CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Infectious Diseases Associated H. Dele Davies, MD, MS, MHCM, FAAP,​a Mary Anne Jackson, MD, FAAP,b​ Stephen G. Rice, MD, PhD, MPH, FAAP,c​ COMMITTEEWith ON INFECTIOUS Organized DISEASES, COUNCIL ON SPORTSSports MEDICINE AND FITNESSand Outbreak Control Participation in organized sports has a variety of health benefits but also has abstract 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 aPediatric Infectious Diseases and Public Health, University of with contaminated fomites. Close contact that is intrinsic to team sports Nebraska Medical Center, Omaha, Nebraska; bInfectious Diseases, Children’s Mercy Kansas City and Department of Pediatrics, School and psychosocial factors associated with adolescence are additional risks. of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Minimizing risk requires leadership by the organized sports community and cSports Medicine, Jersey Shore University Medical Center and Department of Pediatrics, Robert Wood Johnson Medical School, (including the athlete’s primary care provider) and depends on outlining key Rutgers University, Neptune, New Jersey hygiene behaviors, recognition, diagnosis, and treatment of common sports- Dr Davies was the lead author of the manuscript; Drs Jackson and related infections, and the implementation of preventive interventions. 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 Introduction 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.

The definition of organized sports includes traditional team sports Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external commonly acknowledged as well as other types of sports (‍Table 1). reviewers. However, clinical reports from the American Academy of Participation in organized sports provides the benefits of (‍1) physical Pediatrics may not reflect the views of the liaisons or the organizations activity, by engaging in vigorous exercise, achieving fitness, and or government agencies that they represent. learning athletic skills; (‍2) socialization, by experiencing camaraderie The guidance in this statement does not indicate an exclusive course and learning teamwork and sportsmanship; and (‍3) competition, of treatment or serve as a standard of medical care. Variations, taking ’ into account individual circumstances, may be appropriate. by challenging oneself to perform against others, by striving to All clinical reports from the American Academy of Pediatrics continually improve oneself toward achieving one s full athletic 1 automatically expire 5 years after publication unless reaffirmed, potential, and by learning to win and lose with grace and dignity. revised, or retired at or before that time. Organized sports participation, however, can result in the acquisition of a variety of infectious diseases and conditions. Physical contact To cite: Davies HD, Jackson MA, Rice SG, AAP COMMITTEE among athletes, sharing of equipment (‍such as worn personal ON INFECTIOUS DISEASES, AAP COUNCIL ON SPORTS protective equipment or braces plus towels, drinking vessels, MEDICINE AND FITNESS. Infectious Diseases Associated showers, and locker rooms), and contact with– athletic surfaces (‍mats, With Organized Sports and Outbreak Control. Pediatrics. 2017;140(4):e20172477 artificial turf, dirt, grass, and gym or weight 2room9 equipment) can all be responsible for transmission of infection. ‍ In addition, certain organized sports carry specific additional risks; for example, wrestlers Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 140, number 4, October 2017:e20172477 From the American Academy of Pediatrics

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 1 Examples of Organized Sports Involving North American Children Traditional Team Sports Other Organized Sports Baseball, softball, basketball, football, soccer, Cheerleading, dance, martial arts, strength include many that are prominent in wrestling, ice hockey, field hockey, lacrosse, training, weightlifting, cycling, skiing, outbreaks typically seen in crowded volleyball, tennis, swimming and diving, track snowboarding, ultimate frisbee, boxing, figure communities or closed community and field, cross country, gymnastics skating, golf, skateboarding, distance running settings or that are facilitated by certain exposures specific to the sport. Infectious pathogens include practicing in close quarters are Although the primary care Staphylococcus aureus those spread by skin contact (‍eg, especially vulnerable to skin pediatrician may appear to be 10,11​ , group infections. ‍ peripheral in this athletic milieu Bacillus cereus A streptococcal skin infections, of organized sports, leadership Tinea capitis Tinea , herpes simplex Athletes should be taught proper from physicians has always corporis Tinea pedis Tinea cruris virus [HSV], , personal hygiene (‍eg, hand-washing, been welcome and expected Pediculosis capitis Pediculosis , , , showering, and proper laundering regarding issues of public health corporis Pediculosis pubis – , of uniforms and practice clothing and safety. Furthermore, because 12 15 , and ), by on a daily or regular basis). ‍ ‍ pediatricians need to provide Escherichia contaminated food or water (‍eg, Avoidance of sharing of drinking medical clearance to athletes to coli Shigella Giardia Shiga-toxin producing vessels (‍water bottles, ladles, participate in organized sports, Cryptosporidium , species, or cups), mouth guards, towels, the preparticipation physical species, species, braces, batting helmets, personal examination is an opportunity to and norovirus, which is further protective equipment, bars of soap, verify that the athlete does not propagated by the person-to-person bath sponges, razors or electric have a skin condition or infection Neisseria route), by respiratory droplet hair shavers, and callus trimmers that could be transmitted to others. meningitidis – (‍eg, influenza, pertussis, is also important in reducing This visit between the physician 2 9 , group A streptococcal infectious risk. ‍ ‍ In addition, and the student athlete allows the pharyngitis, mumps), by airborne athletic programs should ensure primary care pediatrician to deliver particles (‍eg, varicella, measles), or regular (‍daily, weekly, and monthly) anticipatory guidance. Ensuring by certain vectors (‍eg, ticks) (‍Table 2). cleaning of facilities and equipment that immunizations are current per In the case of Epstein-Barr virus (‍eg, weight room, railings, mats, recommendations of the Centers – infection, close contact is required blocking dummies, locker rooms, for Disease Control and Prevention, 16 19 for transmission, and endemic and showers). ‍ ‍ Those who the Advisory Committee on disease within adolescent group manage sports programs and Immunization Practices, and the settings has been reported (‍Table 2). facilities should develop a plan for American Academy of Pediatrics is Although biologically plausible, proper cleaning and maintenance important, and pediatric providers there have been no validated reports of a sanitary sporting environment should identify and document cases of infections from transmission of by using guidelines such as those in which vaccines are refused or bloodborne pathogens, including published by the American College incomplete because of medical 20 hepatitis B, hepatitis C, or HIV of Sports Medicine. exemptions (‍eg, serious allergy to during athletic competitions. a vaccine component). Coaches and Nonetheless, the American Academy Special attention should be paid trainers are primarily responsible of Pediatrics has previously issued to proper management of blood for reviewing and stressing to the 21 specific detailed guidelines for and other body fluids. Just as athlete the key hygiene behaviors management of infections spread hospitals in the United States have needed to minimize the risk of by blood and body fluids, including concentrated on preventing hospital- obtaining or spreading infection guidance for athletes who are associated infections in recent years, in organized sports. However, infected with HIV, hepatitis B virus, the same level of focus on infection primary care pediatricians can or hepatitis C virus, and these will prevention and control needs to help reinforce such educational 21 not be reiterated in this statement. be present within the organized messages. sports community, including Organisms Associated With Transmission of a specific infectious among athletes, parents, coaches, Infections in Athletes agent may be affected by a variety of athletic directors, equipment psychosocial (‍sexually transmitted managers, certified athletic trainers, infection), physical (‍trauma, administrators, janitorial staff, team An athlete can acquire many closed community contact), and physicians, facility managers, and different infections by participating environmental (‍soil, food, water, league officials. in organized sports. The pathogens vector) factors, especially in an Downloaded from www.aappublications.org/news by guest on September 30, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF ​ 25 ‍ 24, s — — — — Outbreaks and Other Considerations Involve public health authorities for outbreaks Topical mupirocin depending on susceptibilities Topical mupirocin if limited skin lesions Azithromycin for serious penicillin allergy Involve public health authorities for outbreak Identification and isolation of infected people Valacyclovir Outbreaks have been reported Griseofulvin contraindicated in pregnancy Topical for limited area T corporis 30 k Prevention care, avoid sharing equipment, refrain from use of common tubs, cosmetic shaving, cleaning of high-touch surfaces bottles, equipment people; no specific treatment is uniformly efficacious in consultation with infectious diseases expert, consider fluconazole prophylaxis, 100 mg, once daily for 3 d, at season onset and repeat in 6 w sharing equipment, sunscreen cleaning equipment Good personal hygiene, wound Good hygiene, not sharing water Avoid skin contact with infected Good personal hygiene, avoid Valacyclovir prophylaxis, proper Rn, Dx, Tx ganisms Responsible for Infections in Children Participating in Organized Sportsganisms Responsible for Infections in Children Participating in Organized cellulitis, impetigo pharyngitis, cellulitis umbilication or doxycycline based on susceptibility for 10 d for GABHS if sore throat and no viral symptoms, Gram-stain, culture of lesions lesions with amoxicillin or penicillin; if penicillin allergic, macrolide; all for 10 d except azithromycin for 5 d rarely, necrotizing fasciitis: if contaminated food, nausea, vomiting, diarrhea, and cramps 7 d griseofulvin ± 1% terbinafine gel or 2% ketoconazole cream identification of enterotoxin from food if contaminated linezolid for severe skin infections, supportive for foodborne Rn: folliculitis, skin abscess, Rn: impetigo, erysipelas, Rn: pearly papule with central Rn: scaly plaque, alopecia In settings of high infection rates, Dx: Gram-stain, culture of lesions Tx: cephalexin, TMP/SMX, Dx: rapid antigen detection test Rx: treat if positive; culture skin Rn: honey-crusted skin lesions; Rn: cropped vesicles Dx: viral PCR of skin lesion Rx: adolescents-valacyclovir for DX: clinical Rx: 10% KOH, cryotherapy Dx: KOH prep, culture Rx: oral itraconazole, terbinafine, Dx: Gram-stain, culture of lesions, Rx: usually IV vancomycin or Risk Factors (turf injuries in football or soccer), wrestling, rugby, judo, and gymnastic mats, sharing equipment erysipelas, droplet in pharyngitis eczema judo practitioners penetrating trauma, contaminated environment abraded skin, sun induced (eg, skiing) Contact sports, wounds Sharing towels, underlying Skin contact, wrestlers, Sharing sunscreen, Skin contact, wrestling, contaminated food infected individual; reactivation 1 ° infection Contact Contact, droplet Skin contact in impetigo/ Contact, Contact with Contact Contact

​ 28 27 m ‍ 29 T tonsurans ), ‍ 24  Summary of Epidemiology and Outbreak Management Considerations for Or 22

A 23 2 S 26 LE V MRS T corporis contagiosu B S aureus including GABH B cereus Molluscum T capitis ( Pathogens Primarily Transmitted by Contact Sports Pathogens Primarily Transmitted Pathogen or Disease Transmission HS TA

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF — — — — Outbreaks and Other Considerations not subside for weeks; indication of treatment failure Evaluate sparring partners; treat suspected cases Itching is attributable to hypersensitivity reaction and may — Prevention 34 s showers T pedis present and other parts of body infected people, no sharing of equipment and towels; wear rubber soled flip-flops or sandals in communal shower Foot powder after bathing Careful drying between toes after Daily change of socks Periodic cleaning of footwear Wear socks before undershorts if Dry crural folds after bathing Use separate towel to dry groin Avoid contact with known Rn, Dx, Tx 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, precipitated sulfur 4% – 8% 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 area webs terbinafine gel OD for 1 wk nitrogen, laser removal or application of salicylic acid and feet under nails, firm hyperkeratotic papules Dx: Rx: topical permethrin 5% cream Dx: KOH prep, culture Rx: children 12 y or older – topical Rn: scaly, itchy eruption on feet Good personal hygiene Rn: scaly, itchy eruption in groin Rn: ++ pruritic rash, interdigital Dx: KOH prep, culture 1% Rx: children 12 y or older, Dx: clinical Rx: none or curettage, liquid Rn: painless warts on hands Risk Factors contact, swimmers, skaters, marathon runners hyperhidrosis, contaminated towels, hotel bedroom sheets equipment, bare feet in common shower areas Common shower, skin Common shower, Heat, humidity, Wrestlers Wrestlers, sharing of Wrestlers, Contact Contact Contact Contact 35 ) ) Continued 33

