Legionella and Legionnaires' disease: 25 years of investigation

Reducing Legionella colonization in water systems with monochloramine

Monochloramine reduced colonization in building hot water systems.

Monochloramine disinfection of municipal water supplies is associated with decreased risk for Legionnaires' disease. We conducted a 2-year, prospective, environmental study to evaluate whether converting from chlorine to monochloramine for water disinfection would decrease Legionella colonization of hot water systems. Water and biofilm samples from 53 buildings were collected for Legionella culture during 6 intervals. Prevalence ratios (PRs) comparing Legionella colonization before and after monochloramine disinfection were adjusted for water system characteristics. Legionella colonized 60% of the hot water systems before monochloramine versus 4% after conversion (PR 0.07, 95% confidence interval 0.03–0.16). The median number of colonized sites per building decreased with monochloramine disinfection. Increased prevalence of Legionella colonization was associated with water heater temperatures <50°C, buildings taller than 10 stories, and interruptions in water service. Increasing use of monochloramine in water supplies throughout the United States may reduce Legionella transmission and incidence of Legionnaires' disease.

Identification and characterization of novel ColE1-type, high-copy number plasmid mutants in Legionella pneumophila

ColE1-type plasmids are commonly used in bacterial genetics research, and replication of these plasmids is regulated by interaction of RNA I and RNA II. Although these plasmids are narrow-host-range, they can be maintained in Legionella pneumophila under antibiotic selection, with low-copy number and instability. Here, we have described the isolation of two novel spontaneous mutants of pBC(gfp)Pmip, pBG307 and pBG309, which are able to mark the L. pneumophila with strong green fluorescence when exposed to visible light. One of the mutants, pBG307, has a single CG-->TA mutation in RNA II promoter located 2-bases upstream the - 10 region. Another one, pBG309, has the same mutation, as well as an additional CG-->AT mutation in the 76th nucleotide of RNA I, or in the 6th nucleotide of RNA II. A plasmid with the single mutation in RNA I, pBG308, was also constructed. Characterization of these plasmids carrying the enhanced green fluorescent protein (gfpmut2) gene revealed that the green fluorescence intensities of these plasmids were 2- to 30-fold higher than that of the wild type and both of the mutations contribute to increase the plasmid copy number and/or plasmid stability. The mutation located in RNA II promoter played a more dominant role in elevating the copy number, compared to the mutation in RNA I. We also tested the mutant plasmids for replication in Escherichia coli, and found that their copy number and stability were dramatically decreased, except pBG307. Our data suggest that these plasmids might be useful and convenient in genetic studies in L. pneumophila.

Quantitative real-time Legionella PCR for environmental water samples: data interpretation

Quantitative Legionella PCRs targeting the 16S rRNA gene (specific for the genus Legionella) and the mip gene (specific for the species Legionella pneumophila) were applied to a total of 223 hot water system samples (131 in one laboratory and 92 in another laboratory) and 37 cooling tower samples (all in the same laboratory). The PCR results were compared with those of conventional culture. 16S rRNA gene PCR results were nonquantifiable for 2.8% of cooling tower samples and up to 39.1% of hot water system samples, and this was highly predictive of Legionella CFU counts below 250/liter. PCR cutoff values for identifying hot water system samples containing >10(3) CFU/liter legionellae were determined separately in each laboratory. The cutoffs differed widely between the laboratories and had sensitivities from 87.7 to 92.9% and specificities from 77.3 to 96.5%. The best specificity was obtained with mip PCR. PCR cutoffs could not be determined for cooling tower samples, as the results were highly variable and often high for culture-negative samples. Thus, quantitative Legionella PCR appears to be applicable to samples from hot water systems, but the positivity cutoff has to be determined in each laboratory.

