Infectious Disease and the Athlete by alicejenny

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									   Infectious Disease
    and the Athlete
  Diagnosis, Treatment and Return to Play
November 2011




         Kevin deWeber, MD, FAAFP, FACSM
  Director, Primary Care Sports Medicine Fellowship
                       USUHS
 Infections in Athletes - AIS Study
 98% of college athletes had >=1 illness
  during winter 2-month period
 246/588 visits for medical problems
     URI  most common
     chest infection
     viral syndrome
     Gastroenteritis
     Asthma/allergy
     Skin problems
     Fatigue
     Otitis externa
              Exercise and Immunity

   Immediate                       Long   term
       leukocyte count                immune   system
                                        enhancement
       leukocyte function              (moderate)
       CD4/CD8                        ? natural killer cell
                                        number (intense)
       secretory immunity             ? antibody levels
       antibody concentrations         (intense)

       natural killer cell function (recovery)
     Infections and Exercise Capacity

   Fever
     forevery degree above 37C
      O2 consumption 13%
     promotes dehydration
     coordination/concentration
     endurance
     strength
         Exercise and Infection Risk (at least for URIs)

                 Above average
Infection Risk




                    Average




                 Below Average


                                 Sedentary            Moderate              Very high

                                               Exercise Intensity

                        From Fields and Fricker, Medical Problems in Athletes, p. 8.
                Case study
           Durakovic, Coll Antropol 2010

 17 yo professional soccer player
 Suppurative tonsillitis
 Sudden death during play; resuscitation
  unsuccessful
 Cause of death: myopericarditis
                  Myocarditis


 Myocarditiscauses 6% of sudden cardiac death in
  young athletes (<35)
 However…
   no direct evidence that exercise during a viral infection
    increases the likelihood of myocarditis in humans
   Fear of this should not limit RTP
          Myocarditis - Causes

 Viral
   Coxsackie   B most common
   Exertionincreases viral replication rates
    and severity of morbidity associated with
    myocarditis in murine models infected
    with Coxsackie virus
           rickettsial, mycotic
 Bacterial,
 Drugs (cocaine)
Myocarditis – Clinical Presentation
       Chest pain
       Exertional dyspnea
       Fatigue
       Recent myalgias
       Syncope
       Palpitations
       Tachyarrhythmias
       Acte heart failure (HF)
Infectious Myocarditis - Diagnosis

    WBC
    ESR
    Cardiac enzymes
   Serology
   EKG nonspecific
       ST-T wave changes
 Echocardiogram
 ? Endomyocardial bx
Myocarditis - Return to Activity

   36th Bethesda Conference 2005
     about    6 month convalescence
     Criteria   for return to activity:
        normal   echo or radionuclude scan
        no   arrhythmias on Holter & GXT
        Serum    markers of inflam & HF resolved
        Normal   EKG
                Acute Pericarditis
   Etiology:
          bacterial,
     Viral,
      mycoplasma,
      mycobacterial
 Classic history: CP
  worse lying down,
  better sitting up
 EKG: ST elevation
  common
    Pericarditis - Return to Play

 No competitive sports during acute
  phase
 RTP criteria:
     No evidence of active disease
     Normal echo
     Serum markers of inflam normal
     No symptoms
   No chronic restrictive disease
    Upper Respiratory Tract Symptoms
   Wide differential diagnosis
     URI
     Vasomotor rhinitis
     Allergy
     EBV infection
     Asthma/EIB
     Otitis media
     Eustacian tube dysfunction
     Pharyngitis
     Sinusitis
     GERD
                    URI
   Most common infection
     >50%   of acute illnesses
 3-4/year per person
 >200 viruses/strains
                   URI - Treatment Options
         “Likely to be benficial” per BMJ Clinical Evidence

   Decongestants                        Antihistamines
       Allowed by NCAA,USADA                allowed by NCAA, USADA
            Except ephedrine
                                             Caution w/ sedating meds
       Sympathomimetic effects
            pulse and BP
              palpitations
            insomnia (or insomnia)
            dizziness
     URI – Other Treatment Options

