The Athlete’s Perspective—Reduce Your Risk of Infection

Tori Kinamon

Deverick J. Anderson

Introduction

The content within this chapter is unique. It has been specifically designed for you, the athlete, and your support group, parents, and coaches. The material in this chapter is intended to provide practical, useful, and easily digestible information to reduce your risk of infection and stay in the game.

Throughout this manual, we provide information on strategies to reduce risk. We provide numerous recommendations for team medical staff in Chapters 3, 4, 5, 6. These recommendations are provided as Best Practices for prevention followed by recommendations to meet the Best Practices. In this chapter, we first describe a risk factor for you, the athlete; we then provide recommendations and action points about how you can reduce that risk, and finally we provide insight into why you should care about these behaviors and recommendations. It’s important to note, however, that no interventions exist to reduce your risk of infection to zero. As a result, you always must remain vigilant for high-risk scenarios or, better yet, diligently practice preventative techniques.

Tips From Tori

Do you experience any of these as an athlete?

Contact: skin to skin
Compromised skin (cuts or scrapes)
Difficulty with cleanliness (think: washing your hands or showering immediately after practice because of time constraints)
Crowded areas or shared personal items (think: locker rooms!)
Contaminated equipment or surfaces shared between players

These “5 C’s” of transmission increase your risk for infection. I should know—my collegiate gymnastics career was threatened by an MRSA infection. Three months and eight surgeries later, I made it back to my team.

As an athlete, you take precautions to protect yourself on the court, field, or mat. You engage in physical therapy for musculoskeletal injuries, receive pre- and postpractice treatments from athletic trainers, and build muscle mass in the weight room. However, did you know that being an athlete places you at increased risk for common infectious diseases? Athletes have increased risk of several infections, including norovirus, influenza, skin and soft-tissue infections due to methicillin-resistant Staphylococcus aureus (MRSA), and herpes gladiatorum. These infections not only have the potential to sideline you from athletic participation but can also place the entire team at risk if not managed appropriately. It is important for you to, first, be aware of your risk for infection as an athlete and, second, adhere to basic infection prevention strategies to help protect yourself and your teammates from these infections.

Infection risk for athletes falls into four broad categories: (1) personal and social behaviors, (2) medical care, (3) interactions with other athletes, and (4) use of facilities and equipment (Figure 2.1). The 5 C’s outlined above contribute to all of these categories. We outline specific risks within each of these categories in Table 2.1. Of course, team medical personnel

have important roles to play and tasks to complete to keep you safe, but you play a critically important role in maintaining your own health and safety. As you read these sections, consider how and when you might face these risks in your routine as an athlete.

Figure 2.1 Framework for infection transmission in athletes.

Table 2.1 Summary of Risk Factors for Infections in Athletes—Behaviors, Risks, and Recommendations to Stay Infection Free

