Abstract
The immune system responds to exercise in various ways. Infectious risk is increased in athletes and active individuals because of physical demands, contact with teammates, frequent traveling, and untidy living quarters. Infectious diseases in teams and individual athletes will need to be addressed in the urgent care setting, and challenges may arise in relation to the need to continue competing or to prevent outbreaks. Contacts, relatives, staff, or teammates may need to be treated as well, as the athlete’s infectious condition is diagnosed and addressed. In athletes and active individuals, upper respiratory tract infections generally represent the most common acute illnesses. In terms of seriousness, however, pulmonary and cardiac infections represent perhaps the most important illnesses to address correctly as these may become life threatening. In the urgent care setting, bacterial skin dermatoses should be identified and treated correctly; they are common in athletes and, if left unaddressed, can have serious implications for the individual and the team, especially in wrestling. Methicillin-resistant Staphylococcus aureus (MRSA) infections have been increasing in recent years, and the approach used in urgent care settings to identify such infections may have long-lasting implications. Widespread outbreaks of viral cutaneous infections are common among athletes and can develop quickly if not identified and treated appropriately in the urgent care clinic. Athletes and active individuals can find gastrointestinal (GI) infections troublesome and debilitating. A comprehensive history is crucial when investigating GI tract symptoms. Urgent care clinics can play an important role in recognizing and appropriately treating infectious conditions in athletes and active individuals; the individual’s ability to return to play is clearly affected as well. The management of acute infectious diseases in athletes here may also have implications for the prevention of outbreaks.
Keywords
acute bronchitis, bacterial, gastrointestinal tract infection, upper respiratory tract infection, viral
Upper Respiratory Tract Infections
The Common Cold
1
How does the common cold present?
Also known as a viral syndrome or upper respiratory tract infection (URI), the common cold is the leading cause of missed school or work days in the United States, often leading to missed athletic participation. Presenting symptoms typically include rhinorrhea and cou, and occasionally fever may be present.
2
What are the risk factors for getting the common cold?
Risk factors that may be concerning for more severe disease include young age, low birth weight, prematurity, chronic disease, immunodeficiency, malnutrition, and crowding.
3
How do you diagnose and manage a common cold?
For the most part, the common cold does not require confirmatory testing or further workup when at the top of the differential diagnosis list. The gold standard of confirmation, however, is viral culture, rarely indicated. A complete blood count (CBC) may show a leukocytosis with a left shift. The mainstay of treatment is symptomatic management. Many agents have been studied in the treatment of the common cold, with antihistamines and decongestants proven to have the highest efficacy. Patients with the common cold should be provided precautions even though the course is commonly benign and self-limited as more serious complications such as acute bacterial sinusitis (which occurs in 2.5% of patients after a viral URI), pneumonia, or asthma exacerbations may result. Exercise and return to play is permitted as tolerated.
Sinusitis
4
How does sinusitis present?
Also among the most commonly diagnosed illnesses in the United States, acute sinusitis affects 16% of the adult population annually. Patients present with significant nasal congestion, purulent nasal discharge, maxillary tooth discomfort, headaches, fever, and facial pain/pressure in an acute (<4 weeks), subacute (4–8 weeks), or chronic (>8 weeks) manner.
5
How do you differentiate viral versus bacterial sinusitis?
When distinguishing between viral and bacterial infections, it is important to note that bacterial infections are less common, last longer than the usual 7- to 10-day course for a viral infection, and are associated with a history of persistent purulent rhinorrhea and facial pain. History and physical examination are key as further diagnostic workup is typically not indicated. Purulent nasal discharge and/or colored rhinorrhea, history of maxillary pain or sinus tenderness on exam, and poor response to decongestants have been shown to increase the likelihood of acute bacterial sinusitis.
6
What diagnostic tests may be helpful in diagnosing sinusitis?
Gold standard for diagnosis, though not routinely done in the outpatient setting, is sinus aspirate culture. Computed tomography (CT) scanning is preferred over other imaging modalities if a diagnosed sinusitis does not respond to initial therapies.
7
How is sinusitis treated?
Antibiotics are typically indicated for acute bacterial sinusitis when symptoms have not improved over 10 days or for severe illness. Amoxicillin should be the initial choice in children and adults with uncomplicated disease for 10–14 days of treatment. Symptomatic management may also include antihistamines, decongestants, and nasal steroids, but studies have not proven efficacy to date and their use is not routinely recommended. Exercise and return to play are permitted as tolerated.
