Hot Tubs & Hydrotherapy – Infection Soup Jim Gauthier A Webber Training Teleclass
Hot Tubs and Hydrotherapy – Objectives Infection Soup? Look at infections associated with: Hot tubs Foot spas ALPHA Teleclass Series Hydrotherapy tubs March 2004 Presented by Jim Gauthier, MLT, CIC Discuss biofilms and cleaning Providence Continuing Care Centre Try to be objective enough that you may Kingston, ON use these tubs again in the future! Hosted by Paul Webber:[email protected]
Is There a Safe Tub? Hot Tubs Referring to large, multi-person, jetted tubs, commonly found in homes, backyards, hotels, health spas or gyms. Quite an increase in the last couple of decades 1977 – 55,000 in the US 1985 - >2,000,000 1998 - >340,000 new tubs sold in US Rental units available Just park, fill, and tub!
Ontario Ministry of Health Ontario Ministry of Health
Section A, 13. Section C, 4 and 6 Spa:..contains water…designed for Exempt: recreational and / or therapeutic use which hydrotherapy pools which are drained, is not drained after each user…may cleaned and sanitized after each user, include…hydro massage jet circulation, hot known as floatation / deprivation tanks water, cold water, mineral baths, air containing brine and are for use by induction bubbles, or some combination individual occupants thereof.
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1 Hot Tubs & Hydrotherapy – Infection Soup Jim Gauthier A Webber Training Teleclass
Ontario Ministry of Health Ontario Ministry of Health
Section F 4 Section Z 5 The operator should The number of days of operation before …ensure that the filtration system and the all the spa water is drained to waste chemical feeders are in continuous operation should be determined using the following throughout the entire 24 hours of each day formula: without regard to the duration of actual use Vol. of tank in litres/ 10 x maximum number of the spa. of users = # of days between drainings per day
Possible Problems Hot Tub Folliculitis
Burns* “Hot tub buns” Folliculitis Most commonly caused by Pseudomonas aeruginosa Inhalational injuries from chemicals* Pruritic erythematous papule which can Humidifier lung progress to erythematous macules or Hot water fever pustules. Legionellosis Typically appears in 48 hours Hot tub lung Range of 6 hours to 5 days One report of 14 days post exposure
Hot Tub Folliculitis Hot Tub Folliculitis
Typically distributed over axilla, Attack rate of 7 to 100% abdomen and buttocks area. Risk factors: crowding, frequent and long Has been confused with: insect bites, hours in tubs (superhydration of skin), hives, allergy, staphylococcal infection, snug one piece bathing suits chicken pox, contact dermatitis, and herpes Even seen in people who don’t wear suits Resolve spontaneously within a period of Showering may not be protective seven to 10 days. Seasonal – winter months higher
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Hot Tub Folliculitis Tubs have a Capacity!
Mild fever and malaise may occur Other associated symptoms include: earache, sore throat, sore eyes, conjunctivitis, lymphadenopathy, rhinitis, swollen and painful breasts, nausea, vomiting, abdominal cramps, malaise, fatigue, headache, chills
Bacterial Analysis of Bacterial Loads1 Whirlpool Tub Water Samples % of positive samples 2 Water Sample Tap (n=34) Tub (n=43) Enterics1 95% (41 of 43) Average cfu/ml 1.38 x 102 2.17 x 106 Fungi 81% (25 of 31) Low Sample 0 (68% of 700 Staphylococcus aureus 34% (13 of 38) cfu/ml samples) Pseudomonas aeruginosa 16% (7 of 43) High Sample 3500 1.48 x 107 (10% Other Pseudomonas sp. 56% (24 of 43) cfu/ml of samples >107) Legionella sp. 36% (8 of 22)
1 Moyes, RB unpublished data 1 includes E. coli, P. mirabilis, Y. pseudotuberculosis, Shigella sp, Serratia 2 Private n = 22, hotel n = 21) sp, Klebsiella sp.
Nosocomial Whirlpool Tub Nosocomial Whirlpool Tub Infections Infections Hematology and Oncology unit Contact time was acceptable Infections include sepsis, line infections, Could not scrub area – biofilm or slime wound infections – not folliculitis layer was protecting organism Epidemic strain found in drain – was New water became colonized with contiguous with tub, closing 2.5 cm below organism tub level Outbreak stopped when tubs removed Significant risk of infection from tub use
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Aerosol-related Infections Legionella
Legionella pneumophila Factors that enhance colonization and Pontiac fever – milder illness with flu-like amplification in man-made water symptoms environments include: 20 persons who used both a whirlpool and Temperatures of 25o –42oC swimming pool at a hotel. Stagnation L. pneumophila isolated from whirlpool Scale and sediment water only, not pool. Presence of certain free living amoeba Support intracellular growth of legionellae
Hypersensitivity Pneumonitis Hypersensitivity Pneumonitis
Associated with Mycobacterium avium Predominate symptom is dyspnea complex Will include fever (38oC), chills, malaise, Considered a hypersensitivity reaction as headaches, weight loss, dry cough and opposed to an infection rhinorrhea Hot tub water not changed frequently Misdiagnosed as atypical pneumonia, enough (8 months in one case) acute asthma with pneumonia, Mycobacteria isolated from several of the sarcoidosis, eosinophilic bronchiolitis tubs
Hypersensitivity Pneumonitis Hypersensitivity Pneumonitis
X-ray – bilateral infiltrates; bilateral patchy Previous treatment history was nodular infiltrates; widespread miliary prednisone and / or antibiotics nodular changes; worsening diffuse bilateral Many cases kept using hot tub to help alveolar inflitrates relieve symptoms! Biopsy – well-formed non-necrotizing and focally necrotizing granulomatous Once tub use stopped (sold, converted to inflammation with virtually all the indoor garden) symptoms resolved granulomas centered on the small airways, usually on their own with focal intrabrochiolar localization, obliterating the lumens
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Hypersensitivity Pneumonitis Humidifier Lung
Organisms recovered in one tub Hypersensitivity pneumonitis associated included: with the inhalation of contaminated water M. avium complex, Pseudomonas sp. from air-conditioning systems, and Penicillium sp, and Scopulariopsis sp. domestic, office, and industrial M. avium complex is resistant to humidifiers. chlorination and can be found in Has been reported in showers, at a domestic water swimming pool, and in a sauna
How to Protect Ourselves from Humidifier Lung Aerosols? Organisms implicated: Thermophilic Actinomyces, Sphaeropsidales, Penicillium sp, protozoa, Pullulalria and Klebsiella oxytoca
Unknown Etiology Amoebae 12 persons in Texas guest ranch Finnish study found 7 of 11 whirlpools Symptoms included exhaustion, sore contained amoebae. muscles, headache, chills, and fever One lady reported a miscarriage during her Microbiological quality of water was illness good in 71% of tubs with amoebae Clinical specimens negative for L. Both samples with P. aeruginosa had pneumophila, influenza, parainfluenza, amoebae adenovirus. Filtering and chlorination is unable to Hot tub had been drained, refilled and destroy cysts. hyperchlorinated before culture could be done.
