Participation in organized sports has a variety of health benefits but also has the potential to expose the athlete to a variety of infectious diseases, some of which may produce outbreaks. Major risk factors for infection include skin-to-skin contact with athletes who have active skin infections, environmental exposures and physical trauma, and sharing of equipment and contact with contaminated fomites. Close contact that is intrinsic to team sports and psychosocial factors associated with adolescence are additional risks. Minimizing risk requires leadership by the organized sports community (including the athlete’s primary care provider) and depends on outlining key hygiene behaviors, recognition, diagnosis, and treatment of common sports-related infections, and the implementation of preventive interventions.

The definition of organized sports includes traditional team sports commonly acknowledged as well as other types of sports (Table 1). Participation in organized sports provides the benefits of (1) physical activity, by engaging in vigorous exercise, achieving fitness, and learning athletic skills; (2) socialization, by experiencing camaraderie and learning teamwork and sportsmanship; and (3) competition, by challenging oneself to perform against others, by striving to continually improve oneself toward achieving one’s full athletic potential, and by learning to win and lose with grace and dignity.1 Organized sports participation, however, can result in the acquisition of a variety of infectious diseases and conditions. Physical contact among athletes, sharing of equipment (such as worn personal protective equipment or braces plus towels, drinking vessels, showers, and locker rooms), and contact with athletic surfaces (mats, artificial turf, dirt, grass, and gym or weight room equipment) can all be responsible for transmission of infection.2,9 In addition, certain organized sports carry specific additional risks; for example, wrestlers practicing in close quarters are especially vulnerable to skin infections.10,11 

TABLE 1

Examples of Organized Sports Involving North American Children

Traditional Team SportsOther Organized Sports
Baseball, softball, basketball, football, soccer, wrestling, ice hockey, field hockey, lacrosse, volleyball, tennis, swimming and diving, track and field, cross country, gymnastics Cheerleading, dance, martial arts, strength training, weightlifting, cycling, skiing, snowboarding, ultimate frisbee, boxing, figure skating, golf, skateboarding, distance running 
Traditional Team SportsOther Organized Sports
Baseball, softball, basketball, football, soccer, wrestling, ice hockey, field hockey, lacrosse, volleyball, tennis, swimming and diving, track and field, cross country, gymnastics Cheerleading, dance, martial arts, strength training, weightlifting, cycling, skiing, snowboarding, ultimate frisbee, boxing, figure skating, golf, skateboarding, distance running 

Athletes should be taught proper personal hygiene (eg, hand-washing, showering, and proper laundering of uniforms and practice clothing on a daily or regular basis).12,15 Avoidance of sharing of drinking vessels (water bottles, ladles, or cups), mouth guards, towels, braces, batting helmets, personal protective equipment, bars of soap, bath sponges, razors or electric hair shavers, and callus trimmers is also important in reducing infectious risk.2,9 In addition, athletic programs should ensure regular (daily, weekly, and monthly) cleaning of facilities and equipment (eg, weight room, railings, mats, blocking dummies, locker rooms, and showers).16,19 Those who manage sports programs and facilities should develop a plan for proper cleaning and maintenance of a sanitary sporting environment by using guidelines such as those published by the American College of Sports Medicine.20 

Special attention should be paid to proper management of blood and other body fluids.21 Just as hospitals in the United States have concentrated on preventing hospital-associated infections in recent years, the same level of focus on infection prevention and control needs to be present within the organized sports community, including among athletes, parents, coaches, athletic directors, equipment managers, certified athletic trainers, administrators, janitorial staff, team physicians, facility managers, and league officials.

Although the primary care pediatrician may appear to be peripheral in this athletic milieu of organized sports, leadership from physicians has always been welcome and expected regarding issues of public health and safety. Furthermore, because pediatricians need to provide medical clearance to athletes to participate in organized sports, the preparticipation physical examination is an opportunity to verify that the athlete does not have a skin condition or infection that could be transmitted to others. This visit between the physician and the student athlete allows the primary care pediatrician to deliver anticipatory guidance. Ensuring that immunizations are current per recommendations of the Centers for Disease Control and Prevention, the Advisory Committee on Immunization Practices, and the American Academy of Pediatrics is important, and pediatric providers should identify and document cases in which vaccines are refused or incomplete because of medical exemptions (eg, serious allergy to a vaccine component). Coaches and trainers are primarily responsible for reviewing and stressing to the athlete the key hygiene behaviors needed to minimize the risk of obtaining or spreading infection in organized sports. However, primary care pediatricians can help reinforce such educational messages.

An athlete can acquire many different infections by participating in organized sports. The pathogens include many that are prominent in outbreaks typically seen in crowded communities or closed community settings or that are facilitated by certain exposures specific to the sport.

Infectious pathogens include those spread by skin contact (eg, Staphylococcus aureus, group A streptococcal skin infections, Bacillus cereus, herpes simplex virus [HSV], Tinea capitis, Tinea corporis, Tinea pedis, Tinea cruris, Pediculosis capitis, Pediculosis corporis, and Pediculosis pubis), by contaminated food or water (eg, Shiga-toxin producing Escherichia coli, Shigella species, Giardia species, Cryptosporidium species, and norovirus, which is further propagated by the person-to-person route), by respiratory droplet (eg, influenza, pertussis, Neisseria meningitidis, group A streptococcal pharyngitis, mumps), by airborne particles (eg, varicella, measles), or by certain vectors (eg, ticks) (Table 2). In the case of Epstein-Barr virus infection, close contact is required for transmission, and endemic disease within adolescent group settings has been reported (Table 2). Although biologically plausible, there have been no validated reports of infections from transmission of bloodborne pathogens, including hepatitis B, hepatitis C, or HIV during athletic competitions. Nonetheless, the American Academy of Pediatrics has previously issued specific detailed guidelines for management of infections spread by blood and body fluids, including guidance for athletes who are infected with HIV, hepatitis B virus, or hepatitis C virus, and these will not be reiterated in this statement.21 

TABLE 2

Summary of Epidemiology and Outbreak Management Considerations for Organisms Responsible for Infections in Children Participating in Organized Sports

