SPORTS HEALTHvol. XX • no. X
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
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: firstname.lastname@example.org).
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.
© 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 etal13 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
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
SPORTS HEALTHvol. XX • no. X
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.
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
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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
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.
SPORTS HEALTHvol. XX • no. X
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 etal,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
etal.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 etal,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 etal 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
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
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
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.
SPORTS HEALTHvol. XX • no. X
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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