Clinics in Dermatology (2008) 26, 1626

The skin in the gym: a comprehensive review of the cutaneous

manifestations of community-acquired methicillin-resistant
Staphylococcus aureus infection in athletes
Philip R. Cohen, MD
University of Houston Health Center, University of Houston, Houston, TX 77204, USA
Department of Dermatology, University of Texas-Houston Medical School, Houston, TX 77030, USA
Department of Dermatology, University of Texas MD Anderson Cancer, Houston, TX 77030, USA

Abstract Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is

currently a problem of epidemic proportion. Athletes represent a specific group of individuals who are at
increased risk to develop CAMRSA skin infections. In this article, the previously published reports of
cutaneous CAMRSA infections in athletes are categorized by sport and summarized. General treatment
guidelines for the management of cutaneous CAMRSA infection and its associated lesions in athletes
are discussed. Also, recommendations for the prevention of CAMRSA skin infection in sports
participants are reviewed.
2008 Elsevier Inc. All rights reserved.

Introduction

Epidemiology and clinical features

Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is a global problem.

Individuals affected by cutaneous CAMRSA infection have
been reported not only from many cities within the United
States but also from numerous nations throughout the world.
Community-acquired methicillin-resistant S aureus (MRSA)
skin infection was initially considered to be an emerging
epidemic by Cohen and Grossman in July 2004.1 Subsequently, several other investigators have also recognized that
the prevalence of CAMRSA infection represents an
epidemic.2-6

Several risk factors for the development of CAMRSA

infection have been identified. Certain groups of individuals
such as children, parenteral substance abusers, men who
have sex with men, miliary personnel, prisoners in correctional facilities, and select ethnic populations (Alaska
natives, native American Indians, and Pacific islanders)
appear to be at increased risk of developing CAMRSA
infection.1,6-10 In addition, athletesparticularly those who
participate in competitive contact sportshave also recently
been recognized as an at-risk population group for acquiring
cutaneous CAMRSA infection.6,8,11-31
Community-acquired MRSA infectious skin lesions are
pleomorphic.32-35 As described by Cohen and Kurzrock13 in
the first reported study on CAMRSA skin infection in the
dermatologic literature in February 2004, cutaneous lesions of
CAMRSA most commonly present as a tender erythematous

E-mail address: mitehead@aol.com.

0738-081X/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2007.10.006

CAMRSA in athletes
Table 1

17

Community-acquired MRSA infection in college football players

Author/reference
11

Maltin and Centers for Disease Control

and Prevention (CDC)12

Cohen and Kurzrock13 and Cohen14

CDC,12 CDC,15 and Nguyen et al16

Arlinghaus et al17 and Begier et al18

Comments
10 members of a Pennsylvania college football team developed MRSA culture-positive skin
and soft tissue infections on their chests, arms, and thighs during September and October
2000. Seventy percent (7/10) of these players required hospitalization to treat their abscesses.
The pulsed-field gel electrophoresis from the bacterial isolates from all of the players had
indistinguishable patterns.
A team from the CDC determined that the following risk factors contributed to the
transmission of MRSA infection from player to player: pathogens spread on shared unwashed
towels, and that the bacteria had easy access to skin that had been damaged by turf burns and
shaving-induced tiny abrasions. No further cases occurred once the players stopped sharing
razors and towels and began to wear protective equipment (such as neoprene sleeves)
especially when playing on artificial turf.
In August 2002, a 22-year-old black varsity football player at the University of Houston,
Houston, Texas, presented with an ingrown nail of the right great toe (onychocryptosis) and an
associated abscess and cellulitis of that toe's lateral nail fold (acute paronychia). He did not
have any MRSA-associated risk factors. Not only MRSA, but also group G -hemolytic
Streptococcus grew from the bacterial culture of the pus expressed from his erythematous
and tender nail fold. After receiving cephalexin (500 mg orally 4 times each day) for 7 d, his
spontaneously draining toe infection continued to worsen. His antimicrobial therapy was
changed to clindamycin (300 mg orally 4 times each day) and rifampin (300 mg orally twice
each day) for 14 d. His cutaneous MRSA infection completely resolved. The source for his
MRSA infection was not able to be identified.
The Los Angeles County Department of Health and the CDC report recurring CAMRSA skin
and soft tissue infections in a college football team during 3 consecutive seasons. Within the
same week in September 2002, 2 football players were hospitalized for MRSA skin infections
whose bacterial isolates had indistinguishable pulsed-field gel electrophoresis patterns. The
treatment of one of the player's cutaneous infection required surgical dbridement and skin
grafts. At that time, potential risk factors for MRSA transmission included frequent skin
trauma, prolonged covering of the skin wounds, and shared items (such as balms and
lubricants) among the team members.
During the outbreak from August 5 to September 5, 2003, 10% (11/107) of the football players
had either culture-confirmed (7) or presumptive (4) CAMRSA cutaneous infection. Skin
lesions presented as either boils (7), folliculitis (2), or an insect bite, and were either located
on the upper extremity (7: elbow [5] or forearm [2]) or lower extremity (4: knee [2], leg [1], or
foot [1]). Incision and drainage was performed for 9 lesions (boils and bites). Hospitalization
was required for 4 players to receive intravenous vancomycin; 2 of these players had either
received cephalexin or levofloxacin without clinical improvement of their infection. All of the
nonhospitalized players were treated with doxycycline and rifampin. All cases ultimately
responded to treatment; daily hexachlorophene showers and hygiene education were in use
from August 25 to September 19, 2003, and no new infection occurred during the subsequent
4 wk. Identified risk factors for transmission of MRSA included sharing soap bars and towels
with teammates and players whose field position was lineman.
From October 20 to November 9, 2003 (and therefore occurring after the outbreak study
period), MRSA cutaneous infections occurred in 4 additional players: a chin abscess in a
lineman, an elbow boil in a linebacker (who was one of the infected players in 2002),
folliculitis on the leg of a quarterback, and a gluteal boil in a tight end. The team switched to
single-use towels on the sidelines at games, and there were no new infections for the remainder
of the 2003 season.
During the August to December 2004 season, no MRSA infections occurred on the football
team. The quarterback with CAMRSA folliculitis in 2003, however, had a recurrence of MRSA
pustules on his forearm and leg in October 2004, which responded to outpatient treatment with
incision and drainage of the lesions and oral antibiotics (doxycycline and rifampin).
During the period from August 6 to October 1, 2003, 10% (10/100) of the players on the college
football team at Sacred Heart University in Fairfield, Connecticut, developed 13 cutaneous
MRSA infections: abscess (9) and cellulitis (4) on the upper extremity (6: elbow [4], forearm [1],
and wrist [1]), lower extremity (6: thigh [2], hip [2], knee [1], and tibial plateau [1]), and chin
(1). Hospitalization was required for 2 players who both had recurrent MRSA infections.
(continued on next page)

