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Upper respiratory tract infections: Considerations in adolescent and adult athletes

Upper respiratory tract infections: Considerations in adolescent and adult athletes
Literature review current through: Jan 2024.
This topic last updated: Jul 27, 2023.

INTRODUCTION — Upper respiratory tract infections (URTIs) are common in athletes. The majority are self-limited viral infections. The evaluation and treatment of athletes with URTIs is typically the same as in the general population. However, there are specific considerations for medication choices in athletes and clinicians may be asked to determine when an athlete can return to play or competition.

This topic will discuss the epidemiology, evaluation, and specific medication considerations in athletes with URTI. It will also discuss how to determine when an athlete can return to play after URTI.

TERMINOLOGY — For the purposes of this topic, "athlete" refers to adolescents and adults who participate in both recreational and competitive sports.

The term "upper respiratory tract infection" may be used to describe a variety of infections. For the purposes of this topic, URTIs include the illnesses listed below. Information regarding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections is provided separately.

The common cold (see "The common cold in adults: Diagnosis and clinical features" and "The common cold in adults: Treatment and prevention" and "The common cold in children: Clinical features and diagnosis" and "The common cold in children: Management and prevention")

Infectious mononucleosis (see "Infectious mononucleosis")

Influenza (see "Seasonal influenza in adults: Clinical manifestations and diagnosis" and "Seasonal influenza in nonpregnant adults: Treatment" and "Seasonal influenza in children: Clinical features and diagnosis" and "Seasonal influenza in children: Management")

Pertussis (see "Pertussis infection in adolescents and adults: Clinical manifestations and diagnosis" and "Pertussis infection in adolescents and adults: Treatment and prevention")

Pharyngitis (see "Evaluation of acute pharyngitis in adults" and "Symptomatic treatment of acute pharyngitis in adults" and "Evaluation of sore throat in children" and "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis" and "Acute pharyngitis in children and adolescents: Symptomatic treatment")

Sinusitis (see "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment" and "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis" and "Acute bacterial rhinosinusitis in children: Microbiology and management")

EPIDEMIOLOGY — Upper respiratory tract infections (URTIs) are the most common type of infection in athletes [1,2]. In general, the incidence in athletes is the same as nonathletes. In the majority of cases, URTIs are self-limited viral infections [3].

Risk factors — There is little evidence that the incidence of URTI varies by sport. However, athletes in some sports are at higher risk for viral illnesses, such as influenza and infectious mononucleosis, as a consequence of close contact with teammates and opponents. URTIs are the most common cause of illness at national and international sporting competitions, likely related to increased exposure to pathogens during both travel and competition [1,4,5]. Risks associated with COVID-19 infection and spread are discussed separately. (See "COVID-19: Epidemiology, virology, and prevention".)

Athletes appear to be at greater risk of infection during the winter months [6,7]. This likely has to do with the seasonal variations of pathogens that cause URTIs (eg, influenza), as well as increased indoor crowding [3]. (See "Influenza: Epidemiology and pathogenesis".)

International travel across more than five time zones is associated with an increased risk of illness [7-9]. Such risk appears to be highest the day after travel. Other factors associated with increased risk include sleep disturbances, severe psychosocial stress, a major personal crisis, or an imbalance between psychological stress and recovery [7-9]. Preliminary studies suggest an increased risk of URTIs among athletes with reduced serum vitamin D concentrations or lower salivary IgA measurements [7].

A small number of athletes experience persistent or recurrent URTIs. The athletes most at risk are those who participate in high-intensity training, including both speed and strength training, or who undertake high loads continuously over weeks to months with insufficient recovery [7]. (See "Overtraining syndrome in athletes".)

Relationship to exercise — The relationship between infection and exercise is poorly understood [10,11]. The risk of illness appears to increase with prolonged and/or intensive training, especially in susceptible athletes (eg, poorly-controlled asthmatics, those with chronic disease, those who are immunosuppressed, or those who have had a recent infection) [12]. However, most athletes can exercise, train, and compete with confidence, as acute exercise more likely improves rather than compromises immune competency [13].

A number of models have been developed to characterize relationships between the volume/intensity of exercise (and training) and risk of URTI. The J-curve model is based on evidence that moderately active individuals typically have a lower risk of URTI compared with sedentary individuals, but some highly trained athletes have a paradoxically heightened risk [14]. Another model is the open window theory, where the immune system is temporarily down-regulated in the hours after strenuous exercise or training leading to a 'window' of opportunity for infections to become established [15].

Effect on competition performance — Infections that coincide with the preparations for or actual competition may impair performance if the symptoms are moderate to severe. For example, the prolonged cough experienced by those with pertussis can hamper athletic performance [3].

