A number of common contagious diseases (Table 18-1) have special significance in the athletic setting. For the athletes, this may mean not being able to continue participation, subpar performance, or risk of potentially serious complications as a result of continued physical stress.
Upper respiratory tract infections |
Systemic viral illnesses |
Acute viral syndrome |
Infectious mononucleosis |
Human immunodeficiency virus infection |
Hepatitis B virus infection |
Influenza A infection |
Measles |
Hepatitis A infection |
Skin and soft tissue infections |
Bacterial |
Impetigo |
Folliculitis, furuncles, carbuncles |
Methicillin resistant staphylococcal aureus infections |
Hidradenitis suppurativa |
Viral |
Herpes simplex virus |
Herpes zoster |
Warts |
Molluscum contagiosum |
Fungal |
Tinea corporis, pedis, capitis |
Zoonosis |
Pediculosis |
Scabies |
Other infectious illnesses |
Enteric pathogens |
Otitis externa |
Conjunctivitis |
Streptococcal pharyngitis |
Sexually transmitted infections |
Tuberculosis |
Sports in which outbreaks or clusters of contagious diseases have been reported are listed in Table 18-2.1 Infections in the athletic settings can be transmitted via either person-to-person spread or common-source spread (Table 18-3).1–6 The most common infection transmitted by direct contact is Herpes simplex virus infection among wrestlers and rugby players. Outbreaks associated with person-to-person spread have also been caused by Staphylococcus aureus, Group A Streptococci, and fungi and involve participation in wrestling, basketball, football, rugby, and orienteering.2 The most frequently reported common-source infections are owing to enteroviruses. Outbreaks of aseptic meningitis and pleurodynia have been documented in football and soccer players associated with oral contamination of shared water sources and drinking containers.2 Most cases of aseptic meningitis are caused by echoviruses (types 5, 9, 16, 24) and Coxsackie viruses (types B1, B2, B4, B5) from sharing of common contaminated source of drinking water.1,5 Epidemics of measles among athletes and spectators have been reported, spread by air-borne droplets in crowded confined environments in basketball, wrestling, and other sports necessitating mass immunizations and relocation or cancellation of events.3
Listed in order of frequency of occurrence |
American football |
Wrestling |
Rugby |
Soccer |
Adventure races or ECHO challenges |
Swimming |
Triathlon |
Track and field events |
Tracking |
Gymnastics |
Basketball |
Fencing |
Mode of Transmission | Pathway of Transmission | Examples | |
|---|---|---|---|
Person-to-person | Direct | Skin-to-skin contact | HSV, tinea, CA-MRSA |
Indirect | Respiratory | Measles | |
Blood borne | HIV, HBV | ||
Fecal-oral | HAV | ||
Common source | Sharing personal items | Equipment, soap, towels | Echoviruses, Coxsackie viruses, enteric pathogens |
Contaminated drinking water | Water coolers, bottles, cups, ice | ||
Exposure to contaminated water | Whirlpools, swimming pool, lakes, rivers |
In contact sports such as wrestling, direct skin contact can spread dermatologic infections. In water sports, the athletes may acquire the infection through unsanitary swimming pools. Infection may also be acquired from contaminated equipment, clothing, and towels; while air-borne and droplet spread can occur in crowded gymnasium and locker room environments.1–6 In air-borne transmission, dissemination of the infection occurs via droplet nuclei or dust particles, which may remain suspended in air for longer periods of time.7 In droplet transmission, micro-organisms are spread during coughing or sneezing to susceptible individuals. The relative humidity around showers and changing rooms predisposes to spread of many respiratory and fungal infections.6
There has been a long-term interest in the relationship between exercise and immunology. Neiman reviewed 629 published papers on the topic between 1900 and 1995.8 It is important to note that most studies of exercise immunity and infections are done in elite endurance athletes in controlled laboratory settings. Generally speaking, an acute exercise of moderate duration and intensity, affected the immune system less than more prolonged high-intensity sessions, such as running a marathon race.8,9 During acute physical activity, the immune and hormonal responses resemble those observed during a stress reaction in general, such as with an acute infection or trauma. The natural killer (NK) cells, neutrophils, and macrophages are most affected by exercise. Unlike the relative immunosuppressive effects of an acute or prolonged high-intensity activity, regular moderate exercise does not seem to have any adverse effects on immune function and in fact may enhance it. Brenner et al. has described a hypothetic model of the relationship between athletic activity and infection which is depicted in Figure 18-1.10
Studies suggest that the relative risk of acquiring upper respiratory infections is decreased with regular moderate exercise compared to a sedentary life style; on the other hand, the risk is increased with excessive or long-term endurance activity.9,11,12 Thus a J-shaped relationship between the risk of URI and the intensity of physical activity has been proposed as depicted in Figure 18-2.9 However, this model is not universally accepted.