18

P.R. Cohen

Table 1 (continued)
Author/reference

Comments

Schindehette et al19

Available isolate (from 6 wounds) had indistinguishable pulsed-field gel electrophoresis

patterns (MRSA strain USA300) and carried the Panton-Valentine leukocidin toxin gene. Risk
factors associated with transmission of MRSA infection included player position (cornerbacks
and wide receivers), abrasions from artificial grass (turf burns), and cosmetic body shaving
(along with sharing the cold whirlpool at least twice each week in 3 of the 4 players whose
infection was located at a covered sitesuch as the hip or thigh).
Two pictures (Ricky Lannetti in his college football uniform and brothers Brett and Dereck
Talley with their football jerseys [one from Ursinus College] and football helmets in the
background) are accompanied by the following legend: In Pennsylvania, deathand fear.
Brothers Brett and Dereck Talley mourned their buddy Ricky Lannetti, 21, a Williamsport, Pa,
college football player who died in '03 from an MRSA infection that began as a pimple. Then
both brothers were also hit with MRSA, though apparently from different sources. Fortunately
the Talleys recovered .

abscess, cellulitis, or both. Less frequent manifestations

include erythematous papules and nodules, erythematous
pustules, and/or crusted plaques.13 Many individuals, including several athletes, initially interpreted their infectious
CAMRSA lesions to be insect or spider bites.13-16,22,36-39

Sports associated with CAMRSA skin infections

The initial report of a community outbreak of MRSA in
athletic participants involved 7 of the 32 members of a high

Table 2

school wrestling team in Southern Vermont between January

1993 and February 1994.27 The next reported occurrence of
CAMRSA skin infection in contact sports participants
involved 25% of the players on a British rugby team in the
United Kingdom in December 1996. Subsequently, between
September and October 2000, cutaneous CAMRSA infection
occurred in 10 members of a Pennsylvania college football
team.11,12 Since then, CAMRSA skin infections have also
been observed in football players from other college teams
(Table 1), 11-19 high school teams (Table 2), 20-24 and
professional teams (Table 3).19,20,25,26 In addition to wrestlers

Community-acquired MRSA infection in high school football players

Author/reference

Comments

Mihoces20 and
Blauvelt21

In Franklin, Wisconsin (a southwestern suburb of Milwaukee), 8 players on the Franklin High School football team
were infected with MRSA from early September 2003 to mid-October 2003. One of the players was hospitalized for
16 d; the other 7 players continued to attend school and did not miss any football games.
A 16-year-old boy (case 1) who participated in high school football in San Antonio, Texas, presented with a boil to
his right axilla of 4 d duration; culture of the lesion grew CAMRSA. A year before, he had a similar infection on his
neck and had been told that it was a spider bite when he sought medical attention. He was not aware of anyone else on
the football team having experienced a similar infection.
It is likely that the risk factor for his CAMRSA infection was not sports related. One week before his developing his
infection, his father had been released from prison and had returned home. Although incarcerated, his father had
twice been treated for similar lesions that had been attributed to spider bites.
A report from Pittsburg, Pennsylvania, described 20 episodes (11 proven and 9 suspected) of CAMRSA occurring in
13 of 90 high school football players (9th to 12th grade) during the football season, which extended from August 17
through December 11, 2003. Community-acquired MRSA cutaneous lesions presented as abscess/cellulitis on the
upper extremity (11), lower extremity (5), face (3), neck (1), and abdomen (1). One player concurrently had 2
separate lesions. Six players had recurrent CAMRSA infection: either 2 episodes (5) or 3 episodes (1). Incision and
drainage was performed for 10 of 21 lesions. Hospitalization was required for 4 players because of either severe soft
tissue involvement (3) or failure to respond to -lactams (1).
Risk factors for developing CAMRSA infection included playing a lineman position and having junior class status;
one player had a coinfected family member or significant other. The investigators noted that although abscesses that
were treated with ineffective antibiotics after drainage tended to heal, they had a significantly higher recurrence rate
than those that were treated with antibiotics guided by culture.
A report from the Division of Infectious Diseases of the Illinois Department of Public Health in Chicago, Illinois,
described an outbreak of MRSA in 2 high school football players during September 2004; in addition, MRSA was
also cultured from one member of the dance team. Both football players had frequent (greater than 10) cuts,
abrasions, or turf burns. Hospitalization was required for one of the football players with an abscess.

Dominguez22

Rihn et al23

Borchardt et al24

CAMRSA in athletes
Table 3

19

Community-acquired MRSA infection in professional football players

Author/reference
Mihoces

Comments

20

Srinivasan and Kazakova,25

Kazakova et al,26 and
Schindehette et al19

Recent cases on pro football teams have been reported from Florida. Those hospitalized included
Miami Dolphins star linebacker Junior Seau, according to Florida newspapers.
During the 2003 football season (August 1 through November 30), 8 MRSA infections occurred in 9% (5/58)
of the St Louis Rams players between September 1 through December 1, 2003. The lineman or linebacker
position and a higher body mass index were significantly associated with the development of MRSA
infection. In addition, all of the cutaneous MRSA infections occurred at sites of skin abrasion (turf burns) on
elbows, forearms, or knees; they rapidly progressed into large, 5 to 7 cm, abscesses that required incision and
drainage. Within 10 d after initiating treatment, most of the infections resolved; none of the players were
hospitalized. All 5 players received oral antibiotics (cephalexin, TMP/SMZ, and rifampineither alone or in
combination), and 2 players had received intravenous therapy (vancomycin and ceftriaxone) before starting
oral treatment. 60% (3/5) of the players developed recurrent infections. Games or practice were missed for
either 1, 4, or 12 d by 3 of the players, respectively.
The first MRSA infections were discovered in 2 of the St Louis Rams players on September 1, 2003. On
Sunday, September 14, 2003, the San Francisco 49ers were playing a football game against the Rams in
St Louis. On the subsequent Sunday (September 21, 2005), the first MRSA infection occurring in a San
Francisco 49er football player was diagnosed; additional MRSA abscesses occurred on members of the
competing San Francisco 49ers football team (referred to as Team A by the investigators). The MRSA
strain from the San Francisco 49ers players had pulsed-field gel electrophoresis patterns that were
indistinguishable from those of the Rams players' MRSA; specifically, all of the MRSA strains carried the
gene for Panton-Valentine leukocidin and the gene complex for SCCmec (staphylococcal cassette
chromosome mec) type IVa resistance (clone USA300-0114).