Pathogens Primarily Transmitted by Contact Sports
Pathogen or DiseaseTransmissionRisk FactorsRn, Dx, TxPreventionOutbreaks and Other Considerations
S aureus including MRSA22  Contact Contact sports, wounds (turf injuries in football or soccer), wrestling, rugby, judo, and gymnastic mats, sharing equipment Rn: folliculitis, skin abscess, cellulitis, impetigo Good personal hygiene, wound care, avoid sharing equipment, refrain from use of common tubs, cosmetic shaving, cleaning of high-touch surfaces Involve public health authorities for outbreaks 
Dx: Gram-stain, culture of lesions Topical mupirocin depending on susceptibilities 
Tx: cephalexin, TMP/SMX, or doxycycline based on susceptibility for 10 d — 
GABHS23  Contact, droplet Skin contact in impetigo/erysipelas, droplet in pharyngitis Rn: impetigo, erysipelas, pharyngitis, cellulitis Good hygiene, not sharing water bottles, equipment Topical mupirocin if limited skin lesions 
Dx: rapid antigen detection test for GABHS if sore throat and no viral symptoms, Gram-stain, culture of lesions Azithromycin for serious penicillin allergy 
Rx: treat if positive; culture skin lesions with amoxicillin or penicillin; if penicillin allergic, macrolide; all for 10 d except azithromycin for 5 d — 
B cereus24  Contact, contaminated food Sharing sunscreen, penetrating trauma, contaminated environment Rn: honey-crusted skin lesions; rarely, necrotizing fasciitis: if contaminated food, nausea, vomiting, diarrhea, and cramps Good personal hygiene, avoid sharing equipment, sunscreen Involve public health authorities for outbreaks24,25  
Dx: Gram-stain, culture of lesions, identification of enterotoxin from food if contaminated food 
Rx: usually IV vancomycin or linezolid for severe skin infections, supportive for foodborne 
HSV26  Contact with infected individual; reactivation 1° infection Skin contact, wrestling, abraded skin, sun induced (eg, skiing) Rn: cropped vesicles Valacyclovir prophylaxis, proper cleaning equipment Identification and isolation of infected people 
Dx: viral PCR of skin lesion Valacyclovir 
Rx: adolescents-valacyclovir for 7 d — 
Molluscum contagiosum27  Contact Sharing towels, underlying eczema Rn: pearly papule with central umbilication Avoid skin contact with infected people; no specific treatment is uniformly efficacious Outbreaks have been reported 
DX: clinical 
Rx: 10% KOH, cryotherapy 
T capitis (T tonsurans),28T corporis29  Contact Skin contact, wrestlers, judo practitioners Rn: scaly plaque, alopecia In settings of high infection rates, in consultation with infectious diseases expert, consider fluconazole prophylaxis, 100 mg, once daily for 3 d, at season onset and repeat in 6 wk30  Griseofulvin contraindicated in pregnancy 
Dx: KOH prep, culture Topical for limited area T corporis 
Rx: oral itraconazole, terbinafine, griseofulvin ±1% terbinafine gel or 2% ketoconazole cream — 
T pedis31  Contact Common shower, skin contact, swimmers, skaters, marathon runners Rn: scaly, itchy eruption on feet Good personal hygiene — 
Dx: KOH prep, culture Foot powder after bathing 
Rx: children 12 y or older – topical 0.77% ciclopirox cream or gel BID for 4 wk, 1% terbinafine gel OD for 1 wk, naftifine ointment BID for 4 wk. Oral terbinafine for 1 wk Careful drying between toes after showers 
Daily change of socks 
Periodic cleaning of footwear 
T cruris32  Contact Heat, humidity, hyperhidrosis, contaminated towels, hotel bedroom sheets Rn: scaly, itchy eruption in groin area Wear socks before undershorts if T pedis present — 
Dx: KOH prep, culture Dry crural folds after bathing 
Rx: children 12 y or older, 1% terbinafine gel OD for 1 wk Use separate towel to dry groin and other parts of body 
Verruca vulgaris (caused by subtypes of HPV33Contact Wrestlers, sharing of equipment, bare feet in common shower areas Rn: painless warts on hands and feet and under nails, firm hyperkeratotic papules Avoid contact with known infected people, no sharing of equipment and towels; wear rubber soled flip-flops or sandals in communal showers34  — 
Dx: clinical 
Rx: none or curettage, liquid nitrogen, laser removal or application of salicylic acid 
S scabiei (scabies)35  Contact Wrestlers Rn: ++ pruritic rash, interdigital webs — Evaluate sparring partners; treat suspected cases 
Dx: Itching is attributable to hypersensitivity reaction and may not subside for weeks; not indication of treatment failure 
Rx: topical permethrin 5% cream to whole body below neck (not pregnant women), remove by bathing after 8–14 h; oral ivermectin, 2 doses 1 wk apart for children >15 kg (not FDA-approved and not for pregnant girls), 10% crotamiton cream or lotion, or precipitated sulfur 4%–8% — 
Pediculus capitis36 (head lice) Contact Sharing clothing, equipment Rn: visible lice on hair shaft, pruritus Although risk of spread is low, sharing of combs, hair brushes, hats, and hair ornaments is not recommended37  Clearance by health care professional before resuming sport 
Dx: clinical: seeing nits, nymphs, or adult lice with naked eye or hand lens No need to treat contacts prophylactically Rinse hair after topical pediculicide application over a sink rather than shower or bath to limit skin exposure, and use warm water instead of hot to limit absorption resulting from vasodilatation 
Rx: manual removal of nits by fine-toothed combing. Start with over-the-counter topical 1% permethrin lotion or pyrethrin combined with piperonyl butoxide; repeat in 7 d; resistance reported, see text for options — — 
Infectious mononucleosis caused by Epstein-Barr virus38  Close contact Adolescent group settings Rn: exudative pharyngitis, splenomegaly; serum antibody panel Counsel regarding close contact and avoiding sharing drinks, utensils Avoid contact sports until recovered and spleen no longer palpable (typically ∼3–4 wk) 
Dx: heterophile antibody test (>4 y of age), IgM antibodies versus viral capsid antigen, Epstein-Barr nuclear antigen 
Rx: supportive 
Pathogens primarily transmitted by airborne route 
 Varicella39  Skin, airborne Close community contact Rn: crops of papules, vesicles, crusts; can be confused with HSV Ensure ACIP/AAP-recommended varicella vaccine is given39  Ensure previous 2 doses of vaccine or history of disease for all exposed people 
Dx: PCR of vesicular fluid Avoid salicylates during infection 
Rx: usually none, oral acyclovir or valacyclovir for 7 d — 
 Measles (rubeola)40  Droplet, airborne International venues, underimmunized populations Rn: febrile prodrome, morbilliform rash Ensure ACIP/AAP-recommended MMR vaccine is given Involve public health authorities for single case 
Dx: PCR of urine and nasopharyngeal specimens, rubeola serology 
Rx: supportive 
Pathogens primarily transmitted by droplet route 
 Mumps41  Droplet Crowded settings, underimmunized populations Rn: parotitis Ensure ACIP/AAP-recommended MMR vaccine is given Involve public health authorities for single case 
Dx: PCR of saliva, serology 
Rx: supportive 
 Influenza42  Droplet Close community contact Rn: febrile upper respiratory tract during influenza season Ensure ACIP/AAP-recommended influenza vaccine is given seasonally Prioritize treatment of those who have increased risk for influenza complications (eg, asthma, heart and/or lung disorders, metabolic disorders, immune compromised) 
Dx: culture, rapid molecular tests 
Rx: oseltamivir if identified in first 2 d, for 5 d 
 Pertussis43  Droplet Close community contact Rn: paroxysmal cough for ≥2 wk Ensure ACIP/AAP-recommended Tdap is given; identify and intervene with chemoprophylaxis in outbreaks Involve public health authorities for outbreaks (>2 cases in closed population) 
Dx: PCR of nasopharyngeal swab specimen 
Rx: azithromycin for 5 d 
N meningitidis44  Droplet Close community contact Rn: bacteremic presentation, shock, purpura Ensure ACIP/AAP-recommended meningococcal conjugate ACWY vaccine is given Involve public health authorities for single case; if serogroup B involved, meningococcal B vaccine 
Dx: Gram-stain, culture 
Rx: begin with intravenous cefotaxime or ceftriaxone; penicillin once diagnosis confirmed 
Pathogens primarily transmitted by contaminated food or water route 
Shigella45  Contaminated food or water; person to person Commonly attended event, restaurant related Rn: diarrhea, blood Hand hygiene Involve public health authorities for outbreaks 
Dx: culture stool 
Rx: TMP/SMX, ciprofloxacin depending on susceptibilities 
Giardia46  Contaminated food or water Public pools, swimmers Rn: watery diarrhea Hand hygiene — 
Dx: stool antigen test 
Rx: metronidazole or nitazoxanide 
Cryptosporidia47  Contaminated food or water Public pools, swimmers Rn: watery diarrhea Hand hygiene — 
Dx: stool examination 
Rx: nitazoxanide 
 Norovirus48  Contaminated food or water; person to person Common environment Rn: abrupt onset of vomiting, watery diarrhea Hand hygiene Involve public health authorities for outbreaks 
Dx: clinical RT-PCR 
Rx: supportive 
 Leptospirosis49  Contaminated water Triathletes,50 fresh water swimming, skin wounds Rn: fever and headache, myalgia (can mimic influenza) Swimmers avoid immersion or swallowing potentially contaminated water — 
Dx: enzyme-linked immunosorbent assay IgM Protective clothing, boots in contaminated water 
Rx: intravenous penicillin G first choice, risk of Jarish-Herxheimer reaction; also cefotaxime, ceftriaxone and doxycycline; supportive care — 
Pathogens Primarily Transmitted by Contact Sports
Pathogen or DiseaseTransmissionRisk FactorsRn, Dx, TxPreventionOutbreaks and Other Considerations
S aureus including MRSA22  Contact Contact sports, wounds (turf injuries in football or soccer), wrestling, rugby, judo, and gymnastic mats, sharing equipment Rn: folliculitis, skin abscess, cellulitis, impetigo Good personal hygiene, wound care, avoid sharing equipment, refrain from use of common tubs, cosmetic shaving, cleaning of high-touch surfaces Involve public health authorities for outbreaks 
Dx: Gram-stain, culture of lesions Topical mupirocin depending on susceptibilities 
Tx: cephalexin, TMP/SMX, or doxycycline based on susceptibility for 10 d — 
GABHS23  Contact, droplet Skin contact in impetigo/erysipelas, droplet in pharyngitis Rn: impetigo, erysipelas, pharyngitis, cellulitis Good hygiene, not sharing water bottles, equipment Topical mupirocin if limited skin lesions 
Dx: rapid antigen detection test for GABHS if sore throat and no viral symptoms, Gram-stain, culture of lesions Azithromycin for serious penicillin allergy 
Rx: treat if positive; culture skin lesions with amoxicillin or penicillin; if penicillin allergic, macrolide; all for 10 d except azithromycin for 5 d — 
B cereus24  Contact, contaminated food Sharing sunscreen, penetrating trauma, contaminated environment Rn: honey-crusted skin lesions; rarely, necrotizing fasciitis: if contaminated food, nausea, vomiting, diarrhea, and cramps Good personal hygiene, avoid sharing equipment, sunscreen Involve public health authorities for outbreaks24,25  
Dx: Gram-stain, culture of lesions, identification of enterotoxin from food if contaminated food 
Rx: usually IV vancomycin or linezolid for severe skin infections, supportive for foodborne 
HSV26  Contact with infected individual; reactivation 1° infection Skin contact, wrestling, abraded skin, sun induced (eg, skiing) Rn: cropped vesicles Valacyclovir prophylaxis, proper cleaning equipment Identification and isolation of infected people 
Dx: viral PCR of skin lesion Valacyclovir 
Rx: adolescents-valacyclovir for 7 d — 
Molluscum contagiosum27  Contact Sharing towels, underlying eczema Rn: pearly papule with central umbilication Avoid skin contact with infected people; no specific treatment is uniformly efficacious Outbreaks have been reported 
DX: clinical 
Rx: 10% KOH, cryotherapy 
T capitis (T tonsurans),28T corporis29  Contact Skin contact, wrestlers, judo practitioners Rn: scaly plaque, alopecia In settings of high infection rates, in consultation with infectious diseases expert, consider fluconazole prophylaxis, 100 mg, once daily for 3 d, at season onset and repeat in 6 wk30  Griseofulvin contraindicated in pregnancy 
Dx: KOH prep, culture Topical for limited area T corporis 
Rx: oral itraconazole, terbinafine, griseofulvin ±1% terbinafine gel or 2% ketoconazole cream — 
T pedis31  Contact Common shower, skin contact, swimmers, skaters, marathon runners Rn: scaly, itchy eruption on feet Good personal hygiene — 
Dx: KOH prep, culture Foot powder after bathing 
Rx: children 12 y or older – topical 0.77% ciclopirox cream or gel BID for 4 wk, 1% terbinafine gel OD for 1 wk, naftifine ointment BID for 4 wk. Oral terbinafine for 1 wk Careful drying between toes after showers 
Daily change of socks 
Periodic cleaning of footwear 
T cruris32  Contact Heat, humidity, hyperhidrosis, contaminated towels, hotel bedroom sheets Rn: scaly, itchy eruption in groin area Wear socks before undershorts if T pedis present — 
Dx: KOH prep, culture Dry crural folds after bathing 
Rx: children 12 y or older, 1% terbinafine gel OD for 1 wk Use separate towel to dry groin and other parts of body 
Verruca vulgaris (caused by subtypes of HPV33Contact Wrestlers, sharing of equipment, bare feet in common shower areas Rn: painless warts on hands and feet and under nails, firm hyperkeratotic papules Avoid contact with known infected people, no sharing of equipment and towels; wear rubber soled flip-flops or sandals in communal showers34  — 
Dx: clinical 
Rx: none or curettage, liquid nitrogen, laser removal or application of salicylic acid 
S scabiei (scabies)35  Contact Wrestlers Rn: ++ pruritic rash, interdigital webs — Evaluate sparring partners; treat suspected cases 
Dx: Itching is attributable to hypersensitivity reaction and may not subside for weeks; not indication of treatment failure 
Rx: topical permethrin 5% cream to whole body below neck (not pregnant women), remove by bathing after 8–14 h; oral ivermectin, 2 doses 1 wk apart for children >15 kg (not FDA-approved and not for pregnant girls), 10% crotamiton cream or lotion, or precipitated sulfur 4%–8% — 
Pediculus capitis36 (head lice) Contact Sharing clothing, equipment Rn: visible lice on hair shaft, pruritus Although risk of spread is low, sharing of combs, hair brushes, hats, and hair ornaments is not recommended37  Clearance by health care professional before resuming sport 
Dx: clinical: seeing nits, nymphs, or adult lice with naked eye or hand lens No need to treat contacts prophylactically Rinse hair after topical pediculicide application over a sink rather than shower or bath to limit skin exposure, and use warm water instead of hot to limit absorption resulting from vasodilatation 
Rx: manual removal of nits by fine-toothed combing. Start with over-the-counter topical 1% permethrin lotion or pyrethrin combined with piperonyl butoxide; repeat in 7 d; resistance reported, see text for options — — 
Infectious mononucleosis caused by Epstein-Barr virus38  Close contact Adolescent group settings Rn: exudative pharyngitis, splenomegaly; serum antibody panel Counsel regarding close contact and avoiding sharing drinks, utensils Avoid contact sports until recovered and spleen no longer palpable (typically ∼3–4 wk) 
Dx: heterophile antibody test (>4 y of age), IgM antibodies versus viral capsid antigen, Epstein-Barr nuclear antigen 
Rx: supportive 
Pathogens primarily transmitted by airborne route 
 Varicella39  Skin, airborne Close community contact Rn: crops of papules, vesicles, crusts; can be confused with HSV Ensure ACIP/AAP-recommended varicella vaccine is given39  Ensure previous 2 doses of vaccine or history of disease for all exposed people 
Dx: PCR of vesicular fluid Avoid salicylates during infection 
Rx: usually none, oral acyclovir or valacyclovir for 7 d — 
 Measles (rubeola)40  Droplet, airborne International venues, underimmunized populations Rn: febrile prodrome, morbilliform rash Ensure ACIP/AAP-recommended MMR vaccine is given Involve public health authorities for single case 
Dx: PCR of urine and nasopharyngeal specimens, rubeola serology 
Rx: supportive 
Pathogens primarily transmitted by droplet route 
 Mumps41  Droplet Crowded settings, underimmunized populations Rn: parotitis Ensure ACIP/AAP-recommended MMR vaccine is given Involve public health authorities for single case 
Dx: PCR of saliva, serology 
Rx: supportive 
 Influenza42  Droplet Close community contact Rn: febrile upper respiratory tract during influenza season Ensure ACIP/AAP-recommended influenza vaccine is given seasonally Prioritize treatment of those who have increased risk for influenza complications (eg, asthma, heart and/or lung disorders, metabolic disorders, immune compromised) 
Dx: culture, rapid molecular tests 
Rx: oseltamivir if identified in first 2 d, for 5 d 
 Pertussis43  Droplet Close community contact Rn: paroxysmal cough for ≥2 wk Ensure ACIP/AAP-recommended Tdap is given; identify and intervene with chemoprophylaxis in outbreaks Involve public health authorities for outbreaks (>2 cases in closed population) 
Dx: PCR of nasopharyngeal swab specimen 
Rx: azithromycin for 5 d 
N meningitidis44  Droplet Close community contact Rn: bacteremic presentation, shock, purpura Ensure ACIP/AAP-recommended meningococcal conjugate ACWY vaccine is given Involve public health authorities for single case; if serogroup B involved, meningococcal B vaccine 
Dx: Gram-stain, culture 
Rx: begin with intravenous cefotaxime or ceftriaxone; penicillin once diagnosis confirmed 
Pathogens primarily transmitted by contaminated food or water route 
Shigella45  Contaminated food or water; person to person Commonly attended event, restaurant related Rn: diarrhea, blood Hand hygiene Involve public health authorities for outbreaks 
Dx: culture stool 
Rx: TMP/SMX, ciprofloxacin depending on susceptibilities 
Giardia46  Contaminated food or water Public pools, swimmers Rn: watery diarrhea Hand hygiene — 
Dx: stool antigen test 
Rx: metronidazole or nitazoxanide 
Cryptosporidia47  Contaminated food or water Public pools, swimmers Rn: watery diarrhea Hand hygiene — 
Dx: stool examination 
Rx: nitazoxanide 
 Norovirus48  Contaminated food or water; person to person Common environment Rn: abrupt onset of vomiting, watery diarrhea Hand hygiene Involve public health authorities for outbreaks 
Dx: clinical RT-PCR 
Rx: supportive 
 Leptospirosis49  Contaminated water Triathletes,50 fresh water swimming, skin wounds Rn: fever and headache, myalgia (can mimic influenza) Swimmers avoid immersion or swallowing potentially contaminated water — 
Dx: enzyme-linked immunosorbent assay IgM Protective clothing, boots in contaminated water 
Rx: intravenous penicillin G first choice, risk of Jarish-Herxheimer reaction; also cefotaxime, ceftriaxone and doxycycline; supportive care — 

AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; BID, twice daily; Dx, diagnosis; FDA, Food and Drug Administration; HPV, human papillomavirus; IgM, immunoglobulin M; IV, intravenous; KOH, potassium hydroxide; OD, once daily; Rn, recognition; RT-PCR, reverse transcription PCR; Tdap, adult tetanus, diphtheria, and acellular pertussis vaccine; TMP/SMX, trimethoprim-sulfamethoxazole; Tx, treatment; —, not applicable.

Transmission of a specific infectious agent may be affected by a variety of psychosocial (sexually transmitted infection), physical (trauma, closed community contact), and environmental (soil, food, water, vector) factors, especially in an immunologically naïve population. This policy will be focused on diagnosis, treatment, and prevention of the most common infections that may be encountered in the athlete participating in organized sports, with an additional focus on factors that are potentially modifiable. It should be noted that some of the organisms discussed can be transmitted in multiple fashions. Transmission of pathogens spread by contaminated food or water, by respiratory droplets, and by vectors are similar to what can be expected under nonsporting conditions51 and are beyond the scope of this report. Although several of these pathogens are summarized in Table 2, detailed descriptions in this clinical report are provided only for the organisms transmitted primarily by contact, manifesting primarily on the skin, and those that are airborne.

Most sports-related skin infections are spread by contact and have been associated with 10% to 15% of time-loss injuries among athletes at the collegiate level.52 For this reason, routine screening of athletes participating in contact sports during practices and before competitions is important. The Sports Medicine Advisory Committee of the National Federation of State High School Associations (NFHS),53 the National Collegiate Athletic Association (NCAA),54 and the National Athletic Trainers Association (NATA)55 have published guidelines for screening and when to return to athletic participation for several conditions (summarized in Table 3). It is noteworthy that many of the recommendations by these organizations are more stringent than ordinary infection control practices for similar conditions in which the likelihood of the type of close bodily contact is not as significant.

