Do Professional Athletes Misuse Antibiotics More Than Non-athletic People

Antibiotics are agents which either induce cell death or inhibit cell growth (Kohanski, 2010) and target bacteria without killing the hosts cells by acting on processes that are unique to bacteria such as the synthesis of cell walls (Tiwari and Tiwari, 2011). The discovery of penicillin by Alexander Fleming in 1928 has reduced death rates from bacterial infections and has seen antibiotics routinely prescribed during surgery and chemotherapy (Ventola, 2015).

Antimicrobial medicines have become the main treatment for humans and animals against bacteria (Special Eurobarometer, 2016) and have seen a rapid increase in use with Buke et al. (2003) stating that antibiotics are the most commonly sold drugs in developing countries. With many in society not knowing the difference between bacterial and viral illnesses and thinking that antibiotics can be used to treat both (McKee et al., 1999), this has led to problems with antibiotic misuse in recent years.

Antibiotic misuse

The World Health Organisation (WHO) report (2007) highlighted that antibiotic resistance is one of the biggest threats to public health in the 21st century, reporting that about half of all medicines are inappropriately prescribed, Wise et al. (1998) and Dellit et al. (2007) as cited by Pulcini et al. (2010), reporting between 20-50% of antibiotic use being inappropriate. Nearly half of all children under the age of 15 with a common cold received antibiotics (Belongia et al., 2002). With these high rates of incorrect antibiotic prescri ptions, it is unsurprising that antibiotic resistance is becoming a worldwide problem.

Antibiotic use in different countries has been widely studied. A study by Cars et al. (2001) found hospital use only accounted for 7-15% of the total sales of antibiotics in 9 countries. Public Health England (2015) suggested that four-fifths of antibiotics are prescribed in primary care. Although most antibiotics in the UK are obtained via prescri ption (Public Health England, 2015), with GP’s responsible for 80% of antibiotics prescribed (Brooks et al., 2008), it is possible to self-medicate either from obtaining via the internet or by using left over antibiotics from a previous course. McNulty et al. (2007) found that 4.8% of respondents had taken antibiotics without medical advice similar to findings in a European study by Grigoryan et al. (2007) who found that the majority who self-medicated did so via reusing antibiotics from a previous course.

The WHO 2012 report estimated that antibiotic resistance leads to in excess of 250,000 deaths in European hospitals, with Aminov (2010) reporting 63,000 deaths in the USA. This is a worldwide problem, needing people to have a better understanding about the dangers of antibiotic misuse and what is causing the resistance. Davey et al. (2002) suggested a common misconception in patients was the belief that taking antibiotics causes them to become resistant to the antibiotics rather than the bacteria becoming resistant to the antibiotic. Individuals might be more concerned about the dangers if they knew it was not just affecting them.

Antibiotic resistance

The most common and affordable antibiotics are likely to become completely ineffective with the spread of resistant bacteria (Special Eurobarometer, 2016). The Staphylococcus aureus bacteria has become resistant to the antibiotic methicillin creating the bacterial disease methicillin-resistant staphylococcus aureus (MRSA). In 2012, 292 death certificates in England and Wales mentioned MRSA (Statistical Bulletin, 2013).

There are many factors contributing to antibiotic resistance. Poor knowledge of when and for what illnesses antibiotics should be taken increased bacterial resistance (Haltiwanger et al., 2001 and Buke et al., 2005). This is knowledge of both consumers and prescribers of antibiotics. Although scientific evidence shows antibiotics have no effect on viral illnesses, a study by Whitfield and Hughes (1981) as cited by Suaifan et al. (2012) found that a large number of clinicians know that antibiotics are prescribed too often in these cases, with Shehadeh et al. (2012) reporting that 22.9% of physicians routinely prescribing antibiotics for common cold symptoms.

Wang et al. (2016) found of those who tried to buy antibiotics from a drugstore, two thirds tried to buy without a prescri ption and of those, 96% of them succeeded. It is more likely that this stems from patient demand (Bauchner, 1997) and putting pressure on the medical professional rather than poor knowledge from those prescribing antibiotics. Patient demand increases the pressure on medical professionals to prescribe antibiotics in situations where they are not needed/should not be needed. A study by Macfarlane et al. (1997) found that 72% of patients wanted and expected to be prescribed antibiotics with one fifth asking for them. Pan et al. (2016) found that when visiting their doctors, 33.8% wanted antibiotics, of those 39.8% would ask the doctor for antibiotics if not given, 8.6% would not accept the doctors decision if no antibiotics were prescribed and 10.2% would see another doctor. Antibiotics are often prescribed immediately rather than waiting for the 24-72 hours it takes for microbiological results (Leekha, 2011).