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Amoebae Hydrotherapy Tubs
Amoebae proliferate in filter Need to wash regularly by reverse flux Conclusion was that contact lenses should not be worn when swimming or bathing in public pools, because of theoretical risk of keratitis.
India Medico Instruments
Hydrotherapy tubs Birthing Tanks
Generally one person at a time Recent addition to obstetrical practice. Need to be drained, cleaned and Have seen P. aeruginosa infections in disinfected between patients neonate from tank water If jetted, must circulate disinfectant Water and walls will be contaminated with skin flora and blood during labor through jets and delivery. Important to ensure proper contact time Follow manufacturer’s instructions for and dilution of disinfectant selection of disinfection method and agent
Footbaths/Foot Spas Footbaths/Foot Spas
Outbreaks have been seen Texas, California Mycobacterium fortuitum and other related mycobacteria Look like spider bites that eventually grow, produces pus, can scar Don’t shave before your pedicure
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Footbaths/Foot Spas Disinfectants
California Department of Consumer Calcium, lithium and sodium Affairs hypochlorite,chloroisocyanurates and Between customers: drain, wash and chlorine gas disinfect Chlorine – activity is shortened by: End of each day, remove filter screen, Aeration, wash system, disinfect Agitation Every other week clean with bleach High temperatures solution, then soak for 6 hours High numbers of bathers
Disinfectants Culturing Frequency
Bromine Depends on state of tub, can look only for Forms bactericidal bromamines Pseudomonas, or total and fecal Some problems with contact dermatitis organisms Iodine Rapid method described using adenosine Does not bleach hair, swim suits or cause triphosphate (ATP) which showed good eye irritation correlation to standard plate counts, but Gives water a greenish-yellowish cast also detected non-coliform bacteria
A Quick Word on Biofilms Biofilms
Biofilms are a substance composed of Organisms within biofilms behave quite cells embedded in a matrix of differently than planktonic (free floating) extracellularly-produced polymers and bacteria associated abiotic particles More resistant to antibiotics and disinfectants Can contain algae, protozoa, and fungi, Chlorine less effective against biofilms but predominating organisms are gram- Requires high concentration negative bacteria Monochloramine can penetrate better, but only used in municipal systems, not as a supplemental water treatment approach
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Biofilms Summary
Accelerated or stabilized hydrogen Keep it clean! peroxide does penetrate and remove Must use elbow grease to clean before biofilms disinfecting Risk of problems seem to be directly Can be corrosive on some plumbing related to sanitization and cleaning of fittings unit Need to keep educating the public on the importance of cleaning their tubs, and to beware of large, public use tubs.
References References
Lorber B. Hot tubs, sex, sushi, and infectious CDC. Surveillance for waterborne disease diseases. Pharmacotherapy 1991;11:56S-63S outbreaks – United States, 1999-2000. MMWR 2002;51:SS-8 Vesaluoma M, et al. Microbiological quality in Finnish public swimming pools and whirlpools Ratnam S. et al. Whirlpool-associated folliculitis caused by Pseudomonas aeruginosa: with special reference to free living amoebae: a report of an outbreak and review. J Clin risk factor for contact lens wearers? Br J Microbiol 1986;23:655-659 Ophthalmol 1995;79:178-181 California Department of Consumer Affairs, Stulberg DL. Common Bacterial Skin Board of Barbering and Cosmetology. Infections. Am Fam Physician 2002;66:119-24 Whirlpool footspa safety fact sheet. 2002 May www.dca.ca.gov/barber
References References
www.click2houston.com/print/2624450/detail.html? Berrouane YF et al. Outbreak of severe use=print Pseudomonas aeruginosa infections caused by a CDC. Guidelines for environmental infection contaminated drain in a whirlpool bathtub. Clin control in health-care facilities. 2003. pp40-54, 67- Infect Dis 2000;31:1331-7 69, 220-222. MOH. Recommended standards for the operation Embil J et al. Pulmonary illness associated with of public spas. 1989 exposure to Mycobacterium-avium complex in hot tub water. Chest 1997;111:813-816 Lee JY et al. Rapid determination of bacteria in Rickman OB et al. Hypersensitivity pneumonitis pools. J Environ Health 2001;64:9-13 associated with Mycobacterium avium complex and hot tub use. May Clin Proc 2002;77:1233-1237
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