Near Drowning

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

Organisms Associated with Pneumonia After Near Drowning

  • Aeromonas Hydrophila (see Aeromonas, [[Aeromonas]]): most commonly isolated Aeromonas species in near drowning cases
    • 70% of cases have a bacteremic pneumonia
    • Associated with near drowning in both fresh and salt water cases
    • 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, [[Aspergillus]])): common fungal contaminant of natural bodies of water, especially those polluted with sewage)
    • Invasive Aspergillosis cases have been reported
    • Rare etiology
    • Usually associated with near drowning near sewage or in polluted water, stagnant water, or muddy water
  • Chromobacterium Violaceum (see Chromobacterium Violaceum, [[Chromobacterium Violaceum]])
    • Epidemiology: found in soil and freshwater in Southeast USA
      • Few case reports of near drowning-associated pneumonia
  • Francisella Philomiragia (see Francisella Philomiragia, [[Francisella Philomiragia]]): few reports (all associated with salt water near drowning cases)
  • Klebsiella Pneumoniae (see Klebsiella Pneumoniae, [[Klebsiella Pneumoniae]]): has been associated with salt water near drowning cases
  • Non-Cholera Vibrio Species (see Vibrio, [[Vibrio]])
  • Oral Anerobes
    Pneumoniae”>Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
  • Pseudoallescheria Boydii (Scedosporium Apiosperium) (see Scedosporiosis, [[Scedosporiosis]]): 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 or contaminated water
    • May also cause meningitis/brain abscess
  • Staphylococcus Aureus (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
  • Streptococcus Pneumoniae (see Disseminated Intravascular Coagulation, [[Disseminated Intravascular Coagulation]])
    • xxx

    Neurologic Manifestations

    Anoxic Encephalopathy

    • xxx

    Pulmonary Manifestations

    Pneumonia (see Pneumonia, [[Pneumonia]])

    • Epidemiology
      • Incidence of Pneumonia After Near-Drowning: 12%
    • Clinical: may occur immediately or days-weeks after initial submersion event

    Acute Lung Injury-ARDS Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])

    • Epidemiology
    • Clinical

    Renal Manifestations

    Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])

    • xxx

    Other Manifestations

    • Organ Dysfunction: due to hypoxia/acidosis/ischemia
      • Includes ARDS/cardiogenic shock

    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, [[Aeromonas]]): most are susceptible to aminoglycosides, extended-spectrum penicillins, 3rd generation cephalosporins, carbapenems, aztreonam, trimethoprim-sulfamethoxazole, and fluoroquinolones.
    • Francisella Philomiragia (see xxxx, [[xxxx]]): sensitive to extended spectrum cephalosporins, fluoroquinolones, aminoglycosides, chloramphenicol, and tetracyclines
    • Pseudoallescheria Boydi (Scedosporium Apiospermium) (see Scedosporiosis, [[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

    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]
    • Use of CPR in cases of drowning. N Engl J Med 2012;366:2102-2110 [MEDLINE]