Another factor leading to bacterial resistance is not completing the full course of antibiotics. Short exposure of antibiotics to bacteria will injure the pathogen but will not completely eliminate it, creating a bacterium that has been exposed to the antibiotic, which eventually will become resistant to that antibiotic.

Student knowledge and use of antibiotics

Young adults who previously relied on parental guidance on antibiotic use are often away from home for the first time when starting university (Haltiwanger et al., 2001). Haltiwanger et al. (2001) also argued that students that are used to being cared for by their parents rely on the internet for information about their healthcare. It has been suggested that antibiotic misuse in undergraduates is becoming a serious problem worldwide (Zafar et al., 2008). However with higher education, increased availability of internet, university students should be more aware of antibiotics use and the dangers associated with their misuse (Haltiwanger et al., 2001).

Some countries allow antibiotics to be purchased without prescri ption. Universities are known for having international students (Blyer et al., 2016), which could lead to a larger proportion obtaining antibiotics without prescri ption.

There is limited evidence on gender and antibiotic knowledge, however it has been seen that females are more knowledgeable about antibiotics, with Cals et al. (2007) finding that female sex, use of antibiotics previously, and recent information were all independently associated with knowledge on antibiotic effectiveness, suggesting medical consultations with children being a possible reason for this.

Physical activity and health

Many studies have examined possible associations between activity levels and health. Athletes are susceptible to the same infections as the general population (Jaworski et al., 2011). Nieman (2000) found that in resting state, athletes and non-athletes have similar immune systems, however when athletes were exposed to prolonged heavy exertion, components of their immune system changed adversely, lowering their immune system, with Nieman (2007) suggesting natural killer cells, neutrophils and macrophages exhibiting the biggest changes. However studies examining resting immune function in athletes and non-athletes have failed to provide consistent evidence to prove this (Nieman et al., 1999).

There are many studies on respiratory tract infections in athletes compared to non-athletes due to the high incidences in athletes. Astrom et al. (1976) as cited by Weidner and Sevier (1996) stated that respiratory infections are the most common illnesses in Olympic athletes.

The relationship between exercise and upper respiratory tract infections (URTI) has been modelled in the form of a J curve, showing that risk of URTI can be lowered by moderate exercise, however the risk increases when exercise increases when performing high intensity exercise (Nieman, 1997 as cited by Nieman, 1998). Respiratory tract infections can be both viral and bacterial (NHS, 2017), however they are mainly viral (Zoorob et al., 2011). URTI’s include colds, flu, tonsillitis, lower respiratory tract infections (LRTI’s, which include pneumonia and bronchitis), with the symptoms of both RTI’s being a cough. Antibiotics should not normally be prescribed for RTI’s with NICE (2016) suggesting that patients should only be prescribed antibiotics if they are very unwell or if symptoms suggest serious illnesses such as pneumonia or are patients over 65 years old.

It has been suggested that moderate physical activity increases various immune system parameters compared to sedentary behaviours. Studies by Brahmi et al. (1985), Nehlsen-Cannarella et al. (1991) and Gleeson (2007) found that moderate exercise can enhance some immune system parameters which in turn will boost the health of participants. Mathews et al. (2002) reported that regular moderate exercise resulted in a reduction of upper respiratory tract infection prevalence by 29% and a study by Pape et al. (2016) found that those with low leisure time when compared to sedentary time had a 10% lower risk of suspected bacterial infections.

Those athletes who train at maximal capacity have a higher risk for illness and infections (Fayock et al., 2014, Gleeson, 2007). Nieman (2000) found that endurance athletes are at an increased risk for upper respiratory tract infections (URTI) when they are performing heavy training. Spence et al. (2007) found that elite athletes had a higher rate of illness compared to recreational athletes and sedentary controls, with elite athletes reporting a total of 311 sick days, recreational athletes 92 and sedentary controls only 137 sick days. Nieman et al. (1990), reported that 2 months before a marathon, 43.2% reported that they suffered from at least one illness. Also in the weeks after vigorous competitions, there is an increased risk for upper respiratory tract infections, which in turn can lead to increased antibiotic use (Nieman, 2000).

