Infection following water exposure: Causes and clinical features

Organism	Bacteriology	Epidemiology	Incubation	Clinical manifestations	Treatment
Aeromonas hydrophila	Gram-negative rod	Fresh and brackish water Incidence increases in warm months May follow alligator, fish, leech, and snake bites Associated with near-drowning	24 to 48 hours	Cellulitis, pyoderma, furuncles, necrotizing infection.	Generally susceptible to third- and fourth-generation cephalosporins, fluoroquinolones, aminoglycosides Resistant to penicillins, first-generation cephalosporins
Burkholderia pseudomallei	Gram-negative rod	Fresh water	1 to 21 days (mean 9 days)	Pneumonia, skin and soft tissue infection, systemic manifestations.	Refer to the UpToDate topic on treatment of melioidosis
Chromobacterium violaceum	Gram-negative rod	Brackish to stagnant water, wet tropical soils (especially Western Pacific) Follows minor injuries and fish bites Associated with immunosuppression, especially chronic granulomatous disease	24 to 48 hours	Cellulitis, pustules, ulcers with black necrotic bases and bluish purulent discharges.	Generally susceptible to fluoroquinolones, tetracyclines, carbapenems, TMP-SMX, aminoglycosides Resistant to ampicillin, most cephalosporins
Edwardsiella tarda	Gram-negative rod	Fresh and brackish water Causes disease in catfish; follows catfish spine punctures Associated with immunosuppression, especially hepatic disease	24 to 48 hours	Pyoderma, necrotizing infection, myonecrosis.	Susceptible to most broad spectrum antibiotics with gram-negative coverage (including ampicillin, cephalosporins, fluoroquinolone, aminoglycosides)
Erysipelothrix rhusiopathiae	Gram-positive rod	Salt water Often follows wounds sustained when filleting fish	24 to 48 hours	Erysipeloid.	Generally susceptible to penicillins, carbapenems, cephalosporins, fluoroquinolones, daptomycin, clindamycin Typically resistant to vancomycin, sulfonamides, aminoglycosides
Mycobacterium fortuitum	Acid-fast, rapidly growing mycobacterium	Fresh and salt water Associated with foot baths, pedicures, ichthyotherapy	3 to 12 weeks	Begins with lower extremity erythematous papules; after weeks to months, these progress to fluctuant violaceous furuncles that ulcerate or resolve with scarring.	Antimicrobial therapy should be guided by susceptibility testing Usually susceptible to ciprofloxacin, clarithromycin, doxycycline, minocycline, sulfonamides, amikacin
Mycobacterium marinum	Acid-fast mycobacterium	Salt water Associated with lacerations sustained while cleaning salt water aquariums (fish tank granuloma) Infection may follow crab bites, spine punctures by sea urchins and crustaceans (sustained during seafood preparation)	1 week to months (mean 21 days)	Localized red-violet verrucous raised patches with lymphadenitis, lymphadenopathy, and possibly sporotrichoid nodular ulcerations along lymphatic drainage routes. Deep infections may occur in untreated cases and in immunocompromised patients.	Susceptible to clarithromycin, ethambutol, rifampin, and TMP-SMX; usually treated with two agents in combination
Plesiomonas shigelloides	Gram-negative rod	Fresh and brackish water	24 to 48 hours	Diarrheal illness; some extraintestinal manifestations include bacteremia, skin and soft tissue infection.	Susceptible to fluoroquinolones; nonsevere diarrhea may be treated with supportive care
Pseudomonas aeruginosa	Gram-negative rod	Fresh water	8 to 48 hours	Broad array of manifestations including skin and soft tissue infections (folliculitis associated with hot tub exposure, burn wound infections, green nail syndrome), eye infections, ear infections, gastrointestinal infections, urinary tract infections.	Refer to the UpToDate topic on therapy of Pseudomonas infections
Shewanella spp	Gram-negative rod	Salt water (especially Mediterranean and Western Pacific) Contaminates shellfish, especially clams Associated with near-drowning, raw shellfish ingestion, wound exposure to salt water (especially in immunocompromised patients)	4 to 24 weeks	Cellulitis, pyoderma, deep ulcers, necrotizing fasciitis, compartment syndrome.	Generally susceptible to third- and fourth- generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides Resistant to penicillins, first- and second- generation cephalosporins
Streptococcus iniae	Gram positive and beta hemolytic	Fresh and brackish water Associated with wounds sustained during preparation of fresh fish, especially farm-raised tilapia	24 to 48 hours	Impetigo, cellulitis.	Susceptible to penicillin, cephalosporins, TMP-SMX, macrolides
Vibrio vulnificus	Curved gram-negative rod	Warm salt water (especially Gulf of Mexico) Associated with puncture wounds sustained in salt water and ingestion of raw or undercooked oysters, especially in males with chronic liver disease (alcoholic cirrhosis)	3 to 7 days	Cellulitis, hemorrhagic bullae, ulcers, necrotizing infection with compartment syndrome, ecthyma gangrenosum, septicemia.	Susceptible to third-generation cephalosporins (such as ceftazidime, ceftriaxone, or cefotaxime), doxycycline, fluoroquinlones

TMP-SMX: trimethoprim-sulfamethoxazole.

Original table modified for this publication. From: Diaz JH, Lopez FA. Skin, soft tissue and systemic bacterial infections following aquatic injuries and exposures. Am J Med Sci 2015; 349:269. Table used with the permission of Elsevier Inc. All rights reserved.

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Infection following water exposure: Causes and clinical features