Microbiological quality of indoor and outdoor swimming pools in Greece: investigation of the antibiotic resistance of the bacterial isolates

During 1997-2005, the microbiological quality and susceptibility of bacterial isolates of swimming pool waters were investigated. A total of 462 water samples were collected from three indoor swimming pools (a teaching pool, a competition public pool, a hydrotherapy pool) and two outdoor swimming pools (a hotel semi-public and a residential private pool) in Northwestern Greece. All water samples were analyzed for the presence of bacteria, protozoa and fungi and susceptibility tests were performed for the bacterial isolates. Sixty-seven percent of the examined water samples conformed to the microbiological standards and 32.9% exceeded at least one of the indicated limits. Out of 107 bacterial isolates, 38 (35.5%) resistant strains were detected. Multi-resistant Pseudomonas alcaligenes, Leuconostoc, and Staphylococcus aureus (isolated from the teaching pool), Staphylococcus wernerii, Chryseobacterium indologenes and Ochrobactrum anthropi (isolated from the competition pool), Pseudomonas aeruginosa, P. fluorescens, Aeromonas hydrophila, Enterobacter cloacae, Klebsiella pneumoniae and S. aureus (isolated from the hydrotherapy pool) and A. hydrophila (isolated from the hotel pool) were detected. The swimming pool with the poorest microbiological quality (THC 500 cfu/ml in 12.1% of the samples, P. aeruginosa counts 1500 cfu/100 ml in 6% of the samples) and the highest prevalence of multi-resistant isolates (73.6%) was the hydrotherapy pool. No Cryptosporidium or Giardia cysts and no Legionella, Mycobacteria and Salmonella were detected, but there were isolations of Candida albicans, Aspergillus spp., Mucor spp., Alternaria spp., Rhizopus spp., Trichophyton spp., and Penicillium spp.

Surveillance data from public spa inspections--United States, May-September 2002

Approximately 5 million public and private hot tubs, whirlpools, and spas are used in the United States. Extensive spa use combined with inadequate maintenance contribute to recreational water illnesses (RWIs) caused by pathogens such as Pseudomonas spp., Legionella spp., and Mycobacterium spp. In the United States, local environmental health inspectors periodically inspect public spas to determine their compliance with local or state health regulations. During inspections for regulatory compliance, data pertaining to spa water chemistry, filtration and recirculation, and management and operations are collected. This report summarizes spa inspection data from six sites in the United States during May 1-September 1, 2002. The findings underscore the utility of these data for public health decision-making and the need for increased training and vigilance by operators to ensure high-quality spa water for use by the public.

Natural history of chronic pain and pain treatment in adults with cerebral palsy

OBJECTIVES

To determine if cerebral palsy-related pain and frequency of use of pain treatments change over time and to examine the association between use of pain treatments and changes in pain intensity.

DESIGN

Longitudinal study of 50 adults with cerebral palsy-related chronic pain, interviewed five times during the course of 2 yrs (6 mos between each interview). Subjects ranged in age from 18 to 76 yrs old and included 25 women and 25 men.

RESULTS

Pain intensity did not change significantly during the time period of the study (2 yrs), although there was a substantial increase in the frequency of use of several pain treatments from the initial to the second interview. Participants reported that many pain treatments were at least moderately helpful, but only three of the treatments (whirlpool, ultrasound, and transcutaneous electrical nerve stimulation) seemed to be associated with a decrease in pain among those who started using these treatments during the study.

CONCLUSION

Pain does not seem to become systematically better or worse during the course of a 2-yr time period in adults with cerebral palsy-related pain. Although several pain treatments are reported to provide pain relief, many of these were rarely used by (or provided to) the study participants. There is a need for more research to determine which pain treatments are most helpful for cerebral palsy-related pain and to increase patient accessibility to effective pain treatments.

Effects of a Circulating-water Garment and Forced-air Warming on Body Heat Content and Core Temperature

Background

Forced-air warming is sometimes unable to maintain perioperative normothermia. Therefore, the authors compared heat transfer, regional heat distribution, and core rewarming of forced-air warming with a novel circulating-water garment.

