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Swimming with Lines and Tubes: It’s a Team Effort
This article is based on a presentation by Dr. Gura at the Oley annual conference in Orlando, Florida, in June, and on an article that appeared in Nutrition in Clinical Practice ("Going with the Flow or Swimming Against the Tide,” February 2014).
Swimming is an excellent form of aerobic exercise and a great social activity, as well as being enjoyable. Many consider recreational swimming to be a rite of summer, but for some, the risk may outweigh the benefit. Individuals who require long-term parenteral nutrition (PN) support or have an enteral (EN) feeding tube have to consider swimming options carefully.
Central venous catheters (CVCs) and EN feeding tubes may be portals for infection. Patients with CVCs may be predisposed to exit site, tunnel, and catheter-related bloodstream infections (CRBSIs) from water submersion. Those with recently placed percutaneous endoscopic gastrostomy (PEG) tubes may get an infection if they go swimming before the tract fully heals.
So what should you do? My colleagues and I recently conducted a literature search on swimming and surveyed several home PN programs about their policies. Here I share the results, as well as some approaches to keeping your line or feeding tube safe.
Despite the growing number of individuals with CVCs, the risk of infection after swimming has not been well studied. There is currently no strong evidence concluding that swimming has caused an increase in catheter-related infections; however, there is also no evidence to suggest that this is a safe practice in this patient population. At Boston Children’s Hospital, our interest in the topic arose after a child with intestinal failure in our program suffered a fatal pseudomonas CVC infection within twenty-four hours of swimming in the ocean.
The Centers for Disease Control and Prevention (CDC) documented a total of 134 recreational water-associated outbreaks from thirty-eight states and Puerto Rico in a two-year period, which resulted in 13,966 cases in the general population (Hlavsa, et al. Surveillance for Waterborne Disease Outbreaks and Other Health Events Associated with Recreational Water, US, 2007–2008, Surveillance Summaries 2011; 60 :1–73). The majority of the outbreaks (86.6%) were associated with treated recreational water (e.g., swimming pools). Proper maintenance of recreational water may play an important role in minimizing outbreaks, as many of the outbreaks occurred in pools that were in violation of maintenance standards.
Common sense suggests that lakes and ponds that are stagnant in nature will more likely be contaminated with fecal matter from birds. Unfortunately, there is also an abundance of evidence showing the presence of human pathogens in the ocean and in chlorinated pools. These include methicillin resistant Staphylococcus aureus, E. coli, Pseudomonas aeruginosa, Cryptosporidium, and Enterococci, as well as viruses (adenovirus, norovirus, echovirus, hepatitis A virus, coxsackie viruses), which can cause potentially fatal illnesses when given direct access to the bloodstream.
The presence of E. coli in many recreational water areas indicates that swimmers themselves often introduce fecal matter into pool areas. Other warm-blooded animals can introduce E. coli in the same manner. In addition, P. aeruginosa often inhabits biofilms on moist surfaces, such as pool walls and filters. These findings suggest that swimming is not a completely safe activity for the general public, let alone for patients with a CVC who are already at great risk of acquiring a serious infection. These factors, along with potential host immunosuppression, can place patients at increased risk of acquiring catheter-related infections.
A recent literature review demonstrated the abundance of human pathogens that have caused infectious outbreaks in the general population in all types of recreational water, including lakes, oceans, public swimming pools, water parks, and more. Human pathogens that have been identified as etiologic agents involved with recreational water outbreaks include those listed above, as well as Shigella and Giardia. These have resulted in primarily gastrointestinal infections. Moreover, it has been shown that Cryptosporidium can live up to ten days in a properly chlorinated pool. This suggests that such environments may not be optimal for patients with CVCs, and that controlled environments such as private swimming pools may theoretically minimize the risk of catheter-related infections in patients choosing to swim. However, this may be a false sense of security as infections that occur as a result of swimming in a contaminated private pool will not be reported to health authorities.
If you are going swimming, it is extremely important to check the contamination levels of the water on the day you plan on swimming (see table 1 for resources). Runoff from recent rains can contaminate lakes and rivers. Pools can be improperly chlorinated. Some bacteria have even adapted so they thrive in salt water.
For the water quality of public or hotel pools, check with the people who are responsible for maintaining them. Ideally, daily testing should be considered the minimum standard. Many facilities test multiple times per day and will close the pool if results exceed a certain threshold. In some states, such as Florida, public pool testing results are posted online. Even if pools are maintained properly, however, other people may be swimming when they shouldn’t (for example, when they have diarrhea). Allowing infants and toddlers who are not toilet trained in the water can also result in recreational water illness.
Proper maintenance and testing is also important with private pools. Make sure your guests stay out of the water if they aren’t feeling well; the same goes for infants or toddlers who aren’t toilet trained. Swimming diapers are great, but they haven’t been tested for efficacy.
What the "Experts” Say
In 2013, a survey was performed to determine the practices of home PN programs in the United States regarding this controversial question. Twenty-five home PN programs were identified through the Oley Foundation Web site. Each program was contacted via e-mail and asked: (1) Do you allow your patients with CVCs to go swimming? If yes, what bodies of water are allowed (ocean, lake, pool, etc.)? (2) Are your patients required to use dressings/coverings? If yes, which product(s)? and (3) Are there any other rules the patients must follow?