‍ 32 V ‍ 31 2 LE (caused by subtypes of HP B T pedis T cruris Verruca vulgaris S scabiei (scabies Pathogens Primarily Transmitted by Contact Sports Pathogens Primarily Transmitted Pathogen or Disease Transmission TA

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF — — Outbreaks and Other Considerations palpable (typically ∼ 3 – 4 wk) sport sink rather than shower or bath to limit skin exposure, and use warm water instead of hot to limit absorption resulting from vasodilatation all exposed people Avoid contact sports until recovered and spleen no longer Involve public health authorities for single case Involve public health authorities for single case Clearance by health care professional before resuming Rinse hair after topical pediculicide application over a Ensure previous 2 doses of vaccine or history disease for Avoid salicylates during infection 39 n 37 d — Prevention MMR vaccine is given MMR vaccine is given and avoiding sharing drinks, utensils varicella vaccine is give prophylactically low, sharing of combs, low, hair brushes, hats, and hair ornaments is not recommende Ensure ACIP/AAP-recommended Ensure ACIP/AAP-recommended Counsel regarding close contact Ensure ACIP/AAP-recommended No need to treat contacts Although risk of spread is Rn, Dx, Tx rash splenomegaly; serum antibody panel of age), IgM antibodies versus viral capsid antigen, Epstein- Barr nuclear antigen crusts; can be confused with HSV nasopharyngeal specimens, rubeola serology or adult lice with naked eye hand lens fine-toothed combing. Start topical with over-the-counter 1% permethrin lotion or pyrethrin combined with piperonyl butoxide; repeat in 7 d; resistance reported, see text for options valacyclovir for 7 d pruritus Rn: febrile prodrome, morbilliform Rn: parotitis Dx: heterophile antibody test (>4 y Rx: supportive Dx: PCR of urine and Rx: supportive Dx: PCR of saliva, serology Rx: supportive Dx: clinical: seeing nits, nymphs, Rx: manual removal of nits by Dx: PCR of vesicular fluid Rx: usually none, oral acyclovir or Rn: visible lice on hair shaft, Risk Factors underimmunized populations underimmunized populations equipment Crowded settings, Sharing clothing, Close contact Adolescent group settings Rn: exudative pharyngitis, Skin, airborne Close community contact Rn: crops of papules, vesicles, Droplet, airborne International venues, Droplet Contact 40 )

‍ 36 38 s 39 a 41 Continued s

2 LE mononucleosis caused by Epstein- Barr viru Varicell Mump Measles (rubeola (head lice) B Infectious Pediculus capitis

Pathogens primarily transmitted by airborne route Pathogens primarily transmitted by droplet route

Pathogens Primarily Transmitted by Contact Sports Pathogens Primarily Transmitted Pathogen or Disease Transmission TA

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF — — — Outbreaks and Other Considerations influenza complications (eg, asthma, heart and/or lung disorders, metabolic immune compromised) closed population) serogroup B involved, meningococcal vaccine Prioritize treatment of those who have increased risk for Involve public health authorities for outbreaks (>2 cases in Involve public health authorities for single case; if Involve public health authorities for outbreaks Involve public health authorities for outbreaks — Prevention influenza vaccine is given seasonally Tdap is given; identify and intervene with chemoprophylaxis in outbreaks meningococcal conjugate ACWY vaccine is given or swallowing potentially contaminated water contaminated water Ensure ACIP/AAP-recommended Ensure ACIP/AAP-recommended Ensure ACIP/AAP-recommended Hand hygiene Hand hygiene Hand hygiene Hand hygiene Swimmers avoid immersion Protective clothing, boots in Rn, Dx, Tx during influenza season shock, purpura 2 d, for 5 d specimen cefotaxime or ceftriaxone; penicillin once diagnosis confirmed depending on susceptibilities watery diarrhea (can mimic influenza) assay IgM first choice, risk of Jarish- Herxheimer reaction; also cefotaxime, ceftriaxone and doxycycline; supportive care Rn: paroxysmal cough for ≥ 2 wk Dx: culture, rapid molecular tests Rx: oseltamivir if identified in first Dx: PCR of nasopharyngeal swab Rx: azithromycin for 5 d Dx: Gram-stain, culture Rx: begin with intravenous Rn: diarrhea, blood Dx: culture stool Rx: TMP/SMX, ciprofloxacin Dx: stool antigen test Rx: metronidazole or nitazoxanide Dx: stool examination Rx: nitazoxanide Dx: clinical RT-PCR Rx: supportive Rn: fever and headache, myalgia Dx: enzyme-linked immunosorbent Rx: intravenous penicillin G fresh water ​ 50 Risk Factors restaurant related swimming, skin wounds Close community contact Rn: febrile upper respiratory tract Close community contact Close community contact Rn: bacteremic presentation, Commonly attended event, Public pools, swimmers Rn: watery diarrhea Public pools, swimmers Rn: watery diarrhea Common environment Rn: abrupt onset of vomiting, Triathletes, or water; person to person or water or water or water; person to person water Droplet Droplet Droplet Contaminated food Contaminated food Contaminated food Contaminated food Contaminated ‍ 47 ‍ 44 49 s 48 43 42 s s ‍ 45 a ‍ 46 Continued

tussi 2 LE Influenz Per N meningitidis Shigella Giardia Cryptosporidia Noroviru Leptospirosi B

Pathogens primarily transmitted by contaminated food or water route Pathogens Primarily Transmitted by Contact Sports Pathogens Primarily Transmitted Pathogen or Disease Transmission TA intravenous; KOH, potassium human papillomavirus; IgM, immunoglobulin M; IV, Advisory Committee on Immunization Practices; BID, twice daily; Dx, diagnosis; FDA, Food and Drug Administration; HPV, American Academy of Pediatrics; ACIP, AAP, reverse transcription PCR; Tdap, adult tetanus, diphtheria, and acellular pertussis vaccine; TMP/SMX, trimethoprim-sulfamethoxazole; Tx, treatment; — , not applicable. hydroxide; OD, once daily; Rn, recognition; RT-PCR,

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF ï S Aureus

immunologically na ve population. 10 (‍5.3%) developed skin infections, This policy will be focused on S aureus including 7 with impetigo and 1 with Community-acquired methicillin- diagnosis, treatment, and prevention folliculitis barbae during the course resistant (‍MRSA) is a cause of the most common infections that of the 2008 season. None of the of outbreaks of skin infections among may be encountered in the athlete cultured specimens tested positive high school and collegiate athletes 65 participating in organized sports, Gforroup MRSA A Streptococcus. participating in contact sports, with an additional focus on factors particularly among football players β Streptococcus that are potentially modifiable. and wrestlers, and is associated with It should be noted that some of Group A -hemolytic significant morbidity. It manifests the organisms discussed can be (‍GABHS) has been associated primarily as cellulitis or skin transmitted in multiple fashions. with outbreaks of skin infections abscesses but may lead to invasive Transmission of pathogens spread after indoor association football disease such as bacteremia, septic 66 67,68​ by contaminated food or water, by tournaments,​ rugby,​ ‍ and other arthritis, osteomyelitis, myositis, respiratory droplets, and by vectors organized sports. The organism fasciitis, and pneumonia in up to are similar to what can be expected 56,57​ can cause localized skin infections 51 10% of cases. ‍ Other noninvasive under nonsporting conditions and such as pyoderma, cellulitis, or forms of disease including impetigo, are beyond the scope of this report. impetigo or invasive infections staphylococcal ecthyma, pustulosis, Although several of these pathogens such as thrombophlebitis, myositis, and folliculitis may also pose a risk are summarized in Table 2, detailed and sepsis. GABHS has also been for transmission of the organism descriptions in this clinical report associated with outbreaks of from those so affected. Players are provided only for the organisms pharyngitis among university who have preexisting skin diseases transmitted primarily by contact, S aureus students (‍median age 19.5 years) such as atopic dermatitis may have 69 manifesting primarily on the skin, participating in judo. Within chronic colonization with and those that are airborne. a 15-day period, 12 of 23 club and may be predisposed to recurrent Infections Primarily Spread by members in Tokyo, Japan, presented secondary infection. Between 10% Contact Transmission with sore throat and high fever. and 23% of football players or – Diagnosis was made by use of either wrestlers have developed signs and 5,58​ 60 a rapid streptococcal antigen test or symptoms during outbreaks. ‍ ‍ Most sports-related skin infections positive throat culture for GABHS Risk factors for infection include skin are spread by contact and have when the clinical presentation breaks associated with turf burns been associated with 10% to 15% 58 was suggestive of pharyngitis. or trauma,​ skin-to-skin contact, of time-loss injuries among athletes Occasionally, outbreaks of invasive 52 sharing of equipment or clothing at the collegiate level. For this 5,19,​ 59​ GABHS disease have been reported (‍towels), and higher BMI. ‍ reason, routine screening of athletes in members of high school football Although 4% to 23% of athletes have 70 participating in contact sports during teams,​ likely attributable to sharing been found to have colonization with practices and before competitions Mofanagement equipment ofand S waterAureus bottles. and GABHS MRSA, high colonization alone does is important. The Sports Medicine Outbreaks not appear sufficient to trigger an Advisory Committee of the National 61 outbreak. Wrestling mats, artificial Federation of State High School 53 turfs, and football training equipment Associations (‍NFHS),​ the National Management of MRSA and GABHS have been documented with MRSA Collegiate Athletic Association 19,62,​ 63​ outbreaks has been accomplished 54 colonization. ‍ ‍ (‍NCAA),​ and the National Athletic55 through meticulous focus on hygiene Trainers Association (‍NATA) Incidence estimates of MRSA-related education, good hygiene practices, have published guidelines for skin and soft tissue infections in prompt identification of infected

screening and when to return to Nebraska student athletes have people, limiting exposure to infected athletic participation for several ranged from 11.3 to 20.9 per 10000 people and contaminated surfaces

conditions (‍summarized in Table football players and 28.1 to 60.8 and objects, decontamination of the

3). It is noteworthy that many of per 1000064 wrestlers from 2008 environment, and proper treatment the recommendations by these to 2012. Among 190 high school and close4,5,​ 7,​follow-up59,​ 60,​ 69,​ 71​ of infected organizations are more stringent football players in northeast Ohio people. ‍ ‍ ‍ ‍ ‍ Of particular than ordinary infection control who were managed prospectively importance for management of MRSA practices for similar conditions in Swith aureus nasal swab cultures, 23% outbreaks is screening of players for which the likelihood of the type displayed methicillin-susceptible carriage along with use of topical of close bodily contact is not as colonization (‍none carried mupirocin for those found to have significant. MRSA). Of the participating athletes, colonization, use of chlorhexidine Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 140, number 4, October 2017 7

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 3 Return to Practice and Competition Guidelines for Infected Athletes Condition NCAA54 NFHS53 NATA55 AAP Notes51 GABHS and S aureus, • Completion of 72 h of • Completion of 72 h of • Completion of 72 h of — (abscesses, cellulitis, antibiotic therapy antibiotic therapy with antibiotic therapy with folliculitis, impetigo, lesions resolving lesions resolving carbuncles) • No new skin lesions for • No moist, weeping, or • No new skin lesions for at 48 h before competition draining lesions; all least 48 h lesions should have well- adhering scabs • No moist, exudative, • Scabbed and/or dry • No moist, exudative, or or draining lesions lesions only can be draining lesions at time of practice or covered with bio- competition occlusive dressing • Gram-stain of exudate of — • Covered active lesions at time questionable lesions of practice or competition not allowed • Cannot cover active — — purulent lesions HSV, primary • All systemic (fever, • Return after all lesions • All systemic (fever, malaise, • Exclude athletes from practice malaise, etc) symptoms are healed with well- etc) symptoms must be or competition until vesicular must be resolved adherent scabs, no new resolved or ulcerative lesions on exposed vesicles, no swollen body parts and around mouth or lymph nodes near eyes are fully crusted26 affected area • No new lesions for 72 h • Oral antiviral agents to • No new lesions for 72 h before examination expedite recovery; if before examination started, no wrestling for 5 d • No moist lesions, all — • No moist lesions, all existing existing lesions must lesions must be dry and be dry and covered by a covered by a firm, adherent firm, adherent crust crust • Must have been on — • Must have been on appropriate systemic appropriate systemic antiviral therapy for at antiviral therapy for at least least 5 d before and at 5 d before and at the time of the time of practice or competition competition • Covered active lesions — • Covered active lesions at time at time of practice or of competition not allowed competition not allowed HSV, recurrent • Lesions must be • Oral antiviral agents to • Lesions must be completely • Exclude athletes from practice completely dry and expedite recovery; if dry and covered by a firm, or competition until vesicular covered by a firm, started, no wrestling adherent crust or ulcerative lesions on exposed adherent crust for 5 d body parts and around mouth or eyes are fully crusted • Must have been on • If no oral antiviral agents, • Must have been on • Consider suppressive antiviral appropriate systemic return after all lesions appropriate systemic agents for rest of season26 antiviral therapy for at healed with well- antiviral therapy for at least least 5 d before and at adherent scabs, no new 5 d before and at the time of the time of competition vesicles in previous 48 h, competition no swollen lymph nodes near affected area • Covered active lesions • Consider prophylactic • Covered active lesions at time — at time of practice or antiviral agents for rest of practice or competition competition not allowed of season not allowed Molluscum contagiosum • Curette or remove lesions • No treatment or • Lesions must be curetted or — before competition restrictions removed • May cover solitary or • Cover lesions prone to • Localized lesions may localized clustered bleeding when abraded be covered with a gas- lesions with gas with a gas-permeable permeable dressing followed permeable membrane membrane and tape by underwrap and stretch and tape tape

