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Infectious Disease and the Athlete

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

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Infectious Disease and the Athlete

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  1. 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

  2. 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 • Otitisexterna

  3. Exercise and Immunity • Immediate • leukocyte count • leukocyte function • CD4/CD8 • secretory immunity • antibody concentrations • natural killer cell function (recovery) • Long term • immune system enhancement (moderate) • ? natural killer cell number (intense) • ? antibody levels (intense)

  4. Infections and Exercise Capacity • Fever • for every degree above 37°C O2 consumption 13% • promotes dehydration • coordination/concentration • endurance • strength

  5. 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.

  6. Case studyDurakovic, CollAntropol 2010 • 17 yo professional soccer player • Suppurative tonsillitis • Sudden death during play; resuscitation unsuccessful • Cause of death: myopericarditis

  7. Myocarditis • Myocarditis causes 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

  8. Myocarditis - Causes • Viral • Coxsackie B most common • Exertion increases viral replication rates and severity of morbidity associated with myocarditis in murine models infected with Coxsackie virus • Bacterial, rickettsial, mycotic • Drugs (cocaine)

  9. Myocarditis – Clinical Presentation • Chest pain • Exertional dyspnea • Fatigue • Recent myalgias • Syncope • Palpitations • Tachyarrhythmias • Acte heart failure (HF)

  10. Infectious Myocarditis - Diagnosis • WBC • ESR • Cardiac enzymes • Serology • EKG nonspecific • ST-T wave changes • Echocardiogram • ? Endomyocardial bx

  11. 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

  12. Acute Pericarditis • Etiology: • Viral, bacterial, mycoplasma, mycobacterial • Classic history: CP worse lying down, better sitting up • EKG: ST elevation common

  13. 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

  14. Upper Respiratory Tract Symptoms • Wide differential diagnosis • URI • Vasomotor rhinitis • Allergy • EBV infection • Asthma/EIB • Otitis media • Eustacian tube dysfunction • Pharyngitis • Sinusitis • GERD

  15. URI • Most common infection • >50% of acute illnesses • 3-4/year per person • >200 viruses/strains

  16. URI - Treatment Options“Likely to be benficial” per BMJ Clinical Evidence • Antihistamines • allowed by NCAA, USADA • Caution w/ sedating meds • Decongestants • Allowed by NCAA,USADA • Except ephedrine • Sympathomimetic effects • pulse and BP • palpitations • insomnia (or insomnia) • dizziness

  17. URI – Other Treatment Options • “Unknown effectiveness” • Analgesics, NSAIDs • Echinacea • Steam inhalation • Zinc • “Unlikely to be beneficial” • Vitamin C • Caution to elite athletes: contaminants • “Likely to be Ineffective or Harmful” • Antibiotics

  18. 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

  19. Acute Pharyngitis • Viral • EBV, etc. • Bacterial • Group A Strep • Mycoplasma • Other (GC)

  20. Centor criteria history of fever anterior cervical adenopathy tonsillar exudates absence of a cough Rapid Strep testing Culture Pharyngitis - Diagnosis

  21. 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

  22. Pharyngitis – Other treatments • NSAIDs, acetaminophen: helpful • Corticosteroids: trade-off between benefit and harm • Reduced severity of pain • Adverse effects • Consider single-dose

  23. “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

  24. 30% coexistent w/ GABHS pharyngitis Posterior cervical adenopathy +/- inguinal/axillary Exudates, palatal petechiae common Other findings: Splenomegaly Rash w/ amox Rare neurologic complications If suspected, WITHHOLD FROM CONPETITION until ruled out Diagnosis: Monospot EBV titers Mononucleosis Pharyngitis

  25. 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

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

  27. 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

  28. 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

  29. 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

  30. Otitis Media Diagnosis assisted with pneumatic otoscopy or tympanometry • Treatment • +/- antibiotics • Analgesics (oral, topical) • Return to play • neck check • 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

  31. 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

  32. 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

  33. Acute Infectious Conjunctivitis • Return to play • Neck check • Contact sports: complete resolution • Swimmers: complete resolution

  34. Acute Bronchitis • “Trade-off between benefits & harms”: • Antibiotics • “Unknown effectiveness”: • Antihistamines • Antitussives • Beta-2 agonists • Expectorants • Return to play • Neck check • Trial of Activity

  35. Acute Bronchitis – Differential Diagnosis • Atypical infections • pertussis • Allergy • Asthma • Sinusitis (post-nasal drip) • Irritants • GERD

  36. 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 • Consider near-normal PFT’s first • Staged exertion tolerance • Monitor RPE

  37. Gastroenteritis – Causes & Tx • Etiology: viral > bacterial > parasitic • “Likely to be beneficial”: • Antibiotics • Avoid in non-typhoidal Salmonella, E. coli O157:H7, Yersinia • Anti-motility (loperamide) • Avoid in bloody diarrhea

  38. Gastroenteritis – Return to Play • No systemic symptoms/signs • Diarrhea and vomiting controlled • Well hydrated

  39. 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.

  40. 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

  41. STD’s - Overview • 12 million cases/year • 3 million cases/year in teens • Athletes • condom use • partners • STD’s • risk of HIV

  42. STD’s - Overview • 12 million cases/year • 3 million cases/year in teens • Athletes • condom use • partners • STD’s • risk of HIV • Physician's Role • Identification • Treatment • Prevention-HPV Keep Doxy and Z-Pak around along w Acyclo/Valcovir

  43. 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

  44. Tick Borne Diseases • Lyme: Borreliaspp. (burgdorferi, afzelii, and garinii) • Dx Clinical w/ ELISA/Western Blot Serologic response takes weeks • RMSF: Rickettsiaspp--50% of early infxn not recognized • Ehrlichiosis: E. chafeensis All respond to Doxycycline Lyme Prophylaxis 200mg Doxycycline w 72 hours of potential exposure

  45. Skin Infections In Contact Athletes(overview; separate lecture)

  46. 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

  47. 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

  48. 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

  49. Methicillin-Resistant Staph Aureus“MRSA” • Staph strains resistant to ß-lactamabx (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

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