Infections occurring early in the season well away from competition are unlikely to have substantial effects on competitive performance, unless a significant amount of training time is lost. In a retrospective study of 69 swimmers, mild infections (predominantly URTIs) lasting two or more days in the six weeks prior to international competition had little adverse effect on performance [16].

EVALUATION — The evaluation of athletes for the various etiologies of upper respiratory tract infections (URTIs) is the same as for the general population. Evaluation and screening for coronavirus disease 2019 (COVID-19) will likely vary by sport and local conditions.

Although it is not always necessary to obtain a white blood cell count (WBC) in the evaluation of URTI, exercise appears to affect WBC counts and function. The clinical importance of these changes is unclear. Prolonged endurance training can lead to leukopenia, but this is likely not pathologic. In one study including over 900 females and 1300 males in 14 sports, 16 percent of athletes who participated in aerobic sports (eg, cycling or the triathlon) had WBC counts that were below the normal reference range [17]. Also, acute exercise will typically increase the numbers of circulating leukocytes, but changes are transient and likely of little clinical significance. (See "Approach to the patient with neutrophilia", section on 'Stress/exercise'.)

MEDICATION CONSIDERATIONS — In general, treatment strategies for upper respiratory tract illnesses (URTIs) in athletes should be the same as for nonathletes. There are some specific considerations for athletes regarding choice of antibiotics and adjunctive medications.

Antibiotics — The same criteria should be used to determine if antibiotic treatment is necessary in athletes as in nonathletes. However, certain antibiotics have adverse effects that may have implications for athletes (table 1):

Fluoroquinolones When other options are available, we avoid prescribing fluoroquinolones in athletes because they are associated with tendinopathy and tendon rupture [18,19]. When fluoroquinolones are the best option for treatment, we monitor athletes for tendon pain. Any athlete that develops tendon pain while on fluoroquinolones should stop the medication and seek prompt evaluation. (See "Achilles tendinopathy and tendon rupture", section on 'Epidemiology and risk factors' and "Fluoroquinolones", section on 'Tendinopathy'.)

In addition, fluoroquinolones are associated with photosensitivity and QT prolongation, which have specific implications for athletes [19]. In athletes that use fluoroquinolones, we recommend precautions such as sunscreen and protective clothing, particularly if they participate in outdoor sports. Some athletes are evaluated with an electrocardiogram (ECG) as part of clearance for participation. If an athlete needs ECG testing around the time of antibiotic therapy, it is reasonable to avoid the use of fluoroquinolones when possible. (See "Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment", section on 'Phototoxicity' and "Fluoroquinolones", section on 'QT interval prolongation' and "Fluoroquinolones", section on 'Other adverse effects'.)

Macrolides The potential adverse effects of macrolides include QT prolongation. Some athletes are evaluated with an ECG as part of clearance for participation. If an athlete needs ECG testing around the time of antibiotic therapy, it is reasonable to avoid the use of macrolides when possible [19]. (See "Azithromycin and clarithromycin", section on 'QT interval prolongation and cardiovascular events' and "Fluoroquinolones", section on 'QT interval prolongation'.)

Tetracyclines and sulfonamides – Side effects of both of these antibiotics include photosensitivity. If these antibiotics are used, we recommend precautions such as sunscreen and protective clothing, particularly if athletes participate in outdoor sports [19]. (See "Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment", section on 'Phototoxicity' and "Tetracyclines", section on 'Allergic and skin reactions'.)

In addition, any antibiotic may have the following side effects that can affect athletes:

Antibiotic-associated diarrhea Antibiotic-associated diarrhea is a common side effect that can impair an athlete's performance and increase the risk of dehydration. As with all patients, when possible, we choose narrow spectrum antibiotics and avoid extended courses [19]. Probiotics in the prevention of antibiotic-associated diarrhea are discussed elsewhere. (See "Probiotics for gastrointestinal diseases", section on 'C. difficile infection'.)

Fatigue Antibiotic use in athletes has been associated with fatigue and impaired performance; however, only limited evidence exists to substantiate this claim [19]. Determining if the fatigue is from illness versus the medication can be difficult. If there is concern that antibiotics may be causing fatigue, when possible, we time the antibiotic to avoid dosing around the time of competition or an important event (eg, stopping antibiotics for acne prophylaxis).

