What is the recommended treatment for a 24-year-old male with a bacterial infection from a wrestling mat, present for 6 days?

Treatment of Wrestling Mat-Acquired Bacterial Skin Infection at 6 Days

For a 24-year-old male wrestler with a 6-day bacterial skin infection, initiate incision and drainage if an abscess is present, combined with oral antibiotics covering community-acquired MRSA (CA-MRSA): trimethoprim-sulfamethoxazole, doxycycline, or clindamycin for 7-10 days, and exclude from wrestling until completing 72 hours of antibiotics with no new lesions for 48 hours and all lesions dry with adherent crusts. 1, 2

Initial Assessment and Diagnosis

Wrestling environments have extremely high rates of MRSA contamination—100% of tested high school wrestling facilities showed MRSA-positive surfaces in environmental sampling 3. At 6 days duration, this infection requires aggressive management as it has already persisted beyond the typical early intervention window.

Key Clinical Features to Identify

The infection likely presents as one of these patterns based on wrestling-associated bacterial infections 4:

• Abscess formation: Tender, erythematous, fluctuant lesions with surrounding cellulitis, most commonly in axillary regions, buttocks, or thighs 4
• Impetigo: Honey-crusted lesions or bullous lesions with weeping drainage 1, 2
• Cellulitis: Diffuse erythema, warmth, and induration without discrete abscess 1

Obtain bacterial culture from any drainage or lesion to confirm MRSA and determine antibiotic susceptibilities 1, 4. This is critical as empiric treatment failures are common when MRSA is not covered initially 4.

Immediate Treatment Protocol

Surgical Management

If an abscess is present, perform incision and drainage immediately—this is the primary treatment and antibiotics are adjunctive 1. Simple drainage alone may be sufficient for small, well-circumscribed abscesses without significant surrounding cellulitis 1.

Antibiotic Selection

Since CA-MRSA is the predominant pathogen in wrestling-associated infections 4, 3, empiric coverage must include MRSA-active agents:

First-line oral options (choose one) 1, 2:

• Trimethoprim-sulfamethoxazole (TMP-SMX): Highly effective with excellent MRSA susceptibility rates 4, 5
• Doxycycline: Can be used safely for <2 weeks duration even in younger patients 1, with high clinical cure rates 5
• Clindamycin: Effective if local susceptibility confirmed, though resistance rates vary (5-18% depending on region) 1, 4

Duration: 7-10 days of therapy, though some sources suggest continuing until clinical improvement with fever resolution for 48-72 hours 1

Important Caveat on TMP-SMX

Do not use TMP-SMX as monotherapy if cellulitis without abscess is present, as it lacks reliable activity against Group A Streptococcus, which causes diffuse cellulitis 1. In pure cellulitis cases, add a beta-lactam or use an alternative agent.

Treatment Failures

The infection has persisted for 6 days, suggesting either:

• Inadequate initial treatment (common if MRSA not covered) 4
• Need for drainage if abscess present
• Possible deeper infection requiring imaging

If the patient was already on antibiotics that failed, switch to a different MRSA-active agent based on culture results 4. All wrestling-associated MRSA isolates in published series showed susceptibility to vancomycin, TMP-SMX, and clindamycin 4.

Return-to-Wrestling Criteria

The athlete must meet ALL of the following before returning to wrestling 2, 6:

1. Completed 72 hours of appropriate antibiotic therapy 2, 6
2. No new skin lesions for at least 48 hours 2, 6
3. No moist, weeping, or draining lesions present 2, 6
4. All lesions must be dry with well-adhering scabs/crusts 2, 6

These criteria are consistent across the American Academy of Pediatrics, NCAA, and National Federation of State High School Associations 2, 6.

Common Pitfall to Avoid

Active purulent lesions cannot be covered with dressings to allow participation—the athlete must be completely excluded until properly treated and meeting all return criteria 2, 6. Premature return is a major source of team outbreaks 1, 2.

Prevention of Team Spread

Given the 100% contamination rate of wrestling environments 3, implement these measures immediately:

• Screen all team members for skin lesions before each practice 1, 2
• Decontaminate all wrestling mats and shared equipment with appropriate disinfectants 1, 3
• Prohibit sharing of towels, razors, or personal items 1, 4
• Enforce immediate showering after practice with soap and water 1, 4
• Consider nasal mupirocin decolonization (twice daily for 5-7 days) if outbreak conditions exist, though resistance can develop 1

Monitoring and Follow-Up

Re-evaluate in 48-72 hours to assess treatment response 1. If no improvement or worsening occurs:

• Verify antibiotic compliance and correct agent selection
• Consider imaging (ultrasound, CT, or MRI) to identify deeper abscess or necrotizing infection 1
• Reassess need for additional drainage 1
• Consider intravenous antibiotics if systemic signs present 1