Membrane vesicles shed by Legionella pneumophila inhibit fusion of phagosomes with lysosomes

When cultured in broth to the transmissive phase, Legionella pneumophila infects macrophages by inhibiting phagosome maturation, whereas replicative-phase cells are transported to the lysosomes. Here we report that the ability of L. pneumophila to inhibit phagosome-lysosome fusion correlated with developmentally regulated modifications of the pathogen's surface, as judged by its lipopolysaccharide profile and by its binding to a sialic acid-specific lectin and to the hydrocarbon hexadecane. Likewise, the composition of membrane vesicles shed by L. pneumophila was developmentally regulated, based on binding to the lectin and to the lipopolysaccharide-specific monoclonal antibody 3/1. Membrane vesicles were sufficient to inhibit phagosome-lysosome fusion by a mechanism independent of type IV secretion, since only approximately 25% of beads suspended with or coated by vesicles from transmissive phase wild type or dotA secretion mutants colocalized with lysosomal probes, whereas approximately 75% of beads were lysosomal when untreated or presented with vesicles from the L. pneumophila letA regulatory mutant or E. coli. As observed previously for L. pneumophila infection of mouse macrophages, vesicles inhibited phagosome-lysosome fusion only temporarily; by 10 h after treatment with vesicles, macrophages delivered approximately 72% of ingested beads to lysosomes. Accordingly, in the context of the epidemiology of the pneumonia Legionnaires' disease and virulence mechanisms of Leishmania and Mycobacteria, we discuss a model here in which L. pneumophila developmentally regulates its surface composition and releases vesicles into phagosomes that inhibit their fusion with lysosomes.

Development of an improved PCR-ICT hybrid assay for direct detection of Legionellae and Legionella pneumophila from cooling tower water specimens

A novelly improved polymerase chian reaction and immunochromatography test (PCR-ICT) hybrid assay comprising traditional multiplex-nested PCR and ICT, (a lateral-flow device) was developed for direct detection of Legionella bacteria from environmental cooling tower samples. The partial 16S rDNA (specific for Legionella spp.) and dnaJ (specific for Legionella pneumophila) genes from Legionella chromosome were first specifically amplified by multiplex-nested PCR, respectively, followed by detection using ICT strip. Reading of results was based on presence or absence of the two test lines on the strips. Presence of test line 1 indicated existence of Legionella spp. specific 16S rDNA and identified Legionella spp. Presence of test line 2 further indicated existence of dnaJ and thus specifically identified L. pneumophila. In contrast, for non-Legionellae bacteria no test line formation was observed. Results of direct detection of Legionella bacteria and L. pneumophila from water tower specimens by this assay showed 100% sensitivity, and 96.6% and 100% specificity, respectively compared with traditional culture, biochemical and serological identification methods. The PCR-ICT hybrid assay does not require sophisticated equipment and was proved to be practically useful in rapid and direct Legionellae detection from environmental water samples.

Genetic variability in environmental isolates of Legionella pneumophila from Comunidad Valenciana (Spain)

Legionella pneumophila is associated to recurrent outbreaks in several Comunidad Valenciana (Spain) localities, especially in Alcoi, where social and climatic conditions seem to provide an excellent environment for bacterial growth. We have analysed the nucleotide sequences of three loci from 25 environmental isolates from Alcoi and nearby locations sampled over 3 years. The analysis of these isolates has revealed a substantial level of genetic variation, with consistent patterns of variability across loci, and comparable to that found in a large, European-wide sampling of clinical isolates. Among the tree loci studied, fliC showed the highest level of nucleotide diversity. The analysis of isolates sampled in different years revealed a clear differentiation, with samples from 2001 being significantly distinct from those obtained in 2002 and 2003. Furthermore, although linkage disequilibrium measures indicate a clonal nature for population structure in this sample, the presence of some recombination events cannot be ruled out.