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 3 Continued Condition NCAA54 NFHS53 NATA55 AAP Notes51 T capitis • Minimum of 2 wk of • Minimum of 2 wk of • Minimum of 2 wk of systemic — systemic antifungal systemic antifungal antifungal therapy therapy 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 • Minimum of 72 h of • Minimum 72 h topical — topical or systemic topical or systemic fungicide terbinafine or antifungal therapy antifungal therapy naftifine • Presence of extensive and • Lesions to be covered • Lesions must be covered with active lesions (based on with a bio-occlusive a gas-permeable dressing KOH prep or review of dressing for return to followed by underwrap and treatment regimen) will practice or competition stretch tape lead to disqualification once no longer considered contagious • 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 • If multiple digitate lesions • No treatment or — — by subtypes of HPV) present on face, will be restrictions disqualified if cannot be covered by a mask • Solitary or scattered • Cover lesions prone to lesions should be bleeding when abraded curetted away before with a gas-permeable competition 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

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 3 Continued Condition NCAA54 NFHS53 NATA55 AAP Notes51 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 • For shingles: 10–14 d — • Skin lesions must have a firm, a firm, adherent crust of systemic antiviral adherent crust and no new at time of practice or medication lesions cropping up at time of competition practice or competition39 • There must be no • Lesions must be scabbed evidence of secondary over with no discharge bacterial infection 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.

S aureus 73 washes, and enhancement of7,19,​ 72​ reduction. Screening for swabbing of a pair of swabs on personal hygiene practices. ‍ and GABHS requires knowledge both tonsils and the posterior Bleach baths (‍Clorox: regular 6.0% of what body sites would have pharynx for rapid antigen detection hypochlorite, 5 mL, added to 1 gallon colonization. Nasal,S aureus skin, vaginal, and culture as well as culture of of water) used twice weekly reduced and rectal carriage are the primary any skin lesions, especially those S aureus 23 the recurrence rates among children reservoirs for . In the context that are oozing or macerated. of sports-related infections, the with community-associated Measurement of sequential primary culture sites should be the infections by 20% compared with streptococcal antibody titers nares and any open skin lesions. control children managed with may also be used to diagnose a

routine hygienic measures, but this GABHS screening should be recent infection, but this is not74 was not a statistically significant performed through vigorous recommended for routine use. Downloaded from www.aappublications.org/news by guest on September 30, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF ±

Skin abscesses are best managed by of treatment is 10 days, with the 11 days, with an average of 6.80 incision and drainage, with culture exception of –azithromycin, which– 1.70 days from onset of exposure to

of the wound for identification of is indicated78 for80 5 days. Local 81 83 development of skin lesions. Most causative agent and antimicrobial mupirocin ‍ ‍ or retapamulin ‍ ‍ outbreaks (‍96%) occur on the ventral susceptibility pattern along with ointment may be useful for surface of the body, with up to three- empirical antibiotic coverage pending limiting person-to-person spread quarters of the cases occurring culture results. Antibiotic choices of nonbullous impetigo and for on areas in direct contact when shouldS aureus be guided by knowledge of eradicating localized GABHS disease. wrestlers are engaged in the lock-up the local patterns of susceptibility Guidelines from the NCAA, NFHS, and position (‍head, face, and neck). Other Sof aureus , especially local rates NATA for whenS aureus the infected athlete body areas frequently involved are of MRSA. Methicillin-susceptible can return to competition for both the extremities16 (‍42%) and trunk typically is treated GABHS and are summarized (‍28%). HSV conjunctivitis (‍5%) β with oral penicillinase-resistant Preventionin Table 3. of S Aureus and GABHS and blepharitis87 have also been -lactam drugs, such as a first- or Outbreaks reported. Between 25% and 40% second-generation cephalosporin. of patients with HG and HR will For patients who are allergic to develop constitutional symptoms

penicillin, or if MRSA is a significant Prevention of infections caused including fever,85, chills,87​ sore throat, consideration, the alternatives are by MRSA and GABHS is achieved and headaches. ‍ There are data trimethoprim-sulfamethoxazole, primarily through good hygiene associating acquired antibody to HSV

doxycycline, or clindamycin22 for practices, not sharing equipment type 1 infection with protection from susceptible isolates. Doxycycline and water bottles, limiting acquiring HG,84 but the association is can be used safely in children ages exposure to infected people and Hveryerpes weak. Outbreak and High-Altitude 2 years and older when given contaminated surfaces and objects, Skiing for durations less than 2 weeks. decontamination of the environment, Trimethoprim-sulfamethoxazole and prompt identification, proper

should not be used as a single agent treatment, and close4,5,​ 7,​ 59,​ follow-up60,​ 69,​ 71​ of High-altitude skiing also has been in the initial treatmentStreptococcus of cellulitis infected people. ‍ ‍ ‍ ‍ ‍ Athletes associated with relapses of orofacial because of the possibility it is with GABHS pharyngitis or skin herpes, presumably because of caused by group A – infections should not return to solar UV radiation exposure, with

and the possibility of intrinsic75 77 competitive sports for at least 24 a median onset of 3.5 days after88 resistance of this organism. ‍ ‍ hours after beginning appropriate23 exposure (‍strong evidence). Topical mupirocin may be used for oral antimicrobial therapy. Table 3 Although sunscreen with a sun localized and nonbullousS aureus impetigo. summarizes recommendations ofS the protection factor of 15 was shown During outbreaks, attempts at aureusNCAA, NFHS, and NATA for return to prevent experimental UV light- eradication of infections to to competition for patients with induced reactivation of herpes 89 limit spread may be accomplished – Herpes infections, Gladiatorum including and Herpes MRSA. labialis compared with placebo,​ it by use of topical nasal mupirocin Rugbiorum has not been shown to influence the

therapy (‍twice daily for 5 7 days) reactivation88 rate among high-altitude among people with colonization. – Mskiersanagement. of HG and HR However, low-level (‍minimum Outbreaks µ HSV (‍primarily type 1) has been inhibitory concentration, 8 256 identified as a cause of outbreak g/mL) and high-level (‍minimum µ of skin infections among wrestlers inhibitory concentration,S aureus >512 (‍herpes gladiatorum [HG]) and rugby There is strong evidence that prompt g/mL) resistance to mupirocin have players (‍herpes rugbiorum [HR]) identification and 3 to 8 days of been identified in . High-level on numerous occasions, affecting isolation of infected wrestlers during resistance has been associated with up to 2.6%– of high school and 7.6% primary outbreaks of HG and HR

subsequent failure of decolonization. of college84 86 wrestlers in the United with suspension of competition States. ‍‍ During outbreaks, up to can help contain outbreaks87,90,​ 91​ in more GABHS typically is susceptible to 34% of all high school wrestlers 87have than 90% of cases. ‍ ‍ Diagnosis penicillin, and74 this is the usual first- been documented to be infected. involves a combination of clinical line therapy. An oral macrolide Risk factors for development of recognition and may be coupled with or azalide (‍eg, erythromycin, HG-related cutaneous HSV lesions cell culture, histologic examination, or clarithromycin, or azithromycin) include direct skin-to-skin exposure rapid diagnostic tests such as direct

is acceptable for patients who to opponents84 with cutaneous fluorescent antibody staining, enzyme are allergic to penicillin. Duration lesions. There is a range of 4 to immunoassay, or polymerase chain Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 140, number 4, October 2017 11

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF reaction (‍PCR) of vesicular lesion double-blind randomization have most often been described

scrapings in complex,26 lingering, or followed by an open enrollment in association with exposure– to unclear cases. Valacyclovir, 500 onto treatment, participants with swimming in public3, pools95​ 97 and mg, every day or twice a day for 7 recurrent HG were treated during underlying eczema. ‍ ‍ Other days, when given within 24 hours the first half of the season with either factors associated with infection of symptoms onset, has been shown 500 mg of valacyclovir or placebo include young age (‍highest incidence to shorten the duration of time until and in the second half with 1000 mg in children younger than 14 years), HSV PCR clearance from lesions of of valacyclovir. The 500 and 1000 mg living in close proximity, skin-to- ∼ adolescent and adult wrestlers with doses of valacyclovir suppressed skin contact, sharing of fomites,3,98​ and recurrent HG by 21% (‍from 8.1 recurrence of outbreaks among Mresidenceanagement in tropical of Molluscum climates . ‍

days with placebo92 to 6.4 days with 100% (‍7 out of 7 and 12 out of 12) of Outbreaks valacyclovir). Wrestlers receiving participants whose last recurrence valacyclovir should be advised about was more than 2 years before. the importance of good hydration to However, the doses were slightly Resolution of uncomplicated minimize the risk of nephrotoxicity. less successful among those with molluscum contagiosum typically Competitors often do not recognize recurrences within 2 years (‍11 out occurs spontaneously in 6 to or may deny possible infection. As a of 14 and 23 out of 25, respectively), 12 months, although complete

result, efforts to reduce transmission with better93 results with the 1000 mg resolution of lesions can take up should include (‍1) examination of dosing. to 4 years. Although no regimen wrestlers and rugby players for has proven highly successful, Similarly, in a Minnesota study vesicular or ulcerative lesions on 10% potassium hydroxide and of 332 male wrestlers 13 to 20 exposed areas of their bodies and cryotherapy with liquid nitrogen years of age who participated at a around their mouths or eyes before have been used to treat lesions 28-day wrestling camp, once-a-day practice or competition by a person that occur in locations that are prophylactic valacyclovir (‍1000 familiar with the appearance of cosmetically bothersome to mg) starting 1 week before camp mucocutaneous infections (‍including patients or for patients with and continuing throughout camp HSV, herpes zoster, and impetigo), underlying skin conditions such as reduced the incidence of clinical (‍2) excluding athletes with these eczema. Both forms of treatment HG outbreaks by 87%. Among lesions from competition until all appear to have similar efficacy in ’ 55 of these wrestlers who were lesions are fully crusted or production children, but cryotherapy may be HSV type 1 immunoglobulin G of a physician s written statement associated with postinflammatory seronegative at the beginning of the indicating that their condition is hyperpigmentation or, uncommonly, camp and had postcamp serologic 99,100​ noninfectious, and (‍3) cleaning scarring. ‍ Imiquimod was not testing performed, none developed of wrestling mats with a freshly shown to be of benefit compared detectable immunoglobulin M against prepared solution of household 94 – with placebo in randomized HSV type 1 or HSV type 2. However, 101,102​ bleach (‍1 quarter cup of bleach controlled trials. ‍ Open-label there is need for a detailed risk 103,104​ in 1 gallon of water) applied for a and observational studies ‍ benefit analysis of using valacyclovir minimum contact time of 15 seconds indicate that cantharidin can be an for prophylaxis in wrestlers who are at least daily and preferably between effective treatment of molluscum 26 seronegative for herpes. matches. NCAA, NFHS, and NATA Molluscum Contagiosum contagiosum; however, in 1 small guidelines for when the infected randomized controlled trial of 29 athlete can return to competition are patients, the improvement seen with summarized in Table 3. cantharidin, although greater than Prevention of HG and HR Outbreaks Molluscum contagiosum is a common, benign viral skin infection with placebo, was not found100 to be presenting as skin-colored papules statistically significant. Guidelines that develop a central umbilication from the NCAA, NFHS, and NATA for Athletes with a history of recurrent as they age. Molluscum contagiosum when the infected athlete can return

