Recreational water exposure

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.

Table 120.2 Clinical manifestations of infections related to recreational water exposure

Skin and mucosal surface exposure



Otitis externa

Dermatitis (including folliculitis)




Endometritis (reported after intercourse in water)

Systemic infection
Aspiration, inhalation, ingestion





Gastroenteritis, colitis

Systemic infection

Table 120.3 Infections and infestations acquired via percutaneous and permucosal recreational water exposure

Pathogen or disease Source
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
(Francisella tularensis)
Fresh water contaminated by infected animal; inoculation of skin, conjunctiva, oropharyngeal mucosa
Schistosomiasisa,b Freshwater streams, lakes (focal in Asia, Africa, South America, parts of Caribbean)
Cercarial dermatitis (avian schistosomes)a Fresh and salt water (worldwide)
Acanthamoeba speciesa,b (keratitis); Naegleria fowlerib; Balamuthia mandrillarisa,b Fresh water, especially stagnant ponds during hot summers; hot tubs, swimming pools, thermal springs
Adenovirusa,b (swimming pool conjunctivitis) Swimming pools; likely other freshwater sites
Coxsackievirusesa,b Fresh water
Seabather’s eruptiona Seawater

Note: Pseudomonas dermatitis and M. marinum are rarely associated with systemic infection, primarily in compromised hosts.

a Skin and soft tissue.

b Systemic infection.

c Conjunctivitis.

Table 120.4 Specific infections or toxins acquired via inhalation, aspiration, or ingestion during recreational water exposure

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.

Table 120.5 Diagnosis and treatment of selected infections

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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Jun 18, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Recreational water exposure
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