What are the guidelines for returning to sports after a Staphylococcus aureus infection?

Guidelines for Return to Sports After Staphylococcus aureus Infection

Athletes with Staphylococcus aureus infections should not return to sports until they have completed at least 72 hours of appropriate antibiotic therapy, have no new skin lesions for at least 48 hours, and have no moist, exudative, or draining lesions at the time of practice or competition. 1

Return-to-Play Criteria

Minimum Requirements Before Return

• Completion of 72 hours of appropriate antibiotic therapy with visible signs of lesion resolution 1
• No new skin lesions for at least 48 hours before competition 1
• No moist, exudative, or draining lesions at time of practice or competition 1
• All existing lesions must be dry with well-adhering scabs 1, 2
• Active purulent lesions cannot be covered to allow participation 1, 2

Sport-Specific Guidelines

• NCAA, NFHS, and NATA all specify similar criteria for return to play after S. aureus infections 1
• For athletes with scabbed and/or dry lesions only, these may be covered with bio-occlusive dressing for return to practice or competition 1, 2
• Gram stain of exudate from questionable lesions may be required for clearance, particularly in NCAA settings 1

Treatment Considerations

Antibiotic Selection

• For methicillin-susceptible S. aureus (MSSA), appropriate antibiotics include cephalexin or dicloxacillin 1
• For methicillin-resistant S. aureus (MRSA), treatment options include:
  • Trimethoprim-sulfamethoxazole 1, 2
  • Clindamycin (if the strain is susceptible) 1, 2
  • Doxycycline (not for children under 8 years) 1, 2
  • For severe infections: intravenous vancomycin, linezolid, daptomycin, or telavancin 1

Duration of Therapy

• 7-14 days of antibiotic therapy is typically recommended, individualized based on clinical response 1
• Minimum of 72 hours of therapy before return to sports 1

Prevention of Recurrence and Outbreaks

Hygiene Measures

• Maintain good personal hygiene with regular bathing and handwashing 1, 3
• Keep draining wounds covered with clean, dry bandages 1
• Avoid sharing personal items (razors, towels, clothing) 1, 3, 4
• Clean shared equipment regularly with appropriate disinfectants 3, 5

Environmental Considerations

• Focus cleaning on high-touch surfaces that contact bare skin 1
• Use commercially available cleaners according to label instructions 1
• Properly disinfect whirlpools and other shared facilities 5

Decolonization Strategies

• For recurrent infections or ongoing transmission among team members, consider:
  • Nasal decolonization with mupirocin twice daily for 5-10 days 1
  • Topical body decolonization with chlorhexidine or dilute bleach baths 1
  • Screening of players for carriage during outbreaks 1

Special Considerations for Athletes

Risk Factors for S. aureus Infections in Athletes

• Direct skin-to-skin contact during practice and competition 4, 5
• Skin breaks from "turf burns" or other trauma 1, 5
• Sharing of equipment, towels, or other personal items 3, 4
• Cosmetic body shaving (increases risk by 6.1 times) 5
• Certain player positions with frequent person-to-person contact (cornerbacks, wide receivers) 5

Common Pitfalls in Management

• Failure to obtain cultures before starting antibiotics, leading to inappropriate treatment 4
• Empiric treatment for MSSA when MRSA is present, resulting in treatment failure 4
• Allowing athletes to return before completing minimum 72 hours of antibiotics 1
• Attempting to cover active purulent lesions rather than excluding the athlete 1, 2
• Inadequate disinfection of shared facilities and equipment 5

By following these evidence-based guidelines, sports medicine professionals can effectively manage S. aureus infections in athletes while minimizing the risk of transmission and recurrence.