Prevention and management of respiratory tract infections in athletes

By Ola Ronsen

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    Athletes performing at high levels in their sports are most often members of a select group of people who are able to withstand the stress imposed by strenuous training and competition schedules without major illness or prolonged periods of fatigue (GLEESON, 2000; NIEMAN, 2000; RONSEN et aI., 2001). Nevertheless several studies suggest that athletes are at increased risk of respiratory tract infections (RTI) (GLEESON, 2000; NIEMAN et aI., 1989; NIEMAN et aI., 1990; PETERS, 1997). Exercise-induced suppression of certain immune functions during periods of strenuous training, increased exposure to foreign pathogens (microbes) while travelling and sharing the same training and living facilities with a team may contribute to this increased frequency or duration of RTI (GLEESON, 2000). Obviously, some sort of microbe (virus, bacteria, fungus, etc.) must be transmitted to the body at a certain point and have the ability to invade the respiratory tract for an RTI to occur. However, several environmental and physiological circumstances, such as heat and cold exposure, psychological stress, nutritional status and training load, are known to modulate the body's response to such pathogens and thus increase or decrease the course of the infection (PEDERSEN et aI., 1994).
    A recent survey among 74 Norwegian athletes participating in the 2002 Olympic Winter Games and the 2004 Olympic Summer Games showed that more than 90% of the athletes reported one or more infectious episodes during the previous year (data to be presented at ISEI Congress in 2005). Respiratory tract infections and gastroenteritis were the most common diseases reported and the duration of symptoms was mostly inside one week. However, since many suffered several infectious episodes through the year, the average number of lost training days was 15 per year. Frequent absence from vital training sessions is highly undesirable for both athletes and coaches and will most likely have a negative impact on the performance level during parts of the season. The study also showed that on average one important competition per year was lost due to illness. Finally, there was a large degree of variability in th e frequency and duration of infectious diseases reported by the athletes, with some never being sick while others missed more than 30 days per year of scheduled training due to illness. This, of course, highlights the need for preventive measures among the most illness susceptible athletes.
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    Prevention is always preferable and superior to treatment, even the best sports medicine based treatment. Therefore, all means and methods to avoid unnecessary and unprotected exposure to microbes should be practiced in athletic settings in order to avoid loss of training and competitions due to episodes of infection (RONSEN, 2003). Consequently, athletes and coaches need to be educated and guided with regard to important preventive measures for avoiding infectious diseases.
    However, all contact with unknown sources of microbes is unavoidable in the normal life style of an athlete. This makes the correct management of infectious illnesses of paramount importance in order to limit the negative consequences of the infection. Management of RTI from a physician's standpoint should always be based on a thorough medical history, an evaluation of clinical signs and symptoms, a skilled physical examination and a specific microbial diagnosis.
    The first section in this article outlines the basics in detection and management of RTI and is aimed at the medical personnel dealing with athletes. This part contains mostly text-book and review article material and thus is not specifically referenced (DASARAJU AND LUI, 1996, GLEESON et aI., 2004, NIEMAN, 1998, NIEMAN, 2000, WEIDNER,1994).
    The second section outlines practical guidelines with respect to the management and prevention of RTI and is aimed primarily at coaches and athletes. The information here is based on a mixture of personal clinical experience from 12 years of providing medical care to Olympic athletes as well as well established knowledge in the field of infectious medicine.


Physician-based management of RTI
    Upper respiratory infections: common cold, otitis, sinusitis, pharyngitis, epiglottitis and laryngotracheitis

    Etiology and pathogenesis: Most upper respiratory infections are caused by viruses. In some cases, bacteria like Haemophilus Influenzae Type B and Streptococcus Pyogenes may be the primary cause of infection (sinusitis, tonsillitis, epiglottitis and laryngotracheitis/croup). An episode of viral infection may also progress into a bacterial infection in certain locations of the respiratory system. The micro-organisms enter the respiratory tract by inhalation of droplets and invade the mucosa, resulting in epithelial destruction with redness, edema and exudate.

    Clinical manifestations and diagnosis: Initial symptoms of a common cold are runny, congested nose, sneezing, and/or a sore throat. Fever and a general feeling of malaise mayor may not accompany these initial symptoms. Common colds typically have mild to moderate symptoms with a duration of approximately 4-7 days. Sinusitis is usually characterised by pressure pain in the forehead or maxillary bone(s) in addition to the symptoms mentioned above. Infections in the middle ear (otitis media) usually present with pressure-pain in/around the earls) in addition to fever and stuffy nose and are mostly seen in children. Bacterial pharyngitis/tonsillitis most often starts with high fever, glandular hypertrophy and a painful throat. Upon inspection the tonsils are enlarged, inflamed and often covered with purulent secretion. Epiglottitis and laryngotracheitis (croup) may also cause difficulties with breathing, but are most common in children. Different strains of influenza virus appear during seasonal epidemics and are usually diagnosed on the basis of clinical manifestations such as high fever, severe feeling of malaise, myalgia and headache.