HG, HR, or herpes labialis should affects 5% to 11% of95 children to competition for molluscum are be considered for suppressive 0 to 16 years of age and most Preventionsummarized of in M Tableolluscum 3. antiviral therapy. There is strong commonly affects the trunk, face, and Contagiosum Outbreaks evidence that nucleoside analogues extremities. Molluscum contagiosum (‍valacyclovir) can suppress recurrent is mostly asymptomatic but may outbreaks of herpes. In a study present with pain, itching, redness, or Given the known associations of involving 42 male wrestlers aged 13 occasionally bacterial superinfection. molluscum contagiosum, the best to 31 years in Minnesota combining Outbreaks of molluscum contagiosum method of prevention would involve Downloaded from www.aappublications.org/news by guest on September 30, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF T corporis

avoiding of skin-to-skin contact preparations for include study revealed the128 efficacy to be low with people known to have lesions but are not limited to azole for both regimens. Itraconazole (‍covering lesions), not sharing towels creams (‍clotrimazole, econazole, given for 2 weeks is also similar in and other fomites, and limiting ketoconazole, oxiconazole), efficacy to 6 weeks of griseofulvin, exposure to swimming pools that allylamine creams and gels (‍1% whereas terbinafine and itraconazole

have recently been associated with gel of terbinafine and butenafine), appear to have similar efficacy for 124 knownTinea Infections outbreaks. and hydroxypyridone (‍ciclopirox) treatment periods of 2 to 3 weeks. T corporis T capitis preparations. Although these all However, terbinafine, itraconazole, are reasonably effective, some and fluconazole are significantly and infections preparations in some studies more expensive than griseofulvin. have been reported more demonstrate superior cure rates. For Furthermore, griseofulvinMicrosporum appears to example, terbinafine emulsion gel be superior for infections attributable frequentlyT corporis among high schoolT ’ capitiswrestlers and judo practitioners has a mycological cure rate superior to certain species of , (‍ gladiatorum– and to that of ketoconazole cream (‍94% which may require 4 weeks versus 69%, respectively) with duration or more of therapy with gladiatorum)T8, 105​corporis112 than among 117 122,129,​ 130​ other athletes. ‍ ‍‍ Studies of the similar adverse events rates. terbinafineT tonsurans and itraconazole. ‍ ‍ prevalence of gladiatorum Terbinafine appears superior for Oral agents also have proven 125 have involved use of potassium T corporis . efficacious in the treatment of most Prevention of T Corporis and hydroxide examination to aid cases of . Different doses T Capitis Outbreaks diagnosis. In 1 such study, 24% of T corporis and durations of itraconazole have 29 wrestlers had lesions of been used in studies. Itraconazole, , versus 0 in a control P 100 mg, given orally once a day, Fluconazole, 100 mg per day for group of track team members T corporis 106 was superior to griseofulvin, 500 3 days, given prophylactically (‍ = .005). In another study, mg, orally, once a day, when given before initiation of competitive was detected in 10 of 19 for 15 days (‍87% mycological cure interscholastic high school wrestling boys (‍53%) 15 to 17 years of age rate versus 57%, respectively, at the and given again 6 weeks into belonging to a judo club in Kyoto, T capitis112 Trichophyton end of 2 weeks after completion of the season, has been reported to Japan. The most common cause of 118 T corporis tonsurans therapy) to adolescents and adults. significantly reduce the incidence gladiatorum is 30 In contrast, 200 mg of itraconazole of from 67.4% to 3.5%. , accounting for more than Trichophyton rubrum was found to be superior to 250 However, the risk-benefit analysis of 80% of cases, but it may also be Trichophyton mentagrophytes mg of terbinafine when given for 7 giving fluconazole prophylactically caused by and T tonsurans 113,114​ days respectively in terms of clinical in this manner has not been . ‍ T mentagrophytes response rates when administered to determined, and its use should be (‍primarily), 119 Microsporum canis adolescentsT capitis and adults. in consultation with an infectious , and diseasesT Pedis expert. T capitis have also For , the traditional treatment in children had been oral been isolated in high rates during T pedis ’ outbreaks of (‍ringworm) griseofulvin, 10 mg/kg per day, among high school wrestlers in microsize formulation, given once (‍athlete s foot) presents

a wrestling109,115,​ boarding116​ school in daily for 6 to 8 weeks, although as a fine scaly or vesiculopustular Turkey. ‍ These organisms doses of griseofulvin as high as 20 eruption that is often itchy. The

have been isolated frequently from to 25 120mg/kg per day have been lesions may involve all areas of individual skin lesions108,109​ and from used. Terbinafine, 125 or 250 mg the foot but commonlyT pedis include the Mwrestlinganagement mats of. T Corporis‍ and (‍adjusted for age), given for 2 to 8 fissures and scaling between toes. T Capitis Outbreaks weeks, has recently been shown to Increased rates of have been have efficacy that is– at least as good, well documented and common

with fewer adverse116,121​ 123 effects and fewer among swimmers and runners TBoth corporis skin-basedT andcapitis oral medications recurrences. ‍ ‍ Cochrane (‍especially marathon runners), are available for the treatment of reviews have concluded that 4 weeks Twith rubrum documentedT mentagrophytes infections in up to , but is managed of terbinafine was equivalent124,125​ to 22%. The predominant causes are131 exclusively with oral medications, 8 weeks of griseofulvin. ‍ andT pedis . often with simultaneous application Similarly, oral fluconazole given for Spread via direct contact with the of topical treatment to the scalp 4 weeks had similar efficacy organism, is prevalent in

(‍because of the need for hair to oral griseofulvin126,127​ given for warm, humid environments and132 follicle penetration). Skin-based 6 weeks,​ ‍ although at least 1 affects men more than women. Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 140, number 4, October 2017 13

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF T pedis 140 Obesity and diabetes are133 additional regimen. It is only approved by the Tineabed sheets) or autoinoculation risk factors for . US Food and Drug Administration for from hands or feet infected with Management of T Pedis Outbreaks Tinea unguium T pedis Tinea use in adults. manuum from another body site (‍ , , or Terbinafine offers the advantage of 133 once-daily dosing and can be given Management). of T Cruris Infection Numerous treatments (‍creams T pedis for briefer periods than skin-based T pedis and oral medications) have been treatments. Oral terbinafine, 250 mg, evaluated for treating . given once daily for 1 week, Similar to , terbinafine 1% In randomized controlled trials has similar efficacy (‍based on Tcream cruris applied daily for 1 week has in adults, ciclopirox olamine (‍a mycological cure rates at week 4) been used effectively to treat broad-spectrumT rubrum hydroxypyridoneT mentagrophytes to 4 weeks of clotrimazole 1% with a mycological cure rate of antifungal with proven efficacy Epidermophyton floccosum cream applied twice a day141 but with approximately 94% and is approved117 against , , faster clinical resolution. Oral for children 12 years and older. and ) terbinafine, 250 mg, also is similar in Butenafine (‍a benzylamine derivative cream or gel (‍0.77%) applied twice mycological efficacy to itraconazole, of clotrimazole) applied twice daily daily to the affectedT pedis areas for 4 weeks 100 mg, when given over a 2-week for 2 weeks and clotrimazole applied has been shown to be effective in duration but may have a slightly twice weekly for 4 weeks are also eradicating and superior to lower rate of relapse. Terbinafine is over-the-counter– alternatives, but 1% clotrimazole cream or ciclopirox ∼ well tolerated in children, with the butenafine145 148 is only approved in vehicle in achieving both clinical most concerning potential adverse adults. ‍ Oral itraconazole and mycological cure (‍ 60% for events being occasional isolated (‍100 mg daily for 2 weeks or 200 mg cyclopirox olamine cream versus neutropenia and rare liver failure, Tdaily cruris for 1 week) has been shown 6% for its vehicle only at end of typically in people with preexisting to be effective in adults for treating treatment, and 85% versus134,135​ 16% two Preventionliver disease. of T Pedis Outbreaks and superior to oral weeks after treatment). ‍ There T pedis griseofulvin118, 149,​(‍500150​ mg daily for are no published studies of use of 2 weeks). ‍ ‍ Several other azole151 ciclopirox to treat in children, The use of foot powder after bathing topical formulations151 (‍oxiconazole,144 ​ but a dosage of topical application T pedis has been associated with a decline luliconazole,​ 152 sertaconazole,​ twice a day is recommended for use 28 in the rates of in a random eberconazole ) have been shown to in children older than 10 years. sampling of users of a swimming be effective in adults, but none have Similarly, naftifine ointment bath in Scotland from 8.5% to 2.1% Preventionbeen studied of in T anyCruris detail Infection in children. applied twice daily for 4 weeks and 142 over a 3.5-year period,​ mostly sulconazole nitrate 1% cream applied T mentagrophytes attributable to the decline in rates of daily for 4 to 6 weeks have been T pedis – from 5.3% to 0.5%. associated with significantly higher Because of risk of spread from Experts believe that careful and mycological clearance rates (‍57% , covering active foot – thorough drying between the toes 66%) compared with their vehicles lesions with socks before wearing after showers, daily changes of socks, alone (‍13% 34% cleared) and were undershorts may reduce the T rubrum– T and periodic cleaning of athletic associated with fewer relapses in likelihood of direct contamination. pedis footwearT Cruris can be helpful. Furthermore, complete drying of the treatment136,137​ of related . However, sulconazole T cruris crural folds after bathing, and use of is not approved for use in children separate (‍clean) towels for drying in the United States. More recently, (‍jock itch or crotch rot) is a the groin and other parts of the body common pruritic fungal infection of topical azoles such as fenticonazole 133 Verrucamay help Vulgaris reduce contamination. the groin and adjacent skin. Heat, powder have been used in adults138 with up to 100% cure rates. humidity, and hyperhidrosis are predisposing factors, as is wearing of Terbinafine 1% creamT pedis applied T pedis Verruca vulgaris (‍common skin daily for 1 week also has been used tight-fitting or wet clothing.T crurisSimilar warts) are benign epithelial to , obesity and diabetes are effectively to treat , with >93% 133 proliferations of the skin and are additional risk factors for T rubrum. mycological cure rate at 4 weeks, and E floccosum T caused by human papillomaviruses. is approved139 for children 12 years and Thementagrophytes predominant cause is They are typically painless, multiple olderT pedis. Luliconazole was recently followed by 143,144​ and in number, and occur on any reported as a 1% cream trial for . ‍ It may be epithelial surface, although most

in adults, but less than 50% of spread by contaminated fomites commonly on the hands, feet,33 and the participants were cured on this (‍contaminated towels, hotel around and under the nails. They Downloaded from www.aappublications.org/news by guest on September 30, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF may be distinguished from calluses are transmitted by contact, avoidance or ivermectin lotion. Spinosad and corns by the presence of black of contact with people known to and ivermectin lotion are ovicidal, dots (‍clotted blood vessels that have have common warts, not sharing and a single treatment may be

grown into the wart) when they are equipment and towels, and wearing adequate,155, but156​ no treatment is 100% pared down as well as the associated rubber soled flip-flops or sandals in ovicidal. ‍ Suffocant treatments, loss of overlying dermatoglyphs. communal showers may minimize such as benzyl alcohol lotion or Although reports indicate that warts risk. malathion lotion, require retreatment Scabies and Lice may occur in outbreaks among approximately 1 week later to kill any athletes, there are no published data Sarcoptes scabiei new lice that hatched from nits. For on the prevalence. Reported risk lice resistant to all topical agents, oral P capitis μ factors appear to include sharing of Scabies (‍caused by ) ivermectin in a single dose of 200

