Staph Infections in Hockey

September 1, 2020

Hockey-equipment-in-dirty-locker-room

Athletes work hard, play hard, and their training facilities and locker rooms often show it. One might expect to see sweaty equipment, damp towels, and scattered personal hygiene products throughout. These are ideal environments for bacterial growth which can put athletes at increased risk of infection by potentially dangerous pathogens, like Staphylococcus aureus.

Staphylococcus aureus, or “staph,” is one of the most common types of bacteria that lives on the skin and inside of  the nose. About 30% of the general public are ‘colonized’ with nasal staph, meaning that they are asymptomatically carrying the bacteria inside their nose. In a healthy person, staph living in the nose or on the skin is kept in check by the  system1. But if it gets under the skin or into the bloodstream, serious, even life-threatening infections can occur.

Staph can be transmitted directly through skin-to-skin contact with someone who is carrying it, or indirectly by coming into contact with a contaminated surface. Athletes are far more likely to be colonized with staph in fact, recent studies have found staph colonization in approximately 50% of college athletes.2,3 Participating in contact sports increases the risk for carrying staph by 61% compared to athletes who participate in non-contact sports4.

Methicillin-resistant Staphylococcus aureus (MRSA) is a particularly dangerous type of staph infection that is a serious concern for athletes. MRSA colonization occurs in about 1% of the general population, but athletes have significantly higher MRSA colonization rates, with one study finding MRSA colonization in up to 29% of college student athletes.2,5 Importantly, MRSA colonization in athletes was often intermittent and correlated with the athletic season, suggesting that participating in sports significantly increases the risk of MRSA colonization.2

Staph and MRSA are commonly found on surfaces in athletic facilities and locker rooms. One recent study tested several athletic facilities and found that an alarming 46.7% of surfaces tested positive for MRSA.6 A similar study found MRSA on 36.3% of athletic facility surfaces.7

What Are Staph Infections?

Staph is a common type of bacteria that people often carry asymptomatically. It can colonize the inside of the nose (the nasal vestibule) and the surface of the skin. The majority of staph infections can be traced back to bacteria living inside the nose of the infected person8. Staph can also be transmitted through hand-to-nose contact or contaminated droplets (e.g. someone sneezing).

When staph gets into broken skin or enters the bloodstream, it may lead to an infection9. Staph skin infections usually look like pimples, boils, or abscesses, and the skin surrounding the site is usually red, swollen, and tender. Even tiny skin abrasions can become infected.

Staph bloodstream infections are far more dangerous. A bloodstream infection is called sepsis, and if it’s not treated quickly, it can be fatal. Other types of infection that staph can cause include bone and joint infections, pneumonia, and a heart infection called endocarditis9. These infections can lead to severe outcomes, including amputations, long-term disability, and even death.

Why are Hockey Players Prone to Staph Infections?

Gyms and locker rooms are notorious for having staph contamination. Staph bacteria can live on fabric for up to 3 weeks and on polyethylene plastic for several months.10 Athletic equipment, weights, towels, clothing, and personal hygiene products can all be sources of staph if they are not disinfected between uses. Countertops, lockers, showers, and the floor are all potential sources of staph.

Hockey is a contact sport, and during a game, elbows and knees can take a lot of damage. Many of hockey players are cut from skates, pucks and sticks. They also get bruises and cuts from blocking shots are indirectly getting hit by a pass or shot. These cuts can happen on hands, wrists, arms, neck, ankles, feet and legs.

Bursae are fluid-filled sacs that cushion joints, and they can rupture with enough acute or repetitive trauma. Bursitis is a “sterile” inflammation of the bursa, meaning that bacteria or other foreign material are not contributing to the inflammation. Septic bursitis occurs when staph gets into the ruptured bursa and causes an infection. Bursitis is common among hockey players, and staph causes 80–90% of cases of septic bursitis.11

Even staph from someone’s own body can infect them; in fact, self-infection is a leading cause of staph skin infections.12 A hockey player with staph bacteria in their nose might touch it before a game, then contaminate the inside of their glove. As long as there are no cuts or abrasions on their hands, they probably won’t get an infection. However, if they use contaminated gloves when they have cuts or abrasions on their hands, they are at increased risk for an infection that originated from their own staph colony.