Methods

Nine volunteers were each evaluated on two randomly ordered study days. They were anesthetized and cooled to a core temperature near 34 degrees C. The volunteers were subsequently warmed for 2.5 h with either a circulating-water garment or a forced-air cover. Overall, heat balance was determined from the difference between cutaneous heat loss (thermal flux transducers) and metabolic heat production (oxygen consumption). Average arm and leg (peripheral) tissue temperatures were determined from 18 intramuscular needle thermocouples, 15 skin thermal flux transducers, and "deep" hand and foot thermometers.

Results

Heat production (approximately 60 kcal/h) and loss (approximately 45 kcal/h) were similar with each treatment before warming. The increases in heat transfer across anterior portions of the skin surface were similar with each warming system (approximately 65 kcal/h). Forced-air warming had no effect on posterior heat transfer, whereas circulating-water transferred 21+/-9 kcal/h through the posterior skin surface after a half hour of warming. Over 2.5 h, circulating water thus increased body heat content 56% more than forced air. Core temperatures thus increased faster than with circulating water than forced air, especially during the first hour, with the result that core temperature was 1.1 degrees +/- 0.7 degrees C greater after 2.5 h (P < 0.001). Peripheral tissue heat content increased twice as much as core heat content with each device, but the core-to-peripheral tissue temperature gradient remained positive throughout the study.

Conclusions

The circulating-water system transferred more heat than forced air, with the difference resulting largely from posterior heating. Circulating water rewarmed patients 0.4 degrees C/h faster than forced air. A substantial peripheral-to-core tissue temperature gradient with each device indicated that peripheral tissues insulated the core, thus slowing heat transfer.

Survey of Staphylococcus aureus contamination in a hospital's spa and hydrotherapy pools

Twenty-seven percent of water samples taken from one spa and two hydrotherapy pools in one Welsh hospital over three months contained Staphylococcus aureus. Four per cent of samples were deemed unacceptable because they contained coliforms, E. coli or Pseudomonas aeruginosa. Aerobic colony counts varied between samples but no counts were > 100 cfu/ml. Disinfection and pH records indicated no significant problems with pool maintenance over the sampling period, and bather loads were generally low. Some samples positive for S. aureus were found after lengthy periods of pool inactivity, indicating persistence of the organism.

Evidence-based practice: tap water cleansing of leg ulcers in the community

To establish and encourage wound management practices based on evidence, a Community Nursing Organization in metropolitan Adelaide began a series of research initiatives in 1997. Based on the results of a wound management survey, and through the processes of participatory action research with clinicians, many wound management practice changes were instigated throughout the Community Nursing Organization. One question remains unanswered: What is the evidence for the use of sterile saline or clean tap water for cleansing of leg ulcers in the community? In this paper we describe a project where we applied the three principles of planning, action and evaluation. Application of these principles enabled clinicians to collaborate in the search for evidence to support or refute tap water cleansing of leg ulcers. To conclude, we report on a pilot research project undertaken to obtain further evidence either to support or refute the use of tap water cleansing for leg ulcers in the community.

Short and long-term effect of spa therapy in chronic low back pain

The effect of spa therapy on chronic low back pain (LBP) was assessed in a randomized trial comparing patients undergoing a 3-week therapy programme in a spa resort in France (n = 50) with patients receiving ambulatory care (n = 52). After 3 weeks, patients in the spa group had significant improvement in their spine mobility and functional score (Waddell index) and a reduction in their daily duration of pain, pain intensity and drug consumption. The long-term effect was assessed after 9 months and showed continued reduction in pain and drug consumption, and improvement in spine mobility but no longer in functional score which returned to baseline level. It is concluded that spa therapy has a positive short-term and a moderate long-term effectiveness on chronic LBP.

Hydrotherapy pools of the future--the avoidance of health problems

The need to minimize the threat of infection to patients and the high incidence of health problems in hydrotherapy pool workers, have led to recommendations especially tailored to the design and operation of the water and air treatment plant of hydrotherapy pools. Hitherto unpublished surveys are detailed which confirm that pathogenic species of Pseudomonas aeruginosa in pools (in which ears may be wetted) cause a high incidence of otitis externa, but rarely cause body rashes (pseudomonas folliculitis) unless there has also been prolonged skin wetting. In brominated pools contact dermatitis is common and can be distinguished clinically from pseudomonas folliculitis by the onset of a pruritic rash less than 12 hours after exposure to the pool and reactivation of the rash on re-exposure to the brominated pool.