    Bacterial and viral cultures of throat swab specimens or nasal discharge are used for diagnosing pharyngitis, sinusitis, epiglottitis and laryngotracheitis. Specific quick-tests (Enzyme-linked immunoassay methods) for diagnosing infections by Streptococcus Type A are commercially available. A rise in the C-reactive protein (CRP) to values between 10-50 mg/L may indicate a viral infection, while bacterial infections most often result in CRP values above 50 mg/L. However, these are general guidelines and must be evaluated along with clinical manifestations of an infection. Blood cultures or serological antibody titres may be helpful in obtaining a microbiological diagnosis in cases of severe or longstanding infections. A CT or MRI scan of the paranasal/cranial sinuses may be helpful in the diagnosis of recurrent or chronic sinusitis.
    It is wise to remember that several of the clinical manifestations that are characteristic of bacterial tonsillitis and pharyngitis are similar to the onset of mononucleosis, an infection caused by the Epstein Bar virus. However, mononucleosis is a systemic infection that affects lymphatic glands in most of the body, the liver and spleen, and often causes prolonged high fever, lethargy, swelling of the lymphatic nodes and organs, in addition to the symptoms of throat infection. When it coincides with a bacterial tonsillitis/pharyngitis, proper antibacterial therapy should be administered even though antibiotics do not affect the EB viral infection. If strenuous physical exercise is performed during the initial or convalescence phase of mononucleosis, this may lead to increased morbidity (worsening of the clinical manifestations) and/or relapse with a more prolonged recovery period (SEVIER, 1994). Therefore, it is essential to recognise th is infection at an early stage with specific Enzyme-linked immunoassay tests and/or serologic detections of specific antigens and/or antibodies to the Epstein Bar virus. The clinical manifestation of mononucleosis may be mild in childhood and thus not specifically recognised and diagnosed. However, when it appears in adolescents or adults, the symptoms are usually much more severe and long standing with higher risks of relapses during the convalescence period.
    With respect to a return to exercise and sports participation, it is important that the physician and the athlete use an individual approach based on the improvement of symptoms, clinical sign and lab results (DOMMERBY et aI., 1986, SEVIER, 1994). However, some general guidelines may be helpful to the physician and athlete in this process. These are summarised in Table 1.


Treatment: Common viral infections of the upper respiratory tract are treated symptomatically and include such measures as nasal washings with sodium cloride, nasal decongestions (beware of possible banned substances for athletes), nonsteroidal anti-inflammatory drugs, paracetamol, acetaminophen, or other analgesics. The main strategy is to facilitate drainage of excessive exudate from the mucosa of the upper airways and prevent stagnation of infected exudate in sinuses, nasopharynx and ear. A purulent sinusitis will in most cases be successfully treated with a beta-lactamase resistant antibiotic such as amoxicillin or a cephalosporin for 10-14 days. Pharyngitis/ tonsillitis with beta-hemolytic streptococci should be treated with Penicillin G for the same number of days. Other bacterial infections should be treated with proper antibiotics, in accordance with the results of a good clinical evaluation and microbiological diagnosis. Epiglottitis and laryngotracheitis (croup) that results in major breathing problems (stridor and cyanosis) must be treated immediately with proper medication facilitating airway expansion, preferably in hospitals. Epiglottitis caused by Hemophilus influenzae bacteria needs to be treated with antibiotics. Surgical treatment should be considered in cases of recurrent bacterial tonsillitis and chronic sinusitis.
    Vaccine against Haemophilus influenzae Type B infections and specific seasonal influenza viruses are commercially available. The influenza vaccine is altered annually according to the change in seasonal epidemics around the world, and thus needs to be taken each year to acquire specific immunization. The need for such vaccines is questionable for healthy people but may be considered in athletes prone to recurrent or prolonged infections during a season with multiple competitions.

