Can I swim before my trauma stitches are removed?
Patients often ask in the outpatient or emergency room how soon they can swim after the stitches have been removed. Most clinicians will probably tell patients not to swim after suturing the wound and to wait until the wound has healed and the sutures have been removed, most often up to 6 weeks after surgery, although clinicians do not give strong evidence to support this recommendation. Orthopaedic surgeons often tell patients with external fixation braces to swim in chlorinated water or clearer pools once the fixation pin tract has healed, but this advice is still not supported by the evidence.
The main concerns about the ability to swim in pools after suturing are twofold: the potential for infection of the wound after contact with water and its potential to disrupt tissue healing. The risk of infection depends on the type of wound (open wounds are more susceptible to infection than superficial wounds), medical comorbidities, the type and quality of water quality and complications with the wound.
However, it is difficult to give an exact clinical probability of infection in sutured wounds, and therefore it is difficult to fully determine whether swimming may actually cause an increased probability of infection in wounds.
What is the current evidence on whether it is possible to swim after trauma suturing?
To further clarify whether swimming is possible after trauma suturing, the authors searched PUBmed, embase, and cochrane databases for data on swimming, trauma suturing, and trauma infection. These data were not reported by WHO or CDC, etc. The authors found only 1 case of infection after exposure to water after trauma suturing.
The incidence of skin infections in exposed swimming pools has increased in recent years, but the predominant infections are still enteric-associated, with E. coli and Cryptosporidium being the most common pathogens. The most common infections of the skin surface in swimming pools are Pseudomonas aeruginosa and Staphylococcus. The pathogenic bacteria change during diving, with Vibrio and Divergent Bacteria being the most common.
Aquatic microorganisms can enter the body through skin breaks during diving, which can lead to skin irritation and produce systemic abscesses and necrotizing limb infections. The current literature reports that infections occurring during diving or swimming in pools are basically due to injuries in the water or earlier skin injuries that were not sutured when entering the water; and there is a lack of research data on whether waterborne pathogenic microorganisms can enter the wound through sutures closed within the wound.
The choice of swimming location and the occurrence of infection show a significant correlation, as the bacterial content varies from water to water. Water quality in public swimming pools should be monitored for bacteria levels to reduce E. coli, Staphylococcus, Pseudomonas aeruginosa, and other bacteria in the water. In fact, bacteria levels in open water are often excessive, with studies in the literature showing levels as high as 100 million bacteria per cubic meter. Overall, the microbial levels in open water are significantly lower than those in swimming pools.
Infection of the patient’s wound during swimming is influenced not only by the bacterial content of the water and the characteristics of the patient’s wound, but also by the presence of medical comorbidities and the type of pathogenic bacteria. There are many medical comorbidities that affect wound healing, including diseases that affect local healing (e.g., eczema) and systemic immunodeficiency diseases (e.g., HIV, diabetes).
Specific immunodeficiencies have a relatively specific propensity for infection. In patients with specific medical comorbidities, intra-traumatic aquatic microbial infections are still relatively uncommon, but when they do occur, they are potentially catastrophic and can lead to the development of multiple diseases such as bacteremia, amputation, or death.
There are no direct studies on post-swimming trauma infections, but there are two relevant Cochrane systematic reviews that are relevant. A systematic review of 11 clinical studies with 3449 patients reviewed the factors that may be associated with infection and found that rinsing the trauma with tap water or distilled or saline water did not significantly alter the likelihood of trauma infection in patients.
Another systematic evaluation analyzed the effect of early bathing (within 12 hours postoperatively) and delayed bathing (after 48 hours postoperatively) on the probability of infection in closed wounds and found no significant correlation between infection rate and time, but the systematic evaluation included only one prospective randomized controlled study with a high risk of error and therefore had a low level of evidence.
Guidance issued by an expert NIH guidance body concluded that it is relatively safe to bathe or wash within 48 hours of wound closure when the epidermis crawls and covers the wound. However, it should be clear that the above guideline time cut-off point is only an expert opinion and is not supported by rigorous evidence.
Do the studies currently being conducted provide sufficient evidence?
Although there are multiple studies currently focusing on how to reduce infections, none of them directly relate to swimming.
What can we do about the current lack of clinical evidence?
Due to the current lack of high-level clinical evidence to support this, a consensus of opinion can be reached through joint expert opinion. The theory is that once the wound is covered with epidermis, cleaning or even swimming is possible. However, the exact time point of epidermal coverage is still unclear, so in clinical practice, patients should be informed that swimming should only be performed after removal of the surgical sutures within the trauma.
The above approach ensures that the patient has complete soft tissue coverage prior to swimming, thus reducing the chances of bacterial infection after entering the water. Although the literature suggests that bathing within 48 hours of wound closure does not affect the chance of wound infection, clinicians should take this with a grain of salt.
In general, the time for suture removal for trauma surgery depends on the site of the trauma and is usually around 7-10 days. Absorbable sutures may be removed slightly later than this, and for wounds closed with absorbable sutures, it is necessary to ensure that there is no exposure on the skin surface before entering the water, and if there is, it needs to be removed. Patients with co-morbid medical conditions are at increased risk of infection, so swimming exercises are not recommended for such patients until the wound is fully healed. Swimming exercises are not recommended for patients with open wounds or ulcers.