Personal and Social Behaviors
Behavior	Risk	Recommendation
Player knowledge and education	Lack of knowledge, unaware of risk for infection Poor team culture	Actively participate in preseason athlete health meetings. Recognize symptoms of infection and present these symptoms to your athletic trainer ASAP. Notify your athletic trainer when you have vomiting or diarrhea. Recognize the signs of “athlete’s foot” and present symptoms to athletic trainer. Recognize the signs of herpes gladiatorum and present symptoms to athletic trainer. Notify your athletic trainer if you develop flu-like symptoms. Become an infection prevention champion.
Hand hygiene practices	Regular skin-to-skin contact Lack of hand cleanliness	Increase use of hand hygiene while in athletic environments. Locate and use alcohol-based hand hygiene dispensers throughout the facility. Promote hand hygiene among your teammates. Clean hands with soap and water if they are visibly soiled.
Body hygiene	Regular skin-to-skin contact Skin contact with contaminated surfaces Lack of body cleanliness	Shower immediately after practice. Do not use bar soap in the shower. Use soap dispensers that utilize prepackaged liquid soap. Bathe with chlorhexidine gluconate 3x/week.
Body shaving	Compromised skin	Avoid cosmetic body shaving. If hair removal is necessary, remove with individual- or single-use clippers. If hair must be removed through shaving, shave clean skin with a fresh razor. Never share a razor.
Medical Care
Type of Medical Care	Risk	Recommendation
Basic medical care	Insufficient knowledge of fundamental infection prevention practices	Talk with your athletic trainer about infection prevention protocols utilized in your athletic training facility. Take an active role in disinfecting the materials that you use in the athletic training room during and after treatments. Practice good hand hygiene in the athletic training facilities.
Cut care	Compromised skin from routine athletic activities High rate of colonization with Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA)	Monitor skin on a daily basis for skin wounds, including cuts, scrapes, and any suspicious lesions. Show all wounds to your athletic trainer for cleaning and treatment as soon as you notice them. Be knowledgeable of the policy for cut care in your athletic training facility and discuss with your athletic trainer.
Hydrotherapy	Use of hydrotherapy pools	Do not enter the hydrotherapy pool with an open wound unless the wound is covered by an impermeable dressing. Shower prior to using hydrotherapy pools. Do not use the hydrotherapy pools if you have a known MRSA infection until the infection is completely resolved. Use a clean, laundered, individual use towel after exiting the whirlpool.
Antimicrobial stewardship	Inappropriate use of antibiotics	Understand the risk of taking unnecessary antibiotics. Do not expect to receive antibiotics for viral illnesses.
Travel medicine and emerging infections	Crowding on planes, buses Tight living quarters Novel exposures	Discuss travel medicine requirements with team medical personnel prior to traveling abroad for an athletic event. Attend travel medicine clinic in order to reduce your risk of contracting an infectious disease while abroad.
Nonmedical wellness practices	Insufficient knowledge of infection risk associated with nonmedical wellness practices	Understand the risk of “alternative therapies” such as acupuncture, home IV therapy, cupping, and massage. Use facilities that have licensed practitioners and are inspected by the health department if you choose to engage in an alternative therapy and receive treatment outside of your athletic facility. Ensure that single-use instruments are used when engaging in a therapy (such as acupuncture, home IV therapy) that punctures the skin.
Medical care-involving procedures	Compromised skin Poor injection practices	Ask your provider if they are using aseptic techniques and “safe injection practices.” Observe the provider washing their hands and using a single-use needle and vial.
Surgical procedures	Compromised skin from the incision High rate of colonization with Staphylococcus aureus and MRSA	Discuss what symptoms might indicate an early infection at the surgical site with your athletic trainer and physician. Monitor surgical incision on a daily basis for symptoms of potential infection. If deemed necessary, follow decolonization protocols as instructed by your physician.
Other Athletes
Behavior	Risk	Recommendation
Direct contact	Transmission of germs through direct contact (skin to skin) with other athletes	Understand how and when direct transmission may occur during athletic participation and take necessary precautions. Practice consistent and frequent hand hygiene.
Shared equipment	Indirect transmission of germs through equipment or surfaces contaminated by other athletes	Do not share personal equipment that comes into contact with the skin, such as towels or razors. Make a habit of disinfecting shared equipment prior to use in the treatment room, training room, and weight room.
Crowding in shared spaces	Vaccine-preventable illnesses	Receive all required vaccinations. Make sure to receive influenza vaccination annually.
Facilities and Equipment
Location	Risk	Recommendation
Weight room	Contaminated surfaces and equipment Crowding	Use an alcohol-based hand sanitizer upon entering the weight room. Pick up a clean towel upon entering the weight room. Place “barriers” (such as a clean towel) over equipment. Wipe down equipment after each use.
Athletic training room	Contaminated surfaces and equipment Crowding	Ask your athletic trainer about cleaning and disinfection protocols in place in your athletic training environment. Ensure that treatment equipment is appropriately disinfected before and after your individual use. Disinfect cardiovascular, rehabilitation, and other training equipment after each use. Be sure that the electrostimulation pads you are using have not been used by another player. Reusable athletic equipment should be appropriately disinfected after it is used, visibly soiled, or otherwise dirty.
Visiting team locker room	See above. The same risks that you face at your home facilities are present at away facilities	Abide by your athletic trainer’s guidelines for infection prevention and follow the recommendations outlined above.

Team medical personnel have important roles to play and tasks to complete to keep you safe, but you play a critically important role in maintaining your own health and safety.

Personal and Social Behaviors

Your personal and social behaviors can increase your risk for infection. However, you have the direct ability to modify behavior, improve habits, and decrease risk. One key strategy highlighted throughout is hygiene.

A key strategy to prevent infection: hygiene

Player Knowledge and Education

Risk Lack of knowledge.

If you are unaware of your risk for athletically acquired infections, you may be missing opportunities to protect yourself and your teammates from these preventable infections.