Antibiotic use in athletes

In athletes performing vigorous exercise, it has been seen that antibiotic use increases with athletes using oral antibiotics more frequently as aged matched controls, 2.7% to 1.3% respectively (Alaranta et al., 2006, 2008 as cited by Fayock et al., 2014). Tscholl et al. (2010) found that over an entire year, 35.2% of athletes took antibiotics at least once, almost double that of a control group. However the effects of exercise on the body are dependent on fitness levels of the subjects, intensity and duration of the exercise performed (Gleeson, 1999), with only those performing vigorous exercise being affected.

Respiratory tract infections, although very common, are not the only illness that athletes suffer from. Athletes travelling overseas to competitions or training locations commonly suffer from travellers’ diarrhoea (Stacey and Atkins, 2000). Rossiter (2014) stated that the most common reason for illness for athletes whilst abroad is travellers’ diarrhoea, which depending on whether it is viral or bacterial, can be treated using antibiotics.

The sport played by an athlete could influence the amount of antibiotics taken. Skin to skin contact is common, especially in contact sports such as rugby and wrestling. S. aureus and Streptococcus are the most common causes of bacterial skin infection in rugby players (Stacey and Atkins, 2000). Skin to skin contact can be perfect for the transmission of bacterial infections (Turbeville, 2006) causing an increase in antibiotic usage. Other sports affected include water sports, with triathletes picking up infections most commonly (Wasinski, 2013) due to the increased risk of athletes swallowing water borne bacteria.

Geographical location of the athletes and antibiotic use has not been researched in depth. However those athletes from Asia and Africa have been found to take more antimicrobial substances more than athletes from other countries (Tscholl, 2010).

Frequently used antibiotics have been linked to possible tendon injuries, cartilage issues and decreased performance (Fayock et al., 2014). Some literature has reported that fluoroquinolones, a type of antibiotic, increases the risk of developing tendinitis or Achilles tendon rupture and therefore should not be prescribed to athletes (Lewis and Cook, 2014). Fluoroquinolones display a high affinity for connective tissue, especially in cartilage and bone (Lewis and Cook, 2014). Although the pathways of how fluoroquinolones effect tendons is unclear (Tsai et al., 2008), 3 mechanisms have been proposed ischemia, degradation of the tendon matrix and adverse alteration of tenocyte activity (Childs, 2007). Sode et al. (2007) reported that fluoroquinolone’s triples the chance of the Achilles tendon rupturing with Van der Linden et al. (2002) reporting that risk of Achilles tendon disorders was increased 6 fold whilst taking fluoroquinolones. This suggests the need for coaches to be aware of the athlete’s medications. Athletes may therefore have a greater knowledge about antibiotics.

Gaps in research

Physical activity in terms of athletic status has been compared with antibiotic use and knowledge in many studies. However there are many sports such as fishing, which do not require vigorous physical activity. In many European countries those who perform these sports are classed as athletes (Shepard, 2003). The amount of literature comparing hours spent performing moderate to vigorous physical activity and antibiotic knowledge and use is limited. It is hoped that this study will identify an association which can be used for future research.

Regarding antibiotic knowledge there are several studies on antibiotic knowledge in a student population, however these tend to be specific with Zoorob et al. (2001) looking just at URI in college students. Scaioli et al. (2015), Sharma et al. (2016), Suaifan et al. (2012), Dyar et al. (2014) and Pulcini et al. (2010) all focused on medical students. Several other studies have been based on non-UK students (Aladejareet al., 2002, Azevedo et al., 2009, Abu-Helalah et al., 2015, Huang et al., 2013). There is very limited research available on the knowledge of antibiotics in athletes. Athletes have access to more medical information than the general population, with access to physiotherapists, coaches and fellow athletes (Gerbing and Thiel, 2016).

Project aims

The Special Eurobarometer report (2016) stated that 34% of respondents took antibiotics in the last 12 months so it is important that with nearly a third of the population taking antibiotics, that they know when and how to take them. The aim of this study was to assess the antibiotic knowledge of specific student populations and to identify if any of them show a poor overall knowledge which could help identify who needs to be educated about the dangers of antibiotic misuse and therefore reduce the spread of antibiotic resistance (Eng et al., 2003). With the possible increased risk of rupturing the tendon (Childs, 2007) and the increased use of antibiotics in athletes (Fayock et al., 2014) this study theorised that athletes should have a greater knowledge of antibiotics and this hypothesis was tested.

Antibiotic resistance is multifactorial, so this study aims to identify if there is a specific factor for example not completing the full course of antibiotics, that people do not understand as well as hopefully finding a population that is more likely to take antibiotics, to enable targeted education, rather than the education of the whole population. Hopefully the data from this study can be used alongside other studies to increase knowledge of antibiotic behaviour to prevent future resistant bacterial strains.