(Table 4),12,27 rugby players (Table 5),28 and football players

(Tables 1, 2, and 3),11-26 cutaneous CAMRSA infections have
also been reported in athletes who participate in baseball
(Table 6),19 basketball (Table 7)14,29 (Fig. 1), canoeing (Table
8), 12,16,27,28,30 fencing (Table 9), 12 soccer (Table
10),12,16,27,28,30 volleyball (Table 11)13,14 (Fig. 2), and weight
lifting (Table 12)14,31 (Figs. 3 and 4).
Sports-related risk factors for the acquisition and
transmission of MRSA in athletes have been identified.6,8,14
Direct skin-to-skin transmission of MRSA can occur during
the physical contact between the participants. Intentional
body contact among the wrestlers during training27 or
incidental skin-to-skin contact between the volleyball
Table 4

Community-acquired MRSA infection in wrestlers

Author/reference
Lindenmayer et al

CDC12

teammates13,14 during practice and competition can be a

factor in the spread of CAMRSA infection from one athlete
to another.
The field position of the players on either the football
team or the rugby team was associated with an increased
risk of developing CAMRSA skin infection. Football
players who were linemen,12,20,23,25,26 linebackers,25,26
cornerbacks,18 and wide receivers18 were more likely to
acquire cutaneous CAMRSA infection. Also, all of the rugby
players who developed CAMRSA skin infections were
forwards.28
Sports-associated skin damage is another risk factor for
the acquisition and transmission of MRSA. Abrasions and

Comments
27

Seven of 32 members of a high school wrestling team in Southern Vermont (and 6 nonwrestlers who had some
connection with the high school) were affected by a community outbreak of MRSA between January 1993 and
February 1994. Risk factors for MRSA infection were absent in all affected individuals. Culture-positive infectious
skin lesions (either an abscess or boils) from 6 of the wrestlers were located on the lower extremities (4 team
members) or forearms (2 team members). The seventh affected wrestling team member was colonized with MRSA
that was cultured from his nares.
Risk factors for the spread of MRSA among the affected individuals were direct skin contact, skin damage, and
shared equipment. Direct contact between infected or colonized wrestlers was likely because they usually
participated in wrestling practice with their arms and legs uncovered for 2 h per day, 6 d a week. The wrestlers
typically had skin damage, which facilitated the entry of bacteria at that location, because they frequently received
mat burns to their extremities. In addition, a source of contact with bacteria-inoculated shared equipment was the
wrestling mat on which they practiced.
Two male wrestlers on an Indiana high school team were diagnosed with cutaneous MRSA infection in January
2003. Neither of the wrestlers required hospitalization. Because the 2 boys were not in the same weight group
and had never wrestled each other, the sharing of itemsinstead of direct contactwas suggested as the source
of bacterial transmission.

20
Table 5

P.R. Cohen
Community-acquired MRSA infection in rugby players

Author/reference Comments
Stacey et al28

Five (25%) of 20 of the members of a rugby

team in the United Kingdom presented with
large abscesses located at various sites (upper
arms, back, neck, and face) in December
1996. Prolonged periods of close contact,
rather than shared equipment or facilities,
was favored as the mechanism of bacterial
transmission because the 5 affected players
were all forwards and had competed together
in a match against a touring team from the
South Pacific 10 d earlier. Initially, no
bacterial cultures from the lesions were
obtained; a -lactam antibiotic was
prescribed, and the infectious lesions did
not respond. Cultures were then performed
from the abscesses and grew MRSA; in
addition, MRSA was also cultured from
samples taken from 6 partly used containers
of petroleum jelly from the club changing
room. Subsequently, after receiving either
erythromycin or clarithromycin antimicrobial
treatment to which the bacterial isolates
were sensitive, the MRSA infection in
the 5 affected players responded well.
Colonization with MRSA was not present in
any of the 15 asymptomatic squad members.

lacerations result in injury and disruption of the normally

intact surface epithelium, facilitating the cutaneous entry of
bacterial pathogens. Turf burns and mat burns are common
sources of abrasions in football players11,12,18,24-26 and
wrestlers,27 respectively. Skin contact with the wooden court
by volleyball players was also postulated as a source of
abrasions in these athletes.13,14 In football players, shaving
of the body with a razor blade was responsible for creating
tiny lacerations, which were associated with an increased risk
of acquiring CAMRSA infection.11,12,18
Finally, sharing of equipment provides a vehicle for
transmission of bacteria. Use of the bench press or cold-water
whirlpoolwithout adequate cleaning of the equipment
between athletesis a likely source for MRSA transmission
for the weight lifters14,31 and football players,18 respectively.
Other sports-related equipment such as the sensor wires for
fencers12 or the wrestling mat for wrestlers,12,27 when
Table 6
players

Community-acquired MRSA infection in baseball

Author/reference Comments
Schindehette
et al19

The June 27, 2005, issue of People magazine

contained an article on MRSA titled Killer
microbe, which commented that players
came down with MRSA infection, and
Baltimore Oriole Sammy Sosa battled one
just last month.

Table 7
players

Community-acquired MRSA infection in basketball

Author/reference Comments
Cohen14

Takizawa et al29

A 19-year-old black woman on the University

of Houston varsity basketball team who had
no MRSA risk factors developed abscesses
and cellulitis on her left anterolateral thigh,
left buttock, and left labia majora. She was
initially treated with double-strength TMP/
SMZ orally twice each day for 10 d and
topical 2% mupirocin ointment applied
topically thrice daily to the lesions for 10 d.
Her abscesses remained intact and her
cutaneous CAMRSA infection persisted.
Incision and drainage of the abscesses was
performed; treatment with double-strength
TMP/SMZ orally twice each day for another
14 d was given; topical 2% mupirocin
ointment applied topically thrice daily not
only to her lesions, but also intranasally, for
14 d, and 7.5% or 10% povidone-iodine soap
were used daily while she received systemic
therapy; once her infection resolved, the
frequency of bathing with the agent was
tapered every 2 wk starting with 3 times each
week (every other day) and decreasing to
2 times each week (every third or fourth day)
before stopping. Her CAMRSA infection
resolved without recurrence.
In Japan, a multiple drugresistant PantonValentine leukocidin (PVL) + CAMRSA
strain (NN12) was isolated from an 18-yearold female high school basketball team
player. She had bilateral abscesses on her
gluteal regions. She was treated as an
outpatient. She subsequently had recurrent
lesions. Treatment included application of
gentamycin ointment. Methicillin-resistant
S aureus infection did not occur in her
teammates, her classmates, or members of
her family.