equipment and exposure of unshod34 and lice (‍ ), although not or 400 g/kg may be used in infants feet in common shower areas. In a commonly reported in sports, can weighing over 15 kg, with a second36 study of 146 adolescents who used be disqualifying if identified in dose given after 9 to 10 days. locker rooms, 27% of those who used children participating in organized, Infections Primarily Spread by communal showers on a regular basis especially contact, sports. They Airborne or Droplet Route were found to have plantar warts are transmitted primarily through Varicella-Zoster Virus versus only 1.25% of those34 who only person-to-person contact. The used the locker rooms. However, scabies parasite can survive on

because the children using communal clothing35 for up to 4 days without skin showers were also members of a contact. Lice do not survive away Although varicella has been reported swim club, it is unclear whether the from the scalp more than 1 to 2 days as a cause 157of airborne sports-related communal shower or the swimming without a blood meal, and although infections,​ such reports are rare Mwasanagement the major of contributing Verruca Vulgaris factor. uncommon, can be transmitted by in the era of immunization with Infections the live attenuated vaccine against hair brushes,37 combs, hats, and hair ornaments. The transmission, the virus. The varicella-zoster risk factors, recognition, diagnosis, virus (‍VZV) manifests primarily as Most cases of common warts will treatment, and prevention are a generalized, pruritic, vesicular eventually spontaneously regress, summarized in Table 2. Successful rash consisting of 250 to 500 with 30% regressing within 6 months treatment of scabies can be achieved lesions in different stages (‍crops)39 and approximately 60% within 2 topically with permethrin 5% of development and crusting. years. Treatment modalities are cream or oral ivermectin (‍not for There is usually an associated low- grade fever, and there may be other usually geared toward chemical or pregnant women), but resistance155,156​ physical destruction of the infected has been reported to both. systemic symptoms. Disease in epithelium and include techniques Pregnant women and infants may be vaccinated children is often milder such as freezing with liquid nitrogen, treated with topical crotamiton or and atypical in nature compared with application of salicylic acid-based precipitated sulfur ointment. Head the wild virus infection and requires products or tretinoin (‍retinoic lice treatment requires attention a high index of suspicion. Diagnosis acid) cream, surgical (‍paring) or not only to the live lice but also to is usually made on the basis of a typical clinical picture coupled with laser removal, and use of topical34 eggs that may subsequently hatch. immunomodulating agents. The Treatment of head lice can be history of exposure, but vesicular more destructive methods may lead started with over-the-counter 1% fluid or scab scraping can be used to pain, which may inhibit athletic permethrin lotion or with pyrethrin for confirmation by using PCR, direct activity. More recently, cantharidin combined with piperonyl butoxide, fluorescent antibody assay, or VZV- specific culture. A significant increase combined with podophyllotoxin- both of which36 have good safety salicylic acid has been used in profiles. Resistance to these over- in serum varicella immunoglobulin adults and reported to be effective the-counter agents is commonplace G antibody between acute and but associated with pain and in many parts of the United States, convalescent serum samples can also 153,154​ – blisteringPrevention. of‍ Verruca Vulgaris and as such, alternative Food and Massistanagement in diagnosis. of VZV Infections Infections Drug Administration approved treatments may be necessary. For lice resistant to over-the-counter Isolation should be instituted for Precise mechanisms of preventing medications, treatment options those suspected to have chickenpox common warts are unknown. include spinosad suspension, until the diagnosis is either ruled However, like most infections that benzyl alcohol lotion, malathion, out or all the lesions are crusted Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 140, number 4, October 2017 15

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF over or in vaccinated children when failure than waning immunity. As a washings, saliva, or cerebrospinal

there are no new39 lesions within a result, the current recommendations fluid, if relevant, for mumps). In an 24-hour period. Oral acyclovir call for a 2-dose vaccine schedule40 for outbreak setting, the MMR vaccine or valacyclovir given within 24 Mchildrenumps and high-risk adults. should be given to all people hours of rash onset results in only a (‍>12 months) who lack evidence modest decrease in symptoms and of immunity. For mumps, a second is not routinely recommended for Mumps is a systemic illness that MMR dose should be offered to most healthy children. It should be presents with swelling of 1 or more all students (‍including those in considered in otherwise healthy of the salivary glands, typically the postsecondary school) who have children who are at increased risk parotid glands. Up to one-third of received only 1 dose of MMR vaccine. of moderate to severe varicella, mumps cases do not cause salivary A second MMR dose should also be including people older than 12 years, gland swelling, presenting instead considered for both conditions in people with chronic cutaneous as a respiratory tract infection. children 1 to 4 years of age if they or pulmonary disorders, those Orchitis is a common complication have only received 1 dose and there receiving long-term salicylate after puberty, but it rarely leads is an ongoing outbreak affecting

therapy, and those on short, to sterility. Approximately 10% of preschool-aged children with 40 intermittent, or aerosolized39 courses patients have an associated viral Preventioncommunity-wide of Measles transmission and Mumps. Preventionof corticosteroids of VZV. Infections meningitis, and numerous other Outbreaks complications occur rarely, including permanent hearing loss, myocarditis, endocardial fibroelastosis, arthritis, The most important method to The most effective proven means thrombocytopenia, thyroiditis, prevent measles and mumps of preventing VZV is via primary mastitis, glomerulonephritis, outbreaks is routine immunization immunization with the live 39 pancreatitis, and oophoritis. The of all children with a live attenuated attenuated vaccine. Children virus has been isolated from saliva vaccine, such as MMR or MMR- exposed to VZV should have their from 7 days before through 8 varicella vaccine, at age 12 through immunity evaluated, either through days after onset of salivary gland 15 months, with a second dose at 4 vaccination records or through swelling. Before introduction to 6 years of age, and people who serologicMeasles testing. of mumps vaccine, outbreaks are not documented to have been40 of mumps were common in the vaccinated during these periods. United States, primarily in crowded People who have altered immunity Measles is characterized by a settings including schools, prisons, (‍except HIV infection, unless they prodrome of cough, coryza, and orphanages, and military facilities. have severe immunosuppression) conjunctivitis with fever followed by Although the incidence of the disease should not receive MMR vaccine. maculopapular or morbilliform rash has declined significantly with the Furthermore, MMR-varicella vaccine that begins on the face and spreads introduction of the 2-dose schedule should not be given to patients with downward to the trunk and out to of the measles-mumps-rubella HIV (‍even if these people have little the extremities. Koplik spots, which (‍MMR) vaccine, outbreaks still to no immune compromise) because

are considered pathognomonic, 40 periodically occur, primarily because of a lack of safety data at the present also appear during the prodrome. ofManagement incomplete ofvaccination. Measles and Mumps time. Outbreaks Patients are contagious 4 days before The epidemiology and outbreak the rash to 4 days after the rash control considerations for other appears. Measles outbreaks have conditions primarily transmitted via been reported during many different Immunization is the cornerstone droplet and contaminated food and types of sporting– events ranging of managing measles and mumps waterLead A uthorsare summarized in Table 2. from gymnastics158 163 to skiing and outbreaks. All suspected cases fencing,​ ‍‍ highlighting the of measles or mumps should be H. Dele Davies, MD, MS, MHCM, FAAP importance of adequate vaccination reported immediately, and every Mary Anne Jackson, MD, FAAP Stephen G. Rice, MD, PhD, MPH, FAAP of all athletes. Up to 5% of people effort should be made for laboratory who have received a single dose of confirmation of the infection either Committee on Infectious Diseases, vaccine at 12 months or older have through serologic testing or detection 2016–2017 vaccine failure. Among previously of virus from clinical specimens Carrie L. Byington, MD, FAAP, Chairperson immunized people, primary vaccine (‍throat washings, nasopharyngeal Yvonne A. Maldonado, MD, FAAP, Vice Chairperson failure (‍inadequate response to secretions, urine, and blood for vaccine) is a more common cause of measles and buccal swabs, throat Downloaded from www.aappublications.org/news by guest on September 30, 2021 16 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Elizabeth D. Barnett MD, FAAP Marc Fischer, MD, FAAP – Centers for Disease Liaisons James D. Campbell, MD, FAAP Control and Prevention Mark Halstead, MD, FAAP American Medical H. Dele Davies, MD, MS, MHCM, FAAP Bruce G. Gellin, MD, MPH National Vaccine – – Society for Sports Medicine Ruth Lynfield, MD, FAAP Program Office Donald W. Bagnall National Athletic Trainers Flor M. Munoz, MD, FAAP Richard L. Gorman, MD, FAAP National Institutes – – Association Dawn Nolt, MD, MPH, FAAP of Health Ann-Christine Nyquist, MD, MSPH, FAAP Natasha Halasa, MD, MPH, FAAP – Pediatric Consultant Sean O’Leary, MD, MPH, FAAP Infectious Diseases Society Mobeen H. Rathore, MD, FAAP Joan L. Robinson, MD – Canadian Paediatric Neeru A. Jayanthi, MD Mark H. Sawyer, MD, FAAP Society William J. Steinbach, MD, FAAP Jamie Deseda-Tous, MD – Sociedad Staff Tina Q. Tan, MD, FAAP Latinoamericana de Infectologia Pediatrica Anjie Emanuel, MPH Theoklis E. Zaoutis, MD, MSCE, FAAP (SLIPE) Geoffrey R. Simon, MD, FAAP – Committee on Practice Ambulatory Medicine Abbreviations Ex Officio Jeffrey R. Starke, MD, FAAP – American Thoracic β David W. Kimberlin, MD, FAAP – Red Book Editor Society Michael T. Brady, MD, FAAP Red Book Associate – GABHS: group A -hemolytic Editor Staff Mary Anne Jackson, MD, FAAP Red Book streptococcus – Jennifer M. Frantz, MPH Associate Editor HG: herpes gladiatorum Sarah S. Long, MD, FAAP – Red Book Associate HR: herpes rugbiorum Council on Sports Medicine and Editor HSV: herpes simplex virus Henry H. Bernstein, DO, MHCM, FAAP Red Book Fitness Executive Committee, – MMR: measles-mumps-rubella Online Associate Editor 2016–2017 Staphylococcus aureus H. Cody Meissner, MD, FAAP Visual Red Book MRSA: methicillin-resistant – Cynthia R. LaBella, MD, FAAP, Chairperson Associate Editor Margaret A. Brooks, MD, FAAP Greg S. Canty, MD, FAAP NATA: National Athletic Trainers Alex Diamond, DO, FAAP Association Liaisons William Hennrikus, MD, FAAP NCAA: National Collegiate James Stevermer, MD – American Academy of Kelsey Logan, MD, FAAP Athletic Association Family Physicians Kody A. Moffatt, MD, FAAP NFHS: National Federation of Amanda C. Cohn, MD, FAAP – Centers for Disease Blaise Nemeth, MD, FAAP Control and Prevention Brooke Pengel, MD, FAAP State High School Karen M. Farizo, MD – US Food and Drug Andrew Peterson, MD, FAAP Associations Administration Paul Stricker, MD, FAAP PCR: polymerase chain reaction VZV: varicella-zoster virus

DOI: https://​doi.​org/​10.​1542/​peds.​2017-​2477

Address correspondence to H. Dele Davies, MD, MS, MHCM, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

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

References 1. Washington RL, Bernhardt DT, Gomez molluscum contagiosum: a case series 5. Centers for Disease Control and J, et al; Committee on Sports Medicine and critical review of the literature. Prevention (CDC). Methicillin-resistant and Fitness and Committee on School Pediatr Dermatol. 2005;22(4):287–294 Staphylococcus aureus among Health. Organized sports for children 4. Centers for Disease Control and players on a high school football and preadolescents. Pediatrics. Prevention (CDC). Methicillin- team–New York City, 2007. MMWR 2001;107(6):1459–1462 resistant staphylococcus aureus Morb Mortal Wkly Rep. 2009;58(3): 52–55 2. Anish EJ. Viral hepatitis: sports- infections among competitive sports related risk. Curr Sports Med Rep. participants–Colorado, Indiana, 6. Choong KY, Roberts LJ. Molluscum Pennsylvania, and Los Angeles contagiosum, swimming and 2004;3(2):100–106 County, 2000-2003. MMWR Morb bathing: a clinical analysis. Australas 3. Braue A, Ross G, Varigos G, Kelly H. Mortal Wkly Rep. 2003;52(33): J Dermatol. 1999;40(2): Epidemiology and impact of childhood 793–795 89–92