TABLE 3

Return to Practice and Competition Guidelines for Infected Athletes

ConditionNCAA54 NFHS53 NATA55 AAP Notes51 
GABHS and S aureus, (abscesses, cellulitis, folliculitis, impetigo, carbuncles) • Completion of 72 h of antibiotic therapy • Completion of 72 h of antibiotic therapy with lesions resolving • Completion of 72 h of antibiotic therapy with lesions resolving — 
• No new skin lesions for 48 h before competition • No moist, weeping, or draining lesions; all lesions should have well-adhering scabs • No new skin lesions for at least 48 h 
• No moist, exudative, or draining lesions at time of practice or competition • Scabbed and/or dry lesions only can be covered with bio-occlusive dressing • No moist, exudative, or draining lesions 
• Gram-stain of exudate of questionable lesions — • Covered active lesions at time of practice or competition not allowed 
• Cannot cover active purulent lesions — — 
HSV, primary • All systemic (fever, malaise, etc) symptoms must be resolved • Return after all lesions are healed with well-adherent scabs, no new vesicles, no swollen lymph nodes near affected area • All systemic (fever, malaise, etc) symptoms must be resolved • Exclude athletes from practice or competition until vesicular or ulcerative lesions on exposed body parts and around mouth or eyes are fully crusted26  
• No new lesions for 72 h before examination • Oral antiviral agents to expedite recovery; if started, no wrestling for 5 d • No new lesions for 72 h before examination 
• No moist lesions, all existing lesions must be dry and covered by a firm, adherent crust — • No moist lesions, all existing lesions must be dry and covered by a firm, adherent crust 
• Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of practice or competition — • Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of competition 
• Covered active lesions at time of practice or competition not allowed — • Covered active lesions at time of competition not allowed 
HSV, recurrent • Lesions must be completely dry and covered by a firm, adherent crust • Oral antiviral agents to expedite recovery; if started, no wrestling for 5 d • Lesions must be completely dry and covered by a firm, adherent crust • Exclude athletes from practice or competition until vesicular or ulcerative lesions on exposed body parts and around mouth or eyes are fully crusted 
• Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of competition • If no oral antiviral agents, return after all lesions healed with well-adherent scabs, no new vesicles in previous 48 h, no swollen lymph nodes near affected area • Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of competition • Consider suppressive antiviral agents for rest of season26  
• Covered active lesions at time of practice or competition not allowed • Consider prophylactic antiviral agents for rest of season • Covered active lesions at time of practice or competition not allowed — 
Molluscum contagiosum • Curette or remove lesions before competition • No treatment or restrictions • Lesions must be curetted or removed — 
• May cover solitary or localized clustered lesions with gas permeable membrane and tape • Cover lesions prone to bleeding when abraded with a gas-permeable membrane and tape • Localized lesions may be covered with a gas-permeable dressing followed by underwrap and stretch tape 
T capitis • Minimum of 2 wk of systemic antifungal therapy • Minimum of 2 wk of systemic antifungal therapy • Minimum of 2 wk of systemic antifungal therapy — 
• Presence of extensive and active lesions (based on KOH prep or review of treatment regimen) will lead to disqualification 
• Presence of solitary or closely clustered, localized lesions that cannot be covered will lead to disqualification 
T corporis • Minimum of 72 h of topical or systemic antifungal therapy • Minimum of 72 h of topical or systemic antifungal therapy • Minimum 72 h topical fungicide terbinafine or naftifine — 
• Presence of extensive and active lesions (based on KOH prep or review of treatment regimen) will lead to disqualification • Lesions to be covered with a bio-occlusive dressing for return to practice or competition once no longer considered contagious • Lesions must be covered with a gas-permeable dressing followed by underwrap and stretch tape 
• Presence of solitary or closely clustered, localized lesions that cannot be covered will lead to disqualification — — 
• Return to practice or competition decision made on an individual basis by examining physician and/or certified athletic trainer — — 
T pedis — — — Exclude from swimming pools, discourage from walking barefoot on locker room and shower floors until treatment has been initiated28,37  
T cruris — — — Exclude from swimming pools until treatment has been initiated28,37  
Verruca vulgaris (caused by subtypes of HPV) • If multiple digitate lesions present on face, will be disqualified if cannot be covered by a mask • No treatment or restrictions — — 
• Solitary or scattered lesions should be curetted away before competition • Cover lesions prone to bleeding when abraded with a gas-permeable membrane and tape 
• Multiple verrucae plana or verrucae vulgaris must be “adequately covered” — 
S scabiei (scabies)35  • Evidence of a negative microscopic skin prep before return to practice or competition — — — 
P capitis36 (head lice) • Appropriate pharmacologic treatment and reexamination for completeness of response before return — — — 
Shigella — — — • Exclude until at least 24 h after diarrhea has ceased45  
Giardia — — — — 
Cryptosporidia — — — • Exclude from swimming while ill for 2 wk after illness completely resolved47  
Norovirus — — — • Exclude from activities until 48 h after symptoms have resolved48  
Leptospirosis — — — • Usually acquired from exposure to contaminated urine or body fluids of wild and domestic animals; no restrictions from contact sports because person-to-person spread is rare unless contact with wet fomites contaminated with human urine or rarely blood 
• Risk is exposure to swimming, rafting, kayakinga 
Influenza — — — • Early treatment with 5 d of a neuraminidase inhibitor (oseltamivir and zanamivir) recommended (decrease in duration of clinical symptoms would be warranted to reduce spread)42  
• Return when no longer febrile, respiratory symptoms resolved, and if on neuraminidase inhibitor, has completed 5 d of therapy 
Pertussis — — — • Exclude from close contact until 5 d after initiation of effective therapy or until 3 wk after onset of cough43  
N meningitidis — — — • Exclude for at least 24 h after initiation of effective antimicrobial therapy44  
V zoster • Skin lesions must have a firm, adherent crust at time of practice or competition • For shingles: 10–14 d of systemic antiviral medication — • Skin lesions must have a firm, adherent crust and no new lesions cropping up at time of practice or competition39  
• There must be no evidence of secondary bacterial infection • Lesions must be scabbed over with no discharge and no new lesions in preceding 48 h 
ConditionNCAA54 NFHS53 NATA55 AAP Notes51 
GABHS and S aureus, (abscesses, cellulitis, folliculitis, impetigo, carbuncles) • Completion of 72 h of antibiotic therapy • Completion of 72 h of antibiotic therapy with lesions resolving • Completion of 72 h of antibiotic therapy with lesions resolving — 
• No new skin lesions for 48 h before competition • No moist, weeping, or draining lesions; all lesions should have well-adhering scabs • No new skin lesions for at least 48 h 
• No moist, exudative, or draining lesions at time of practice or competition • Scabbed and/or dry lesions only can be covered with bio-occlusive dressing • No moist, exudative, or draining lesions 
• Gram-stain of exudate of questionable lesions — • Covered active lesions at time of practice or competition not allowed 
• Cannot cover active purulent lesions — — 
HSV, primary • All systemic (fever, malaise, etc) symptoms must be resolved • Return after all lesions are healed with well-adherent scabs, no new vesicles, no swollen lymph nodes near affected area • All systemic (fever, malaise, etc) symptoms must be resolved • Exclude athletes from practice or competition until vesicular or ulcerative lesions on exposed body parts and around mouth or eyes are fully crusted26  
• No new lesions for 72 h before examination • Oral antiviral agents to expedite recovery; if started, no wrestling for 5 d • No new lesions for 72 h before examination 
• No moist lesions, all existing lesions must be dry and covered by a firm, adherent crust — • No moist lesions, all existing lesions must be dry and covered by a firm, adherent crust 
• Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of practice or competition — • Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of competition 
• Covered active lesions at time of practice or competition not allowed — • Covered active lesions at time of competition not allowed 
HSV, recurrent • Lesions must be completely dry and covered by a firm, adherent crust • Oral antiviral agents to expedite recovery; if started, no wrestling for 5 d • Lesions must be completely dry and covered by a firm, adherent crust • Exclude athletes from practice or competition until vesicular or ulcerative lesions on exposed body parts and around mouth or eyes are fully crusted 
• Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of competition • If no oral antiviral agents, return after all lesions healed with well-adherent scabs, no new vesicles in previous 48 h, no swollen lymph nodes near affected area • Must have been on appropriate systemic antiviral therapy for at least 5 d before and at the time of competition • Consider suppressive antiviral agents for rest of season26  
• Covered active lesions at time of practice or competition not allowed • Consider prophylactic antiviral agents for rest of season • Covered active lesions at time of practice or competition not allowed — 
Molluscum contagiosum • Curette or remove lesions before competition • No treatment or restrictions • Lesions must be curetted or removed — 
• May cover solitary or localized clustered lesions with gas permeable membrane and tape • Cover lesions prone to bleeding when abraded with a gas-permeable membrane and tape • Localized lesions may be covered with a gas-permeable dressing followed by underwrap and stretch tape 
T capitis • Minimum of 2 wk of systemic antifungal therapy • Minimum of 2 wk of systemic antifungal therapy • Minimum of 2 wk of systemic antifungal therapy — 
• Presence of extensive and active lesions (based on KOH prep or review of treatment regimen) will lead to disqualification 
• Presence of solitary or closely clustered, localized lesions that cannot be covered will lead to disqualification 
T corporis • Minimum of 72 h of topical or systemic antifungal therapy • Minimum of 72 h of topical or systemic antifungal therapy • Minimum 72 h topical fungicide terbinafine or naftifine — 
• Presence of extensive and active lesions (based on KOH prep or review of treatment regimen) will lead to disqualification • Lesions to be covered with a bio-occlusive dressing for return to practice or competition once no longer considered contagious • Lesions must be covered with a gas-permeable dressing followed by underwrap and stretch tape 
• Presence of solitary or closely clustered, localized lesions that cannot be covered will lead to disqualification — — 
• Return to practice or competition decision made on an individual basis by examining physician and/or certified athletic trainer — — 
T pedis — — — Exclude from swimming pools, discourage from walking barefoot on locker room and shower floors until treatment has been initiated28,37  
T cruris — — — Exclude from swimming pools until treatment has been initiated28,37  
Verruca vulgaris (caused by subtypes of HPV) • If multiple digitate lesions present on face, will be disqualified if cannot be covered by a mask • No treatment or restrictions — — 
• Solitary or scattered lesions should be curetted away before competition • Cover lesions prone to bleeding when abraded with a gas-permeable membrane and tape 
• Multiple verrucae plana or verrucae vulgaris must be “adequately covered” — 
S scabiei (scabies)35  • Evidence of a negative microscopic skin prep before return to practice or competition — — — 
P capitis36 (head lice) • Appropriate pharmacologic treatment and reexamination for completeness of response before return — — — 
Shigella — — — • Exclude until at least 24 h after diarrhea has ceased45  
Giardia — — — — 
Cryptosporidia — — — • Exclude from swimming while ill for 2 wk after illness completely resolved47  
Norovirus — — — • Exclude from activities until 48 h after symptoms have resolved48  
Leptospirosis — — — • Usually acquired from exposure to contaminated urine or body fluids of wild and domestic animals; no restrictions from contact sports because person-to-person spread is rare unless contact with wet fomites contaminated with human urine or rarely blood 
• Risk is exposure to swimming, rafting, kayakinga 
Influenza — — — • Early treatment with 5 d of a neuraminidase inhibitor (oseltamivir and zanamivir) recommended (decrease in duration of clinical symptoms would be warranted to reduce spread)42  
• Return when no longer febrile, respiratory symptoms resolved, and if on neuraminidase inhibitor, has completed 5 d of therapy 
Pertussis — — — • Exclude from close contact until 5 d after initiation of effective therapy or until 3 wk after onset of cough43  
N meningitidis — — — • Exclude for at least 24 h after initiation of effective antimicrobial therapy44  
V zoster • Skin lesions must have a firm, adherent crust at time of practice or competition • For shingles: 10–14 d of systemic antiviral medication — • Skin lesions must have a firm, adherent crust and no new lesions cropping up at time of practice or competition39  
• There must be no evidence of secondary bacterial infection • Lesions must be scabbed over with no discharge and no new lesions in preceding 48 h 