unintentionally shared, can also result in transmission of

MRSA infection. Clothing, such as towelsespecially if
they have not been laundered between userswas shown to
be a source for the transmission of MRSA between football
team players.11,12,15,16 Sharing of other common objects that
have become contaminated with MRSA, such as personal
hygiene items including razors,11,12,18 soap bars,12,15,16 and
skin lubricants,12,15,16,28 have also been demonstrated to
contribute to the spread of CAMRSA infection in athletes.

Management of cutaneous CAMRSA infections

Incision and drainage is an essential component of therapy
when CAMRSA infection presents as an abscess.1,10,13,40-42

CAMRSA in athletes

21
Table 9

Community-acquired MRSA infection in fencers

Author/reference Comments
CDC12

Fig. 1 Distant (A) and closer (B) views of an abscess with

surrounding cellulitis, from which the bacterial culture grew
MRSA, on the left thigh of a 19-year-old black female varsity
basketball player (republished with permission from South Med J
2005;98:596, copyright 2005 by the Southern Medical Association,
Lippincott Williams & Wilkins).

Indeed, as described in one of the basketball players,

in the absence of surgical intervention or spontaneous
rupture of the infectious abscess, the cutaneous CAMRSA
infection may persisteven when the patient is receiving

Table 8

Community-acquired MRSA infection in canoers

Author/reference Comments
Nguyen et al

16

The community-acquired methicillin resistant

S aureus (CAMRSA) strains have been a
cause of SSTI [skin and soft tissue infection]
outbreaks among athletes participating in
canoeing (4-7 [references 12, 27, 28, and 30 in
current article]; Jon Rosenberg, pers comm;
Los Angeles County Department of Health,
unpub data).

Between July 2002 and February 2003,

MRSA infection occurred in 6% (4 of 70
members) of a Colorado fencing club and one
household contact of a fencer. Culture
confirmation of MRSA was obtained for 3
of these individuals. In 4 of the patients (2 of
whom required hospitalization to receive
intravenous antibiotics), the cutaneous
MRSA infection presented as a single
abscess or multiple abscesses; the skin
lesions were most commonly located on the
lower extremities and abdomen. The fifth
patient developed paraspinal myositis with
bacteremia and required hospitalization. All
of the patients recovered from their infection.
In 2 of the patients (from whose skin
infections had subsequently been cultured
MRSA), however, similar episodes of
antimicrobial-treated cutaneous infection
had previously occurred.
The investigators were not able to determine
the mode of MRSA transmission. Clothing,
masks, or weapons had not been shared
among the infected fencers. Sensor wires (a
piece of equipment that is worn under the
uniform to record when a fencer has been
touched by their opponent's weapon),
however, are usually shared by club member
and are not cleaned on a routine schedule. The
investigators, therefore, speculated that it is
possible that the infected fencers may have
unknowingly used the same sensor wires.

systemic antimicrobial therapy to which the bacterial strain

is susceptible.14
A recent study has concluded that incision and drainage
without adjunctive antibiotic therapy is effective management of CAMRSA skin and soft tissue abscesses with a
diameter of less than 5 cm in immunocompetent children41;
however, the investigators noted that 4 (6.5%) of the 62
patients required hospitalization at follow-up and subsequently observed that 3 (4.3%) of their patients developed
Table 10
players

Community-acquired MRSA infection in soccer

Author/reference Comments
Nguyen et al16

The community-acquired methicillin

resistant S aureus (CAMRSA) strains have
been a cause of SSTI [skin and soft tissue
infection] outbreaks among athletes
participating in soccer (4-7 [references
12, 27, 28,
and 30 in current article]; Jon
Rosenberg, pers comm; Los Angeles County
Department of Health, unpub data).

22
Table 11

P.R. Cohen
Community-acquired MRSA infection in volleyball players

Author/reference
Cohen and Kurzrock
Cohen14

Comment
13

and Two women on the varsity volleyball team at the University of Houston, Houston, Texas, presented with
culture-confirmed MRSA-associated abscesses and cellulitis between August and December 2002; both of the
women initially interpreted their lesions to be secondary to an insect bite. In addition, there was a third team
member with a similar appearing cutaneous infection that was evaluated and treated elsewhere.
The first player was a 19-year-old white woman with no MRSA-related risk factors whose infection was
located on her left posterior thigh; at her initial visit, the abscess had spontaneously ruptured and was draining
purulent serosanguineous pus. She was initially treated with cephalexin (500 mg orally 4 times a day) for 2 d;
however, her infection had worsened and her antibiotic therapy was changed to double-strength TMP/SMZ
(one tablet orally twice daily) and 2% mupirocin ointment (applied topically thrice daily intranasally and to
the lesions) for 10 d. Her infection resolved.
The second player was a 20-year-old black woman who had received systemic ciprofloxacin for treatment of
a urinary tract infection within the prior year. She had cutaneous MRSA lesions on her left buttock and left
chin. Her abscesses had spontaneously ruptured, and the infection continued to worsen as she received
ceftriaxone sulfate (250 mg intramuscularly) for 2 d, followed by cephalexin (500 mg orally 4 times a day)
for 14 d. Her infection resolved after her antibiotic therapy was changed to double-strength TMP/SMZ
(one tablet orally twice daily) and 2% mupirocin ointment (applied topically thrice daily intranasally and to
the lesions) for 14 d.
Physical contact and skin damage were postulated as potential risk factors for the transmission of MRSA
infection in these women. Incidental skin-to-skin contact between team members may have occurred
during volleyball team practice and competition. Also, nonintentional frictional contact of the player's skin
with the wooden court may have resulted in cutaneous injury, which would facilitate the entry of bacteria
at that skin location.