Most athletes present with symptoms and signs of either skin infections or viral upper respiratory illness or viral systemic illnesses.1,7,12,13 The clinical presentations of various infectious illnesses in athletes are similar to those seen in the nonathletic settings. Aspects relevant to athletes and sports participation are reviewed under specific sections later in the chapter.
Most contagious diseases are diagnosed based on clinical presentation. Microscopic examination of skin scraping may be useful in some cases of skin infections. Cultures of skin lesions are rarely warranted to diagnose fungal infections. Complete blood counts and erythrocyte sedimentation rate are nonspecific tests considered in some cases of systemic febrile illnesses. Specific serologic tests may be indicated in hepatitis virus, human immunodeficiency virus, and Epsetin-Barr virus infections. In diarrheal illnesses, stool studies are rarely indicated. Material aspirated from abscesses should be sent for culture and sensitivity.
Treatment of specific infectious diseases in athletes is no different than those in the nonathletic settings. Treatment modalities and medications used in the treatment of warts are summarized in Table 18-4.14–16 Drugs used in the treatment of herpes virus infections are listed in Table 18-5, those used for fungal infections of the skin in Table 18-6, and 18-7,17–19 and commonly used antibiotics for skin and soft tissue infections are listed in Table 18-8.7,20–22
Generic Name | Brand Name | Directions for Use |
|---|---|---|
Salicylic acid 5%–17% in collodion vehicle | ||
Salicylic acid 17% with collodion (topical liquid) | Compound W® | Apply solution until affected area is covered while avoiding healthy skin |
Salicylic acid 17% in flexible collodion (topical liquid) | DuoFilm® | Apply twice daily for up to 12 wk |
Salicylic acid 17% in flexible collodion (topical liquid) | Wart-Off® | Allow solution to harden after each application |
Salicylic acid 12.6% in flexible collodion (topical liquid) | Dr Scholl’s Corn/Callus® remover | Cap tightly to avoid evaporation |
Salicylic acid ”’% plaster/pads | ||
Salicylic acid 40% (topical plaster) | Mediplast® | Plaster: Trim to fit the wart, apply to skin and cover with adhesive occlusive tape |
Salicylic acid 40% (topical disk) | Dr. Scholl’s Clear Away Plantar® | Disks with pads: Apply appropriate size disk to wart and cover with pad |
Salicylic acid 40% (topical strips) | Dr. Scholl’s Clear Away OneStep | Reapply every 48 h for up to 12 wks |
Salicyclic acid 40% (topical pad) | Compound W for kids® | |
Salicylic acid 15% in karaya gum-glycol vehicle | ||
Salicylic acid 15% with karayah | Trans-Ver-Sal PlantarPatch® | Apply plaster at bedtime and leave on for a minimum of 8 h |
Trans-Ver-Sal PediaPatch® | ||
Trans-Ver-Sal AdultPatch® | Remove and discard each morning | |
Repeat daily for up to 12 wks | ||
Trichloroacetic acid | Trichlor Fresh Pac® 15%, 20%, 25%, 30%, 35%, 40% and 50% | Utilized within PCP office for wart removal |
