Information for clinicians
The CDC encourages clinicians to consider MRSA in the differential diagnosis of skin and soft tissue infections (SSTIs) compatible with S. aureus infections, especially those that are purulent (fluctuant or palpable fluid-filled cavity, yellow or white center, central point or “head,” draining pus, or possible to aspirate pus with needle or syringe). A patient’s presenting complaint of “spider bite” should raise suspicion of an S. aureus infection.
Recent data suggest that MRSA as a cause of skin infections in the general community remains at high probability. The spectrum of disease caused by MRSA appears to be similar to that of Staphylococcus aureus in the community. SSTIs, specifically furuncles (abscessed hair follicles or “boils”), carbuncles (coalesced masses of furuncles), and abscesses, are the most frequently reported clinical manifestations. The role of MRSA in cellulitis without abscess or purulent drainage is less clear since cultures are rarely obtained.
In the community, incision and drainage remains the primary therapy for these purulent skin infections. Empiric antimicrobial coverage for MRSA may be warranted in addition to incision and drainage based on clinical assessment (e.g., presence of systemic symptoms, severe local symptoms, immune suppression, extremes of patient age, infections in a difficult to drain area, or lack of response to incision and drainage alone).
Antibiotic treatment, if indicated, should be guided by the susceptibility profile of the organism. Obtaining specimens for culture and susceptibility testing is useful to guide therapy, particularly for those with more severe infections and those who fail to respond adequately to initial management.
MRSA skin infections can develop into more serious infections. It is important to discuss a follow-up plan with your patients in case they develop systemic symptoms or worsening local symptoms, or if symptoms do not improve within 48 hours.
Information and Advice about MRSA for School and Daycare Officials
5 Steps to Take if You Think a Student Might Have a Skin Infection
The decision to close a school for any communicable disease should be made by school officials in consultation with local and/or state public health officials. However, in most cases, it is not necessary to close schools because of an MRSA infection in a student. It is important to note that MRSA transmission can be prevented by simple measures such as hand hygiene and covering infections.
Closing to Clean or Disinfect
In general, it is not necessary to close entire schools to “disinfect” them when MRSA infections occur. MRSA skin infections are transmitted primarily by skin-to-skin contact and by contact with surfaces that have come into contact with someone else’s infection. Covering infections will greatly reduce the risks of surfaces becoming contaminated with MRSA.
School Notifications to the School Community following an MRSA Infection
Staphylococcus (staph) bacteria, including MRSA, have been and remain a common cause of skin infections. Usually, it should not be necessary to inform the entire school community about a single MRSA infection. When an MRSA infection occurs within the school population, the school clinician should determine, based on medical judgment, whether some or all students, parents, and staff should be notified. If medical personnel are not available at the school, consultation with the local public health authorities should be used to guide this decision. Repeat cases, spread to other students, or complex cases should be reported to the health department for consultation.
Notifications to the School that a Student has an MRSA Infection
Most schools require that any communicable disease be reported to the student’s teacher or administration. Consult with your school about its policy.
Excluding Students with MRSA Infections from School
- Unless directed by a physician, students with MRSA infections should not be excluded from attending school.
- Exclusion from school and sports activities should be reserved for those with wound drainage (“pus”) that cannot be covered and contained with a clean, dry bandage and for those who cannot maintain good personal hygiene.
Practical Advice for Teachers
- If you observe children with open draining wounds or infections, refer the child to the school nurse. If a nurse is not available, call the child’s guardian and refer them to seek medical attention.
- Enforce hand hygiene with soap and water or alcohol-based hand sanitizers (if available) before eating and after using the bathroom.
Advice for School Health Personnel
- Students with skin infections may need to be referred to a licensed health care provider for diagnosis and treatment. School health personnel should notify parents/guardians when possible skin infections are detected.
- Use standard precautions (e.g., hand hygiene before and after contact, wearing gloves) when caring for nonintact skin or potential infections.
- Use barriers such as gowns, masks, and eye protection if splashing of body fluids is anticipated.
Coaches, Athletic Directors, and Team Healthcare Providers
5 Steps to Take if You Think an Athlete Might Have a Skin Infection
- Refer athletes with possible infections to a healthcare provider such as team physician, athletic trainer, school nurse, or primary care doctor.
- If the athlete is younger than 18 years old, notify parents/guardians about the possible infection.
- Instruct the athletes with a potential or confirmed infection or open wound to avoid using whirlpools or therapy pools not cleaned between athletes and other common-use water facilities like swimming pools until infections and wounds are healed.
- Review and implement cleaning and disinfecting guidance: Environmental Cleaning & Disinfecting for MRSA.
- Educate athletes about ways to prevent spreading the infection.
- Refer athletes to the Information & Advice for Athletes page.
- Make sure supplies are available to comply with prevention measures (e.g., soap in shower and at sinks, bandages for covering wounds, hand hygiene such as alcohol-based hand rubs).
- Make sure athletes:
- keep wounds covered and contained
- shower immediately after participation
- shower before using whirlpools
- wash and dry uniforms after each use
- report possible infections to coach, athletic trainer, school nurse, other healthcare providers, or parents.
- Using the criteria above, consider excluding the athlete from participation until evaluated by a healthcare provider.
Recommended Practices for Treating Athletes with Skin Infections
- Use Standard Precautions, including hand hygiene before and after contact and after removing gloves, when caring for non-intact skin or possible infections.
- If hands are not visibly dirty and no sinks are available for hand washing (for example, while on the field) alcohol-based hand rubs and sanitizers can be used to improve hand hygiene.
- Ensure infected wounds on athletes are properly covered.
- Encourage athletes to cover acute, non-infected wounds (e.g., abrasions, blisters, lacerations) until healed to prevent infection.
Excluding Athletes with MRSA Infections from Participation
- If sport-specific rules do not exist, in general, athletes should be excluded if wounds cannot be properly covered during participation.
- The term “properly covered” means that the skin infection is covered by a securely attached bandage or dressing that will contain all drainage and will remain intact throughout the activity. If wounds can be properly covered, good hygiene measures should be stressed to the athlete such as performing hand hygiene before and after changing bandages and throwing used bandages in the trash.
- A healthcare provider might exclude an athlete if the activity poses a risk to the health of the infected athlete (such as injury to the infected area), even though the infection can be properly covered.
- Athletes with active infections or open wounds should not use whirlpools or therapy pools not cleaned between athletes and other common-use water facilities like swimming pools until infections and wounds are healed.