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF 7. Nguyen DM, Mascola L, Brancoft fluids in the high school setting. J Athl Pediatrics; 2015:432–445. (2018 edition E. Recurring methicillin-resistant Train. 1997;32(4):320–322 in press) Staphylococcus aureus infections 19. Oller AR, Province L, Curless B. 27. American Academy of Pediatrics. in a football team. Emerg Infect Dis. Staphylococcus aureus recovery from Molluscum contagiosum. In: Kimberlin 2005;11(4):526 532 – environmental and human locations in DW, Brady MT, Jackson MA, Long SS, 8. Poisson DM, Rousseau D, Defo D, 2 collegiate athletic teams. J Athl Train. eds. Red Book: 2015 Report of the Estève E. Outbreak of tinea corporis 2010;45(3):222–229 Committee on Infectious Diseases. Elk gladiatorum, a fungal skin infection 20. American College of Sports Medicine. Grove Village, IL: American Academy of due to Trichophyton tonsurans, in Health/Fitness Facility Standards and Pediatrics; 2015:561–562. (2018 edition a French high level judo team. Euro Guidelines. 4th ed. Champaign, IL: in press) Surveill. 2005;10(9):187–190 Human Kinetics; 2012 28. American Academy of Pediatrics. 9. Redziniak DE, Diduch DR, Turman K, et al. 21. American Academy of Pediatrics. Tinea capitis. In: Kimberlin DW, Brady Methicillin-resistant Staphylococcus Infections spread by blood and body MT, Jackson MA, Long SS, eds. Red aureus (MRSA) in the athlete. Int J fluids. In: Kimberlin DW, Brady MT, Book: 2015 Report of the Committee Sports Med. 2009;30(8):557–562 Jackson MA, Long SS, eds. Red Book: on Infectious Diseases. 30 ed. Elk 10. Anderson BJ. Skin infections 2015 Report of the Committee on Grove Village, IL: American Academy of in Minnesota high school state Infectious Diseases. 30th ed. Elk Grove Pediatrics; 2015:778–783. (2018 edition tournament wrestlers: 1997-2006. Clin Village, IL: American Academy of in press) J Sport Med. 2007;17(6):478–480 Pediatrics; 2015:158–161. (2018 edition 29. American Academy of Pediatrics. Tinea 11. Wilson EK, Deweber K, Berry JW, in press) corporis. In: Kimberlin DW, Brady MT, Wilckens JH. Cutaneous infections 22. American Academy of Pediatrics. Jackson MA, Long SS, eds. Red Book: in wrestlers. Sports Health. Staphylococcal infections. In: Kimberlin 2015 Report of the Committee on 2013;5(5):423–437 DW, Brady MT, Jackson MA, Long SS, Infectious Diseases. Elk Grove Village, 12. Daly P, Gustafson R. Public health eds. Red Book: 2015 Report of the IL: American Academy of Pediatrics; recommendations for athletes Committee on Infectious Diseases. Elk 2015:781–783. (2018 edition in press) Grove Village, IL: American Academy of attending sporting events. Clin J Sport 30. Brickman K, Einstein E, Sinha S, Pediatrics; 2015:715 732. (2018 edition Med. 2011;21(1):67–70 – Ryno J, Guiness M. Fluconazole as in press) 13. Howe WB. Preventing infectious a prophylactic measure for tinea disease in sports. Phys Sportsmed. 23. American Academy of Pediatrics. gladiatorum in high school wrestlers. Group A streptococcal infections. In: 2003;31(2):23–29 Clin J Sport Med. 2009;19(5):412–414 Kimberlin DW, Brady MT, Jackson MA, 14. Tillett E, Loosemore M. Setting Long SS, eds. Red Book: 2015 Report of 31. American Academy of Pediatrics. Tinea standards for the prevention and the Committee on Infectious Diseases. pedis and tinea unguium. In: Kimberlin management of travellers’ diarrhoea 30th ed. Elk Grove Village, IL: American DW, Brady MT, Jackson MA, Long SS, in elite athletes: an audit of one team eds. Red Book: 2015 Report of the Academy of Pediatrics; 2015:732–744. during the Youth Commonwealth (2018 edition in press) Committee on Infectious Diseases. Elk Games in India. Br J Sports Med. Grove Village, IL: American Academy of 24. American Academy of Pediatrics. 2009;43(13):1045–1048 Pediatrics; 2015:784–786. (2018 edition Bacillus cereus Infections. In: Kimberlin in press) 15. Centers for Disease Control and DW, Brady MT, Jackson MA, Long SS, Prevention (CDC). Microbes in pool eds. Red Book: 2015 Report of the 32. American Academy of Pediatrics. Tinea filter backwash as evidence of Committee on Infectious Diseases. Elk cruris. In: Kimberlin DW, Brady MT, the need for improved swimmer Grove Village, IL: American Academy of Jackson MA, Long SS, eds. Red Book: hygiene - metro-Atlanta, Georgia, 2015 Report of the Committee on Pediatrics; 2015:255–256. (2018 edition 2012. MMWR Morb Mortal Wkly Rep. in press) Infectious Diseases. Elk Grove Village, 2013;62(19):385–388 IL: American Academy of Pediatrics; 25. Centers for Disease Control and 2015:783–784. (2018 edition in press) 16. Anderson BJ. The epidemiology and Prevention (CDC). Outbreak of clinical analysis of several outbreaks cutaneous Bacillus cereus infections 33. American Academy of Pediatrics. of herpes gladiatorum. Med Sci Sports among cadets in a university Human papillomaviruses. In: Kimberlin Exerc. 2003;35(11):1809 1814 – military program–Georgia, August DW, Brady MT, Jackson MA, Long SS, 17. Hostetter KS, Lux M, Shelley K, 2004. MMWR Morb Mortal Wkly Rep. eds. Red Book: 2015 Report of the Drummond JL, Laguna P. MRSA as a 2005;54(48):1233–1235 Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of health concern in athletic facilities. 26. American Academy of Pediatrics. Pediatrics; 2015:576 583. (2018 edition J Environ Health. 2011;74(1):18–25; Herpes simplex. In: Kimberlin DW, – in press) quiz 42 Brady MT, Jackson MA, Long SS, 18. Jessee KB, Middlemas DA, Mulder eds. Red Book: 2015 Report of the 34. Johnson LW. Communal showers and DK, Rehberg RS. Exposure of athletic Committee on Infectious Diseases. Elk the risk of plantar warts. J Fam Pract. trainers to potentially infectious bodily Grove Village, IL: American Academy of 1995;40(2):136–138

Downloaded from www.aappublications.org/news by guest on September 30, 2021 18 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF 35. American Academy of Pediatrics. 2015 Report of the Committee on Infectious Diseases. Elk Grove Village, Scabies. In: Kimberlin DW, Brady Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; MT, Jackson MA, Long SS, eds. Red IL: American Academy of Pediatrics; 2015:510–513. (2018 edition in press) Book: 2015 Report of the Committee 2015:476 493. (2018 edition in press) – 50. Brockmann S, Piechotowski I, on Infectious Diseases. 30th ed. Elk 43. American Academy of Pediatrics. Bock-Hensley O, et al. Outbreak Grove Village, IL: American Academy of Pertussis (whooping cough). In: of leptospirosis among triathlon Pediatrics; 2015:702 704. (2018 edition – Kimberlin D, Brady MT, Jackson MA, participants in Germany, 2006. BMC in press) Long SS, eds. Red Book: 2015 Report of Infect Dis. 2010;10:91 36. American Academy of Pediatrics. the Committee on Infectious Diseases. Pediculosis capitis. In: Kimberlin Elk Grove Village, IL: American Academy 51. American Academy of Pediatrics. Red Book: 2015 Report of the Committee DW, Brady MT, Jackson MA, Long SS, of Pediatrics; 2015:608–621. (2018 eds. Red Book: 2015 Report of the edition in press) on Infectious Diseases. 30th ed. Elk Committee on Infectious Diseases. Grove Village, IL: American Academy 44. American Academy of Pediatrics. 30th ed. Elk Grove Village, IL: American of Pediatrics; 2015. (2018 edition in Meningococcal infections. In: Kimberlin Academy of Pediatrics; 2015:597 601. press) – DW, Brady MT, Jackson MA, Long SS, (2018 edition in press) eds. Red Book: 2015 Report of the 52. Johnson R. Herpes gladiatorum and 37. American Academy of Pediatrics. Committee on Infectious Diseases. Elk other skin diseases. Clin Sports Med. Infections spread by direct contact. In: Grove Village, IL: American Academy of 2004;23(3):473–484, x Kimberlin DW, Brady MT, Jackson MA, Pediatrics; 2015:547–558. (2018 edition 53. National Federation of State High Long SS, eds. Red Book: 2015 Report of in press) School Association, Sports Medicine the Committee on Infectious Diseases. 45. American Academy of Pediatrics. Advisory Committee. Sports related Elk Grove Village, IL: American Academy Shigella. In: Kimberlin DW, Brady skin infections position statement of Pediatrics; 2015:156 157. (2018 – MT, Jackson MA, Long, SS, eds. Red and guidelines. 2014. Available at: edition in press) Book: 2015 Report of the Committee https://​www.​nfhs.​org/​sports-​resource-​ 38. American Academy of Pediatrics. on Infectious Diseases. 30th ed. Elk content/​sports-​related-​skin-​infections-​ Epstein-Barr virus infections. In: Grove Village, IL: American Academy of position-​statement-​and-​guidelines/​. Kimberlin DW, Brady MT, Jackson MA, Pediatrics; 2015:706–709. (2018 edition Accessed March 7, 2017 Long SS, eds. Red Book: 2015 Report of in press) 54. National Collegiate Athletic Association. the Committee on Infectious Diseases. 46. American Academy of Pediatrics. 2014-15 NCAA Sports Medicine Elk Grove Village, IL: American Academy Giardia intestinalis (formerly Giardia Handbook. 25th ed. Indianapolis, IN: of Pediatrics; 2015:336 340. (2018 – lamblia and Giardia duodenalis) National Collegiate Athletic Association; edition in press) infections. In: Kimberlin DW, Brady MT, 2014 39. American Academy of Pediatrics. Jackson MA, Long SS, eds. Red Book: Varicella-zoster virus infections. In: 2015 Report of the Committee on 55. Zinder SM, Basler RS, Foley J, Kimberlin D, Brady MT, Jackson MA, Infectious Diseases. Elk Grove Village, Scarlata C, Vasily DB. National Long SS, eds. Red Book: 2015 Report of IL: American Academy of Pediatrics; athletic trainers’ association position statement: skin diseases. J Athl Train. the Committee on Infectious Diseases. 2015:353–355. (2018 edition in press) Elk Grove Village, IL: American Academy 2010;45(4):411–428 47. American Academy of Pediatrics. of Pediatrics; 2015:846 860. (2018 – Cryptosporodiosis. In: Kimberlin 56. Gouveia C, Gavino A, Bouchami edition in press) DW, Brady MT, Jackson MA, Long SS, O, et al. Community-associated 40. American Academy of Pediatrics. eds. Red Book: 2015 Report of the methicillin-resistant Staphylococcus Measles. In: Kimberlin D, Brady MT, Committee on Infectious Diseases. Elk aureus lacking PVL, as a cause of Jackson MA, Long SS, eds. Red Book: Grove Village, IL: American Academy of severe invasive infection treated with linezolid. Case Rep Pediatr. 2015 Report of the Committee on Pediatrics; 2015:312–315. (2018 edition Infectious Diseases. Elk Grove Village, in press) 2013;2013:727824 IL: American Academy of Pediatrics; 48. American Academy of Pediatrics. 57. Lu D, Holtom P. Community-acquired 2015:535 547. (2018 edition in press) – Norovirus and other human calicivirus methicillin-resistant Staphylococcus 41. American Academy of Pediatrics. infections. In: Kimberlin DW, Brady MT, aureus, a new player in sports Mumps. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: medicine. Curr Sports Med Rep. Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on 2005;4(5):265–270 2015 Report of the Committee on Infectious Diseases. Elk Grove Village, 58. Begier EM, Frenette K, Barrett NL, Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; et al; Connecticut Bioterrorism Field IL: American Academy of Pediatrics; 2015:573 574. (2018 edition in press) – Epidemiology Response Team. A high- 2016:564 568. (2018 edition in press) – 49. American Academy of Pediatrics. morbidity outbreak of methicillin- 42. American Academy of Pediatrics. Leptospirosis. In: Kimberlin DW, Brady resistant Staphylococcus aureus Influenza. In: Kimberlin DW, Brady MT, MT, Jackson MA, Long SS, eds. Red among players on a college football Jackson MA, Long, SS, ed. Red Book: Book: 2015 Report of the Committee on team, facilitated by cosmetic body