recurrent CAMRSA skin infections.41,43 In addition, persistence, worsening, and/or recurrence of cutaneous CAMRSA
infection occurred not only in athletes but also in other
patients who were treated with an antibiotic to which their
MRSA strain was not susceptible after incision and
drainage.12-16,23,31,44,45 A conservative approach to the
management of CAMRSA skin abscesses would therefore
be to initiate culture-guided treatment with systemic
antimicrobial therapy after incision and drainage.
Most CAMRSA strains are susceptible to trimethoprimsulfamethoxazole (TMP/SMZ) (alone or in combination with
rifampin),46-48 clindamycin (alone or in combination with
rifampin),47,49,50 and tetracyclines (such as minocycline and
doxycycline, either alone or in combination with other
agents).7,51,52 The potential to develop allergic reactions to
sulfonamides,53 the rate of inducible clindamycin resistance
in CAMRSA isolates in the community,5 and whether the
patient is younger than 9 years of age49 may influence the
choice of antibiotic. Although some CAMRSA strains are
susceptible to the older fluoroquinolones (such as ciprofloxacin and levofloxacin), these agents may not be optimal
for treatment of cutaneous CAMRSA infection because the
bacteria readily develops resistance to them.50,51
For critically ill patients with severe CAMRSA skin
infections, hospitalization and intravenous vancomycin are
recommended.7,50,53 Some of the athletes with cutaneous
MRSA infections required hospitalizationthis occurred
most frequently in football players11,12,15-21,23,24 and, to a
lesser extent, in fencers.12 New antistaphylococcal agents
for patients with severe CAMRSA infection have recently
been developed (such as linezolid, daptomycin, quinupris-

tin-dalfopristin, and teicoplanin) or are being evaluated

(such as oritavancin, dalbavancin, telavancin, and
tigecycline).50,51,54,55
The management of cutaneous CAMRSA infection
should include adjuvant topical treatment. Mupirocin 2%
ointment can be applied to the infectious lesions and to
potential sites of bacterial colonization, such as the nares.1,14
Bathing with an antimicrobial agent, such as 10% or 7.5%
povidone-iodine liquid soap, 0.3% or 2% triclosan-

Fig. 2 Methicillin-resistant S aureus skin infection: abscess and

surrounding cellulitis on anterolateral aspect of the right thigh of a
19-year-old white woman who is on the varsity volleyball team
(republished with permission from J Am Acad Dermatol
2004;50:277, copyright 2004 by the American Academy of
Dermatology, Inc, Mosby-Yearbook Publishers).

CAMRSA in athletes
Table 12

Community-acquired MRSA infection in weight lifters

Author/reference
Cohen

14

23

and Cohen

Comments
31

Three college students who were weight lifters at the University of Houston, Houston, Tex, presented with cultureconfirmed MRSA-associated abscesses and cellulitis between August and December 2002; 2 of the students were
also physical fitness trainers. Shared use of the same equipment (such as the bench press) was hypothesized as the
source of transmission of the MRSA skin infections because all of the weight lifters not only exercised at the same
recreation center, but also had cutaneous MRSA lesions that were located in a similar distribution.
The first weight lifter was a 19-year-old black man; he was not a fitness trainer and did not have any MRSAassociated risk factors. His MRSA skin lesions presented in the right axillae as cellulitis surrounding a smaller
tender red indurated nodule superiorly and a larger painful fluctuant erythematous abscess inferiorly. He received
empirical antibiomicrobial therapy with cephalexin (500 mg orally 4 times daily) for 7 d after his infectious lesions
had been incised, drained, and cultured. The culture grew MRSA, his infection persisted, and his antibiotic
treatment was changed to double-strength TMP/SMZ (one tablet orally twice daily) and 2% mupirocin ointment
(applied topically thrice daily intranasally and to the lesions) for 15 d. In addition, 7.5% or 10% povidone-iodine
soap was used daily while he received systemic therapy; once his infection resolved, the frequency of bathing with
the agent was tapered every 2 wk starting with 3 times each week (every other day) and decreasing to 2 times each
week (every third or fourth day) before stopping. His CAMRSA cutaneous infection resolved without recurrence.
The second weight lifter was a 24-year-old Hispanic man who had received systemic ciprofloxacin for treatment of
a skin infection within the previous year. His abscesses (which had ruptured spontaneously) and surrounding
cellulitis were located on his left and right flanks, adjacent to his axillae. His initial therapy included cephalexin
(500 mg orally 4 times daily) for 7 d, 2% mupirocin ointment, and 7.5% or 10% povidone-iodine soap; the latter
2 agents were used in a manner similar to that described for the first weight lifter. Definitive treatment involved
changing the antibiotic to double-strength TMP/SMZ (one tablet twice daily) for 24 d and continuing with the
mupirocin and antibacterial soap. He had a culture-confirmed recurrence of his cutaneous infection within 2 wk
after completing the definitive systemic antibiotic treatment for his initial episode. His recurrent MRSA infection
presented as an intact enlarging tender erythematous fluctuant nodule with surrounding cellulitis in his right axillae;
the lesion was incised and drained, oral double-strength TMP/SMZ was taken twice daily for 25 d, and topical 2%
mupirocin ointment and 4% chlorhexidine detergent were used. The CAMRSA infection resolved completely, and
there were no additional recurrences during the next 5 mo.
The third weight lifter was a 25-year-old black woman with no MRSA-related risk factors whose infection appeared
as a tender red fluctuant abscess with surrounding cellulitis involving the left proximal arm and adjacent axilla.
Initial therapy included incision and drainage of the lesion, cephalexin (500 mg orally 4 times daily), and topical
2% mupirocin ointment, and 4% chlorhexidine detergent; the latter 2 agents were used in a manner similar to that
described for the first weight lifter. The following day, the systemic antibiotic was changed to double-strength
TMP/SMZ (one tablet orally twice daily) for 8 d. Her CAMRSA cutaneous infection resolved without recurrence.

containing preparations, or 4% chlorhexidine gluconate

liquid detergent, is also useful.1,14,56,57 Tea tree 10% cream
and 5% body wash were recently shown to be more effective
than chlorhexidine gluconate 4% soap or silver sulfadiazine
2% cream in clearing MRSA from superficial skin sites and
wounds.58 To prevent recurrence of CAMRSA skin infection, bathing twice a week for 15 minutes in bleachcontaining water (1 teaspoon of bleach per gallon of water)
may be helpful.49