AAP, American Academy of Pediatrics; KOH, potassium hydroxide; —, not applicable.

a

Centers for Disease Control and Prevention. Leptospirosis. Available at: https://www.cdc.gov/leptospirosis/pdf/fact-sheet.pdf. Accessed September 7, 2017.

Community-acquired methicillin-resistant S aureus (MRSA) is a cause of outbreaks of skin infections among high school and collegiate athletes participating in contact sports, particularly among football players and wrestlers, and is associated with significant morbidity. It manifests primarily as cellulitis or skin abscesses but may lead to invasive disease such as bacteremia, septic arthritis, osteomyelitis, myositis, fasciitis, and pneumonia in up to 10% of cases.56,57 Other noninvasive forms of disease including impetigo, staphylococcal ecthyma, pustulosis, and folliculitis may also pose a risk for transmission of the organism from those so affected. Players who have preexisting skin diseases such as atopic dermatitis may have chronic colonization with S aureus and may be predisposed to recurrent secondary infection. Between 10% and 23% of football players or wrestlers have developed signs and symptoms during outbreaks.5,58,60 Risk factors for infection include skin breaks associated with turf burns or trauma,58 skin-to-skin contact, sharing of equipment or clothing (towels), and higher BMI.5,19,59 Although 4% to 23% of athletes have been found to have colonization with MRSA, high colonization alone does not appear sufficient to trigger an outbreak.61 Wrestling mats, artificial turfs, and football training equipment have been documented with MRSA colonization.19,62,63 

Incidence estimates of MRSA-related skin and soft tissue infections in Nebraska student athletes have ranged from 11.3 to 20.9 per 10 000 football players and 28.1 to 60.8 per 10 000 wrestlers from 2008 to 2012.64 Among 190 high school football players in northeast Ohio who were managed prospectively with nasal swab cultures, 23% displayed methicillin-susceptible S aureus colonization (none carried MRSA). Of the participating athletes, 10 (5.3%) developed skin infections, including 7 with impetigo and 1 with folliculitis barbae during the course of the 2008 season. None of the cultured specimens tested positive for MRSA.65 

Group A β-hemolytic Streptococcus (GABHS) has been associated with outbreaks of skin infections after indoor association football tournaments,66 rugby,67,68 and other organized sports. The organism can cause localized skin infections such as pyoderma, cellulitis, or impetigo or invasive infections such as thrombophlebitis, myositis, and sepsis. GABHS has also been associated with outbreaks of pharyngitis among university students (median age 19.5 years) participating in judo.69 Within a 15-day period, 12 of 23 club members in Tokyo, Japan, presented with sore throat and high fever. Diagnosis was made by use of either a rapid streptococcal antigen test or positive throat culture for GABHS when the clinical presentation was suggestive of pharyngitis. Occasionally, outbreaks of invasive GABHS disease have been reported in members of high school football teams,70 likely attributable to sharing of equipment and water bottles.

Management of MRSA and GABHS outbreaks has been accomplished through meticulous focus on hygiene education, good hygiene practices, prompt identification of infected people, limiting exposure to infected people and contaminated surfaces and objects, decontamination of the environment, and proper treatment and close follow-up of infected people.4,5,7,59,60,69,71 Of particular importance for management of MRSA outbreaks is screening of players for carriage along with use of topical mupirocin for those found to have colonization, use of chlorhexidine washes, and enhancement of personal hygiene practices.7,19,72 Bleach baths (Clorox: regular 6.0% hypochlorite, 5 mL, added to 1 gallon of water) used twice weekly reduced the recurrence rates among children with community-associated S aureus infections by 20% compared with control children managed with routine hygienic measures, but this was not a statistically significant reduction.73 Screening for S aureus and GABHS requires knowledge of what body sites would have colonization. Nasal, skin, vaginal, and rectal carriage are the primary reservoirs for S aureus. In the context of sports-related infections, the primary culture sites should be the nares and any open skin lesions.

GABHS screening should be performed through vigorous swabbing of a pair of swabs on both tonsils and the posterior pharynx for rapid antigen detection and culture as well as culture of any skin lesions, especially those that are oozing or macerated.23 Measurement of sequential streptococcal antibody titers may also be used to diagnose a recent infection, but this is not recommended for routine use.74 

Skin abscesses are best managed by incision and drainage, with culture of the wound for identification of causative agent and antimicrobial susceptibility pattern along with empirical antibiotic coverage pending culture results. Antibiotic choices should be guided by knowledge of the local patterns of susceptibility of S aureus, especially local rates of MRSA. Methicillin-susceptible S aureus typically is treated with oral penicillinase-resistant β-lactam drugs, such as a first- or second-generation cephalosporin. For patients who are allergic to penicillin, or if MRSA is a significant consideration, the alternatives are trimethoprim-sulfamethoxazole, doxycycline, or clindamycin for susceptible isolates.22 Doxycycline can be used safely in children ages 2 years and older when given for durations less than 2 weeks. Trimethoprim-sulfamethoxazole should not be used as a single agent in the initial treatment of cellulitis because of the possibility it is caused by group A Streptococcus and the possibility of intrinsic resistance of this organism.75,77 Topical mupirocin may be used for localized and nonbullous impetigo. During outbreaks, attempts at eradication of S aureus infections to limit spread may be accomplished by use of topical nasal mupirocin therapy (twice daily for 5–7 days) among people with colonization. However, low-level (minimum inhibitory concentration, 8–256 µg/mL) and high-level (minimum inhibitory concentration, >512 µg/mL) resistance to mupirocin have been identified in S aureus. High-level resistance has been associated with subsequent failure of decolonization.

GABHS typically is susceptible to penicillin, and this is the usual first-line therapy.74 An oral macrolide or azalide (eg, erythromycin, clarithromycin, or azithromycin) is acceptable for patients who are allergic to penicillin. Duration of treatment is 10 days, with the exception of azithromycin, which is indicated for 5 days. Local mupirocin78,80 or retapamulin81,83 ointment may be useful for limiting person-to-person spread of nonbullous impetigo and for eradicating localized GABHS disease. Guidelines from the NCAA, NFHS, and NATA for when the infected athlete can return to competition for both GABHS and S aureus are summarized in Table 3.

