Antibiotic Medications for Infections in Athletes:

which to use or not to use?

Prof Wayne DermanMBChB,BSc (Med)(Hons) PhD, FFIMS

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Clinical questions team physicians encounter

regarding antibiotic treatment

• What are the most common infections

encountered in a team setting?

• What are the other considerations regarding

prescribing antibiotics?

• Clinical recommendations?

4 Alaranta et al., Int. J Sports Med, 2006.

Factors to take into account when considering

antibiotic therapy

• Most “infections” we

encounter are not bacterial

• Likelihood of specific

causative pathogen

• Susceptibility

• Dosing frequency

• Mode of administration

• Allergies

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Resp/ENT: Causative Organisms

Viruses (over 200) Bacteria Idiopathic

Rhinovirus Group A Streptococcus *(No organism isolated)*

Corona virus Bordetella Pertussis

Influenza & Parainfluenza virus Corynaebacterium Diphtheria

Respiratory Syncytial Virus

Adenovirus

Enterovirus

Bacterial vs Viral can you tell?

• Moderate indicators:– Typical examination

– Fever higher in bacterial

– Fever gets worse few days in

– Symptoms persist longer than expected (10-14 days)

– Localized (Sinusitis, ear, lung).

– Full blood count

Good indicators:

Swab for MC&S

Specific blood tests: ASO, EBV, H1N1

New tests? CRP? Rapid PCR?

Bacterial vs Viral can you tell?

• Moderate indicators:– Typical examination

– Fever higher in bacterial

– Fever gets worse few days in

– Symptoms persist longer than expected (10-14 days)

– Localized (Sinusitis, ear, lung).

– Full blood count

Good indicators:

Swab for MC&S

Specific blood tests: ASO, EBV, H1N1

New tests? CRP? Rapid PCR?

• The diagnosis of nonspecific upper respiratory tract infection should be used to denote an acute infection in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent.

• These infections are predominantly viral in origin, and complications are rare.

• Antibiotics should not be used to treat nonspecific upper respiratory tract infections in previously healthy adults.

• Purulent secretions from the nares or throat do not predict bacterial infection or benefit from antibiotic treatment.

• Antibiotic treatment of adults with non-specific upper respiratory tract infections does not enhance illness resolution or prevent complications.

Snow et al., Annals Internal Medicine: 134, 2011

• Toxins: – ETEC (entero-toxic E Coli - principal cause of

traveler’s diarrhea

• Infective:– Viral (norovirus, rotavirus)

– Bacterial (Eschericia Coli, Camplyobacter jejuni, Shigella, Clostridium difficile)

– Parasitic (Giardia lamblia, Entamoebahistolytica)

Infectious “traveller’s” diarrheaMore common pathogens

Simple travellers diarrhea • > 2 lose stools in 24hrs• Other symptoms: nausea, vomiting, mild intermittent abdominal

cramping • No fever or blood in stools

Significant travellers diarrhea • As for simple travellers diarrhea and >1 of the following:• Temperature > 37oC• Blood in stools• Constant or severe abdominal pain• Rebound and/or guarding

Infectious “traveller’s” diarrheaClinical features - classification

Tillett et al, BJSM, 2009, 1045-1048

Infectious “traveller’s” diarrheaPharmacological treatment

Drug Dose Notes

Ciprofloxacin 500mg bd. for 3 days

Risk of tendon injury, rupture (NB: Athletes)

Levofloxacin 500mg qds. for 3 days

Risk of tendon injury, rupture (NB: Athletes)

Azithromycin 1000mg single dose

Nausea, effective against invasive forms (bloody stool and fever), risk of arrthymia (NB: Athletes)

Rifaximin (Xifaxin)

200mg tds. For 3 days

Not effective against invasive forms (bloody stool and fever) ? Athletes

Du Pont, Alim Pharm Ther, 2009, 187-196

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Tendon injuries

• 2002 – Flouroquinolones most commonly prescribed class of

antibiotic in US adult population.

• Increasing association with Achilles tendon

• 2008 – black box warning of Achilles tendinopathy and rupture

• 3-6x increased risk of tendon problems or rupture

• Absolute risk of 7.74 per 100.000 days at risk and 3.2 /1000 patient

years

• Mechanism free radical & toxin damage to watershed area of the

tendon, remodeling of tendon and matrix disorder

• Association with increased age and corticosteroid use

• Discuss risk, alternate drugs.

• Tendinopathy can be a complication of treatment with

fluoroquinolone antibiotics and usually is linked with 1 or more

synergistic factors.

• Symptoms of fluoroquinolone-related tendinopathy can present

within hours of starting treatment or up to 6 months after ceasing

treatment, and recovery can be slower and require a less

aggressive approach early in rehabilitation than for other types of

tendinopathy.

• Treatment with fluoroquinolones should be discontinued and

treatment with a nonquinolone antibiotic should be considered in

patients who present with tendinopathy.

• Clinicians, athletes, athletic trainers, and medical support teams

should be aware of and alert to the potential adverse effects of

fluoroquinolones.

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Antibiotic prescription Risk of serious arrhythmia

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Amoxycillin Azithromycin Levofloxacin

Gowtham A, et al Ann Fam Med. 2014;12(2):121-127

Cardiac Arrhythmia

• Macrolides and fluoroquinalones may

be associated with an increased risk

of ventricular arrhythmia and cardiac

arrest

• Small increase number of

cardiovascular related deaths with

azithromycin

• Prolongation of QT interval by

erythromycin, clarythromycin and

moxifloxacin

• Mean increase in the QT interval

with fluoroquinolones is 3-6 ms little

clinical significance in N but might

place extra risk in those with long

QT syndrome

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Antibiotic- induced diarrhea

• Acutely or up to 3-4 wks after

initiation of antibiotic treatment

• Most common after broad

spectrum, enterobacteriaciae

• Proliferation of C.difficile or

impaired microflora

• Risk factors: duration, repeated

use or combination AB’s

• Minimum exposure, narrow

spectrum, probiotics

• Saccharomyces boulardii &

Lactobacillus rhamnosus

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Photosensitivity

• Photosensitivity : phototoxicity after single does or photoallergic –

an immune mediated response and requires re-exposure

• Tetracyclines – doxycyline (most), minocycline (rare;

hyperpigmentation 2-15%)

• Seen with 2 weeks of onset of treatment, dosage dependent

• Fluoroquinalones also cause photosensitivity (ciplofloxacin 1-4%).

Levofloxacin least

• Sulfonamides also; Stevens-Johnson syndrome

• If athlete is participating in outdoor events avoid photosensitizing

antibiotics or use anti-sun measures

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Other adverse effects to consider

• Tetracyclines staining teeth skin, sclera conjunctiva and

bone.

• Chelation & is reversible through remodeling.

• Teeth permanent

• Contraindicated in young athletes

• Fatigue and underperformance

• ? Effects of illness or drug

• Tetracycline, ampicillin and trimethoprim-sulfamethoxazole

to placebo over three days showed no effect on VO2max,

muscle strength, [CK], fatigue scores

• Higher fatigue with multiple antibiotics, tetracyclines 1,2%

with doxycycline, 23% with minocycline.

• Know your destination and the risks

• Develop a prevention strategy

• Education of athletes and officials

• Develop a clinical approach to diagnosis

• Develop a management approach

• Get to know 4-5 agents that you can use that work

for you

Prevention of Infections

fosfamycin

Kantrexil

Thank you for your attention!

Prof Wayne DermanMBChB,BSc (Med)(Hons) PhD, FFIMS