Prevention of CAMRSA infections in

sports participants
Several personal, environmental, and health care
initiated measures can be incorporated to prevent the
spread of CAMRSA in athletes.1,7,12,14,15,59-64 Improvement of athlete's personal hygiene is essential. Handwashing is the single most effective behavior in preventing
transmission of CAMRSA59,63,64; always use soap and

warm water and/or sanitation gels. Team members should

shower, with soap and warm to hot water, as soon as possible
after completion of practices and competitions.7,59,60,63
When outbreaks occur, soap bars should not be shared and
sports teams should consider using liquid soap.16 Players
should not share towels, clothing, razors, and other personal
items.11,12,14-16,18,64
Sports participants should promptly treat abrasions and
cuts. After cleaning with soap and water, they should be
covered with dry clean dressings.7,62 If the wound cannot be
adequately covered, exclusion of the athlete with a
potentially infectious skin lesion from practice and competitions should be considered until either healing has occurred
or the lesion can be covered adequately.60,62,63
Athletes should avoid skin-to-skin contact with other
sports participants who have draining skin lesions.7,14 If an
athlete has a draining cutaneous wound, they should be kept
from participating in practice and competition until an
accurate diagnosis has been established, appropriate treatment for an adequate duration has been used, and there has
been sufficient resolution of the lesion.63

24
Environmental measures to control the transmission of
CAMRSA infection among sports participants focus predominantly on appropriate cleaning and disinfecting of
equipment that they either use or contact. A routine schedule
for cleaning and disinfecting should be established and
maintained.12,14,60 For example, practice surfaces such as
wrestling mats12,27 and shared equipment such as the bench
press14,31 and the whirlpool18 should ideally be cleaned
before and after each practice and individual use, respectively. 62,63 Appropriate disinfectants, germicides, and
cleansing solutions are commercially available15,63; alternatively, dilute bleach (ranging from 1 part bleach in 9 parts
water63 to 1 tablespoon bleach in 1 quart water15) can be
used. Also, team supplied uniforms, towels, and other

P.R. Cohen

Fig. 4 Cutaneous MRSA infection appearing as a tender red

fluctuant abscess with surrounding cellulitis involving the left
proximal arm and adjacent axillae of a 25-year-old black female
weight lifter (republished with permission from South Med J
2005;98:596, copyright 2005 by the Southern Medical Association,
Lippincott Williams & Wilkins).

clothing should be laundered in hot water with detergent or

bleach after each use.7
Health careinitiated measures involve educating not
only the athletes but also their coaches regarding the
presentation of cutaneous CAMRSA infections and the first
aid measures that should be performed for skin wounds that
are potentially infected. Early recognition of potential
CAMRSA skin lesions, followed by prompt evaluation
and appropriate treatment, will be helpful to the sports
participant in minimizing the duration and transmission of
their infection. In addition to athletes reporting new skin
wounds to their coaches, coaches should therefore regularly
inspect their players for cutaneous lesionsespecially when
there is a team member who has a cutaneous CAMRSA
infection.7,12,14,28,60,62

Conclusions

Fig. 3 Distant (A) and closer (B) views of the right axillae of a
19-year-old black male weight lifter with infectious MRSA skin
lesions presenting as cellulitis surrounding a smaller tender red
indurated nodule superiorly and a larger painful fluctuant
erythematous abscess inferiorly. The accessory areola and nipple
are an incidental finding (A, republished with permission from
South Med J 2005;98:596, copyright 2005 by the Southern Medical
Association, Lippincott Williams & Wilkins; B, republished with
permission from SKINmed: Dermatology for the Clinician
2005;4:115, copyright 2005 by LeJacq, Ltd).

The features of cutaneous CAMRSA infection in

participants of athletic activities were summarized, the
potential mechanisms and risk factors for the transmission
of CAMRSA skin infection in sports participants were
discussed, the management (including surgical, systemic
antibiotics and topical agents) of infectious CAMRSA skin
lesions was reviewed, and the measures for preventing the
spread of cutaneous CAMRSA infection in athletes were
presented in this article. Cutaneous CAMRSA infection
occurs predominantly in athletes who participate in contact
sports, such as football, wrestling, and rugby, in which there
is frequent and intentional skin-to-skin physical contact; in
addition, participants in these sports are likely to develop
superficial injury to their skin. Community-acquired MRSA
skin infection also occurs in participants of sports in which

CAMRSA in athletes
the contact between team members is incidental or
accidental, such as volleyball and basketball. In addition,
cutaneous CAMRSA infection occurs in sports participants
in which the team members are likely to have had contact
with CAMRSA-contaminated equipment, such as fencing
and weight lifting. Hence, risk factors that enhance the
acquisition and transmission of CAMRSA skin infection are
physical skin-to-skin contact, sport-induced skin damage,
and sharing of potentially contaminated equipment, clothing,
or other personal items. The most common infectious
CAMRSA skin lesion in athletes is an abscess, with or
without associated cellulitis. An essential component of the
management of cutaneous CAMRSA infection therefore
includes incision and drainage of the abscess. Subsequently,
initiation of culture-guided treatment with systemic antimicrobial therapy should be considered. Adjuvant treatment
with topical antibiotic ointment and bathing with antibacterial liquid soap or detergent can also be helpful. Prevention of
cutaneous CAMRSA infections in sports participants
includes the incorporation of personal, environmental, and
health careinitiated measures.65,66

25

13.

14.

15.

16.

17.

18.

19.
20.

References
21.
1. Cohen PR, Grossman ME. Management of cutaneous lesions associated
with an emerging epidemic: community-acquired methicillin-resistant
Staphylococcus aureus skin infections [Commentary]. J Am Acad
Dermatol 2004;51:132-5.
2. Young DM, Harris HW, Charlebois ED, et al. An epidemic of
methicillin-resistant Staphylococcus aureus soft tissue infections
among medically underserved patients. Arch Surg 2004;139:
947-53.
3. Chambers HF. Community-associated MRSA-resistance and virulence
converge [editorial]. N Engl J Med 2005;352:1485-7.
4. Crawford SE, Daum RS. Epidemic community-associated methicillinresistant Staphylococcus aureus. Modern times for an ancient pathogen.
Pediatr Infect Dis J 2005;24:459-60.
5. Purcell K, Fergie J. Epidemic of community-acquired methicillinresistant Staphylococcus aureus infections. A 14-year study at Driscoll
children's hospital. Arch Pediatr Adolesc Med 2005;159:980-5.
6. Gosbell IB. Epidemiology, clinical features and management of
infections due to community methicillin-resistant Staphylococcus
aureus (cMRSA). Intern Med J 2005;35:S120-35.
7. Kowalski TJ, Berbari EF, Osmon DR. Epidemiology, treatment, and
prevention of community-acquired methicillin-resistant Staphylococcus aureus infections. Mayo Clin Proc 2005;80:1201-8.
8. Weber JT. Community-associated methicillin-resistant Staphylococcus
aureus. Clin Infect Dis 2005;41:S269-72.
9. Beilman GJ, Sandifer G, Skarda D, et al. Emerging infections with
community-associated methicillin-resistant Staphylococcus aureus in
outpatients at an army community hospital. Surg Infect 2005;6:87-92.
10. Elston DM. Optimal antibacterial treatment of uncomplicated skin and
skin structure infections: applying a novel treatment algorithm. J Drugs
Dermatol 2005;4:s15-9.
11. Maltin LJ. Share and share alikeexcept in locker room. WebMD
with AOL Health [Accessed 06 September 2004]. Available from
http://aolsvc.health.webmd.aol.com/content/article/36/1676_52814.
htm; 2004.
12. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus infections among competitive sports participants