Experiences with bacteriological monitoring of pool water

A bacteriological study was completed on pools and whirlpools operated by hotels and private health clubs in the metropolitan area of Toronto, Ontario, Canada. Coliform bacteria, fecal coliform bacteria, and fecal streptococci were found only when other indices showed a drastic deterioration in water quality. Aerobic plate counts were higher, and staphylococci and Pseudomonas aeruginosa occurred more often in whirlpools than in swimming pools. There was a correlation between aerobic plate counts and the presence of staphylococci and P. aeruginosa. P. aeruginosa was rare in swimming pools in the absence of staphylococci; however, in whirlpools the organism was often found in the absence of staphylococci, and when aerobic plate counts were low. P. aeruginosa and plate counts in excess of 3,000 per ml occurred more frequently in whirlpools when the free chlorine residual was less than one part per million. The surface film showed concentrations of staphylococci far greater than the pool water. Whirlpools appear to present a different ecosystem that favors the establishment of P. aeruginosa. Staphylococci, but not Staphylococcus aureus, are useful in indicators of pool water quality but better laboratory methodology is required. Additional attention should be directed to the bacteriology of the water surface film, which presents a more direct hazard to bathers.

Public health implications regarding the epidemiology and microbiology of public whirlpools

High temperature bathing in hot tubs, spas and whirlpools poses four potential public health concerns: injury/death, disease transmission, possible teratogenic effects, and congestive heart failure or dysrhythmias for individuals with cardiac problems. Health departments need criteria before initiating environmental and epidemiologic investigations. These criteria must include severity of the disease and number of individuals possibly exposed. In addition, public health officials are obligated to define the magnitude of the problem, inform affected individuals and institute appropriate control measures. Optional information should be collected during an environmental and epidemiologic investigation to clarify the mechanisms of disease transmission and design control measures. The public health response to improving hot water bathing safety and sanitation should be directed at primary prevention. Educational efforts would be directed toward whirlpool operators, users and the medical community. Included should be a review of regulations addressing the construction and operation of public spas and whirlpools.

Whirlpool operation and the prevention of infection

Disease outbreaks involving public whirlpools have been reported frequently since their use has become popular in recent years. Because public whirlpools are often used by persons who have only transient contact, infections resulting from their use are difficult to identify, and published reports probably represent only a small portion of a larger public health problem. Most published outbreaks have reported Pseudomonas aeruginosa contamination of the whirlpool as a result of failure to operate the pool according to recommended practices. Maintaining the microbiologic quality of whirlpool water and preventing infection absolutely require regular operation and maintenance, including monitoring and record keeping by qualified personnel.

Hospital hydrotherapy pools treated with ultra violet light: bad bacteriological quality and presence of thermophilic Naegleria

The microbiological quality of eight halogenated and two u.v.-treated hydrotherapy pools in hospitals was investigated. The microbiological quality of halogenated hydrotherapy pools was comparable to halogenated public swimming pools, although in some Pseudomonas aeruginosa and faecal pollution indicators were more frequent due to bad management. On the other hand u.v.-treated hydrotherapy pools had very bad microbiological quality. Apart from faecal pollution indicators, P. aeruginosa was present in very high numbers. Halogenated hydrotherapy pools were not highly contaminated with amoebae, and Naegleria spp. were never detected. On the other hand u.v.-treated pools contained very high numbers of thermophilic Naegleria. The Naegleria isolated were identified as N. lovaniensis, a species commonly found in association with N. fowleri. Isoenzyme analysis showed a different type of N. lovaniensis was present in each of two u.v.-treated pools.

Enterobacter cloacae septicemia in a burn center: epidemiology and control of an outbreak

An outbreak of infections due to Enterobacter cloacae occurred in the burn center at the Medical College of Virginia (Richmond, Virginia) in 1976. Fifteen patients had bacteremia due to E. cloacae; 10 cases of bacteremia occurred during a six-week period in January and February. The development of bacteremia was significantly related to the extent of third-degree burn and to admission to the burn center in January and February but not to the presence of an intravenous cannula, underlying disease, or antimicrobial therapy. E. cloacae was spread by contaminated hands of personnel and by cross-contamination of hydrotherapy water. A shortage of staff appeared to be an important factor in the occurrence of the outbreak. Control measures included an increase in the number of personnel, instruction of personnel in proper aseptic technique, and adoption of a new hydrotherapy protocol.