What Measures Can Hockey Players Take to Prevent Staph Infections?

There are several ways that hockey players can minimize their risk for getting a staph infection:

●      Do not share equipment, clothing, or towels

●      Disinfect all gear between uses

●      Shower soon after playing, and don’t use bar soap in a locker room

●      Do not leave damp equipment in a bag

●      Keep cuts clean, dry, and covered

Coaches and facilities managers have a role too:

●      Locker rooms and equipment should be disinfected daily

●      Alcohol-based sanitizers should be readily available for both hand and nose decolonization

●      Disinfectant should be next to every machine and weight set in the gym

●      Clean towels should be available

Alcohol-based nasal decolonization

Alcohol-based nasal decolonization is an innovative infection control strategy.13 Rather than targeting staph after it has been transmitted from a carrier, nasal decolonization targets it at its source. Staph colonies often colonize the nose, so it is easily spread after hand-to-nose contact or through sneezes. As staph is a resilient bacteria that can survive for weeks on clothing or plastic, one of the best ways to minimize transmission is to prevent contamination.

The goal of nasal decolonization is to reduce staph levels in high-risk environments to protect team members and staff from infection. Infection prevention programs should include appropriate strategies to address staph on the skin, on equipment and importantly, in the nose. For a hockey team, this would mean that everyone who goes into the locker room, gym, or onto the ice would have access to an alcohol based nasal antiseptic to decolonize staph in their nose, effectively reducing the chance that the bacteria could be transferred to someone or something else.

Clinical studies in hospitals have consistently shown that implementing nasal decolonization protocols significantly reduces the amount of staph (including MRSA) that is found in the environment.13,14 Used in a locker room setting, nasal decolonization may significantly reduce the potential for staph contamination and transmission, resulting in fewer staph infections and more time on the ice.

hockey-players-colliding

Examples of Hockey Players Affected by Staph Infections

Many professional hockey players have been sidelined by staph infections:

●      Evander Kane (now with the San Jose Sharks) had to sit out several games after a staph infection in his hand left him unable to play for the Winnipeg Jets15

●      Patrick Sieloff (now with the Syracuse Crunch) was unable to play for most of the Calgary Flames’ 2013-2014 season due to a serious staph infection16

●      Joe Thornton (now an alternate captain for the San Jose Sharks) got a serious staph infection from his elbow pad while playing for the Boston Bruins; Thornton went on to be awarded the NHL’s Hart Memorial Trophy for most valuable player and was named an NHL First-Team All-Star in 200617,18

●      Mikael Renberg (retired) of the Toronto Maple Leafs nearly lost his hand to a staph infection after a blister broke open when he was lacing up his skates17

●      Jack Hillen (retired) of the Washington Capitals was on antibiotics for a month due to a staph infection in his knee18

Staph infections don’t just affect professional players. 9-year-old  hockey player Jack Dulson died from staph-related complications. His name lives on through the Jack Dulson Memorial Fund and the Jack Dulson Hockey Academy.20

Summary

Hockey players are often well-known for their grit, but staph infections can sideline even the toughest players. Athletes who participate in contact sports, including hockey, are at higher risk for staph infections than those in non-contact sports. While minor staph skin infections rarely require antibiotics or serious medical treatment, soft tissue infections in the muscle or joint can become serious enough to require amputation. Staph infections in the bloodstream are critical and can be life-threatening.

It is important that hockey players take precautions to protect themselves  and their teammates from staph infections. Disinfecting all gear between uses, not sharing equipment or towels, and practicing good hygiene to include nasal decolonization, can help players avoid infection.