   “Unknown effectiveness”  “Unlikely to be
      Analgesics, NSAIDs
                              beneficial”
                                    Vitamin C
       Echinacea
                                    Caution to elite athletes:
       Steam inhalation             contaminants
       Zinc                    “Likely to be Ineffective
                                 or Harmful”
                                    Antibiotics
                       URI - Return to Play
                          “Neck Check”
   If symptoms only Neck or above
       exercise x 10 min.
            if worse, stop
            if not worse, may RTP
       Hygiene to prevent spread
   If symptoms BELOW NECK or SYSTEMIC (eg cough,
    CP, F/C, myalgia)
            rest until those sxs are resolved
            Gradual RTP: 1-2d moderate exercise per day of rest
              Acute Pharyngitis
   Viral
     EBV,   etc.
   Bacterial
     Group  A Strep
     Mycoplasma
     Other (GC)
   Pharyngitis - Diagnosis
Centor   criteria
 history  of fever
 anterior cervical adenopathy
 tonsillar exudates
 absence of a cough
Rapid Strep testing
Culture
       Pharyngitis - Management
   Centor 0-1:
     No testing
     Non-antibiotic tx

   Centor of 2-4:
     Rapid Strep testing
     Treat positives w/ abx
     Cultures negatives

   Centor 4: consider empiric abx w/o testing
    Pharyngitis – Other treatments
 NSAIDs, acetaminophen: helpful
 Corticosteroids: trade-off between benefit
  and harm
     Reduced  severity of pain
     Adverse effects
     Consider single-dose
“But I’m Special! I’m an Elite Athlete!”

    Education is important
      Usually viral
      Side-efx of abx
         Nausea,   rash, vaginitis, headache
         MRSA

    Consider empiric antibiotics if important
     competition upcoming soon
      Abx reduce proportion of people w/ sxs at 3
       days post-tx (BMJ); NNT = 6
         Mononucleosis Pharyngitis
 30% coexistent w/
  GABHS pharyngitis
 Posterior cervical
  adenopathy
       +/- inguinal/axillary
 Exudates, palatal
  petechiae common               If suspected,
 Other findings:                 WITHHOLD FROM
       Splenomegaly
                                  CONPETITION until
                                  ruled out
       Rash w/ amox
       Rare neurologic          Diagnosis:
        complications                  Monospot
                                       EBV titers
    Mononucleosis and Splenomegaly

 50% - 100% of infected pts
 Peaks week 2-3
 Exam with poor sensitivity
 Imaging UNRELIABLE to eval size
 Splenic rupture
     0.1- 0.2%
     Almost all in first 3 weeks of illness
     50% were non-traumatic
Mononucleosis - Other Complications

   Neurologic (Guillain-
                                Hemolytic-Uremic
    Barre Syndrome,
    meningitis)                  Syndrome
   Hematologic (DIC,           Renal
    aplastic anemia)            Ophthalmologic
   Psychiatric                 GU
   Respiratory (tonsillar      Rheumatoligic
    enlargement)
                                Dermatologic
   Cardiac
                                Infectious
   Gastrointestinal
         Mononucleosis - Treatment

 REST
 Analgesics, saltwater gargles
 Fluids, hydration
 No proven benefit from acyclovir
       Meta-analysis, Scand J Infect Dis 1999
   Corticosteroids of marginal benefit
    ? Indications: severe pharyngitis, hepatitis,
      myocarditis, hemolytic anemia
     Decreased symptoms w/in 12 hrs, for 2-4 days
       Cochrane review 2006
    Mononucleosis - Return to Play

   Day 1-20: No physical activity
   Days 21-28 (if asympt): Gradual return to NON-
    contact activity
       Individualized based on clinical progress
   Return to CONTACT activity and “Valsalva
    sports” is controversial
       Rare splenic ruptures out to 7 weeks
       Educate athletes/parents/staff
       Reasonable to allow if asymptomatic, well-hydrated,
        appropriately fit
        Evidence-based review, Clin J Sports Med 2008
                          Acute Sinusitis
   “Likely to be beneficial”:
       Intra-nasal Corticosteroids
       Antibiotics--in radiologically confirmed sinusitis
            macrolide or cephalosporin > amox or amox/clav
            3-5 days as good as longer course
   “Unknown effectiveness”:
       Decongestants, antihistamines
       Saline washes, steam inhalation
   “Unlikely to be beneficial”:
       Antibiotics in clinically diagnosed acute sinusitis
   Return to play
       neck check
       no SCUBA until completely resolved
                                                   Diagnosis assisted with
                 Otitis Media                      pneumatic otoscopy or
                                                   tympanometry