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF shaving and turf burns. Clin Infect Dis. 68. Quoilin S, Lambion N, Mak R, et al. F, and G beta-hemolytic streptococcal 2004;39(10):1446–1453 Soft tissue infections in Belgian isolates to 24 antimicrobial drugs. rugby players due to Streptococcus Chemotherapy. 1997;43(1):10 20 59. Hall AJ, Bixler D, Haddy LE. Multiclonal – pyogenes emm type 81. Euro Surveill. outbreak of methicillin-resistant 78. Dagan R, Bar-David Y. Double-blind 2006;11(12):E061221.2 Staphylococcus aureus infections on study comparing erythromycin and a collegiate football team. Epidemiol 69. Aoki A, Ashizawa T, Ebata A, Nasu Y, Fujii mupirocin for treatment of impetigo Infect. 2009;137(1):85–93 T. Group A Streptococcus pharyngitis in children: implications of a high outbreak among university students 60. Lindenmayer JM, Schoenfeld S, prevalence of erythromycin-resistant in a judo club. J Infect Chemother. O Grady R, Carney JK. Methicillin- Staphylococcus aureus strains. ’ 2014;20(3):190 193 resistant Staphylococcus aureus in – Antimicrob Agents Chemother. a high school wrestling team and the 70. Manning SE, Lee E, Bambino M, 1992;36(2):287–290 surrounding community. Arch Intern et al. Invasive group A streptococcal 79. Geor ge A, Rubin G. A systematic review Med. 1998;158(8):895–899 infection in high school football and meta-analysis of treatments players, New York City, 2003. Emerg 61. Creech CB, Saye E, McKenna BD, et al. for impetigo. Br J Gen Pract. Infect Dis. 2005;11(1):146 149 One-year surveillance of methicillin- – 2003;53(491):480–487 resistant Staphylococcus aureus 71. Benjamin HJ, Nikore V, Takagishi J. 80. Goldfarb J, Crenshaw D, O’Horo J, nasal colonization and skin and Practical management: community- Lemon E, Blumer JL. Randomized soft tissue infections in collegiate associated methicillin-resistant clinical trial of topical mupirocin athletes. Arch Pediatr Adolesc Med. Staphylococcus aureus (CA-MRSA): the versus oral erythromycin for impetigo. 2010;164(7):615–620 latest sports epidemic. Clin J Sport Antimicrob Agents Chemother. Med. 2007;17(5):393 397 62. Stanfor th B, Krause A, Starkey C, – 1988;32(12):1780–1783 Ryan TJ. Prevalence of community- 72. Archibald LK, Shapiro J, Pass A, Rand 81. Koning S, van der Wouden JC, associated methicillin-resistant K, Southwick F. Methicillin-resistant Chosidow O, et al. Efficacy and safety Staphylococcus aureus in high school Staphylococcus aureus infection in of retapamulin ointment as treatment wrestling environments. J Environ a college football team: risk factors of impetigo: randomized double-blind Health. 2010;72(6):12–16 outside the locker room and playing multicentre placebo-controlled trial. field. Infect Control Hosp Epidemiol. 63. Waninger KN, Rooney TP, Miller Br J Dermatol. 2008;158(5):1077–1082 2008;29(5):450–453 JE, Berberian J, Fujimoto A, 82. Oranje AP, Chosidow O, Sacchidanand Buttaro BA. Community-associated 73. Kaplan SL, Forbes A, Hammerman S, et al; TOC100224 Study Team. methicillin-resistant Staphylococcus WA, et al. Randomized trial of “bleach Topical retapamulin ointment, 1%, aureus survival on artificial turf baths” plus routine hygienic measures versus sodium fusidate ointment, substrates. Med Sci Sports Exerc. vs. routine hygienic measures alone 2%, for impetigo: a randomized, 2011;43(5):779–784 for prevention of recurrent infections. observer-blinded, noninferiority study. Clin Infect Dis. 2014;58(5):679 682 64. Buss BF, Connolly S. Surveillance of – Dermatology. 2007;215(4):331–340 physician-diagnosed skin and soft 74. Bisno AL, Gerber MA, Gwaltney JM Jr, 83. Weinber g JM, Tyring SK. Retapamulin: tissue infections consistent with Kaplan EL, Schwartz RH; Infectious an antibacterial with a novel mode methicillin-resistant Staphylococcus Diseases Society of America. Practice of action in an age of emerging aureus (MRSA) among Nebraska high guidelines for the diagnosis and resistance to Staphylococcus aureus. school athletes, 2008-2012. J Sch Nurs. management of group A streptococcal J Drugs Dermatol. 2010;9(10):1198–1204 2014;30(1):42–48 pharyngitis. Clin Infect Dis. 2002;35(2):113–125 84. Becker TM, Kodsi R, Bailey P, Lee F, 65. Lear A, McCord G, Peiffer J, Levandowski R, Nahmias AJ. Grappling Watkins RR, Parikh A, Warrington S. 75. Hoskins TW, Bernstein LS. with herpes: herpes gladiatorum. Am J Incidence of Staphylococcus aureus Trimethoprim/sulphadiazine Sports Med. 1988;16(6):665–669 nasal colonization and soft tissue compared with penicillin V in the infection among high school football treatment of streptococcal throat 85. Skinner GR, Davies J, Ahmad A, McLeish players. J Am Board Fam Med. infections. J Antimicrob Chemother. P, Buchan A. An outbreak of herpes 2011;24(4):429–435 1981;8(6):495–496 rugbiorum managed by vaccination of players and sociosexual contacts. 66. Falck G. Group A streptococcal skin 76. Kaplan EL, Johnson DR, Del Rosario J Infect. 1996;33(3):163–167 infections after indoor association MC, Horn DL. Susceptibility of group A football tournament. Lancet. beta-hemolytic streptococci to thirteen 86. Dworkin MS, Shoemaker PC, Spitters 1996;347(9004):840–841 antibiotics: examination of 301 strains C, et al. Endemic spread of herpes isolated in the United States between simplex virus type 1 among adolescent 67. Ludlam H, Cookson B. Scrum kidney: 1994 and 1997. Pediatr Infect Dis J. wrestlers and their coaches. Pediatr epidemic pyoderma caused by 1999;18(12):1069 1072 Infect Dis J. 1999;18(12):1108 1109 a nephritogenic Streptococcus – – pyogenes in a rugby team. Lancet. 77. T raub WH, Leonhard B. Comparative 87. Belongia EA, Goodman JL, Holland EJ, 1986;2(8502):331–333 susceptibility of clinical group A, B, C, et al. An outbreak of herpes gladiatorum

Downloaded from www.aappublications.org/news by guest on September 30, 2021 20 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF at a high-school wrestling camp. clinical trial. J Dermatolog Treat. experience. Clin J Sport Med. N Engl J Med. 1991;325(13):906–910 2014;25(3):249–250 2002;12(3):165–171 88. Mills J, Hauer L, Gottlieb A, Dromgoole 100. Shor t KA, Fuller LC, Higgins EM. Double- 111. Stiller MJ, Klein WP, Dorman S, Spruance S. Recurrent herpes blind, randomized, placebo-controlled RI, Rosenthal S. Tinea corporis labialis in skiers. Clinical observations trial of the use of topical 10% gladiatorum: an epidemic of and effect of sunscreen. Am J Sports potassium hydroxide solution in the Trichophyton tonsurans in student Med. 1987;15(1):76–78 treatment of molluscum contagiosum. wrestlers. J Am Acad Dermatol. Pediatr Dermatol. 2006;23(3):279 281 1992;27(4):632–633 89. Rooney JF, Bryson Y, Mannix ML, et al. – Prevention of ultraviolet-light-induced 101. Coloe Dosal J, Stewart PW, Lin JA, 112. Yonezawa M, Idei T, Takahashi K, herpes labialis by sunscreen. Lancet. Williams CS, Morrell DS. Cantharidin Miyachi Y, Tanaka S, Mochizuki T. 1991;338(8780):1419–1422 for the treatment of molluscum Outbreak of tinea corporis caused by contagiosum: a prospective, double- infection with Trichophyton tonsurans 90. Anderson BJ. Managing herpes blinded, placebo-controlled trial. in boys belonging to a judo club of gladiatorum outbreaks in competitive Pediatr Dermatol. 2014;31(4):440–449 a high school in Kyoto. Skin Res. wrestling: the 2007 Minnesota 2004;3(2):220–226 experience. Curr Sports Med Rep. 102. Katz KA. Dermatologists, imiquimod, 113. Adams BB. Tinea corporis 2008;7(6):323–327 and treatment of molluscum contagiosum in children: gladiatorum. J Am Acad Dermatol. 91. Stacey A, Atkins B. Infectious righting wrongs. JAMA Dermatol. 2002;47(2):286–290 diseases in rugby players: incidence, 2015;151(2):125–126 114. Aghamirian MR, Ghiasian SA. A treatment and prevention. Sports Med. clinico-epidemiological study on tinea 2000;29(3):211–220 103. Silverber g NB, Sidbury R, Mancini AJ. Childhood molluscum contagiosum: gladiatorum in Iranian wrestlers and 92. Anderson BJ. Valacyclovir to expedite experience with cantharidin therapy mat contamination by dermatophytes. the clearance of recurrent herpes in 300 patients. J Am Acad Dermatol. Mycoses. 2011;54(3):248–253 gladiatorum. Clin J Sport Med. 2000;43(3):503–507 115. Er gin S, Ergin C, Erdoğan BS, Kaleli I, 2005;15(5):364–366 104. Cathcar t S, Coloe J, Morrell DS. Evliyaoğlu D. An experience from an 93. Anderson BJ. The effectiveness of Parental satisfaction, efficacy, and outbreak of tinea capitis gladiatorum valacyclovir in preventing reactivation adverse events in 54 patients treated due to Trichophyton tonsurans. Clin of herpes gladiatorum in wrestlers. with cantharidin for molluscum Exp Dermatol. 2006;31(2):212–214 Clin J Sport Med. 1999;9(2):86 90 – contagiosum infection. Clin Pediatr 116. Cáceres-Ríos H, Rueda M, Ballona 94. Anderson BJ. Prophylactic valacyclovir (Phila). 2009;48(2):161–165 R, Bustamante B. Comparison of to prevent outbreaks of primary 105. Beller M, Gessner BD. An outbreak of terbinafine and griseofulvin in the herpes gladiatorum at a 28-day tinea corporis gladiatorum on a high treatment of tinea capitis. J Am Acad wrestling camp. Jpn J Infect Dis. school wrestling team. J Am Acad Dermatol. 2000;42(1 pt 1):80–84 2006;59(1):6 9 – Dermatol. 1994;31(2 pt 1):197–201 117. Bonifaz A, Saúl A. Comparative study 95. Olsen JR, Gallacher J, Piguet V, Francis 106. Adams BB. Tinea corporis gladiatorum: between terbinafine 1% emulsion-gel NA. Epidemiology of molluscum a cross-sectional study. J Am Acad versus ketoconazole 2% cream in tinea cruris and tinea corporis. Eur J contagiosum in children: a systematic Dermatol. 2000;43(6):1039–1041 review. Fam Pract. 2014;31(2):130–136 Dermatol. 2000;10(2):107–109 107. el Fari M, Gr ser Y, Presber W, Tietz HJ. ä 118. Bourlond A, Lachapelle JM, Aussems 96. Castilla MT, Sanzo JM, Fuentes S. An epidemic of tinea corporis caused J, et al. Double-blind comparison Molluscum contagiosum in children by Trichophyton tonsurans among of itraconazole with griseofulvin and its relationship to attendance at children (wrestlers) in Germany. in the treatment of tinea corporis swimming-pools: an epidemiological Mycoses. 2000;43(5):191–196 study. Dermatology. 1995;191(2):165 and tinea cruris. Int J Dermatol. 108. Hedayati MT, Afshar P, Shokohi T, Aghili 1989;28(6):410–412 97. Niizeki K, Kano O, Kondo Y. An epidemic R. A study on tinea gladiatorum in 119. Decroix J, Fritsch P, Picoto A, study of molluscum contagiosum. young wrestlers and dermatophyte Thurlimann W, Degreef H. Short-term Relationship to swimming. contamination of wrestling mats itraconazole versus terbinafine Dermatologica. 1984;169(4):197–198 from Sari, Iran. Br J Sports Med. in the treatment of superficial 2007;41(5):332 334 98. Thompson AJ, Matinpour K, Hardin – dermatomycosis of the glabrous J, Hsu S. Molluscum gladiatorum. 109. Ilkit M, Ali Saracli M, Kurdak H, et skin (tinea corporis or cruris). Eur J Dermatol Online J. 2014;20(6) al. Clonal outbreak of Trichophyton Dermatol. 1997;7(5):353–357 tonsurans tinea capitis gladiatorum 99. Handjani F, Behazin E, Sadati MS. 120. Gupta AK, Adam P, Dlova N, et al. among wrestlers in Adana, Turkey. Comparison of 10% potassium Therapeutic options for the treatment Med Mycol. 2010;48(3):480 485 hydroxide solution versus cryotherapy – of tinea capitis caused by Trichophyton in the treatment of molluscum 110. Kohl TD, Giesen DP, Moyer J Jr, Lisney species: griseofulvin versus the new contagiosum: an open randomized M. Tinea gladiatorum: Pennsylvania’s oral antifungal agents, terbinafine,