References

1. Sakr, A., et al. (2018). Staphylococcus aureus Nasal Colonization: An Update on Mechanisms, Epidemiology, Risk Factors, and Subsequent Infections. Frontiers in Microbiology. doi:10.3389/fmicb.2018.02419

2. Jiménez-Truque, N., et al. (2016). Longitudinal Assessment of Colonization With Staphylococcus aureus in Healthy Collegiate Athletes. Journal of the Pediatric Infectious Diseases Society, 5(2):105–113. https://doi.org/10.1093/jpids/piu108

3. Mascaro, V., Capano, M. S., Iona, T., Nobile, C., Ammendolia, A., & Pavia, M. (2019). Prevalence of Staphylococcus aureus carriage and pattern of antibiotic resistance, including methicillin resistance, among contact sport athletes in Italy. Infection and Drug Resistance, 12, 1161–1170. doi:10.2147/IDR.S195749

4. Jiménez-Truque, N., et al. (2017). Association Between Contact Sports and Colonization with Staphylococcus aureus in a Prospective Cohort of Collegiate Athletes. Sports Medicine, 47(5), 1011–1019. doi:10.1007/s40279-016-0618-6

5. Kyoung-Bok, M., et al. (2019). Nasal colonization with methicillin-resistant Staphylococcus aureus associated with elevated homocysteine levels in the general US adults. Medicine, 98(18):e15499. doi:10.1097/MD.0000000000015499

6. Montgomery, K., et al. (2009). Assessment of Athletic Health Care Facility Surfaces for MRSA in the Secondary School Setting. Journal of Environmental Health 72(6):8-11. PMID: 20104827

7. Dalman, M., et al. (2019). Characterizing the molecular epidemiology of Staphylococcus aureus across and within fitness facility types. BMC Infectious Diseases 19(69). https://doi.org/10.1186/s12879-019-3699-7

8. von Eiff, et al. (2001). Nasal Carriage as a Source of Staphylococcus aureus Bacteremia. New England Journal of Medicine 344:11-16. DOI: 10.1056/NEJM200101043440102

9. U.S. National Library of Medicine. (2019). Staphylococcal Infections. MedlinePlus. Retrieved February 8, 2020.

10. Neely, A. N., & Maley, M. P. (2000). Survival of enterococci and staphylococci on hospital fabrics and plastic. Journal of clinical microbiology, 38(2), 724–726.

11. Tuff, T., & Chrobak, K. (2016). Septic olecranon and prepatellar bursitis in hockey players: a report of three cases. The Journal of the Canadian Chiropractic Association, 60(4), 305–310. PMID: 28065991

12. Coates, T., Bax, R., & Coates, A. (2009). Nasal decolonization of Staphylococcus aureus with mupirocin: strengths, weaknesses and future prospects. Journal of Antimicrobial Chemotherapy. doi:10.1093/jac/dkp159

13. Steed, L. L., et al. (2014). Reduction of nasal Staphylococcus aureus carriage in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antiseptic. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2014.04.008

14. Arden, S. (2019). 567-Does Universal Nasal Decolonization with an Alcohol-Based Nasal Antiseptic Reduce Infection Risk and Cost? Poster presented at: IDWeek; 2019 October 2-6; Washington D.C.

15. Penton, K. (2014). Evander Kane out of Jets' lineup until after Olympic break. Winnipeg Sun. Retrieved February 8, 2020.

16. Tucker, C. (2014). Flames prospect Sieloff continues comeback from staph infection. NBC Sports. Accessed February 8, 2020.

17. King, M. (2008). Smells like success. Montreal Gazette. Retrieved February 8, 2020.

18. McKeon, R. (2006). NHL AWARDS / 'Humbled' Thornton named MVP. SF Gate. Retrieved February 8, 2020.

19. National Hockey League. (2014). Hard-luck Hillen ‘100 percent’ after staph infection. NHL Stories Blog. Retrieved February 8, 2020.

20. Jack Dulson Memorial Fund. (n.d.). Get Involved & Help. Retrieved February 8, 2020.



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