Cantharidin | Cantharone® | Utilized within physician office Ordinary and periungual warts: Apply directly to lesion; cover with nonporous plastic tape; remove within 24 h and replace with loose bandage; remove necrotic tissue ˜ 7 d after application. |
Plantar warts: Remove keratin and apply directly to lesion; apply protective cut-out cushion; cover with nonporous plastic tape; leave in place for 1 wk; remove necrotic tissue. | ||
Duct tape | Apply to wart; leave on for 6 d; remove tape and soak the wart; file with emory board | |
Cryotherapy | ||
Liquid nitrogen | Utilized within PCP office and may require repeat treatments at 1–3 wk intervals | |
Other | ||
Laser treatment | Local injections (bleomycin and interferon) | |
Immunotherapy | Tretinoin | |
Drug | Oral Dose First Episode | Episodic Recurrent | Daily Suppressive |
|---|---|---|---|
Acyclovir (Zovirax) | Oral pediatric dose: 40–80 mg/kg/d divided in 3–4 doses for 5–10 d (maximum 1 g/d). 12 y: 1–1.2 g/d in 3–5 divided doses for 7–10 d | 12 y: 1200 mg/d in 3 divided doses for 5 d or 1600 mg/d in 2 divided doses for 5 d or 2400 mg/d in 3 divided doses for 2 d | 12 y: 800 mg/d in 2 divided doses for 1 y then reassess |
Famciclovir (Famvir) | Adult: 750 mg/d divided in 3 doses for 7–10 d | Adult: 250 mg/d in 2 divided doses for 5 d or 2 g/d in 2 divided doses for 1 d | Adult: 500 mg/d in 2 divided doses for 1 y then reassess |
Valacyclovir (Valtrex) | Adolescents: 2 g/d in 2 divided doses for 7–10 d | 1g/d in 2 divided doses for 3 d or 1 g once a day for 5 d | 500–1000 mg once/d for 1 y then reasses |
Topical Antifungal Agent | Product Brand Name | Formulations and Directions* |
|---|---|---|
Clotrimazole | Lotrimin AF®, Desenex® (OTC) | Cream lotion and topical solution (1%)—massage into affected area twice daily |
Econazole | Spectazole® (Rx) | Cream (1%)—apply to affected area once daily |
Miconazole | Micatin® (OTC) | Cream, powder, spray powder, spray liquid, solution & gel (2%)—apply or spray thin layer over affected area twice daily |
Ketoconazole | Nizoral® (Rx) | Cream (2%)—apply once daily to affected area Shampoo (2%)—apply twice weekly with at least 3 d between each shampoo |
Ciclopirox | Loprox®, Penlac® (Rx) | Lotion, cream, and gel (0.77%)—massage into affected area twice daily Nail lacquer (8%)—apply to affected nail and adjacent skin once daily. Remove nail lacquer once weekly with alcohol |
Naftifine | Naftin (Rx) | Cream and gel (1%)—massage into affected area twice daily |
Nystatin | Mycostatin® (Rx) | Cream and ointment (100,000 units/g) —apply to affected area twice daily Powder (100,000 units/g)—apply to affected area 2–3 times daily |
Terbinafine | Lamisil AT® (OTC) | Cream, gel, and spray (1%)
|
Tolnaftate | Tinactin® (OTC) | Cream, solution, gel, powder, spray powder and spray liquid (1%)—apply to affected area twice daily |
Undecylenic acid | Fungi-Nail® (OTC) | Solution (25%)—apply to affected area twice daily |
Drug | Indication | Pediatric Dose | Adolescent/Adult Dose |
|---|---|---|---|
Intraconazole (Sporanox®) | Tinea unguium | 3–5 mg/kg/d Efficacy not established in children | Toenails with or without fingernail involvement: 200 mg daily for 12 wk Fingernails only: 400 mg/d in 2 divided doses for 1 wk/mo × 2 mo |