Prevention of infections caused by MRSA and GABHS is achieved primarily through good hygiene practices, not sharing equipment and water bottles, limiting exposure to infected people and contaminated surfaces and objects, decontamination of the environment, and prompt identification, proper treatment, and close follow-up of infected people.4,5,7,59,60,69,71 Athletes with GABHS pharyngitis or skin infections should not return to competitive sports for at least 24 hours after beginning appropriate oral antimicrobial therapy.23Table 3 summarizes recommendations of the NCAA, NFHS, and NATA for return to competition for patients with S aureus infections, including MRSA.

HSV (primarily type 1) has been identified as a cause of outbreak of skin infections among wrestlers (herpes gladiatorum [HG]) and rugby players (herpes rugbiorum [HR]) on numerous occasions, affecting up to 2.6% of high school and 7.6% of college wrestlers in the United States.84,86 During outbreaks, up to 34% of all high school wrestlers have been documented to be infected.87 Risk factors for development of HG-related cutaneous HSV lesions include direct skin-to-skin exposure to opponents with cutaneous lesions.84 There is a range of 4 to 11 days, with an average of 6.80 ± 1.70 days from onset of exposure to development of skin lesions. Most outbreaks (96%) occur on the ventral surface of the body, with up to three-quarters of the cases occurring on areas in direct contact when wrestlers are engaged in the lock-up position (head, face, and neck). Other body areas frequently involved are the extremities (42%) and trunk (28%).16 HSV conjunctivitis (5%) and blepharitis have also been reported.87 Between 25% and 40% of patients with HG and HR will develop constitutional symptoms including fever, chills, sore throat, and headaches.85,87 There are data associating acquired antibody to HSV type 1 infection with protection from acquiring HG, but the association is very weak.84 

High-altitude skiing also has been associated with relapses of orofacial herpes, presumably because of solar UV radiation exposure, with a median onset of 3.5 days after exposure (strong evidence).88 Although sunscreen with a sun protection factor of 15 was shown to prevent experimental UV light-induced reactivation of herpes labialis compared with placebo,89 it has not been shown to influence the reactivation rate among high-altitude skiers.88 

There is strong evidence that prompt identification and 3 to 8 days of isolation of infected wrestlers during primary outbreaks of HG and HR with suspension of competition can help contain outbreaks in more than 90% of cases.87,90,91 Diagnosis involves a combination of clinical recognition and may be coupled with cell culture, histologic examination, or rapid diagnostic tests such as direct fluorescent antibody staining, enzyme immunoassay, or polymerase chain reaction (PCR) of vesicular lesion scrapings in complex, lingering, or unclear cases.26 Valacyclovir, 500 mg, every day or twice a day for 7 days, when given within 24 hours of symptoms onset, has been shown to shorten the duration of time until HSV PCR clearance from lesions of adolescent and adult wrestlers with recurrent HG by 21% (from ∼8.1 days with placebo to 6.4 days with valacyclovir).92 Wrestlers receiving valacyclovir should be advised about the importance of good hydration to minimize the risk of nephrotoxicity. Competitors often do not recognize or may deny possible infection. As a result, efforts to reduce transmission should include (1) examination of wrestlers and rugby players for vesicular or ulcerative lesions on exposed areas of their bodies and around their mouths or eyes before practice or competition by a person familiar with the appearance of mucocutaneous infections (including HSV, herpes zoster, and impetigo), (2) excluding athletes with these lesions from competition until all lesions are fully crusted or production of a physician’s written statement indicating that their condition is noninfectious, and (3) cleaning of wrestling mats with a freshly prepared solution of household bleach (1 quarter cup of bleach in 1 gallon of water) applied for a minimum contact time of 15 seconds at least daily and preferably between matches.26 NCAA, NFHS, and NATA guidelines for when the infected athlete can return to competition are summarized in Table 3.

Athletes with a history of recurrent HG, HR, or herpes labialis should be considered for suppressive antiviral therapy. There is strong evidence that nucleoside analogues (valacyclovir) can suppress recurrent outbreaks of herpes. In a study involving 42 male wrestlers aged 13 to 31 years in Minnesota combining double-blind randomization followed by an open enrollment onto treatment, participants with recurrent HG were treated during the first half of the season with either 500 mg of valacyclovir or placebo and in the second half with 1000 mg of valacyclovir. The 500 and 1000 mg doses of valacyclovir suppressed recurrence of outbreaks among 100% (7 out of 7 and 12 out of 12) of participants whose last recurrence was more than 2 years before. However, the doses were slightly less successful among those with recurrences within 2 years (11 out of 14 and 23 out of 25, respectively), with better results with the 1000 mg dosing.93 

Similarly, in a Minnesota study of 332 male wrestlers 13 to 20 years of age who participated at a 28-day wrestling camp, once-a-day prophylactic valacyclovir (1000 mg) starting 1 week before camp and continuing throughout camp reduced the incidence of clinical HG outbreaks by 87%. Among 55 of these wrestlers who were HSV type 1 immunoglobulin G seronegative at the beginning of the camp and had postcamp serologic testing performed, none developed detectable immunoglobulin M against HSV type 1 or HSV type 2.94 However, there is need for a detailed risk–benefit analysis of using valacyclovir for prophylaxis in wrestlers who are seronegative for herpes.

Molluscum contagiosum is a common, benign viral skin infection presenting as skin-colored papules that develop a central umbilication as they age. Molluscum contagiosum affects 5% to 11% of children 0 to 16 years of age95 and most commonly affects the trunk, face, and extremities. Molluscum contagiosum is mostly asymptomatic but may present with pain, itching, redness, or occasionally bacterial superinfection. Outbreaks of molluscum contagiosum have most often been described in association with exposure to swimming in public pools and underlying eczema.3,95,97 Other factors associated with infection include young age (highest incidence in children younger than 14 years), living in close proximity, skin-to-skin contact, sharing of fomites, and residence in tropical climates.3,98 

Resolution of uncomplicated molluscum contagiosum typically occurs spontaneously in 6 to 12 months, although complete resolution of lesions can take up to 4 years. Although no regimen has proven highly successful, 10% potassium hydroxide and cryotherapy with liquid nitrogen have been used to treat lesions that occur in locations that are cosmetically bothersome to patients or for patients with underlying skin conditions such as eczema. Both forms of treatment appear to have similar efficacy in children, but cryotherapy may be associated with postinflammatory hyperpigmentation or, uncommonly, scarring.99,100 Imiquimod was not shown to be of benefit compared with placebo in randomized controlled trials.101,102 Open-label and observational studies103,104 indicate that cantharidin can be an effective treatment of molluscum contagiosum; however, in 1 small randomized controlled trial of 29 patients, the improvement seen with cantharidin, although greater than with placebo, was not found to be statistically significant.100 Guidelines from the NCAA, NFHS, and NATA for when the infected athlete can return to competition for molluscum are summarized in Table 3.

Given the known associations of molluscum contagiosum, the best method of prevention would involve avoiding of skin-to-skin contact with people known to have lesions (covering lesions), not sharing towels and other fomites, and limiting exposure to swimming pools that have recently been associated with known outbreaks.

T corporis and T capitis infections have been reported more frequently among high school wrestlers and judo practitioners (T corporis gladiatorum and T capitis gladiatorum) than among other athletes.8,105,,,,,,,112 Studies of the prevalence of T corporis gladiatorum have involved use of potassium hydroxide examination to aid diagnosis. In 1 such study, 24% of 29 wrestlers had lesions of T corporis, versus 0 in a control group of track team members (P = .005).106 In another study, T corporis was detected in 10 of 19 boys (53%) 15 to 17 years of age belonging to a judo club in Kyoto, Japan.112 The most common cause of T capitis gladiatorum is Trichophyton tonsurans, accounting for more than 80% of cases, but it may also be caused by Trichophyton rubrum and Trichophyton mentagrophytes.113,114T tonsurans (primarily), T mentagrophytes, and Microsporum canis have also been isolated in high rates during outbreaks of T capitis (ringworm) among high school wrestlers in a wrestling boarding school in Turkey.109,115,116 These organisms have been isolated frequently from individual skin lesions and from wrestling mats.108,109 

Both skin-based and oral medications are available for the treatment of T corporis, but T capitis is managed exclusively with oral medications, often with simultaneous application of topical treatment to the scalp (because of the need for hair follicle penetration). Skin-based preparations for T corporis include but are not limited to azole creams (clotrimazole, econazole, ketoconazole, oxiconazole), allylamine creams and gels (1% gel of terbinafine and butenafine), and hydroxypyridone (ciclopirox) preparations. Although these all are reasonably effective, some preparations in some studies demonstrate superior cure rates. For example, terbinafine emulsion gel has a mycological cure rate superior to that of ketoconazole cream (94% versus 69%, respectively) with similar adverse events rates.117 

Oral agents also have proven efficacious in the treatment of most cases of T corporis. Different doses and durations of itraconazole have been used in studies. Itraconazole, 100 mg, given orally once a day, was superior to griseofulvin, 500 mg, orally, once a day, when given for 15 days (87% mycological cure rate versus 57%, respectively, at the end of 2 weeks after completion of therapy) to adolescents and adults.118 In contrast, 200 mg of itraconazole was found to be superior to 250 mg of terbinafine when given for 7 days respectively in terms of clinical response rates when administered to adolescents and adults.119 