Recommendation 1 Participate in preseason athlete health meetings and ask athletic trainers and medical staff for additional information about infection prevention and control protocols in your athletic facility.

Rationale: Athletes are at increased risk for infection for several reasons. Primarily, athletes are often in close quarters and have frequent, close contact with other athletes. Athletic activities often lead to skin abrasions, cuts, and scrapes. Finally, athletes often have inadequate access to clean equipment/facilities and/or simply don’t practice good hand and body hygiene. During just 1 day of training, you will be repeatedly exposed to these risks not only on the court, field, or mats but also in the athletic training room, weight room, and locker room.

You know the cliché—“knowledge is power.” Cliché or not, education is a critical and effective component of infection prevention. In preseason meetings, you should be educated about recognizing and preventing several types of infection, such as skin and soft-tissue infections. One such example, MRSA, is of particular importance. These infections occur commonly among athletes and may produce outbreaks or clusters of infection that consequently impact numerous players.¹

Recommendation 2 Recognize the signs and symptoms of skin infection and present these symptoms to your athletic trainer.

Rationale: You know your body better than anyone, and you know when something might be wrong. So, it’s important that you know of and remain vigilant for early signs of infection. Symptoms of an early infection include but are not limited to a skin lesion with:

Redness
Swelling
Warmth
Excessive pain
Pus or other drainage

These symptoms may also be accompanied by fever, chills, and generalized malaise. Notify your athletic trainer immediately if you develop any of these symptoms.

More specifically, present any concerning issues or symptoms to your athletic trainer immediately if they occur. We’ve spoken to hundreds of athletic trainers, and we know they agree: when in doubt, point it out. Proper diagnosis and prompt treatment could prevent these infections from becoming more severe. The earlier you receive treatment, the less likely the infection will cause serious problems.

Additionally, you should communicate with your athletic trainer about the infection prevention policies that are in place in your athletic facility. These may include but are not limited to protocols regarding hydrotherapy room usage, cut care, laundry services, and hand hygiene. Understanding and abiding by these policies can help you avoid preventable infections.

Recommendation 3 Notify your athletic trainer when you have vomiting and/or diarrhea.

Rationale: If you have vomiting AND diarrhea, you could potentially have norovirus. Norovirus is the most common cause of outbreaks of acute gastroenteritis in the United States. It is highly contagious and is easily spread from person to person and via aerosols, food, or contact with contaminated environmental surfaces.

Outbreaks among athletes have been documented. For instance, an outbreak of norovirus infections occurred during a football game between Duke and Florida State University. The original source of infection was thought to be turkey sandwiches in box lunches served to the Duke team 50 hours before the game. 50% of the team personnel became ill before and during the game. 11 Florida State players then developed norovirus infection after the game.² A similar team-to-opposing team transmission occurred in the National Basketball Association (NBA).

Wash your hands thoroughly with soap and water if norovirus is suspected. Norovirus is not inactivated by alcohol-based sanitizers.

Due to the highly contagious nature of norovirus, it is very important that you are transparent with your athletic trainer about your symptoms. Doing so could save all members of your team from missed game time. Your athletic trainers and athletic facility will use special
disinfection strategies when a case of norovirus has been identified. You should do the same. At home, wash your hands frequently and disinfect your bathroom with a bleach or hydrogen peroxide-containing disinfectant.

Recommendation 4 Recognize the signs of “athlete’s foot” and present these symptoms to your athletic trainer.

Rationale: Tinea pedis or “athlete’s foot” is a fungal infection of the skin, typically between the toes. Athlete’s foot can be easily diagnosed by its appearance, which your athletic trainer will be able to evaluate. Your athletic trainer will likely advise you to apply a topical antifungal cream for 4 weeks. Athlete’s foot should be treated for two reasons. First, the presence of athlete’s foot, and the resulting damage to the skin, can put you at risk for skin infection in the foot and lower leg. Second, athlete’s foot can be spread to other athletes. When an athlete has tinea pedis, the spore-like cells of the fungus are shed on the training floor. Other athletes in the facility can then acquire tinea pedis through contact with that training floor. If untreated, the infection could persist indefinitely.

Recommendation 5 Recognize the signs of herpes gladiatorum and present these symptoms to your athletic trainer. Know that you are at particularly increased risk for these infections in contact sports, such as wrestling, rugby, and football.

