The authors have reviewed hydrotherapy practices in North American burn centers and described the epidemiology of hydrotherapy-associated nosocomial infections. A web-based survey was distributed to the directors of all burn care facilities listed by the American Burn Association. Questions addressed aspects of practice, including the method, additives, disposable liners, decontamination practices, nosocomial pathogens, and perceptions regarding the "ideal" method of hydrotherapy. The response rate was 44%, 59 of 142 centers, or 827 of 1900 beds. Hydrotherapy is regularly used by 83% of centers. Among these centers, 10% use exclusively immersion hydrotherapy (IH), 54% use exclusively shower cart hydrotherapy (SCH), and 35% use a combination of IH and SCH. Disposable liners are used at 80% of centers. Tap water alone is used by 51% of centers, 27% add detergent, 16% chlorhexidine, and 7% povidone-iodine. The majority of centers (57%) do not routinely culture their hydrotherapy equipment, 20% culture weekly, 7% monthly, and 17% less than once per month. Directors believe that Pseudomonas aeruginosa, methicillin-sensitive Staphylococcus aureus, and methicillin-resistant S. aureus are the most common nosocomial pathogens, followed by Acinetobacter species and Candida albicans. The relative frequency of occurrence of the first three pathogens did not vary with regard to the hydrotherapy method used. Given the opportunity to redesign, 45% of burn unit directors would implement SCH only, 42% a combination of SCH and IH, 2% exclusively IH, and 11% no hydrotherapy or bedside irrigation only. The prevalence of hydrotherapy use at North American burn centers has decreased since 1990 (83% vs 95%), yet continues to be used at the majority of centers. The use of IH has also declined (55% vs 81%). The trend away from the exclusive use of IH will likely continue, because more centers incorporate showering methods.