For T capitis, the traditional treatment in children had been oral griseofulvin, 10 mg/kg per day, microsize formulation, given once daily for 6 to 8 weeks, although doses of griseofulvin as high as 20 to 25 mg/kg per day have been used.120 Terbinafine, 125 or 250 mg (adjusted for age), given for 2 to 8 weeks, has recently been shown to have efficacy that is at least as good, with fewer adverse effects and fewer recurrences.116,121,,123 Cochrane reviews have concluded that 4 weeks of terbinafine was equivalent to 8 weeks of griseofulvin.124,125 Similarly, oral fluconazole given for 4 weeks had similar efficacy to oral griseofulvin given for 6 weeks,126,127 although at least 1 study revealed the efficacy to be low for both regimens.128 Itraconazole given for 2 weeks is also similar in efficacy to 6 weeks of griseofulvin, whereas terbinafine and itraconazole appear to have similar efficacy for treatment periods of 2 to 3 weeks.124 However, terbinafine, itraconazole, and fluconazole are significantly more expensive than griseofulvin. Furthermore, griseofulvin appears to be superior for infections attributable to certain species of Microsporum, which may require 4 weeks’ duration or more of therapy with terbinafine and itraconazole.122,129,130 Terbinafine appears superior for T tonsurans.125 

Fluconazole, 100 mg per day for 3 days, given prophylactically before initiation of competitive interscholastic high school wrestling and given again 6 weeks into the season, has been reported to significantly reduce the incidence of T corporis from 67.4% to 3.5%.30 However, the risk-benefit analysis of giving fluconazole prophylactically in this manner has not been determined, and its use should be in consultation with an infectious diseases expert.

T pedis (athlete’s foot) presents as a fine scaly or vesiculopustular eruption that is often itchy. The lesions may involve all areas of the foot but commonly include the fissures and scaling between toes. Increased rates of T pedis have been well documented and common among swimmers and runners (especially marathon runners), with documented infections in up to 22%. The predominant causes are T rubrum and T mentagrophytes.131 Spread via direct contact with the organism, T pedis is prevalent in warm, humid environments and affects men more than women.132 Obesity and diabetes are additional risk factors for T pedis.133 

Numerous treatments (creams and oral medications) have been evaluated for treating T pedis. In randomized controlled trials in adults, ciclopirox olamine (a broad-spectrum hydroxypyridone antifungal with proven efficacy against T rubrum, T mentagrophytes, and Epidermophyton floccosum) cream or gel (0.77%) applied twice daily to the affected areas for 4 weeks has been shown to be effective in eradicating T pedis and superior to 1% clotrimazole cream or ciclopirox vehicle in achieving both clinical and mycological cure (∼60% for cyclopirox olamine cream versus 6% for its vehicle only at end of treatment, and 85% versus 16% two weeks after treatment).134,135 There are no published studies of use of ciclopirox to treat T pedis in children, but a dosage of topical application twice a day is recommended for use in children older than 10 years.28 Similarly, naftifine ointment applied twice daily for 4 weeks and sulconazole nitrate 1% cream applied daily for 4 to 6 weeks have been associated with significantly higher mycological clearance rates (57%–66%) compared with their vehicles alone (13%–34% cleared) and were associated with fewer relapses in treatment of T rubrum–related T pedis.136,137 However, sulconazole is not approved for use in children in the United States. More recently, topical azoles such as fenticonazole powder have been used in adults with up to 100% cure rates.138 Terbinafine 1% cream applied daily for 1 week also has been used effectively to treat T pedis, with >93% mycological cure rate at 4 weeks, and is approved for children 12 years and older.139 Luliconazole was recently reported as a 1% cream trial for T pedis in adults, but less than 50% of the participants were cured on this regimen.140 It is only approved by the US Food and Drug Administration for use in adults.

Terbinafine offers the advantage of once-daily dosing and can be given for briefer periods than skin-based treatments. Oral terbinafine, 250 mg, given once daily for 1 week, has similar efficacy (based on mycological cure rates at week 4) to 4 weeks of clotrimazole 1% cream applied twice a day but with faster clinical resolution.141 Oral terbinafine, 250 mg, also is similar in mycological efficacy to itraconazole, 100 mg, when given over a 2-week duration but may have a slightly lower rate of relapse. Terbinafine is well tolerated in children, with the most concerning potential adverse events being occasional isolated neutropenia and rare liver failure, typically in people with preexisting liver disease.

The use of foot powder after bathing has been associated with a decline in the rates of T pedis in a random sampling of users of a swimming bath in Scotland from 8.5% to 2.1% over a 3.5-year period,142 mostly attributable to the decline in rates of T mentagrophytes from 5.3% to 0.5%. Experts believe that careful and thorough drying between the toes after showers, daily changes of socks, and periodic cleaning of athletic footwear can be helpful.

T cruris (jock itch or crotch rot) is a common pruritic fungal infection of the groin and adjacent skin.133 Heat, humidity, and hyperhidrosis are predisposing factors, as is wearing of tight-fitting or wet clothing. Similar to T pedis, obesity and diabetes are additional risk factors for T cruris.133 

The predominant cause is T rubrum followed by E floccosum and T mentagrophytes.143,144 It may be spread by contaminated fomites (contaminated towels, hotel bed sheets) or autoinoculation from hands or feet infected with Tinea from another body site (Tinea unguium, T pedis, or Tinea manuum).133 

Similar to T pedis, terbinafine 1% cream applied daily for 1 week has been used effectively to treat T cruris with a mycological cure rate of approximately 94% and is approved for children 12 years and older.117 Butenafine (a benzylamine derivative of clotrimazole) applied twice daily for 2 weeks and clotrimazole applied twice weekly for 4 weeks are also over-the-counter alternatives, but butenafine is only approved in adults.145,,,148 Oral itraconazole (100 mg daily for 2 weeks or 200 mg daily for 1 week) has been shown to be effective in adults for treating T cruris and superior to oral griseofulvin (500 mg daily for 2 weeks).118,149,150 Several other azole topical formulations (oxiconazole,151 luliconazole,151 sertaconazole,144 eberconazole152) have been shown to be effective in adults, but none have been studied in any detail in children.

Because of risk of spread from T pedis, covering active foot lesions with socks before wearing undershorts may reduce the likelihood of direct contamination. Furthermore, complete drying of the crural folds after bathing, and use of separate (clean) towels for drying the groin and other parts of the body may help reduce contamination.

Verruca vulgaris (common skin warts) are benign epithelial proliferations of the skin and are caused by human papillomaviruses. They are typically painless, multiple in number, and occur on any epithelial surface, although most commonly on the hands, feet, and around and under the nails.33 They may be distinguished from calluses and corns by the presence of black dots (clotted blood vessels that have grown into the wart) when they are pared down as well as the associated loss of overlying dermatoglyphs. Although reports indicate that warts may occur in outbreaks among athletes, there are no published data on the prevalence. Reported risk factors appear to include sharing of equipment and exposure of unshod feet in common shower areas.34 In a study of 146 adolescents who used locker rooms, 27% of those who used communal showers on a regular basis were found to have plantar warts versus only 1.25% of those who only used the locker rooms.34 However, because the children using communal showers were also members of a swim club, it is unclear whether the communal shower or the swimming was the major contributing factor.

Most cases of common warts will eventually spontaneously regress, with 30% regressing within 6 months and approximately 60% within 2 years. Treatment modalities are usually geared toward chemical or physical destruction of the infected epithelium and include techniques such as freezing with liquid nitrogen, application of salicylic acid-based products or tretinoin (retinoic acid) cream, surgical (paring) or laser removal, and use of topical immunomodulating agents.34 The more destructive methods may lead to pain, which may inhibit athletic activity. More recently, cantharidin combined with podophyllotoxin-salicylic acid has been used in adults and reported to be effective but associated with pain and blistering.153,154 

Precise mechanisms of preventing common warts are unknown. However, like most infections that are transmitted by contact, avoidance of contact with people known to have common warts, not sharing equipment and towels, and wearing rubber soled flip-flops or sandals in communal showers may minimize risk.