Evaluation of Vircell enzyme-linked immunosorbent assay and indirect immunofluorescence assay for detection of antibodies against Legionella pneumophila

We evaluated the abilities of the Vircell immunoglobulin G (IgG) and IgM indirect immunofluorescence assay (IFA) for Legionella pneumophila serogroup 1, the IgM and IgG enzyme-linked immunosorbent assay (ELISA) for Legionella pneumophila serogroup 1, and the IgM-plus-IgG ELISA for Legionella pneumophila serogroups 1 to 6 to diagnose Legionnaires' disease (LD) in a well-described sample of patients with and without LD. Also, we determined the agreements, sensitivities, and specificities of the different Vircell assays in comparison to a validated ELISA (Serion classic ELISA). Clinical sensitivity and specificity were 74.6% and 96.6%, respectively, for the IgM IFA, 65.1% and 88.0% for the IgG IFA, 92.3% and 100% for the IgM ELISA, 43.3% and 96.6% for the IgG ELISA, and 90.8% and 100% for the IgM-plus-IgG ELISA. Compared to Serion classic ELISA, agreement, sensitivity, and specificity were 80.0%, 83.1%, and 78.4%, respectively, for the IgM IFA, 75.2%, 66.0%, and 79.5% for the IgG IFA, 89.5%, 82.0%, and 97.6% for the IgM ELISA, 81.9%, 88.9%, and 78.0% for the IgG ELISA, and 93.5%, 90.0%, and 96.6% for the IgM-plus-IgG ELISA. The value of a positive diagnostic result obtained by the Vircell IgM IFA, the Vircell IgG IFA, and the Vircell IgG ELISA might not be acceptable for a diagnostic assay. Both the high specificities and sensitivities of the Vircell IgM ELISA and the IgM-plus-IgG ELISA and the high correlation with the Serion classic ELISA indicate that they are useful in the diagnosis of LD.

Legionellosis from Legionella pneumophila serogroup 13

Legionella pneumophila serogroup 13 may be underrecognized.

We describe 4 cases of Legionella pneumophila serogroup 13–associated pneumonia. These cases originate from a broad geographic range that includes Scotland, Australia, and New Zealand. L. pneumophila serogroup 13 pneumonia has a clinically diverse spectrum that ranges from relatively mild, community-acquired pneumonia to potentially fatal severe pneumonia with multisystem organ failure. All cases were confirmed by culture and direct fluorescent antibody staining or indirect immunofluorescent antibody tests. Proven or putative sources of L. pneumophila serogroup 13 infections in 2 patients included a contaminated whirlpool spa filter and river water. An environmental source was not found in the remaining 2 cases; environmental cultures yielded only other L. pneumophila serogroups or nonpneumophila Legionella species. We describe the clinical and laboratory features of L. pneumophila serogroup 13 infections. L. pneumophila serogroup 13 pneumonia is rarely reported, but it may be an underrecognized pathogenic serogroup of L. pneumophila.

Detection and quantification of Legionella pneumophila DNA in serum: case reports and review of the literature

Legionella pneumonia can be difficult to diagnose. Existing laboratory tests all have shortcomings, especially the ability to diagnose all Legionella spp. at an early stage. Detection of Legionella DNA in serum can be a valuable tool for the diagnosis of Legionnaires' disease (LD). This report describes two patients with LD diagnosed by PCR using serum samples. In addition, quantification of L. pneumophila DNA using real-time PCR during the course of illness was carried out. The results obtained mirrored both the clinical condition and C-reactive protein values during the course of the illness. Quantification of Legionella DNA in serum using real-time PCR could be a valuable tool to monitor the effects of antimicrobial therapy in patients with LD.

Detection of Legionella spp. by fluorescent in situ hybridization in dental unit waterlines

AIMS

To confirm the presence of viable Legionella spp. in dental unit waterlines (DUWL) using fluorescent in situ hybridization (FISH) and compare this method with culture approach and also to validate the utility of an enrichment to increase FISH sensitivity.

METHODS AND RESULTS

Water samples from 40 dental units were analysed. Three different techniques for detecting Legionella spp. were compared: (i) culture approach, (ii) direct FISH and (iii) FISH with a previous R2A medium enrichment (R2A/FISH). The FISH detection was confirmed by PCR. The use of the direct FISH does not improve significantly the detection of legionellae when compared with the culture. On the contrary, when R2A/FISH was performed, sensitivity was, respectively, two- and threefold higher than that with the direct FISH and culture approach. Using R2A/FISH, 63% of water samples analysed showed a contamination by legionellae.

