Yosefa Hefter, MD

Between 2000 and 2014, 493 outbreaks linked to treated recreational water were reported to the Centers for Disease Control and Prevention (CDC), resulting in 27,219 cases of infections and 8 deaths.

 Additional outbreaks have been reported in connection with untreated fresh and marine water. Pediatricians should be ready to recognize and treat these infections and to appropriately advise families on safe water practices.

Signs and symptoms of recreational water illness

The most common recreational water illness is gastrointestinal disease, particularly diarrhea. When a child sick with diarrhea enters a body of water, small bits of fecal material that naturally remain on the body even when visibly clean can contaminate surrounding water. Another individual who swallows that water may become sick. 

, a protozoan, is the most commonly identified organism in water illnesses, likely because it can tolerate chlorine and survive for long periods. Although most bacterial and viral organisms are rapidly killed in properly disinfected water, they may survive in improperly disinfected or untreated water. Other pathogens implicated in diarrheal illnesses following recreational water exposure include bacteria (

), viruses (norovirus), and other parasites (

). Giardia cysts survive in mountain streams, where water-dwelling mammals such as beavers can contaminate water, leading to the nickname of “beaver fever.”

 Skin infections can also occur following recreational water activities. 

can form a biofilm on surfaces of 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 areas of recent piercings, leading to cellulitis and deeper soft tissue infections. 

, present in certain coastal waters especially when water temperatures are warmer, can cause severe, even life-threatening, rapidly progressing wound infections including necrotizing fasciitis that require timely recognition and treatment. More indolent skin infections following water exposure may be caused by nontuberculosis mycobacterium (NTM) such as 

 Also known as “swimmer’s ear,” this occurs when contaminated water stays in an individual’s ear for a prolonged period, providing an opportunity for bacteria to thrive in this moist, warm environment. Children with otitis externa usually have pain with tugging of the ear or placement of 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 

 is an environmental bacteria found in water and soil that can lead to pneumonia via inhalation of aerosols from contaminated water. Outbreaks have occurred from contaminated mists generated by cooling towers, showers, faucets, decorative fountains, and grocery store mist machines.

Most diarrheal illnesses caused by exposure to waterborne organisms are self-limited and can be appropriately managed with supportive care. With certain infections, such as cryptosporidiosis, symptoms may persist for several days and up to 2 weeks. Children with severe diarrhea leading to significant dehydration or children with com- promised immune systems may require therapy. In those scenarios, evaluation with stool studies is war- ranted to identify a causative organism. Therapy is then directed to the identified cause.

, is usually self-limited and does not require treatment. However, more extensive infections of skin, wounds, and surgical areas following recreational water exposure may require systemic antibiotic therapy. When possible, cultures should be sent from the infected site to inform treatment decisions. Empiric treatment may be determined by the type of water exposure because different organisms can be found in treated, fresh, brackish, or salt water.

In addition, common skin organisms may also be the causative pathogens, unrelated to water exposure. Examples of antibiotic regimens are clindamycin or a first-generation cephalosporin (eg, cephalexin) for coverage of skin organisms plus a fluoroquinolone (eg, ciprofloxacin) for coverage of commonly found water organisms such as Pseudomonas. Doxycycline should be considered in cases of exposure to brackish or salt water for treatment of 

. If an NTM infection is suspected, biopsy and culture can help confirm the diagnosis and guide therapy. Treatment for NTM infection often involves use of multiple agents for a prolonged period. Infectious diseases consultation would be warranted.

In otherwise healthy children, acute otitis externa can be treated with topical antibiotic otic drops, such as ciprofloxacin, for 7 to 10 days.

 However, in immunocompromised children, children with diabetes, and healthy children with involvement of surrounding tissues, systemic treatment should be used. Because these infections may be polymicrobial, with 

 being the most common causative organisms, broad empiric therapy is warranted for severe cases.

Advising families on practices to prevent infections from exposure to recreational water is essential. Both the American Academy of Pediatrics

 offer recommendations for safe water practices.

Below are key tips to provide to families:

Regularly test home pools for appropriate chlorine or bromine concentrations.

Avoid recreational water when ill with diarrhea. After receiving a diagnosis of cryptosporidiosis, avoid swimming for an additional 2 weeks.

Avoid exposing open wounds to recreational water, including following recent surgery or piercings.

Practice water hygiene such as showering before entering recreational water, regularly bringing children to the bathroom, and checking diapers of young children to avoid water contamination.

Keep ears as dry as possible during swimming (such as with use of a bathing cap), and dry ears thoroughly following water exposure.

In addition, children who are immunocompromised should take extra precautions to avoid exposure to possibly contaminated water.

Although recreational water infections are on the rise,

 awareness of these infections allows for recognition and appropriate treatment. Importantly, pediatricians can play a key role in advising families how to best avoid infection by following safe water practices.

1. Hlavsa MC, Cikesh BL, Roberts VA, et al. Outbreaks associated with treated recreational water — United States, 2000-2014. 

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. 

 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.

4. Prevention of illnesses associated with recreational water use. In: Kimberlin DW, ed. 

Red Book: 2018 Report of the Committee on Infectious Diseases.

 American Academy of Pediatrics; 2018:201-204.

5. Swimming and Ear Infections. Centers for Disease Control and Prevention. Updated June 3, 2020. Accessed April 29, 2021. 

https://www.cdc.gov/healthywater/swimming/swimmers/rwi/ear-infections.html

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As summer approaches, many children will spend time playing in pools, water parks, lakes, rivers, and oceans. Several serious types of infections, although relatively infrequent, have been associated with recreational water activities.

Yosefa Hefter, MD

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Common recreational water illnesses in children