   Treatment
     +/-antibiotics
     Analgesics (oral, topical)
   Return to play
     neckcheck
     No SCUBA or flying until TM mobility normal
          TM rupture may occur with rapid changes in atmospheric
           pressure. Similar fluctuations in pressure can occur
           underwater, with depths as shallow as 4 feet
             Tympanostomy Tubes
 Okay to swim
 No diving
 No ear plugs needed
     No plugs: 16% infection
     Plugs: 30% infection
     No swimming: 30% infection
         Prospective study in Lyringoscope 1987
   Otorrhea?
       Topical Floxin
           Otitis Externa
   “Beneficial” Treatment
     Topical   antibiotics
        Any   of usual abx
     Topical   corticosteroids
   Return to water
     no symptoms
     no clinical evidence of infection

   Prevention
     “Unknown      effectiveness” of acetic acid
      drops
   Acute Infectious Conjunctivitis

 Return   to play
   Neck check
   Contact sports: complete resolution
   Swimmers: complete resolution
                Acute Bronchitis
   “Trade-off between    Return   to play
    benefits & harms”:      Neck  check
     Antibiotics
                            Trial of Activity
   “Unknown
    effectiveness”:
     Antihistamines
     Antitussives
     Beta-2agonists
     Expectorants
Acute Bronchitis – Differential
         Diagnosis
      Atypical infections
        pertussis

    Allergy
    Asthma
    Sinusitis (post-nasal drip)
    Irritants
    GERD
                        Pneumonia
 Antibiotics indicated
 Rest is important; may be prolonged
 Return to play issues
     “Rapid return to training and competition should
      not be the primary goal of any therapeutic
      program” - Fields and Fricker, p. 30
     Risks of premature return:
       prolonged   infection, empyema, abscess
     Considernear-normal PFT’s first
     Staged exertion tolerance
       Monitor   RPE
    Gastroenteritis – Causes & Tx

 Etiology: viral > bacterial > parasitic
 “Likely to be beneficial”:
     Antibiotics
        Avoidin non-typhoidal Salmonella, E. coli O157:H7,
        Yersinia
     Anti-motility   (loperamide)
        Avoid   in bloody diarrhea
    Gastroenteritis – Return to Play

 No systemic symptoms/signs
 Diarrhea and vomiting controlled
 Well hydrated
Gastroenteritis and RTP: Case study
        The Duke University teammates vomited in the
      locker room and on the sidelines during the Sept.
      19, 1998, game against Florida State after getting
       sick on a turkey lunch. Duke lost 62-13, but not
        before the virus crossed the line of scrimmage.
      "The only contact between the two teams was on
          the playing field," said Dr. Christine Moe, an
     assistant professor of epidemiology at the University
        of North Carolina at Chapel Hill. "The virus was
            passed by people touching each other's
     contaminated hands, uniforms and maybe even the
                          football itself."
      Game films showed ill Duke players with vomit on
       their jerseys colliding with opponents, and Duke
       players wiping their mouthpieces on their hands,
      then touching opponents' faces and later shaking
                           their hands.
UTI’s - Predisposing Factors in
           Athletes
     Female cyclists
     Spinal cord injury
     No proof in other sports


     Treat as with non-athletes
     RTP: no systemic sxs
           STD’s - Overview
 12 million cases/year
 3 million cases/year in teens
 Athletes
     condom use
     partners
     STD’s
     risk of HIV
           STD’s - Overview
 12 million cases/year
 3 million cases/year in teens
 Athletes
     condom use
                          Physician's Role
     partners          • Identification
     STD’s
                        • Treatment
     risk of HIV
                        • Prevention-HPV
                    Keep Doxy and Z-Pak around along
                    w Acyclo/Valcovir
Blood-Borne Diseases and Sports
   Hepatitis B, C; HIV
       Extremely low risk of transmission in sports
   Bleeding athletes
       Medical personnel use PPE
       Stop bleeding
       Remove from play until bleeding controlled
   Athletes with HIV or AIDS
       No restriction if asymptomatic
       AIDS: as tolerated
            Reduce activity during acute illness
                  Tick Borne Diseases

   Lyme: Borrelia spp. (burgdorferi, afzelii, and garinii)
       Dx Clinical w/ ELISA/Western Blot Serologic response takes weeks
 RMSF: Rickettsia spp--50% of early infxn not
  recognized
 Ehrlichiosis: E. chafeensis


All respond to Doxycycline
Lyme Prophylaxis
    200mg Doxycycline w 72 hours of potential exposure
Skin Infections In Contact Athletes
   (overview; separate lecture)
       Herpes infections:
    NCAA participation criteria

