| Swimming, wading, diving |
| Near-drowning events |
| Fishing, hunting |
| Rafting, boating, kite sailing, sailing, surfing, windsurfing, water-skiing |
| Water parks (wave pools and water slides) |
| Sitting in hot tubs, whirlpools |
| Showering and bathing, ritual washing |
| Drinking water and water-containing beverages (untreated surface water consumed during hiking, camping) |
| Care of fish tanks, aquaria |
Ingestion of contaminated water, whether during swimming, showering, or drinking often causes infections manifested by diarrhea. Some pathogens have the capacity to cause systemic infection after ingestion. Fecally contaminated water may contain a potpourri of microbes – bacteria, viruses, protozoa, and helminths – causing a variety of illnesses with differing manifestations and incubation periods. Swimming at beaches near a sewage outlet, for example, leads to increased rates of conjunctivitis, otitis externa, skin and soft-tissue infections, as well as gastrointestinal infections. Interactive fountains are known to be particularly vulnerable to contamination as they are open to young children, the homeless, and animals, and recirculate potentially contaminated water back onto users.
Recreational water activities are often group activities, so contaminated water may be associated with outbreaks, sometimes involving dozens or even hundreds of people. In addition to caring for the acutely ill patient, the clinician must consider the public health implications and alert the appropriate authorities. Early interventions may slow or halt an outbreak and allow early recognition of other cases. In many instances, outbreaks are the result of inadequate operation or maintenance procedures. For example, in a recent US-wide inspection of >5000 spas, nearly 3000 were found to be in violation of water quality and other maintenance parameters, resulting in the immediate closure of 11% of those inspected. As further illustration of this point, in August 2003, inadequate disinfection of an athletic facility spa resulted in an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) skin infections among college football players, thus establishing this emerging pathogen as one with potential for waterborne transmission. A review of 18 outbreaks of Pseudomonas from spas implicated substandard levels of chlorination in each case.
The route of entry may influence the clinical findings for several of the water-associated pathogens, with skin penetration causing local wound infections and ingestion causing diarrheal infections. Table 120.2 lists the range of clinical manifestations of infections that follow water exposure. With some of the more virulent organisms or in the setting of immune compromise, infection may enter the bloodstream after any one of several entry points. Minor trauma, cuts, bites, and breaks in the skin can provide the portal of entry for many water-dwelling microbes. Table 120.3 summarizes infections and infestations that enter through the skin. Table 120.4 lists specific infections acquired via aspiration, inhalation, and ingestion.
| Skin and mucosal surface exposure Conjunctivitis Keratitis Otitis externa Dermatitis (including folliculitis) Mastitis Cellulitis Fasciitis Endometritis (reported after intercourse in water) Systemic infection |
| Aspiration, inhalation, ingestion Pharyngitis Sinusitis Meningoencephalitis Pneumonitis Gastroenteritis, colitis Systemic infection |
| Pathogen or disease | Source |
|---|---|
| Bacteria | |
| Aeromonas hydrophilaa,b | Freshwater streams, lakes, soil |
| Burkholderia pseudomallei (melioidosis)a,b | Fresh water, soil (tropics, subtropics) |
| Chromobacterium violaceuma,b | Freshwater rivers, soil (tropics, subtropics) |
| Leptospirosisb | Fresh water contaminated with animal urine (especially tropics, subtropics) |
| Mycobacterium marinuma | Fish tanks, swimming pools |
| Pseudomonas aeruginosaa | Hot tubs, whirlpools, swimming pools |
| Vibrio vulnificus, other vibriosa,b | Seawater |
| Tularemiaa,b,c (Francisella tularensis) | Fresh water contaminated by infected animal; inoculation of skin, conjunctiva, oropharyngeal mucosa |