Medications used for symptom relief — Some medications used for symptom relief (adjunctive medications) may contain banned substances (eg, decongestants) and should be avoided (table 1). The clinician should refer to the appropriate governing body based on the athlete's sport for information about regulations on banned substances. These agencies include the World Anti-Doping Agency (WADA) (see prohibited substances list) and the International Olympic Committee (IOC) [20]. The National Collegiate Athletic Association (NCAA) has its own listing for American collegiate athletes [21]. (See "Use of androgens and other hormones by athletes", section on 'Banned drugs'.)

Expectorants (eg, guaifenesin) are typically well-tolerated and can help to loosen and thin mucus production. Antihistamines, antitussives, and oral decongestants can have side effects that are harmful for athletes (table 1):

Use of first-generation antihistamines (eg, diphenhydramine) can increase risk of heat illness and dehydration due to anticholinergic effects. They can also cause sedation. Second-generation antihistamine formulations are less sedating but can still be dehydrating. Athletes may be more susceptible to injury when using sedating medications.

Some antitussives (eg, dextromethorphan) may cause fatigue and should be used with caution in athletes.

Oral decongestants are associated with a risk of dehydration and hyperthermia in athletes [3].

Bronchodilators may be needed for short-term relief of URI-associated bronchospasm. Occasional use of an inhaled, short-acting beta-agonist is usually all that is required. Athletes and coaches should note that beta-agonists are not permitted in some sports due to their potential ergogenic effects. If the need for treatment with such medications persists, they should check with the organizations that supervise drug testing for their sport. The management of exercise-related bronchoconstriction is discussed in greater detail separately. (See "Exercise-induced bronchoconstriction".)

Medication and competition — Unless necessary, we do not start new medications one or two days prior to competition as side effects cannot always be predicted. Other medications we avoid in competition include (table 1):

Antipyretics – These should not be used to mask fevers in order to allow participation.

Sedating medications – These may make the athlete more susceptible to injury from decreased alertness. (See 'Medications used for symptom relief' above.)

Adjunctive medications – Those that contain banned substances should not be used. (See 'Medications used for symptom relief' above.)

Some question exists whether antibiotics cause fatigue. When possible, we time the prescription of antibiotics as far from competition as possible. (See 'Antibiotics' above.)

CLEARANCE FOR SPORTS

General participation — Athletes with mild, viral upper respiratory tract infections (URTIs) not involving coronavirus disease 2019 (COVID-19) or other highly contagious pathogens can continue to play as long as they feel able (algorithm 1) [22]. Athletes may be more susceptible to dehydration during or after a URTI. For this reason, we advise athletes to stay well-hydrated after returning to play, particularly if the athlete plans on participating in their sport/activity at high altitude or in adverse weather conditions [23].

Athletes with pre-existing conditions and/or moderate to severe illness (fever or systemic symptoms) may need to refrain from play until such symptoms have resolved. There may be particular considerations for return to play in specific situations. (See 'Special circumstances' below and 'Preventing spread of infection' below.)

Criteria — Clinicians can use the "neck check" as a way to determine if athletes can return to play immediately or not (algorithm 1).

Passes the neck check The "neck check" is a widely used screening method for determining appropriateness for participation in sports while ill [3]. Athletes may return to sport if their symptoms are all "above the neck" (eg, rhinorrhea or sore throat) [24]. If there are symptoms present "below the neck" (eg, fever, malaise, chest congestion, or gastrointestinal symptoms), athletes should be kept from participation until symptoms have resolved. Cough may be an "above" or "below" the neck symptom depending on its etiology. For example, if cough is from post-nasal drip, it is "above the neck," but if from pneumonia, it is "below the neck."

Fever or systemic signs (presumed viral illness) When fever or other systemic signs of illness are present from presumed viral illness, the athlete should refrain from exercise. Clearance is contingent on the athlete testing negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), afebrile, off antipyretics for a minimum of one day, well-hydrated, and feeling physically ready to return to sport.

Athletes with viral illnesses should also refrain from exercise if he or she has unexplained sinus tachycardia. Unexplained sinus tachycardia may be the only sign of myocarditis, an uncommon complication of URTI caused by certain viruses (historically, the most common of which included coxsackie B virus, adenovirus, and Epstein-Barr virus (table 2)). Potential cardiac involvement of SARS-CoV 2 is discussed separately. (See "COVID-19: Cardiac manifestations in adults" and "COVID-19: Clinical manifestations and diagnosis in children".)

Athletes with unexplained sinus tachycardia following viral URTI should be evaluated promptly if they develop symptoms or signs of myocarditis (table 3). (See "Myocarditis: Causes and pathogenesis", section on 'Viral or "idiopathic" myocarditis' and "Clinical manifestations and diagnosis of myocarditis in children", section on 'Clinical manifestations'.)

