and is almost twice than in intensive care units. Importantly, colonization is associated with an over 7-fold increase in the incidence of subsequent MRSA infection. Infection control and decontamination protocols for this population need to be studied and implemented with urgency.
Context: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become a leading cause of skin and soft tissue infection in the nonhospitalized community. Care of the athletes in athletic training rooms is specifically designed with equipment tailored to the health care needs of the athletes, yet recent studies indicate that CA-MRSA is still prevalent in athletic facilities and that cleaning methods may not be optimal. Objective: To investigate the prevalence of Staphylococcus aureus and CA-MRSA in and around whirlpools in the athletic training room. Design: Cross-sectional study. Setting: National Collegiate Athletic Association Division I university. Patients or other participants: Student-athletes (n = 109) consisting of 46 men (42%) and 63 women (58%) representing 6 sports. Main outcome measure(s): Presence of MRSA and Staphylococcus aureus in and around the whirlpool structures relative to sport and number of athletes using the whirlpools. Results: We identified Staphylococcus aureus in 22% (n = 52/240) of the samples and MRSA in 0.8% (n = 2/240). A statistically significant difference existed between the number of athletes using the whirlpool and the presence of Staphylococcus aureus in and around the whirlpools (F(2,238) = 2.445, P = .007). However, Staphylococcus aureus was identified regardless of whether multiple athletes used a whirlpool or no athletes used a whirlpool. We did not identify a relationship between the number of athletes who used a whirlpool and Staphylococcus aureus or MRSA density (P = .134). Conclusions: Staphylococcus aureus and MRSA were identified in and around the whirlpools. Transmission of the bacteria can be reduced by following the cleaning and disinfecting protocols recommended by the Centers for Disease Control and Prevention. Athletic trainers should use disinfectants registered by the Environmental Protection Agency to sanitize all whirlpools between uses.
Old, evolving, and new infectious agents continually threaten the participation of competitors in sports. To provide an update of the medical literature on infectious disease outbreaks in sport for the last 5 years (May 2005-November 2010). Main Outcome Measure(s): A total of 21 outbreaks or clusters were identified. Methicillin-resistant Staphylococcus aureus (n = 7, 33%; mainly community acquired) and tinea (trichophytosis: n = 6, 29%) were the most common pathogens responsible for outbreaks. Skin and soft tissue was the most common site of infection (n = 15, 71%). The majority of outbreaks reported occurred in close-contact sports, mainly combat sports (ie, wrestling, judo) and American football. Twelve outbreaks (57%) involved high school or collegiate competitors. Common community outbreak pathogens, such as influenza virus and norovirus, have received little attention.