Rationale: Herpes gladiatorum is a viral skin infection caused by the herpes simplex virus (HSV). Most people are familiar with herpes-related cold sores, as almost two-thirds of adults have HSV. HSV is classified into two broad types, HSV-1 and HSV-2. Nearly all reported outbreaks of herpes gladiatorum involve HSV-1, the same virus responsible for nearly 80% of cold sores.

Since the virus gains entry to the body via small breaks in the skin, athletes involved in contact sports are at increased risk. While the majority of outbreaks have been described among wrestlers, transmission between rugby players has also been described (informally called “scrum pox”). The same mechanisms of transmission described above—frequent abrasions and skin-to-skin contact between athletes—put athletes at risk. Sometimes mistaken for other common skin infections, delayed diagnosis contributes to ongoing transmission.

Recommendation 6 Notify your athletic trainer if you develop flu-like symptoms.

Rationale: Flu-like symptoms typically include the sudden onset of fever, chills, myalgias, headache, cough, loss of appetite, and a generalized feeling of weakness. These symptoms can be caused by different viral infections, but influenza should be suspected during the “flu season,” especially when flu levels are high in your area. Your athletic trainer may want to have you tested for influenza and other respiratory viruses. If you test positive for influenza, you can be treated with oseltamivir to shorten the duration of the symptoms. As importantly, your athletic trainer can initiate a layered response to help prevent you from spreading the flu to other teammates.

Risk Poor team culture.

Recommendation 1 Become an infection prevention champion to improve the “culture” of infection prevention and accountability.

Rationale: As an athlete, you are well aware of how team culture affects performance, and likely, the final outcome of a game, match, or competition. Just as you, your teammates, and
coaches try to build a culture of athletic excellence, you can and need to create a “culture” of quality in infection prevention. Accountability is a key component of both your culture of athletic excellence and the culture of quality in infection prevention.

Who do you identify as a leader in your team? Are you the leader? Leaders play a critical role in developing team culture. In quality improvement initiatives, leaders are often labeled as “champions.” Infection prevention champions serve as role models for effective infection prevention practices and hold other members of the team accountable. In order to be an infection prevention champion, you must be familiar with specific infection prevention policies used at the facilities and integrate them into your daily routine. What can you do to lead the way?

Infection prevention champions serve as role models for effective infection prevention practices and hold other members of the team accountable.

Here is a list of suggested actions that will demonstrate to your teammates that you are committed to creating a safe environment and upholding a culture of quality:

Shower immediately after practice
Don’t use whirlpools with open wounds
Perform hand hygiene in the weight room
Get up-to-date with recommended vaccinations

By adhering to these recommendations, you can motivate and stimulate others to embrace and follow good infection prevention practices (Figure 2.2). Lead by example! You also can effectively reeducate and remind teammates who violate infection prevention principles by positively motivating them to change their behaviors. For example, teammates are less likely to enter a whirlpool with open wounds if they see you, a leader on your team, adhering to team-based protocols and good practices.

Figure 2.2 Infection prevention champions model behavior for other athletes.

Risk Poor hygiene.

As in any athletic endeavor, focusing on the fundamentals is critical to success. Hygiene is a fundamental component of health and one that you can directly control. This subsection includes specific strategies to help you improve and maintain your hygiene through hand washing, showering, and using appropriate strategies for hair removal, as necessary. You have a responsibility to yourself and your teammates to adhere to these strategies!

Hand Hygiene

Risk Factors Regular hand contact (skin to skin); hand cleanliness (or lack thereof).

Recommendation 1 Increase use of hand hygiene while in all athletic environments.

Recommendation 2 Locate and use alcohol-based hand hygiene dispensers throughout the facility.

Recommendation 3 Be an infection prevention champion by promoting hand hygiene.

Rationale: Skin-to-skin transmission is the primary method of transmission for most bacterial pathogens, such as MRSA, and viruses (Figure 2.3). These pathogens may temporarily be present on the hands of other athletes or athletic trainers. As a result, these pathogens are most commonly transmitted through direct contact. Since this type of interaction is universal, how do you eliminate this type of exposure? Frequent, consistent hand washing is your best strategy to stop the infection cycle (Figure 2.4).

Overall, hand hygiene is the #1 method for preventing transmission of germs and should be integrated frequently into your daily routine. Simply utilizing alcohol-based hand hygiene dispensers upon entering and exiting facilities can decrease your risk of infection and effectively position you as an infection prevention champion. Alcohol-based hand hygiene products are highly effective in reducing person-to-person transmission in pathogens such as influenza, the common cold, and MRSA.