Lower Respiratory Infections: bronchitis, bronchiolitis and pneumonia
    Etiology and pathogenesis: Lower respiratory infections may be viral or bacterial. Viruses cause most cases of bronchitis and bronchiolitis. In community-acquired pneumonias, the most common bacterial agent is Streptococcus pneumoniae. Atypical pneumonias are cause by such agents as Mycoplasma pneumoniae, Chlamydia pneumoniae and viruses. Organisms enter the distal airway by inhalation, aspiration of gastric content or by hematogenous seeding. The pathogen multiplies in or on the epithelium, causing inflammation, increased mucus secretion and impaired mucociliary function, which may lead to airway obstruction.
    Clinical manifestations and diagnosis: Lower respiratory infections are usually characterised by cough, sputum production, shortness of breath and/or tachypnea, fever, generalised malaise, and/or chest pain. Patients with pneumonia and bronchopneumonia may also exhibit non-respiratory symptoms such as, headache, myalgia, nausea and abdominal pain.
    Auscultation of the lungs often reveals a characteristic crepitating sound or reduced ventilation in localised (lobar pneumonia) or more generalised (bronchopneumonia) areas. A two-way chest X-ray may be helpful in differentiating between pneumonia, bronchopneumonia and other causes of persistent cough and lower airway symptoms. A differential count of white blood cells and measurement of CRP may be helpful in the initial assessment of respiratory infections. However, a specific microbial diagnosis requires a specimen from sputum or nasal discharge to be cultured for bacteria, fungi and viruses. Blood cultures and/or serologic detections of antigens and antibodies can also be used to identify several micro-organisms. Enzyme-linked immunoassay methods and detection of nucleotide fragments specific for the microbial antigen in question by DNA probe or polymerase chain reaction can offer a rapid diagnosis.

Treatment: Symptomatic treatment is used for most viral infections of the lower respiratory tract. Cough reducing medications should for the most part be restricted to conditions of dry, non-productive coughing, and athletes must be careful not to use medications with banned substances. The inflammatory reaction during an acute episode of bronchitis may lead to temporary constriction of the bronchial airways and ventilatory obstruction (asthma). Such conditions need to be properly diagnosed and treated with bronchio-dilatory medications and inhalation steroids. Bacterial bronchitis and pneumonias are treated with antibiotics, according to the identification of a specific micro-organism and its sensitivity/resistance pattern to selected antibiotics.

Athlete-based prevention and management of RTI
    There is no single method or measure that completely eliminates the risk of contracting a RTI, but there are several effective ways of reducing the number of infectious episodes incurred over a period. Some of these measures are scientifically founded while others are supported mostly by clinical and personal experience. In essence, it is all about avoiding transmission of microbes from one person to another! It is important to underline that virus and bacteria causing RTI may be both received by and passed on from the same individual. This means that one should pay as much attention to preventing transmission of potentially contagious material from oneself to others as the opposite way, from others to oneself. Therefore, the "golden rule" of practising the same standard of hygiene when you are in contact with others as you expect others to practice towards you, should be the general objective of RTI prevention. A list of the most common preventive measures and practical guidelines against RTI infections, but also against any contagious disease, is given in Table 2.


    Even if one meticulously practices all the important preventive measures that athletes, coaches and medical support staff can put up against respiratory tract infections, it is everybody's experience that RTI, nevertheless, takes its toll, both on individual athletes and in teams. Therefore, it is crucial that all episodes of RTI, including the initial symptomatic phase are well managed and that the spread of microbes between members of a team or family is limited. For athletes on a training schedule, the obvious question when initial symptoms of RTI appears is about continuing, decreasing or stopping their regular exercise.
    The athletes themselves must make the first assessment on these matters and then consult with a physician to make clinically based decision. Nevertheless, some general "rules of thumb" may be offered to guide the athlete and his support team to make the best choices on if and how exercise should be continued through an infectious episode. The guidelines are summarised in Table 3.


    In a similar fashion, and with the same constraint of not substituting these guidelines for physician based individual advice, further strategies for safe and healthy return to a regular training schedule are given in Table 4. It must be emphasised that the author cannot be responsible for the individual medical outcome of adhering to these guidelines.


    Although regular exercise seems to have a stimulatory effect on the immune system and thus may decrease the risk of respiratory tract infections, both personal experience as well as some scientific evidence support the contention that athletes may be at increased risk of RTI during periods of intense training and competition. Several factors may explain this phenomenon, including training-induced immune suppression, increased exposure to foreign microbes while travelling, as well as sharing of training and living facilities, which increase the exposure as well as the transmission of pathogens. Most of the common microbes that cause RTI are relatively harmless for healthy people with the possible exception of the Epstein Bar virus, which causes mononucleosis. Nevertheless, if extreme environmental factors, stress and strenuous training schedules are imposed on a person who has contracted a respiratory infection it may result in significant aggravation and protraction of the symptoms and physiological disturbances in the body. Thus, immediate diagnostic assessment and patient management is imperative to reduce the negative consequences on the health as well as on the performance level of the athlete. However, the most effective way of fighting respiratory tract infection for an athlete may be to apply common-sense preventive measures against transmission of contagious material in his/her environment and life style.



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