Between 2000 and 2014, 493 outbreaks related to purified recreational water were reported to the Centers for Disease Control and Prevention (CDC), resulting in 27,219 cases of infections and 8 deaths.1 Additional outbreaks have been reported related to untreated freshwater and marine water. Pediatricians should be ready to recognize and treat these infections and to properly advise families on safe water use.
Signs and Symptoms of Recreational Water Sickness
Gastrointestinal Infections: The most common recreational water sickness is gastrointestinal illness, especially diarrhea. When a child sick with diarrhea enters a body of water, small pieces of fecal material that naturally remain on the body, even if they are visibly clean, can contaminate the surrounding water. Another person who swallows that water could get sick. Cryptosporidium, a protozoan, is the most commonly identified organism in aquatic diseases, probably because it can tolerate chlorine and survive for a long time. While most bacterial and viral organisms are quickly killed in properly disinfected water, they can survive in improperly disinfected or untreated water. Other pathogens implicated in diarrheal diseases after recreational exposure to water include bacteria (Shigella, Escherichia coli), viruses (norovirus), and other parasites (Giardia lamblia). Giardia cysts survive in mountain streams, where aquatic mammals such as beavers can contaminate the water, leading to the nickname “beaver fever.”
Skin infections: Skin infections can also occur after recreational water activities. Pseudomonas can form a biofilm on the surfaces of swimming pools and hot tubs. After prolonged skin exposure, infections such as folliculitis can occur. Folliculitis can present as a bumpy, red, itchy rash, or you may see pustules or blisters around a hair follicle. Organisms in water can also infect wounds, surgical sites and recent piercing sites, leading to cellulitis and deeper soft tissue infections. Vibrio vulnificus, present in certain coastal waters, especially when water temperatures are warmer, can cause serious, even life-threatening, rapidly progressing wound infections, including necrotizing fasciitis that require early recognition and treatment. More indolent skin infections after water exposure can be caused by nontuberculosis mycobacterium (NTM) such as Mycobacterium marinum and Mycobacterium fortuitum.
External otitis: This is also known as ‘swimmer’s ear’. This happens when contaminated water stays in a person’s ear for an extended period of time, giving bacteria a chance to thrive in this moist, warm environment. Children with otitis externa usually have pain when pulling the ear or putting pressure on the tragus. The ear may be red and swollen and drainage may be present. Otitis externa can be caused by several organisms, but Pseudomonas is the most common
Acute respiratory diseases: Legionella is an environmental bacterium found in water and soil that can cause pneumonia through inhalation of aerosols from contaminated water. Outbreaks have occurred due to contaminated mists generated by cooling towers, showers, faucets, decorative fountains and fog machines in supermarkets.
Treatment of recreational water sickness
Most diarrheal diseases caused by exposure to waterborne organisms are self-limiting and can be treated appropriately with supportive care. With certain infections, such as cryptosporidiosis, symptoms can last from a few days to 2 weeks. Children with severe diarrhea leading to significant dehydration or children with compromised immune systems may require therapy. In those scenarios, evaluation with stool examination is warranted to identify a causative organism. Therapy is then directed to the identified cause.
Folliculitis, usually caused by Pseudomonas, usually goes away on its own and does not require treatment. However, more extensive infections of skin, wounds and surgical areas after recreational water exposure may require systemic antibiotic therapy. If possible, cultures should be sent from the infected site to inform treatment decisions. Empirical treatment can be determined by the type of exposure to water, as different organisms can be found in treated, fresh, brackish or salt water.
In addition, common skin organisms can also be the causative agents, which are unrelated to water exposure. Examples of antibiotic regimens are clindamycin or a first generation cephalosporin (e.g. cephalexin) for capping skin organisms and a fluoroquinolone (e.g. ciprofloxacin) for capping common aquatic organisms such as Pseudomonas. Doxycycline should be considered in cases of exposure to brackish or salt water for the treatment of Vibrio species. If an NTM infection is suspected, biopsy and culture can help confirm the diagnosis and guide therapy. Treatment for NTM infection often involves the use of multiple agents over an extended period of time. Consultation on infectious diseases would be warranted.
In otherwise healthy children, acute otitis externa can be treated with topical antibiotic ear drops, such as ciprofloxacin, for 7 to 10 days.4 However, systemic treatment should be considered in immunocompromised children, children with diabetes, and healthy children with involvement of surrounding tissues. are used. Because these infections can be polymicrobial, with Pseudomonas and Staphylococcus aureus being the most common causative agents, broad empirical therapy is warranted for severe cases.
Advising safe practices
It is essential to advise families on practices to prevent infections from exposure to recreational water. Both the American Academy of Pediatrics4 and the CDC5 offer recommendations for safe water use.
Below are the top tips for families:
Regularly test home pools for appropriate concentrations of chlorine or bromine. Avoid recreational water if you are sick with diarrhea. After receiving a diagnosis of cryptosporidiosis, avoid swimming for an additional 2 weeks. Avoid exposure of open wounds to recreational water, even after recent surgery or piercing. Avoid swallowing recreational water. Practice water hygiene, such as showering before entering recreational water, and take children to the bathroom regularly, and checking young children’s diapers to avoid water contamination. Keep the ears as dry as possible when swimming (such as when using a swimming cap) and dry the ears thoroughly after exposure to water.
In addition, children who are immunocompromised should take extra precautions to avoid exposure to potentially contaminated water.
Although recreational water infections are on the rise, awareness of these infections allows recognition and appropriate treatment. Importantly, pediatricians can play a key role in advising families on how best to prevent infection by following safe aquatic practices.
1. Hlavsa MC, Cikesh BL, Roberts VA, et al. Outbreaks associated with purified recreational water — United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2018;67(19):547-551. doi:10.15585/mmwr.mm6719a3
2. Vanden Esschert KL, Mattioli MC, Hilborn ED, et al. Outbreaks Associated with Untreated Recreational Water – California, Maine and Minnesota, 2018-2019. MMWR Morb Mortal Wkly Rep. 2020;69(25):781-783. doi:10.15585/mmwr.mm6925a3
3. Carrillo-Marquez M. Otitis externa. In: Cherry J, Demmler-Harrison GJ, Kaplan SL, Steinbach MJ, Hotez PJ, eds. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. Elsevier Inc; 2019:146-147.
4. Prevention of diseases associated with recreational water use. In: Kimberlin DW, ed. Red Book: Report 2018 of the Infectious Diseases Commission. American Academy of Pediatrics; 2018: 201-204.
5. Swimming and ear infections. Center for Disease Control and Prevention. Updated June 3, 2020. Accessed April 29, 2021. https://www.cdc.gov/healthywater/swimming/swimmers/rwi/ear-infections.html