| Helminths | |
| Schistosomiasisa,b | Freshwater streams, lakes (focal in Asia, Africa, South America, parts of Caribbean) |
| Cercarial dermatitis (avian schistosomes)a | Fresh and salt water (worldwide) |
| Protozoa | |
| Acanthamoeba speciesa,b (keratitis); Naegleria fowlerib; Balamuthia mandrillarisa,b | Fresh water, especially stagnant ponds during hot summers; hot tubs, swimming pools, thermal springs |
| Viruses | |
| Adenovirusa,b (swimming pool conjunctivitis) | Swimming pools; likely other freshwater sites |
| Coxsackievirusesa,b | Fresh water |
| Other | |
| Seabather’s eruptiona | Seawater |
| Disease or pathogen | Main clinical finding |
|---|---|
| Adenovirus 3 | Pharyngitis, fever, conjunctivitis |
| Amebiasis (Entamoeba histolytica) | Colitis, liver abscess |
| ARTRI (aerosolized red tide respiratory irritation) | Rhinorrhea, cough, bronchospasm |
| Balantidiasis (Balantidium coli) | Diarrhea or dysentery |
| Campylobacteriosis | Diarrhea |
| Cholera (Vibrio cholerae) | Diarrhea, dehydration |
| Coxsackieviruses | Diarrhea |
| Cryptosporidiosis | Diarrhea, fever, nausea, vomiting |
| Cyclospora | Diarrhea, fever, nausea, vomiting |
| E. coli O157:H7 | Bloody diarrhea |
| Free-living amoebae (especially Naegleria fowleri) | Meningoencephalitis |
| Giardiasis | Subacute diarrhea, fever, nausea, vomiting |
| Hepatitis A virus | Acute hepatitis |
| Hepatitis E virus | Acute hepatitis (potentially fatal in pregnancy) |
| Legionnaires’ disease (Legionella) | Pneumonia |
| Leptospirosis | Fever, severe myalgia, conjunctival suffusion; may cause severe icterohemorrhagic fever |
| Melioidosis | Pneumonia, sepsis, skin lesions; protean manifestations |
| Norovirus (“Norwalk-like viruses”) | Diarrhea, vomiting |
| Pfiesteria (possible estuary-associated syndrome) | Eye irritation, cough, rash, vomiting, abdominal cramps, neurocognitive changes |
| Poliovirus | Nonspecific febrile illness; flaccid paralysis ≤1% |
| Pontiac fever (Legionella) | Fever (self-limited) |
| Primary amebic meningoencephalitis (PAM) | See Free-living amoebae |
| Rotavirus | Watery diarrhea |
| Salmonellosis | Diarrhea; extraintestinal manifestations if bacteremic diarrhea; dysentery |
| Shigellosis | Diarrhea, dysentery |
| Toxoplasmosis | Fever, lymphadenopathy, lymphocytosis |
| Tularemia | Fever, lymphadenopathy, pneumonia; manifestations depend on route of transmission |
| Typhoid/paratyphoid fever (enteric fever due to Salmonella enterica serotype Typhi or Paratyphi) | Fever, systemic infection, gastrointestinal sequelae |
| Vibrio parahaemolyticus | Watery diarrhea; occasionally dysentery |
| Vibrio vulnificus | Sepsis, bullous skin lesions; high rate of hospitalization and mortality |
| Yersinia enterocolitica | Fever, diarrhea, acute mesenteric lymphadenitis |
Several water-associated infections and intoxications can be rapidly progressive or can lead to serious complications. Because some of these are infrequent or rare, they may be unfamiliar to most physicians. The following section provides a brief summary of each. More common infections, such as shigellosis, campylobacteriosis, salmonellosis, and E. coli O157:H7 that can be acquired through water exposure are covered in more detail in other chapters of this book. Table 120.5 lists the recommended treatment for the less familiar water-associated infections and ones that are not covered in other chapters of the text.
| Pathogen or disease | Diagnosisa | Treatment |
|---|---|---|
| Aeromonas hydrophila | C | TMP–SMX or FQb,c (third-generation cephalosporins; AG; imipenem) |
| Burkholderia pseudomallei | C | Ceftazidimeb,c (imipenemb,c or meropenem; TMP/SMX + doxycyclinec) |
| Chromobacterium violaceum | C | Limited clinical data; may be sensitive to FQ, TMP–SMX, tetracyclines, AG, extended-spectrum penicillins |
| Francisella tularensis (tularemia) | S, C | Gentamicin,b streptomycin,b or tobramycinb (doxycycline or ciprofloxacin; chloramphenicol) |
| Leptospirosis | S, C | Penicillin Gb,c
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