Figure 2.3 Methods for microbe transmission between athletes.

Recommendation 4 Clean hands with soap and water instead of alcohol-based products after using the toilet, when visibly soiled, or when heavily contaminated with dirt, debris, body fluids, or blood.

Rationale: Alcohol-based hygiene products are not effective when hands are soiled with dirt or other materials such as oils, blood, or other body fluids.

Showering After Athletic Participation

Risk Factors Body cleanliness (or lack thereof). Body contact (skin to skin). Skin contact with contaminated items or surfaces.

Figure 2.4 Cycle of transmission and infection in athletes.

Athlete Connection

Consider this scene.

You finish a 3-hour practice at 6:00 PM and have an examination review session that starts at 6:30 PM. You rush off the field, into the training room to do a foam rolling session or ice bath, then into the locker room to return your uniform. No time for a shower! Finally, you’re off to the academic side of campus. Following the study session, you go to the dining hall, put in a few more hours at the library, and finally return to your dorm where you shower hours after your athletic participation.

During that time, you’ve had bacteria sitting on your skin that you acquired through interacting with other athletes during practice. Any cuts or scrapes may already be contaminated. In addition, you may have deposited those bacteria onto surfaces in the athletic training room, locker room, library, dining hall, and your dorm room.

Recommendation 1 Immediately shower after practice to decrease your risk of infection and bacterial transmission from player to player and from player to environment. Encourage your teammates to do the same.

Rationale: You will be exposed to MRSA and other pathogens during athletic participation. Humans are the natural reservoirs for MRSA, meaning that we are the agent by which the bacteria are spread and the source for MRSA in the environment. Showering after practice decreases the risk of MRSA infection because it removes the bacteria from the skin. As with hand hygiene, this intervention stops the infection cycle for you. More specifically, showering after practice can remove MRSA and other pathogens acquired during practice.

You will be exposed to MRSA and other pathogens during athletic participation.

Removal of these bacteria decreases risk of infection in two ways. First, with fewer bacteria present, the risk of infection in compromised skin is decreased in the short term. Second, removing bacteria will prevent long-term colonization on the skin. Colonization means that a person carries the bacteria on their skin without showing signs of infection. However, colonization increases the risk of infection in the long term. That is, the germ is present and ready to cause trouble when an opportunity occurs later on (eg, a subsequent scratch or cut).

Key Terms

Primary transmission: transmission occurs when there is direct skin-to-skin contact.

Athlete connection: primary transmission can occur during the skin-to-skin contact that happens when you tackle an opponent.

Secondary transmission: transmission occurs when there is interaction with a contaminated surface.

Athlete connection: secondary transmission can occur if you share athletic equipment without disinfecting it in between uses. You can acquire the bacteria from contaminated surfaces!

As above, showering decreases risks associated with new acquisition of a pathogen like MRSA. Showering will also decrease risks for athletes who are already colonized. A recent study showed that 13% of US collegiate athletes are colonized with MRSA without showing signs of infection.³ In other words, on a 50-member team, nearly 7 players are silently colonized
with MRSA. The study also demonstrated that players with MRSA colonization were 7.3 times more likely to experience a subsequent MRSA infection. In comparison, only 2% of people in the general American public carry the bacteria on their skin. So, to relate to the hypothetical team we described above, that means that out of 50 people, only 1 person would be silently colonized with MRSA. Showering after practice improves skin health and decreases the risk that MRSA (or some other germ) will enter a skin abrasion, even if the MRSA is already on the skin.

Finally, showering after practice will decrease the risk of secondary transmission to your teammates both by direct contact (primary transmission) and through contamination of the environment (secondary transmission). By reducing the amount of MRSA on the skin, you will reduce the amount of MRSA in the environment. This intervention will reduce contamination of a training facility and athletic environment, ultimately protecting other athletes from contamination as well.

REMEMBER—contact with MRSA is inevitable in team settings. MRSA exposure increases the risk of subsequent infection as well, particularly in the setting of skin abrasions and cuts acquired through athletic participation. Simple interventions can help you decrease this risk.

Recommendation 2 Do not use bar soap present in the shower. Use soap dispensers that utilize prepackaged liquid soap in the shower.

Rationale: Bar soap has previously been implicated as a potential source of MRSA transmission. Specifically, sharing bar soap was associated with MRSA infections during an outbreak among football players and in an outbreak in a prison.⁴

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