Pharyngitis
8
How is pharyngitis assessed?
Responsible for approximately 2% of all ambulatory visits in the United States, acute pharyngitis is caused by an equal proportion of viral and bacterial pathogens. The most commonly treated etiology is group A streptococcus (GAS), but this only accounts for ∼10% of adult cases. Centor criteria are used in an attempt to differentiate viral causes from bacterial, especially GAS. These include tender anterior cervical adenopathy, tonsillar exudates, fever by history, and absence of cough. In a large study of 206,870 patients, 7% of patients with one Centor criterion, 21% of patients with two Centor criteria, 38% of patients with three Centor criteria, and 57% of patients with four Centor criteria tested positive for GAS.
9
What diagnostic tests may be helpful?
Throat cultures are the gold standard of diagnosis but can take 24–48 hours to become positive and therefore are not as readily useful for same-day management. The rapid streptococcal antigen test (RSAT) is the first test of choice with a good sensitivity and specificity and is available in minutes.
10
How is pharyngitis treated?
If positive, treatment for GAS is warranted, with penicillin V being the first-line antibiotic. Otherwise, symptomatic management is typically sufficient. Athletes who are sexually active may warrant suspicion and workup for gonococcal infection as a cause of pharyngitis, which is easily treatable with antibiotics. We treat pharyngitis to prevent the risk of rheumatic fever, acute glomerulonephritis, and supportive complications. Important to remember, athletes with acute bacterial pharyngitis must be held from play and are considered contagious until treated with an antibiotic for 24 hours. After this time has passed, activity as tolerated is recommended.
Infectious Mononucleosis
11
How does infectious mononucleosis present?
More commonly known as “mono” or “the kissing disease,” this illness occurs commonly at the high school and collegiate level and is spread primarily by the passage of saliva. It is caused by the Epstein-Barr virus (EBV), which can persist in the oropharynx for up to 18 months after clinical recovery. Classical presentation includes the triad of fever, tonsillar pharyngitis, and posterior cervical lymphadenopathy. Typical pharyngitis in mono is described as white or gray exudate. This is often accompanied by severe fatigue and splenomegaly.
12
What diagnostic tests are useful?
Diagnostic evaluation usually starts and stops with the Monospot test, which detects heterophile antibodies that appear within 1 week of the onset of clinical symptoms and may persist at low levels for up to 1 year. EBV-specific antibodies can also be detected and are commonly used in athletes to determine acuity of illness. A peripheral smear, although not always warranted, will show a mild leukocytosis on occasion with a predominance of lymphocytes, with more than 10% of these being atypical.
13
How is “mono” treated?
Treatment for infectious mononucleosis is supportive care. It is especially important in these patients to stress adequate nutrition, hydration, and rest.
14
When can athletes return to play after a bout of “mono”?
Return to play guidelines for athletes with mono has been heavily disputed and is largely based on the prevention of splenic rupture, which occurs most commonly in 1–2 per 1,000 patients 4–21 days after onset of symptoms. For this reason, gradual return to play may be started after 3 weeks but typically contact and vigorous exercise are prohibited for the first 4 weeks after onset of symptoms. It is also important to ensure the athlete is afebrile and without pharyngitis, the spleen is not enlarged or painful, and liver enzymes are at baseline.
Pulmonary Infections
Pneumonia
15
How does pneumonia present?
Athletes with pneumonia will typically be classified as community-acquired (CAP), and common pathogens in this population include streptococcal pneumonia, legionella, chlamydia, and influenza. Patients will present with cough, sputum production, shortness of breath, and/or chest pain. Other associated symptoms may include malaise, anorexia, headache, myalgias, fever, and chills. Physical examination is very important in diagnosis, and vital signs will often be abnormal including fever, tachycardia, tachypnea, hypoxemia, or hypotension. Exam may reveal dullness to percussion of the chest, tactile fremitus, or egophony. Auscultation can be positive for crackles, rales, or bronchial breath sounds.
16
What diagnosis tests may be helpful?
Gold standard for diagnosis includes a chest radiograph showing an infiltrative lesion. Other workup may include complete blood count (CBC) showing leukocytosis, sputum cultures with Gram stain, and urine antigens for streptococcus or legionella.