Ketoconazole (Nizoral®) | Unlabeled indications: Tinea unguium, tinea pedis, tinea corporis, tinea cruris and tinea capitis | 3.3–6.6 mg/kg/d Children > 2 y | 200–400 mg/d Maximum 800 mg/d in 2 divided doses |
Terbinafine (Lamisil®) | Tinea unguium | Unlabeled 10—20 kg: 62.5 mg/d 20–40 kg: 125 mg/d >40 kg: 250 mg/d | Fingernails: 250 mg/d for 6 wks Toenails: 250 mg/d for 12 wks |
Griseofulvin microsize (Grifulvin®) | Tinea corporis (2–4 wk) Tinea pedis (4–8 wk) Tinea capitis (4–6 wk) Tinea cruris Tinea unguium (4–6 mo) | 10–20 mg/kg/d in 1–2 divided doses | Tinea corporis, cruris, and capitis: 500 mg/d Tinea pedis and unguium: 1 g/d |
Griseofulvin Ultramicrosize (Gris-PEG®) | Same as Griseofulvin microsize | 5–15 mg/kg/d in 1–2 divided doses Maximum dose: 750 mg/d in 2 divided doses | Tinea corporis, cruris and capitis: 330–375 mg/d Tinea pedis and unguium: 660–750 mg/d |
Antibiotic | Pediatric Dose | Adolescent/Adult Dose |
|---|---|---|
Amoxicillin | 25–45 mg/kg/d in 2divided doses | 500–875 mg twice daily |
Amoxicillin-clavulanate | 25–45 mg/kg/d in 2 divided dose | 500–875 mg twice daily |
Weight ≤40 kg | ||
Pediatric suspension formulations for twice daily dosing: 200 mg/5 mL or 400 mg/5 mL | ||
Penicillin V | 25–50 mg/kg/d divided every 6–8 h | 250–500 mg every 6–8 h |
Dicloxacillin | 12.5–25 mg/kg/d divided every 6 h Weight ≤40 kg | 125–250 mg every 6 h |
Cephalexin | 25–50 mg/kg/d divided every 6–8 h | 250–500 mg every 6 h |
Maximum dose: 4 g/d | Maximum dose: 4 g/d | |
Cefdinir | 14 mg/kg/d divided every 12 h | 300 mg every 12 h |
Clindamycin | 10–30 mg/kg/d divided every 6–8 h | 150–450 mg every 6 h |
Maximum dose: 1.8 g/d | Maximum dose: 1.8 g/d | |
Doxycycline | 2–4 mg/kg/d divided every 12 h | 100 mg every 12 h |
Maximum dose: 200 mg/d | ||
Not for children ≤8 y of age | ||
Clarithromycin | 15 mg/kg/d divided every 12 h | 250–500 mg every 12 h |
Ciprofloxacin | 20–30 mg/kg/d divided every 12 h | 500–750 mg every 12 h |
Maximum dose: 1.5 g/d | ||
Trimethoprim-sulfamethoxazole | 8 mg/kg/d (based on trimethoprim) divided every 12 h | 160 mg/800 mg every 12 h |
Aspect of treatment that is different in athletes is the decision when to allow the athlete back to sport participation. The nature of the particular infection, athlete’s sense of well-being, route and likelihood of transmission to other athletes, nature of the particular sport, and availability of effective treatment are major factors considered in making return to play decisions. General guidelines for sport participation by athletes with skin and soft tissue infections are presented in Table 18-9.23–26 Guidelines to minimize the risk of transmission of blood-borne infections are summarized in Table 18-10.27–31 Minimum treatment guidelines before allowing wrestlers with certain infections back to wrestling are summarized in Table 18-11.24 Since several infectious outbreaks that occur in the athletic settings are vaccine-preventable, all athletes should receive the recommended vaccines, if there are no contraindications (Table 18-12; Table 18-13).7,32
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