Bacterial illness – Athletes being treated for bacterial illnesses should be afebrile off antipyretics and on antibiotics for at least 24 hours prior to returning to activity. They should also be well-hydrated and feel physically ready to return to play.

Transition back to play — Transition back to play depends on the anatomic location, severity of illness, and resolution of symptoms [25]. Return to play following COVID-19 infection is discussed separately. (See "COVID-19: Return to sport or strenuous activity following infection".)

Returning after passing the "neck check" If an athlete passes the "neck check," they should be counseled to initially attempt only 10 to 15 minutes of light exercise or training. If they feel well during this initial trial, they may proceed with exercise as tolerated. Anecdotally, some athletes report that light exercise provides symptomatic relief and an opportunity to clear the sinuses and airways of phlegm and mucus. If an athlete is not able to tolerate light exercise, they should rest and try again the following day.

Returning after non-COVID-19 fever or systemic illness When the athlete returns to play, they should start with light activity and follow a graded return to play based on their response [9]. Typically, the sequence of training increments should be increasing frequency first, then duration, and finally, intensity of exercise. The exact time course will depend on the severity and duration of the underlying infection. A general rule is for every day missed due to illness, the athlete needs two to three days of graded return (eg, if an athlete misses two days of practice due to illness, they should gradually increase activity over four to six days until they are back to normal practice). Increments in training volume and intensity should be limited to approximately 10 percent at a time to avoid overexertion in the early phase of return.

In certain situations, it may be appropriate to allow modified participation in sport while an athlete recovers from a URTI. For example, the athlete may be allowed to shoot free throws at basketball practice away from the team if they are afebrile but still recovering from "below the neck" symptoms.

Return to competition — Clearance for competition is the same as for general sports participation. Athletes with mild viral URTIs can compete as long as they feel able. An athlete should be held from competition if they have fever or systemic signs of illness in order to prevent more significant illness and avoid the spread of disease. Fever, hypoxia, and dehydration are absolute contraindications to participation. Relative contraindications include the athlete not feeling physically able to participate and infection with an illness that is highly contagious (eg, influenza or pertussis). (See 'General participation' above and 'Influenza' below and 'Pertussis' below.)

Special circumstances

COVID-19 — The presentation and management of athletes infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) do not differ from the general population. (See "COVID-19: Clinical features" and "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "COVID-19: Management of adults with acute illness in the outpatient setting".)

Return to play following COVID-19 infection is discussed separately. (See "COVID-19: Return to sport or strenuous activity following infection".)

Infectious mononucleosis — Return to sports after infectious mononucleosis is discussed elsewhere. (See "Infectious mononucleosis", section on 'Return to sports'.)

Underlying respiratory conditions — The athlete with poorly-controlled underlying respiratory conditions, such as asthma or chronic obstructive pulmonary disease, should seek the advice of their clinician before reinitiation of activity. (See "An overview of asthma management" and "Chronic obstructive pulmonary disease: Diagnosis and staging".)

SCUBA diving — Athletes need to be clear of URTI symptoms for a minimum of 10 days prior to resuming SCUBA diving due to the risk of hypercarbia and lung injury/pneumothorax during ascent. It is also a contraindication to dive with ruptured tympanic membranes [26,27]. (See "Complications of SCUBA diving", section on 'Barotrauma'.)

PREVENTION

Preventing spread of infection — Upper respiratory tract infections (URTIs) are often very contagious and may spread through athletic teams quickly. Athletes with URTIs should follow precautions to help prevent spread of infection. Moreover, there are specific considerations to prevent the spread of infection for influenza and pertussis.

General measures — Implementing simple precautions can minimize the spread of URTI among athletic teams [28]:

Hand hygiene can reduce transmission of organisms (table 4). (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Hand hygiene'.)

All team members should be educated on the importance of coughing etiquette and disposal of soiled tissues. Patient information flyers are available from the Centers for Disease Control and Prevention. Sharing of personal items such as towels, drinks, and sporting equipment should be discouraged.

An athlete with infection should be isolated from team members and the general public when possible. This includes during meals, transport, and for competitions, at both accommodations and sporting venues. Some teams and sporting groups organize spare accommodations and separate meal rooms from the general public.

Influenza — Influenza infections are highly contagious and can spread quickly through a team's roster if left unattended. We test for influenza in athletes with an influenza-like illness who participate in competitive team sports. Rapid point-of-care analyzers can be used for this process [29]. If an athlete tests positive for influenza, prophylaxis for close contacts, particularly during competitions, may be reasonable to prevent further spread of the disease [30]. (See "Seasonal influenza in children: Clinical features and diagnosis", section on 'Diagnosis' and "Seasonal influenza in children: Prevention with antiviral drugs" and "Seasonal influenza in children: Management", section on 'Antiviral therapy' and "Seasonal influenza in adults: Clinical manifestations and diagnosis" and "Seasonal influenza in adults: Role of antiviral prophylaxis for prevention" and "Seasonal influenza in nonpregnant adults: Treatment".)