17
How is pneumonia treated?
The pneumonia severity index is often used to help determine whether outpatient management is appropriate, but clinician judgment is the final word. Typically, a patient with unstable vital signs, including hypoxemia, or inability to maintain hydration or oral intake requires inpatient hospitalization. Treatment usually consists of a macrolide, such as azithromycin, for 7–10 days. If athletes are short of breath for extended periods of time despite adequate antibiotic therapy and resolution of other symptoms, they may have developed a transient reactive airway disease and would benefit from a short course of inhaled bronchodilator therapy. Continued fevers should warrant suspicion for other complications such as empyema, abscess, sepsis, or secondary lung infection.
18
When can an athlete return to play?
Although there are few studied recommendations for return to play in these patients, the athlete should be afebrile and returned to participation in a gradual and progressive fashion.
Acute Bronchitis
19
How does acute bronchitis present?
Accounting for more than 10 million office visits yearly, bronchitis is characterized by cough lasting up to 3 weeks and concurrent upper airway infection. Most commonly caused by viral infection, less than 10% of patients with bronchitis have a bacterial etiology. Examination is nonspecific, and patients may have pharyngeal erythema, lymphadenopathy, rhinorrhea, and less commonly fever. It is a clinical diagnosis and should be suspected in patients with prolonged cough after resolution of other URI symptoms. Postnasal drip, sinusitis, asthma, and GERD are often in the differential diagnosis.
20
How is acute bronchitis treated?
Acetaminophen, ibuprofen, and nasal decongestants are commonly used. As with pneumonia above, these patients may also develop a reactive airway disease or worsening of asthmatic symptoms and may benefit from short-term inhaled bronchodilator therapy. Exercise and return to play is permitted as tolerated.
Pertussis
21
How does pertussis (also known as “whooping cough”) present?
“Whooping cough” is caused by the gram-negative coccobacillus Bordetella pertussis and is a highly contagious infection transmitted by droplets. For this reason, it is important not to miss this diagnosis in the training room or when working with athletes in constant close contact. Athletes present with a persistent cough with URI symptoms, which may have a paroxysmal quality lasting more than 2 weeks, posttussive emesis, and/or inspiratory whooping.
22
How is pertussis diagnosed and managed?
Diagnosis is confirmed by nasopharyngeal culture and/or polymerase chain reaction (PCR). The Centers for Disease Control and Prevention (CDC) recommends reporting and treating pertussis even prior to laboratory confirmation, however, when clinical suspicion is high. Treatment, including prophylaxis for athletes in close contact with a suspected case of pertussis, includes 500 mg erythromycin four times a day for 14 days.
23
How is the spread of pertussis prevented?
Athletes with pertussis need to be isolated from participation for 5 days from the start of treatment. Routine preventive measures in the general population are recommended by means of Tdap vaccine for 11- to 18-year-olds who require a booster dose as well as a single dose for adults 19–64 years of age. After isolation for 5 days, athletes must be monitored for further complications of pertussis such as reactive airway disease, pneumonia, dehydration, weight loss, and sleep disturbances prior to return to play.
Influenza
24
How does influenza present?
Usually presenting in the winter months, these athletes may complain of abrupt onset of fever, headache, myalgia, malaise, nausea, vomiting, cough, and/or sore throat. Physical exam findings may include minimal cervical lymphadenopathy, oropharyngeal hyperemia, eye lacrimation or redness, or dehydration.
25
How is influenza diagnosed and managed?
Rapid viral diagnostic tests completed with the use of nasal or throat swabs can be helpful in the outpatient setting. Influenza A and B can be treated with the neuraminidase inhibitors zanamivir and oseltamivir, whereas influenza A alone can be treated with amantadine and rimantadine. Studies have shown a 2- to 3-day shortening of symptoms when these antiviral medications are given within the first 24–30 hours of symptoms. Symptomatic treatment is the mainstay of therapy for patients presenting outside of that initial 1–2 days of symptom onset and includes acetaminophen or ibuprofen, cough suppressants, and adequate sleep and hydration.
26
How is influenza prevented, and when can athletes return to play?
Annual vaccine is important for all athletes for prevention of illness. Similar to the recommendations for pertussis, athletes with influenza should be isolated for 5 days after which they should be monitored for fever, dehydration, or dyspnea prior to return to play.
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