22.

23.

24.

25.

26.

27.

28.

29.

30.

Colorado, Indiana, Pennsylvania, and Los Angeles county, 2000-2003.

MMWR Morb Mortal Wkly Rep 2003;52:793-5.
Cohen PR, Kurzrock R. Community-acquired methicillin-resistant
Staphylococcus aureus skin infection: an emerging clinical problem.
J Am Acad Dermatol 2004;50:277-80.
Cohen PR. Cutaneous community-acquired methicillin-resistant Staphylococcus aureus infection in participants of athletic activities. South
Med J 2005;98:596-602.
Centers for Disease Control and Prevention. Outbreaks of communityassociated methicillin-resistant Staphylococcus aureus skin infections
Los Angeles county, California, 2002-2003. MMWR Morb Mortal Wkly
Rep 2003;52:88.
Nguyen DM, Mascola L, Bancroft E. Recurring methicillin-resistant
Staphylococcus aureus infections in a football team. Emerg Infect Dis
2005;11:526-32. 2005 Apr [Accessed 14 November 2007]. Available
from http://www.cdc.gov/ncidod/EID/vol11no04/04-1094.htm.
Arlinghaus E, Hann MJ, Nguyen A-D. Community acquired methicillin
resistant Staphylococcus aureus in an athletic environment. Case
Poster Presentation [Accessed 14 November 2007]. Available
from http://www1.ncaa.org/membership/ed_outreach/health-safety/
healthcare/sports_med_education/MRSAposter.pdf; 2004.
Begier EM, Frenette K, Barrett NL, et al. A high-morbidity outbreak of
methicillin-resistant Staphylococcus aureus among players on a college
football team, facilitated by cosmetic body shaving and turf burns. Clin
Infect Dis 2004;39:1446-53.
Schindehette S, Morehouse M, Erwin S. Killer microbe. People 2005;
63:133-4.
Mihoces G. Sports teams warned about unique skin infection. USA
Today 2003 [Accessed 22 December 2005]. Available from http://www.
usatoday.com/sports/2003-10-14-sports-infections_x.htm.
Blauvelt H. High school team hit with MRSA [online]. USA Today
2003 [Accessed 14 November 2007]. Available from http://www.
usatoday.com/sports/preps/football/2003-10-15-skin-disease_x.htm.
Dominguez TJ. It's not a spider bite, it's community-acquired
methicillin-resistant Staphylococcus aureus. J Am Board Fam Pract
2004;17:220-6.
Rihn JA, Posfay-Barbe K, Harner CD, et al. Community-acquired
methicillin-resistant Staphylococcus aureus outbreak in a local high
school football team unsuccessful interventions. Pediatr Infect Dis J
2005;24:841-3.
Borchardt SM, Yoder JS, Dworkin MS. Is the recent emergence of
community-associated methicillin-resistant Staphylococcus aureus
among participants in competitive sports limited to participants?
[letter]Clin Infect Dis 2004;40:906-7.
Srinivasan A, Kazakova S. The bigger they are, the harder they fall:
methicillin-resistant Staphylococcus aureus skin and soft tissue
infections among professional football players2003 [abstract #383].
Presented at the 14th Annual Scientific Meeting of the Society for
Healthcare Epidemiology of America; Philadelphia, Pennsylvania;
Apr 17-20; 2004.
Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillinresistant Staphylococcus aureus among professional football players.
N Engl J Med 2005;352:468-75.
Lindenmayer JM, Schoenfeld S, O'Grady R, Carney JK. Methicillinresistant Staphylococcus aureus in a high school wrestling team and the
surrounding community. Arch Intern Med 1998;158:895-8.
Stacey AR, Endersby KE, Chan PC, Marples RR. An outbreak of
methicillin resistant Staphylococcus aureus infection in a rugby football
team. Br J Sports Med 1998;32:153-4.
Takizawa Y, Taneike I, Nakagawa S, et al. A Panton-Valentine
leucocidin (PVL)positive community-acquired methicillin-resistant
Staphylococcus aureus (MRSA) strain, another such strain carrying a
multiple-drug resistance plasmid, and other more-typical PVLnegative MRSA strains found in Japan. J Clin Microbiol 2005;43:
3356-63.
Goodman RA, Thacker SB, Solomon SL, Osterholm MT, Hhughes JM.
Infectious diseases in competitive sports. JAMA 1994;271:862-7.