Sixteen of the programs responded. For the programs that did allow swimming, two programs allowed any body of water; two programs allowed oceans or pools; one program allowed oceans, pools, and private hot tubs; six programs only allowed pools; and one program did not specify. (Table 3) Dressings or line covers varied among the programs and there was no consistency in the products recommended, but Tegaderm® and AquaGuard® were both mentioned. All programs that allowed their patients to go swimming recommended cleaning the site and changing the dressing immediately after swimming.
Protecting Your Site
Consumers and caregivers looking for guidance as they struggle with the decision of whether they should go swimming with a CVC or G-tube should visit the Oley Foundation Web site for additional information. The Oley Foundation advises performing site care immediately after swimming (i.e., dressing changes) and lists several products such as AquaGuard®, Dry Pro™ PICC, XeroSox®, Tegaderm®, or OpSite® that may be used for protecting catheter sites. It is important to remember that these products do not replace the primary dressing; they simply attempt to keep the site dry.
Latex-sensitive individuals need to use caution as some products may contain latex or rubber. For example, older versions of the Dry Pro system, which uses a vacuum seal over a PICC or IV line, may contain latex. Proper sizing is also important. In order to size the Dry Pro for PICC lines, for example, you must accurately measure the circumference of the forearm and the bicep. In some cases, the protective sleeve can be trimmed to fit. AnchorDry Water Resistant Barrier is a relatively newer single-use product that is designed to keep surgical sites clean and dry, but also to cover and protect PICC lines, stomas, dressings, and CVC sites. This product is both latex and DEHP free.
It is important to remember these products are not FDA approved for swimming use. Most may have been evaluated for showering only and not the rigors of swimming. Furthermore, these evaluations should not be confused with traditional studies; oftentimes they are simply product evaluations conducted at a hospital by staff before the product becomes part of the hospital inventory. Some individuals will utilize Glad "Press ‘n Seal” to wrap around their line before or after applying one of these other dressing covers. Remember, what works for one individual may not for another.
Special outfits have also been created for this purpose. A dry suit is a fairly expensive, custom-designed outfit that features gaskets at the wrist, neck, and ankles to keep water out. This should not be confused with a wet suit, as wet suits are designed to let some water in (to keep the individual warm) and would be totally inappropriate for this purpose. See table 2 for several product ideas.
Ostomies and Tubes
Care should also be taken to keep ostomy sites dry. One device developed for this indication is the Dry Pro Waterproof Ostomy Protector. This device is made from surgical latex and uses the Dry Pro pump to create a vacuum seal. Once the ostomy protector is put in place, the vacuum pump sucks out the air so that device cannot come off and the ostomy pouch stays dry and secure. Unlike many covers that are designed for one time use, the Dry Pro for ostomy is reusable.
A recently created PEG tube site should also be kept dry when swimming. Individuals should wait at least four to six weeks after placement, when the site is healed, before swimming. The cap and/or clamp should be closed, and to prevent accidental dislodgement, the PEG tube should be tucked into a bathing suit. A T-shirt or a one-piece bathing suit will help prevent pulling by the tube getting caught on something. The tube should be securely taped to the abdomen with waterproof tape as an additional precaution.
Although many individuals seek guidance from online blogs, these blogs may send mixed or even incorrect messages. Anyone interested in healthy swimming should visit the CDC’s Healthy Swimming Program Web site (see table 1, below). The site provides information for the public, public health and medical professionals, and aquatics staff on how to minimize risks and maintain sanitary swimming conditions. Links to state-specific healthy swimming resources, such as beach monitoring, water quality programs, facts on recreational water illnesses, pool code information, and contacts to local public health authorities are also provided.
The topic of swimming with a CVC, PEG, or ostomy is wrought with mixed messages and little evidence. Unfortunately, due to the limited information available, a firm recommendation cannot be made. Recreational water–associated outbreaks are well documented in the general public, as is the presence of human pathogens even in chlorinated swimming pools.
As a medical team, practitioners can provide information regarding the potential risk, but ultimately the decision lies with the individual. Consumers and caregivers need to have an open and frank discussion with their team to determine what approach is best for them. Due to our experience at Boston Children’s with a fatal event immediately after swimming, we continue to strongly discourage patients with CVCs from swimming. However, if the decision to engage in this popular pastime is still considered worth the risk, we encourage our families to ensure proper line/site maintenance (e.g., dressing and cap change immediately after swimming) and to use products that are specifically designed for this use that may mitigate infection risk. Further studies regarding the risk of swimming with a CVC are needed to make a strong, evidence-based recommendation.
Editor’s note: A well healed port site with no in-place needle or inflammation from prior needle access may be a good option for teenagers and adults who want to swim. Ideally they would require only intermittent infusions and have learned to insert a needle into their own port as needed.
Table 1: Useful Web sites for Determining Water Quality
Table 2: Products That Have Been Used to Protect Lines (inclusion on this list does mean endorsement)
LifelineLetter, July/August 2014