Epidemiology

• Definition of Near Drowning: defined as submersion in water severe enough to require medical attention
  • WHO Definition of Drowning: “the process of experiencing respiratory impairment from immersion/immersion in liquid”
• Mortality Rates Associated with Drowning
  • Worldwide: 500k deaths (or 0.7% of all deaths) occur annually due to unintentional drowning
  • US: 8k deaths occur annually due to unintentional drowning
    • Near drowning is believed to occur 2-20x more frequently

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Organisms Associated with Pneumonia After Near Drowning

• General Comments
  • Near Drowning-Associated Pneumonia Can Be Due to Multidrug-Resistant Organisms (Resuscitation, 2012) [MEDLINE]
• Aeromonas Hydrophila (see Aeromonas)
  • Epidemiology
    • Associated with Near Drowning in Both Fresh and Salt Water
    • Most Commonly Isolated Aeromonas Species in Near Drowning Cases
  • Clinical
    • Approximately 70% of Cases Have a Bacteremic Pneumonia
    • Virulent Infection: >70% of Cases Have Bacteremia and Mortality Rates are Close to 60%
    • Highest Risk in Those with Liver Disease and Hematologic Malignancies
• Aspergillus (see Aspergillus)
  • Epidemiology
    • Common Fungal Contaminant of Natural Bodies of Water, Especially Those Polluted with Sewage
    • Associated with Near Drowning Near Sewage or in Polluted Water, Stagnant Water, or Muddy Water
    • Rare Etiology of Near-Drowning-Associated Pneumonia
    • Near Drowning-Associated Invasive Aspergillosis Cases Have Been Reported
• Chromobacterium Violaceum (see Chromobacterium Violaceum)
  • Epidemiology
    • Found in Soil and Freshwater in Southeast USA
    • Few Case Reports of Near Drowning-Associated Pneumonia
• Francisella Philomiragia (see Francisella Philomiragia)
  • Epidemiology
    • Few Case Reports (All Associated with Salt Water Near Drowning)
• Klebsiella Pneumoniae (see Klebsiella Pneumoniae)
  • Epidemiology
    • Associated with Salt Water Near Drowning
• Non-Cholera Vibrio Species (see Vibrio)
• Oral Anerobes
• Scedosporium Apiospermum Complex (see Scedosporiosis)
  • Epidemiology
    • Found in Freshwater Lakes, Coastal Waters, and Polluted Streams
    • Most Common Fungus Associated with Near Drowning
    • More Common Etiology of Pneumonia After Near Drowning than Aspergillus
    • Associated with Near Drowning in Both Coastal and Fresh Water, as Well as in Polluted/Contaminated Water
  • Clinical
    • Meningitis/Brain Abscess: may occur
• Staphylococcus Aureus (see Staphylococcus Aureus)
• Streptococcus Pneumoniae (see Streptococcus Pneumoniae)

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Physiology

• Prolonged submersion results in initial breath holding followed by involuntary aspiration of water (often contaminated by organisms)
• Initial laryngospasm remits and 90% of cases experience a large volume aspiration
• Autopsy studies demonstrate that 25% of drowning cases have gastric contents their lungs/ 60% have evidence of particulate aspiration

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Clinical Presentations

Cardiovascular Manifestations

Cardiogenic Shock

• Physiology: due to hypoxia/acidosis/ischemia

Hematologic Manifestations

Disseminated Intravascular Coagulation (DIC) (see Disseminated Intravascular Coagulation)

• Epidemiology

Neurologic Manifestations

Hypoxic-Ischemic Brain Injury (see Hypoxic-Ischemic Brain Injury)

• Epidemiology: may occur (depending on duration of anoxia)

Pulmonary Manifestations

Pneumonia (see Pneumonia)

• Epidemiology
  • Incidence of Pneumonia After Near-Drowning: 12% (Emerg Med J, 2010) [MEDLINE]
• Clinical: may occur immediately or days-weeks after initial submersion event

Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome)

• Epidemiology
  • XXXXX
• Physiology
  • Due to hypoxia/acidosis/ischemia
• Clinical
  • XXXX

Renal Manifestations

Acute Kidney Injury (AKI) (see Acute Kidney Injury)

• Physiology
  • Due to hypoxia/acidosis/ischemia

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Treatment

Supportive Care

• Mechanical Ventilation: as required

Antibiotics

• General Comments: since incidence of pneumonia after near-drowning is only 12%, it is recommended to withhold antibiotics and monitor patient daily for fever/infiltrates/leukocytosis

Treatment of Specific Pathogens

• Aeromonas Species (see Aeromonas): most are susceptible to aminoglycosides, extended-spectrum penicillins, 3rd generation cephalosporins, carbapenems, aztreonam, trimethoprim-sulfamethoxazole, and fluoroquinolones.
• Francisella Philomiragia (see xxxx): sensitive to extended spectrum cephalosporins, fluoroquinolones, aminoglycosides, chloramphenicol, and tetracyclines
• Pseudoallescheria Boydi (Scedosporium Apiospermium) (see Scedosporiosis): miconazole has the best in vivo activity against P boydii and the drug is usually given IV and intraventricularly in patients with central nervous system involvement

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References

• Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary: BET 1: prophylactic antibiotics in near-drowning. Emerg Med J 2010;27:393-394 [MEDLINE]
• Drowning. N Engl J Med. 2012 May 31;366(22):2102-10. doi: 10.1056/NEJMra10133 [MEDLINE]
• Drowning associated pneumonia: a descriptive cohort. Resuscitation. 2012 Mar;83(3):399-401. doi: 10.1016/j.resuscitation.2011.08.023. Epub 2011 Sep 10 [MEDLINE]