Those athletes with influenza should be isolated from others on the team and only allowed to return to participation after symptom resolution. The athlete must be afebrile off antipyretics for a minimum of one day, well-hydrated, and free of any myalgias or systemic symptoms. (See "Seasonal influenza in nonpregnant adults: Treatment", section on 'Infection control and returning to work/school'.)

Once an index influenza case has been confirmed, it remains important to test subsequent cases for both influenza and SARS-CoV-2, as symptoms are similar. Athletes should receive the influenza and COVID-19 vaccines to minimize the risks posed by these illnesses. (See 'Immunizations' below.)

COVID-19 — The presentation and management of athletes infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) do not differ from the general population and are reviewed in detail in several topics, including those that follow. (See "COVID-19: Clinical features" and "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "COVID-19: Management of adults with acute illness in the outpatient setting".)

Pertussis — For athletes with confirmed pertussis, we agree with the American College of Chest Physicians recommendations that they be isolated for the first five days of antibiotic treatment [31]. Teammates and coaches should receive post-exposure prophylaxis. (See "Pertussis infection in adolescents and adults: Treatment and prevention" and "Pertussis infection in adolescents and adults: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Immunizations — Immunizations schedules should typically follow recommendations for the general population. For athletes, the timing of vaccine administration should be planned with the goal of minimizing any adverse effect on training and competition [32]. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

When possible, vaccines should be administered at the onset of a rest period from training and competition [32,33]. If vaccination within a training and/or competition period cannot be avoided, we administer the vaccine shortly after a competition to provide as long of a period of time until the next competition as possible. After immunizations, exercise intensity should be transiently decreased if an athlete feels unwell, or is inconvenienced by pain and soreness at or around the injection site. Side effects from inactivated vaccines can be expected within the first two days after vaccination, while side effects are typically seen approximately 10 to 14 days after receiving live attenuated vaccines [33].

It is essential to know the athlete's travel schedule during the season. Early preparation will allow time for the athlete to be immunized as appropriate. (See "Immunizations for travel".)

Overtraining syndrome — Almost every athlete feels the effects of fatigue at some point in training and competition. However, some athletes may develop overtraining syndrome, which can lead to recurrent respiratory infections. Measures to prevent overtraining syndrome are discussed separately. (See "Overtraining syndrome in athletes", section on 'Clinical presentation' and "Overtraining syndrome in athletes", section on 'Prevention measures'.).

Nutrition — Immune function can be compromised with micronutrient deficiencies (eg, zinc) in the general population, but this is less likely in trained athletes who consume a well-balanced diet. Some athletes struggle to maintain good dietary practices, and may benefit from nutritional supplementation [34]. However, adolescent athletes in particular may have limited or inaccurate knowledge and information about supplements [35]. Dietary review with a registered dietitian is useful in identifying athletes with poor dietary practices, and in developing sports-specific strategies. (See "Overview of dietary trace elements", section on 'Deficiency'.)

There is little evidence to support the use of nutritional supplements (eg, vitamin supplements or probiotics) in preventing URTI in athletes [36]. Additionally, supplements may be contaminated with banned substances. (See "The common cold in adults: Treatment and prevention", section on 'Prevention'.)

SUMMARY AND RECOMMENDATIONS

Epidemiology – Upper respiratory tract infections (URTIs) are the most common type of infection among athletes. (See 'Epidemiology' above.)

Evaluation – The evaluation of athletes for the various etiologies of upper respiratory tract infections (URTIs) is the same as for the general population. (See 'Evaluation' above.)

Treatment – In general, treatment strategies and medications for upper respiratory tract illnesses in athletes should be the same as for nonathletes. There are some specific considerations for athletes regarding choice of antibiotics and medications used for symptom relief (table 1). (See 'Antibiotics' above and 'Medications used for symptom relief' above.)

Return to play – Athletes with mild viral URTIs not involving highly contagious or dangerous pathogens can continue to play and compete if they feel able (algorithm 1). Athletes with pre-existing conditions and/or moderate to severe illness (fever or systemic symptoms) may need to refrain from play until such symptoms have resolved. There may be particular considerations for return to play in certain situations. (See 'General participation' above and 'Special circumstances' above and 'Influenza' above and 'Pertussis' above.)

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Topic 13806 Version 17.0

References

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