Scabies (caused by Sarcoptes scabiei) and lice (P capitis), although not commonly reported in sports, can be disqualifying if identified in children participating in organized, especially contact, sports. They are transmitted primarily through person-to-person contact. The scabies parasite can survive on clothing for up to 4 days without skin contact.35 Lice do not survive away from the scalp more than 1 to 2 days without a blood meal, and although uncommon, can be transmitted by hair brushes, combs, hats, and hair ornaments.37 The transmission, risk factors, recognition, diagnosis, treatment, and prevention are summarized in Table 2. Successful treatment of scabies can be achieved topically with permethrin 5% cream or oral ivermectin (not for pregnant women), but resistance has been reported to both.155,156 Pregnant women and infants may be treated with topical crotamiton or precipitated sulfur ointment. Head lice treatment requires attention not only to the live lice but also to eggs that may subsequently hatch. Treatment of head lice can be started with over-the-counter 1% permethrin lotion or with pyrethrin combined with piperonyl butoxide, both of which have good safety profiles.36 Resistance to these over-the-counter agents is commonplace in many parts of the United States, and as such, alternative Food and Drug Administration–approved treatments may be necessary. For lice resistant to over-the-counter medications, treatment options include spinosad suspension, benzyl alcohol lotion, malathion, or ivermectin lotion. Spinosad and ivermectin lotion are ovicidal, and a single treatment may be adequate, but no treatment is 100% ovicidal.155,156 Suffocant treatments, such as benzyl alcohol lotion or malathion lotion, require retreatment approximately 1 week later to kill any new lice that hatched from nits. For lice resistant to all topical agents, oral ivermectin in a single dose of 200 or 400 μg/kg may be used in infants weighing over 15 kg, with a second dose given after 9 to 10 days.36 

Although varicella has been reported as a cause of airborne sports-related infections,157 such reports are rare in the era of immunization with the live attenuated vaccine against the virus. The varicella-zoster virus (VZV) manifests primarily as a generalized, pruritic, vesicular rash consisting of 250 to 500 lesions in different stages (crops) of development and crusting.39 There is usually an associated low-grade fever, and there may be other systemic symptoms. Disease in vaccinated children is often milder and atypical in nature compared with the wild virus infection and requires a high index of suspicion. Diagnosis is usually made on the basis of a typical clinical picture coupled with history of exposure, but vesicular fluid or scab scraping can be used for confirmation by using PCR, direct fluorescent antibody assay, or VZV-specific culture. A significant increase in serum varicella immunoglobulin G antibody between acute and convalescent serum samples can also assist in diagnosis.

Isolation should be instituted for those suspected to have chickenpox until the diagnosis is either ruled out or all the lesions are crusted over or in vaccinated children when there are no new lesions within a 24-hour period.39 Oral acyclovir or valacyclovir given within 24 hours of rash onset results in only a modest decrease in symptoms and is not routinely recommended for most healthy children. It should be considered in otherwise healthy children who are at increased risk of moderate to severe varicella, including people older than 12 years, people with chronic cutaneous or pulmonary disorders, those receiving long-term salicylate therapy, and those on short, intermittent, or aerosolized courses of corticosteroids.39 

The most effective proven means of preventing VZV is via primary immunization with the live attenuated vaccine.39 Children exposed to VZV should have their immunity evaluated, either through vaccination records or through serologic testing.

Measles is characterized by a prodrome of cough, coryza, and conjunctivitis with fever followed by maculopapular or morbilliform rash that begins on the face and spreads downward to the trunk and out to the extremities. Koplik spots, which are considered pathognomonic, also appear during the prodrome.40 Patients are contagious 4 days before the rash to 4 days after the rash appears. Measles outbreaks have been reported during many different types of sporting events ranging from gymnastics to skiing and fencing,158,,,,,163 highlighting the importance of adequate vaccination of all athletes. Up to 5% of people who have received a single dose of vaccine at 12 months or older have vaccine failure. Among previously immunized people, primary vaccine failure (inadequate response to vaccine) is a more common cause of failure than waning immunity. As a result, the current recommendations call for a 2-dose vaccine schedule for children and high-risk adults.40 

Mumps is a systemic illness that presents with swelling of 1 or more of the salivary glands, typically the parotid glands. Up to one-third of mumps cases do not cause salivary gland swelling, presenting instead as a respiratory tract infection. Orchitis is a common complication after puberty, but it rarely leads to sterility. Approximately 10% of patients have an associated viral meningitis, and numerous other complications occur rarely, including permanent hearing loss, myocarditis, endocardial fibroelastosis, arthritis, thrombocytopenia, thyroiditis, mastitis, glomerulonephritis, pancreatitis, and oophoritis. The virus has been isolated from saliva from 7 days before through 8 days after onset of salivary gland swelling. Before introduction of mumps vaccine, outbreaks of mumps were common in the United States, primarily in crowded settings including schools, prisons, orphanages, and military facilities. Although the incidence of the disease has declined significantly with the introduction of the 2-dose schedule of the measles-mumps-rubella (MMR) vaccine, outbreaks still periodically occur, primarily because of incomplete vaccination.

Immunization is the cornerstone of managing measles and mumps outbreaks. All suspected cases of measles or mumps should be reported immediately, and every effort should be made for laboratory confirmation of the infection either through serologic testing or detection of virus from clinical specimens (throat washings, nasopharyngeal secretions, urine, and blood for measles and buccal swabs, throat washings, saliva, or cerebrospinal fluid, if relevant, for mumps). In an outbreak setting, the MMR vaccine should be given to all people (>12 months) who lack evidence of immunity. For mumps, a second MMR dose should be offered to all students (including those in postsecondary school) who have received only 1 dose of MMR vaccine. A second MMR dose should also be considered for both conditions in children 1 to 4 years of age if they have only received 1 dose and there is an ongoing outbreak affecting preschool-aged children with community-wide transmission.40 

The most important method to prevent measles and mumps outbreaks is routine immunization of all children with a live attenuated vaccine, such as MMR or MMR-varicella vaccine, at age 12 through 15 months, with a second dose at 4 to 6 years of age, and people who are not documented to have been vaccinated during these periods.40 People who have altered immunity (except HIV infection, unless they have severe immunosuppression) should not receive MMR vaccine. Furthermore, MMR-varicella vaccine should not be given to patients with HIV (even if these people have little to no immune compromise) because of a lack of safety data at the present time.

The epidemiology and outbreak control considerations for other conditions primarily transmitted via droplet and contaminated food and water are summarized in Table 2.

     
  • GABHS

    group A β-hemolytic streptococcus

  •  
  • HG

    herpes gladiatorum

  •  
  • HR

    herpes rugbiorum

  •  
  • HSV

    herpes simplex virus

  •  
  • MMR

    measles-mumps-rubella

  •  
  • MRSA

    methicillin-resistant Staphylococcus aureus

  •  
  • NATA

    National Athletic Trainers Association

  •  
  • NCAA

    National Collegiate Athletic Association

  •  
  • NFHS

    National Federation of State High School Associations

  •  
  • PCR

    polymerase chain reaction

  •  
  • VZV

    varicella-zoster virus

Dr Davies was the lead author of the manuscript; Drs Jackson and Rice were coauthors of the manuscript with substantial input into content and revision; and all authors approved the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

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H. Dele Davies, MD, MS, MHCM, FAAP

Mary Anne Jackson, MD, FAAP

Stephen G. Rice, MD, PhD, MPH, FAAP

Carrie L. Byington, MD, FAAP, Chairperson

Yvonne A. Maldonado, MD, FAAP, Vice Chairperson

Elizabeth D. Barnett MD, FAAP

James D. Campbell, MD, FAAP

H. Dele Davies, MD, MS, MHCM, FAAP

Ruth Lynfield, MD, FAAP

Flor M. Munoz, MD, FAAP

Dawn Nolt, MD, MPH, FAAP

Ann-Christine Nyquist, MD, MSPH, FAAP

Sean O’Leary, MD, MPH, FAAP

Mobeen H. Rathore, MD, FAAP

Mark H. Sawyer, MD, FAAP

William J. Steinbach, MD, FAAP

Tina Q. Tan, MD, FAAP

Theoklis E. Zaoutis, MD, MSCE, FAAP

David W. Kimberlin, MD, FAAP – Red Book Editor

Michael T. Brady, MD, FAAP – Red Book Associate Editor

Mary Anne Jackson, MD, FAAP – Red Book Associate Editor

Sarah S. Long, MD, FAAP – Red Book Associate Editor

Henry H. Bernstein, DO, MHCM, FAAP – Red Book Online Associate Editor

H. Cody Meissner, MD, FAAP – Visual Red Book Associate Editor

James Stevermer, MD – American Academy of Family Physicians

Amanda C. Cohn, MD, FAAP – Centers for Disease Control and Prevention

Karen M. Farizo, MD – US Food and Drug Administration

Marc Fischer, MD, FAAP – Centers for Disease Control and Prevention

Bruce G. Gellin, MD, MPH – National Vaccine Program Office

Richard L. Gorman, MD, FAAP – National Institutes of Health

Natasha Halasa, MD, MPH, FAAP – Pediatric Infectious Diseases Society

Joan L. Robinson, MD – Canadian Paediatric Society

Jamie Deseda-Tous, MD – Sociedad Latinoamericana de Infectologia Pediatrica (SLIPE)

Geoffrey R. Simon, MD, FAAP – Committee on Practice Ambulatory Medicine

Jeffrey R. Starke, MD, FAAP – American Thoracic Society

Jennifer M. Frantz, MPH

Cynthia R. LaBella, MD, FAAP, Chairperson

Margaret A. Brooks, MD, FAAP

Greg S. Canty, MD, FAAP

Alex Diamond, DO, FAAP

William Hennrikus, MD, FAAP

Kelsey Logan, MD, FAAP

Kody A. Moffatt, MD, FAAP

Blaise Nemeth, MD, FAAP

Brooke Pengel, MD, FAAP

Andrew Peterson, MD, FAAP

Paul Stricker, MD, FAAP

Mark Halstead, MD, FAAP – American Medical Society for Sports Medicine

Donald W. Bagnall – National Athletic Trainers Association

Neeru A. Jayanthi, MD

Anjie Emanuel, MPH

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data