CONCLUSIONS

Legionellae detection by direct FISH and R2A/FISH in dental unit water is possible but is more rapid and more sensitive (R2A/FISH) than the culture approach.

SIGNIFICANCE AND IMPACT OF THE STUDY

R2A/FISH showed that several pathogens present in DUWL are viable but may not be culturable. Unlike PCR, R2A/FISH is designed to detect only metabolically active cells and therefore provides more pertinent information on infectious risk.

Pathogenese, Diagnostik und Therapie der Legionella-Infektion

Legionella species are ubiquitous in aquatic environments. About 50 years ago they entered the engineered (technical) environment, i.e. warm water systems with zones of stagnation. Since that time they represent a hygienic problem. After transmission to humans via aerosols legionellae might cause Legionella pneumonia (legionnaires' disease) or influenza-like respiratory infections (Pontiac fever). Epidemiological data suggest that Legionella strains might differ substantially in their virulence properties. Although the molecular basis is not understood L. pneumophila serogroup 1 especially MAb 3/1-positive strains cause the majority of infections. The main virulence feature is the ability to multiply intracellularly. After uptake into macrophages legionellae multiply in a specialized vacuole and finally lyse their host cells. Several bacterial factors like surface components, secretion systems and iron uptake systems are involved in this process. Since the clinical picture of Legionella pneumonia does not allow differentiation from pneumoniae caused by other pathogens, microbiological diagnostic methods are needed to establish the diagnosis. Cultivation of legionellae from clinical specimens, detection of antigens and DNA in patients' samples and detection of antibodies in serum samples are suitable methods. However, none of the diagnostic tests presently available offers the desired quality with respect to sensitivity and specificity. Therefore, the standard technique is to use several diagnostic tests in parallel. Advantages and disadvantages of the diagnostic procedures are discussed. Therapeutic options for Legionella infections are newer macrolides like azithromycin and chinolones (ciprofloxacin, levofloxacin and moxifloxacin).

Temperature-regulated formation of mycelial mat-like biofilms by Legionella pneumophila

Fifty strains representing 38 species of the genus Legionella were examined for biofilm formation on glass, polystyrene, and polypropylene surfaces in static cultures at 25 degrees C, 37 degrees C, and 42 degrees C. Strains of Legionella pneumophila, the most common causative agent of Legionnaires' disease, were found to have the highest ability to form biofilms among the test strains. The quantity, rate of formation, and adherence stability of L. pneumophila biofilms showed considerable dependence on both temperature and surface material. Glass and polystyrene surfaces gave between two- to sevenfold-higher yields of biofilms at 37 degrees C or 42 degrees C than at 25 degrees C; conversely, polypropylene surface had between 2 to 16 times higher yields at 25 degrees C than at 37 degrees C or 42 degrees C. On glass surfaces, the biofilms were formed faster but attached less stably at 37 degrees C or 42 degrees C than at 25 degrees C. Both scanning electron microscopy and confocal laser scanning microscopy revealed that biofilms formed at 37 degrees C or 42 degrees C were mycelial mat like and were composed of filamentous cells, while at 25 degrees C, cells were rod shaped. Planktonic cells outside of biofilms or in shaken liquid cultures were rod shaped. Notably, the filamentous cells were found to be multinucleate and lacking septa, but a recA null mutant of L. pneumophila was unaffected in its temperature-regulated filamentation within biofilms. Our data also showed that filamentous cells were able to rapidly give rise to a large number of short rods in a fresh liquid culture at 37 degrees C. The possibility of this biofilm to represent a novel strategy by L. pneumophila to compete for proliferation among the environmental microbiota is discussed.

Prevalence study of Legionella spp. contamination in ferries and cruise ships

BACKGROUND

In the last years, international traffic volume has significantly increased, raising the risk for acquisition of infectious diseases. Among travel-associated infections, increased incidence of legionellosis has been reported among travellers. Aim of our study was: to describe the frequency and severity of Legionella spp. contamination in ferries and cruise ships; to compare the levels of contamination with those indicated by the Italian ministerial guidelines for control and prevention of legionellosis, in order to assess health risks and to adopt control measures.