   Primary infection
       No systemic sxs
       No new lesions x 3 days
       All lesions crusted
       On oral meds >120 hours ( 5 days)
       Crusts covered
   Recurrent infection
     Ulcers dry, covered by FIRM ADHERENT CRUST
     On oral meds for >120 hours
     Crusts covered
       Tinea Infections:
    NCAA participation criteria

 >72 hours topical treatment
 DQ if extensive lesions
 Lesions covered with OpSite and tape
  after washing with Ketoconazole shampoo
  and applying antifungal cream
      Bacterial Infections:
    NCAA participation criteria
 No new lesions for 48 hours
 >72 hours of antibiotics completed
 No moist, exudative or draining lesions
 Active bacterial infections shall NOT be
  covered to allow participation if above
  criteria not met
    Methicillin-Resistant Staph Aureus
                  “MRSA”
 Staph strains resistant to ß-lactam abx (e.g.
  dicloxacillin, methicillin)
 May be resistant to other abx
 Cause skin infections usually
       Cellulitis, folliculitis, furuncles, abscesses
   Cause significant morbidity
   Spread directly person-to-person
       Football linemen, rugby, fencing, wrestling
       Through injured skin
       HANDS especially
          MRSA: when to suspect
 Skin abscesses
 Infections resistant to initial abx
 “Spider bites” but no insect seen


   Proper treatment
     Cultureall abscesses before tx
     Susceptibility should guide abx choice
       Community-acquired strains usually sensitive to
        SMX-TMP, fluoroquinolones, clindamycin
              MRSA: Prevention
 No participation of infected athletes until
  cured
 Protect exposed skin if high-risk sport
 Properly clean/protect injured skin
 Proper general hygiene
     HAND   WASHING!
   Report MRSA to PrevMed and CDC
Infection Prevention in Sports Medicine
    Appropriate immunizations for the team
      HepatitisB
      Age-appropriate vaccines
      Appropriate travel vaccines

  Avoid sharing personal items
  Proper equipment & facility cleaning
  Temporary suspension of ill athletes
      +/-   isolation
  +/- Probiotic supplements in winter
  Consider prophylaxis for HSV and Tinea
                   Probiotics
   Lactobacillus casei Shirota daily x16 weeks
    in highly-active men/women in winter
    months (R-DB/PC trial)
     >=1  URTI: placebo 90%, LcS 66%
     #URTIs: placebo 2.1, LcS 1.2
     Gleeson M et al, Int J Sports Nutr Exer Metab
      2011
                 Probiotics (cont)
   Lactobacillus fermentum VRI-003 daily in
    highly-trained endurance athletes during 4
    months of winter (R-DB/PC trial)
     Days  of resp sxs: placebo 72, Lf 30 (p<.001)
     Lf: lower severity of sxs (P<.06)
     Cox AJ et al, Brit J Sports Med 2010

   Lactobacillus rhamnosum vs PL in
    marathon runners in summer (R-DB/PC):
     No   difference in URTI
       Kekkonen at al, Int J Sports Nutr Exer Metab 2007
               Probiotics (cont)
   Lactobacillus fermentum (PCC®) daily in
    competitive cyclists x11 weeks
     Men:  31% lower URTI sx load (duration x
      severity)
     Women: 200% higher sx load
     West NP et al Nutr J 2011

   Probiotics in French commando training x4
    weeks
     No  change in RTI incidence but less LRTI’s in
      Probiotic group
     Tiollier et al, Mil Med 2007
    Prevention of HSV and Tinea in
               wrestlers
   Tinea prevention (LOE 1):
     Itraconazole   200 mg bid 1 day every 2 weeks
      of season
     Fluconazole 100 mg daily x3d at season onset
      and mid-season
   Herpes Gladiatorum prevention (LOE 2)
     Valacyclovir   500 to 1000 mg daily is effective
        Anderson BJ, Clin J Sports Med 1999
        Anderson BJ, Jpn J Inf Dis 2006
Medical Team Responsibilities to
Prevent Blood-Borne Pathogens
   Stop bleeding
   Cover open wounds
   Appropriate supplies
   Universal precautions
   Blood jerseys (generally should change them)
   Clean playing surface
   Wash uniforms after event
   Ensure first aid and infection control training
                Review
 Exercise affects the immune system in a
  J-shaped curve
 Infections can diminish exercise capacity
 Neck check guides return to play in URI’s
 Use prevention strategies
 Clearance guidelines

								
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