26
31. Cohen PR. Community-acquired methicillin-resistant Staphylococcus
aureus skin infection presenting as an axillary abscess with cellulitis in
a college athlete. SKINmed: Dermatology for the Clinician 2005;
4:115-8.
32. Cohen PR. What caused this abscess and cellulitis? Diagnosis:
community-acquired methicillin-resistant Staphylococcus aureus
(CAMRSA) skin infection. Skin & Aging 2004;12:56-8.
33. Cohen PR. Enlarging facial abscess with cellulitis (community-acquired
methicillin-resistant Staphylococcus aureus [Dermatology Dx]. Cortlandt Forum 2005;18:42,45.
34. Cohen PR. Enlarging facial abscess with cellulitis (community-acquired
methicillin-resistant Staphylococcus aureus [Dermatology Clinic]. Clin
Advis 2005;8:60, 63.
35. Cohen PR. Community-acquired methicillin-resistant Staphylococcus
aureus skin infection presenting as a periumbilical folliculitis: case
reports. Cutis 2006;77:229-32.
36. Fagan SP, Berger DH, Rahwan K, Awad SS. Spider bites presenting
with methicillin-resistant Staphylococcus aureus soft tissue infection
require early aggressive treatment. Surg Infect 2003;4:311-5.
37. Miller LG, Spellberg B. Spider bites and infections caused by
community-associated methicillin-resistant Staphylococcus aureus
[letter]. Surg Infect 2004;5:321-2.
38. Center for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus infections in correctional facilitiesGeorgia,
California, and Texas, 2001-2003. MMWR Morb Mortal Wkly Rep
2003;52:992-6.
39. Tripoli L, Bick J. HIV Education Prison Project (HEEP) news-spotlight:
methicillin-resistant Staphylococcus aureus (MRSA). Aegis 2003;6
[Accessed 14 November 2007]. Available from: www.aegis.com
(Publications: Professional: HIV Educational Prison Project Report:
2003 Publications).
40. Arkwright PD, Daniel TO, Sanyal D, David TJ, Patel L. Age-related
prevalence and antibiotic resistance of pathogenic staphylococci and
streptococci in children with infected atopic dermatitis at a singlespecialty center. Arch Dermatol 2002;138:939-41.
41. Lee MC, Rios AM, Aten MF, et al. Management and outcome of
children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis
J 2004;23:123-7.
42. Cohen PR. Empiric treatment of skin infections. Dr. Cohen responds.
[letter]. Clin Advis 2006;9:11-2.
43. Rios AM, Lee MC, Hardy RD. Staphylococcal skin infections. Reply
[letter]. Pediatr Infect Dis J 2004;23:795-6.
44. Miller LG, Spellberg B. Treatment of community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections
with drainage but no antibiotic therapy [letter]. Pediatr Infect Dis J
2004;23:795.
45. Faden H. Staphylococcal skin infections [letter]. Pediatr Infect Dis J
2004;23:690.
46. Moran GJ, Talan DA. Community-associated methicillin-resistant Staphylococcus aureus: is it in your community and should it change
practice? [editorial] Ann Emerg Med 2005;45:321-2.
47. Moran GJ, Amii RN, Abrahamian FM, Talan DA. Methicillin-resistant
Staphylococcus aureus in community-acquired skin infections. Emerg
Infect Dis 2005;11:928-30. Available from: www.cdc.gov/eid.
48. Grim SA, Rapp RP, Martin CA, Evans ME. Trimethoprim-sulfamethoxazole as a viable treatment option for infections caused by
methicillin-resistant Staphylococcus aureus. Pharmacotherapy 2005;
25:253-64.

P.R. Cohen
49. Kaplan SL. Treatment of community-associated methicillin-resistant
Staphylococcus aureus infections. Pediatr Infect Dis J 2005;24:
457-8.
50. Ladhani S, Garbash M. Staphylococcal skin infections in children.
Rational drug therapy recommendations. Paediatr Drugs 2005;7:
77-102.
51. Ellis MW, Lewis II JS. Treatment approaches for community-acquired
methicillin-resistant Staphylococcus aureus infections. Curr Opin Infect
Dis 2005;18:496-501.
52. Ruhe JJ, Monson T, Bradsher RW, Menon A. Use of long-acting
tetracyclines for methicillin-resistant Staphylococcus aureus infections: case series and review of the literature. Clin Infect Dis
2005;40:1429-34.
53. Rybak MJ, LaPlante KL. Community-associated methicillin-resistant
Staphylococcus aureus: a review. Pharmacotherapy 2005;25:74-85.
54. Bradley JS. Newer antistaphylococcal agents. Curr Opin Pediatr
2005;17:71-7.
55. Ashourian N, Cohen PR. Systemic antibacterial agents (Chapter 4).
In: Wolverton SE, editor. Comprehensive dermatologic drug therapy.
2nd edition. Philadelphia, PA: WB Saunders Company; 2007. p. 39-74.
56. Zafar AB, Butler RC, Reese DJ, Gaydos LA, Mennonna PA. Use of
0.3% triclosan (Bacti-Stat*) to eradicate an outbreak of methicillinresistant Staphylococcus aureus in a neonatal nursery. Am J Infect
Control 1995;23:200-8.
57. Bartzokas CA, Paton JH, Gibson MF, Graham R, McLoughlin CA,
Croton RS. Control and eradication of methicillin-resistant Staphylococcus aureus on a surgical unit. N Engl J Med 1984;311:
1422-5.
58. Dryden MS, Dailly S, Crouch M. A randomized, controlled trial of tea
tree topical preparations versus a standard topical regimen for the
clearance of MRSA colonization. J Hosp Infect 2004;56:283-6.
59. Texas Department of State Health Services, Infection Disease Control
Unit. Information on staphylococcal infections for school athletic
departments [Accessed 14 November 2007]. Available from: http://
www.dshs.state.tx.us/idcu/health/antibiotic_resistance/mrsa/.
60. R.S.Jones RS. Expert advice on erasing the MRSA threat. Pract
Dermatol 2005;2:33-7.
61. Cohen PR. Community-acquired methicillin-resistant Staphylococcus
aureus skin infections: implications for patients and practitioners. Am J
Clin Dermatol 2007;8:259-70.
62. Centers for Disease Control and Prevention. CDC suggests prevention
measures for community-acquired MRSA infection [Accessed 14
November 2007]. Available from: http://www1.ncaa.org/membership/
ed_outreach/health-safety/healthcare/sports_med_education/CDC_
preventionmeasures.pdf.
63. W.B.Howe WB. Preventing infectious disease in sports. Phys
Sportsmed 2003;31 Available from: http://www.physsportsmed.com/
issues/2003/0203/howe.htm.
64. Rieger D, Bick J. HIV Education Prison Project (HEEP) reportspotlight: so your facility has CA-MRSA. The body: the complete HIV/
AIDS. Resource 2004;7 [Accessed 14 April 2005]. Available from:
http://www.thebody.com/hepp/julaug04/spotlight.html.
65. Cohen PR. Cutaneous community-acquired methicillin-resistant Staphylococcus aureus infection: a personal perspective of a world-wide
epidemic [editorial]. Expert Rev Dermatol 2006;1:631-7. http://www.
future-drugs.com/doi/pdf/10.1586/17469872.1.5.631.
66. Cohen PR. Community-acquired methicillin-resistant Staphylococcus
aureus skin infection: a review of epidemiology, clinical features,
management, and prevention. Int J Dermatol 2007;46:1-11.