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF itraconazole, and fluconazole. Pediatr in the treatment of tinea capitis. J Am 142. Gentles JC, Evans EG, Jones GR. Control Dermatol. 2001;18(5):433–438 Acad Dermatol. 2011;64(4):663–670 of tinea pedis in a swimming bath. BMJ. 1974;2(5919):577 580 121. Friedlander SF, Aly R, Krafchik B, et al; 131. Auger P, Marquis G, Joly J, Attye – Tinea Capitis Study Group. Terbinafine A. Epidemiology of tinea pedis in 143. del Palacio Hernandez A, López Gómez in the treatment of Trichophyton tinea marathon runners: prevalence S, González Lastra F, Moreno Palancar capitis: a randomized, double-blind, of occult athlete’s foot. Mycoses. P, Iglesias Díez L. A comparative parallel-group, duration-finding study. 1993;36(1–2):35–41 double-blind study of terbinafine (Lamisil) and griseofulvin in tinea Pediatrics. 2002;109(4):602–607 132. Kamihama T, Kimura T, Hosokawa JI, corporis and tinea cruris. Clin Exp 122. Fuller LC, Smith CH, Cerio R, et al. A Ueji M, Takase T, Tagami K. Tinea pedis Dermatol. 1990;15(3):210–216 randomized comparison of 4 weeks of outbreak in swimming pools in Japan. terbinafine vs. 8 weeks of griseofulvin Public Health. 1997;111(4):249–253 144. Choudhary S, Bisati S, Singh A, Koley S. Efficacy and safety of terbinafine for the treatment of tinea capitis. Br J 133. Patel GA, Wiederkehr M, Schwartz hydrochloride 1% cream vs. Dermatol. 2001;144(2):321–327 RA. Tinea cruris in children. Cutis. sertaconazole nitrate 2% cream in 2009;84(3):133 137 123. Memisoglu HR, Erboz S, Akkaya S, et al. – tinea corporis and tinea cruris: a Comparative study of the efficacy and 134. Evaluation of ciclopirox olamine cream comparative therapeutic trial. Indian J tolerability of 4 weeks of terbinafine for the treatment of tinea pedis: Dermatol. 2013;58(6):457–460 therapy with 8 weeks of griseofulvin multicenter, double-blind comparative therapy in children with tinea capitis. 145. Ramam M, Prasad HR, Manchanda studies. Clin Ther. 1985;7(4):409–417 J Dermatolog Treat. 1999;10(3):189–193 Y, et al. Randomised controlled trial 135. Aly R, Fisher G, Katz I, et al. Ciclopirox of topical butenafine in tinea cruris 124. Gonzalez U, Seaton T, Bergus G, gel in the treatment of patients with and tinea corporis. Indian J Dermatol Jacobson J, Martinez-Monzon C. interdigital tinea pedis. Int J Dermatol. Venereol Leprol. 2003;69(2):154–158 Systemic antifungal therapy for tinea 2003;42(suppl 1):29–35 capitis in children.Cochrane Database 146. Saple DG, Amar AK, Ravichandran Syst Rev. 2007;(4):CD004685 136. Naftifine gel in the treatment of tinea G, Korde KM, Desai A. Efficacy and pedis: two double-blind, multicenter safety of butenafine in superficial 125. Chen X, Jiang X, Yang M, et al. Systemic studies. Naftifine Gel Study Group. dermatophytoses (tinea pedis, tinea antifungal therapy for tinea capitis in Cutis. 1991;48(1):85–88 cruris, tinea corporis). J Indian Med children. Cochrane Database Syst Rev. Assoc. 2001;99(5):274–275 2016;(5):CD004685 137. Akers WA, Lane A, Lynfield Y, et al. Sulconazole nitrate 1% cream in the 147. Singal A, Pandhi D, Agrawal S, 126. Dastghaib L, Azizzadeh M, Jafari P. treatment of chronic moccasin-type Das S. Comparative efficacy of Therapeutic options for the treatment tinea pedis caused by Trichophyton topical 1% butenafine and 1% of tinea capitis: griseofulvin versus rubrum. J Am Acad Dermatol. clotrimazole in tinea cruris and tinea fluconazole. J Dermatolog Treat. 1989;21(4 pt 1):686–689 corporis: a randomized, double- 2005;16(1):43–46 blind trial. J Dermatolog Treat. 138. Albanese G, Di Cintio R, Giorgetti P, 2005;16(5 6):331 335 127. Filho ST, Cucé LC, Foss NT, Marques Galbiati G, Ciampini M. Recurrent – – SA, Santamaria JR. Efficacy, safety tinea pedis: a double blind 148. van Zuuren EJ, Fedorowicz Z, and tolerability of terbinafine for study on the prophylactic use of El-Gohary M. Evidence-based topical Tinea capitis in children: Brazilian fenticonazole powder. Mycoses. treatments for tinea cruris and tinea multicentric study with daily oral 1992;35(5–6):157–159 corporis: a summary of a Cochrane tablets for 1,2​ and 4 weeks. J Eur Acad systematic review. Br J Dermatol. 139. Evans EG. A comparison of terbinafine Dermatol Venereol. 1998;11(2):141–146 2015;172(3):616 641 (Lamisil) 1% cream given for one – 128. Foster KW, Friedlander SF, Panzer week with clotrimazole (Canesten) 149. Boonk W, de Geer D, de Kreek E, H, Ghannoum MA, Elewski BE. A 1% cream given for four weeks, in Remme J, van Huystee B. Itraconazole randomized controlled trial assessing the treatment of tinea pedis. Br J in the treatment of tinea corporis the efficacy of fluconazole in the Dermatol. 1994;130(suppl 43):12–14 and tinea cruris: comparison of treatment of pediatric tinea capitis. two treatment schedules. Mycoses. 140. Jarratt M, Jones T, Kempers S, et al. J Am Acad Dermatol. 2005;53(5):798 809 1998;41(11 12):509 514 – Luliconazole for the treatment of – – 129. Hamm H, Schwinn A, Bräutigam M, interdigital tinea pedis: a double- 150. Pariser DM, Pariser RJ, Ruoff G, Weidinger G; The Study Group. Short blind, vehicle-controlled study. Cutis. Ray TL. Double-blind comparison duration treatment with terbinafine for 2013;91(4):203–210 of itraconazole and placebo in the tinea capitis caused by Trichophyton or treatment of tinea corporis and tinea 141. Barnetson RS, Marley J, Bullen M, Microsporum species. Br J Dermatol. cruris. J Am Acad Dermatol. 1994;31(2 et al. Comparison of one week of oral 1999;140(3):480 482 pt 1):232 234 – terbinafine (250 mg/day) with four – 130. Tey HL, Tan ASL, Chan YC. Meta-analysis weeks of treatment with clotrimazole 151. Kalis B, Grosshans E, Binet O, of randomized, controlled trials 1% cream in interdigital tinea pedis. et al. Oxiconazole cream versus comparing griseofulvin and terbinafine Br J Dermatol. 1998;139(4):675–678 ketoconazole cream. A prospective,

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF randomized, double-blind, infestations in the United States-a 160. Centers for Disease Control and multicenter study in the treatment literature review. Pediatr Dermatol. Prevention (CDC). Interstate measles of inguinocrural dermatophytoses 2016;33(5):466–472 transmission from a ski resort– [in French]. Ann Dermatol Venereol. 156. Leulmi H, Diatta G, Sokhna C, Colorado, 1994. MMWR Morb Mortal 1996;123(8):447–452 Rolain JM, Raoult D. Assessment Wkly Rep. 1994;43(34):627–629 152. Choudhary SV, Aghi T, Bisati S. Efficacy of oral ivermectin versus shampoo 161. Centers for Disease Control and and safety of terbinafine hydrochloride in the treatment of pediculosis Prevention (CDC). Multistate measles 1% cream vs eberconazole nitrate 1% (head lice infestation) in rural outbreak associated with an cream in localised tinea corporis and areas of Sine-Saloum, Senegal. Int J international youth sporting event– tinea cruris. Indian Dermatol Online J. Antimicrob Agents. 2016;48(6): Pennsylvania, Michigan, and Texas, 2014;5(2):128–131 627–632 August-September 2007. MMWR Morb 153. Becerro de Bengoa Vallejo R, Losa 157. Buescher ES. Infections Mortal Wkly Rep. 2008;57(7): 169 173 Iglesias ME, Gómez-Martín B, Sánchez associated with pediatric sport – Gómez R, Sáez Crespo A. Application of participation. Pediatr Clin North Am. 162. Ehresmann KR, Hedberg CW, cantharidin and podophyllotoxin for 2002;49(4):743–751 Grimm MB, Norton CA, MacDonald the treatment of plantar warts. J Am 158. Centers for Disease Control and KL, Osterholm MT. An outbreak of Podiatr Med Assoc. 2008;98(6):445–450 Prevention. From the Centers for measles at an international sporting 154. López López D, Vilar Fernández Disease Control and Prevention. event with airborne transmission JM, Losa Iglesias ME, et al. Safety Interstate measles transmission from in a domed stadium. J Infect Dis. and effectiveness of cantharidin- a ski resort–Colorado, 1994. JAMA. 1995;171(3):679–683 podophylotoxin-salicylic acid in the 1994;272(14):1097–1098 163. Sasaki A, Suzuki H, Sakai T, Sato treatment of recalcitrant plantar 159. Centers for Disease Control M, Shobugawa Y, Saito R. Measles warts. Dermatol Ther (Heidelb). (CDC). Measles at an international outbreaks in high schools 2016;29(4):269 273 – gymnastics competition–Indiana, closely associated with sporting 155. Koch E, Clark JM, Cohen B, et al. 1991. MMWR Morb Mortal Wkly Rep. events in Niigata, Japan. J Infect. Management of head louse 1992;41(7):109–111 2007;55(2):179–183

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Infectious Diseases Associated With Organized Sports and Outbreak Control H. Dele Davies, Mary Anne Jackson, Stephen G. Rice, COMMITTEE ON INFECTIOUS DISEASES and COUNCIL ON SPORTS MEDICINE AND FITNESS Pediatrics 2017;140; DOI: 10.1542/peds.2017-2477 originally published online September 25, 2017;

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