METHOD

A prevalence study was carried out on 9 ships docked at the seaports of northern Sardinia in 2004. Water samples were collected from critical sites: passenger cabins, crew cabins, kitchens, coffee bars, rooms of the central air conditioning system. It was performed a qualitative and quantitative identification of Legionella spp. and a chemical, physical and bacteriological analysis of water samples.

RESULTS

Forty-two percent (38/90) water samples were contaminated by Legionella spp.. Positive samples were mainly drawn from showers (24/44), washbasins (10/22). L. pneumophila was isolated in 42/44 samples (95.5%), followed by L. micdadei (4.5%). Strains were identified as L. pneumophila serogroup 6 (45.2%; 19 samples), 2-14 (42.9%), 5 (7.1%) and 3 (4.8%). Legionella spp. load was high; 77.8% of the water samples contained > 10(4) CFU/L. Low residual free chlorine concentration (0-0.2 mg/L) was associated to a contamination of the 50% of the water samples.

CONCLUSION

Legionella is an ubiquitous bacterium that could create problems for public health. We identified Legionella spp. in 6/7 ferries. Microbial load was predominantly high (> 10(4) CFU/L or ranging from 10(3) to 10(4) CFU/L). It is matter of concern when passengers are subjects at risk because of Legionella spp. is an opportunist that can survive in freshwater systems; high bacterial load might be an important variable related to disease's occurrence. High level of contamination required disinfecting measures, but does not lead to a definitive solution to the problem. Therefore, it is important to identify a person responsible for health safety in order to control the risk from exposure and to apply preventive measures, according to European and Italian guidelines.

Domestic exposure to legionellae for Dutch Legionnaires' disease patients

The source of infection for travelers who develop Legionnaires' disease (LD) shortly after a journey abroad is difficult to ascertain. Infection is likely to have occurred abroad, but could also have occurred at the patient's own residence. The authors conducted a case-control study to determine risk for acquiring LD at home in the Netherlands after traveling abroad. They compared homes of 44 traveling LD patients with 44 homes of nontraveling LD patients, using logistic regression models. Geographic distribution was confounding the association between traveling and presence of Legionella spp. in residences; adjustment was necessary. In traveler's homes, legionellae were present more often, with crude and adjusted OR (95% CI) being 1.6 (0.5-5.0) and 1.4 (0.4-4.4), respectively. The authors' findings indicate that the patient's residence can be a potential source of infection after traveling.

Prospective 3-year surveillance for nosocomial and environmental Legionella pneumophila: implications for infection control

OBJECTIVES

To perform a 3-year, prospective surveillance program for legionnaires disease (LD) in a large university hospital in Rome, and to assess the usefulness of the hospital water monitoring program in predicting the risk of nosocomial LD.

METHODS

Samples from patients with new cases of nosocomial pneumonia were sent for legionella laboratory investigations. Meanwhile, water samples for bacteriological analysis were collected every 6 months from high- and medium-risk hospital wards (10 in total). Legionella pneumophila isolates collected were serotyped and analyzed by pulsed-field gel electrophoresis.

RESULTS

From June 2001 through May 2004, the pneumonia surveillance identified one case of nosocomial LD among 43 cases of nosocomial pneumonia (2.3%). Environmental investigations detected L. pneumophila in 12 (18.7%) of the 64 water samples, of which 50% belonged to serogroup 1. The L. pneumophila count and the percentage of positive locations never exceeded 10(2) colony-forming units/L and 20%, respectively, except when the LD nosocomial case occurred (positive water samples, 40%; L. pneumophila count, <10(2) colony-forming units/L). Genotyping showed 3 prevalent clones of L. pneumophila in the water distribution network, of which one persisted over the 3 years. One clone contained 3 different L. pneumophila serogroups (2, 4, and 6).

CONCLUSIONS

The low incidence of nosocomial cases of LD appears to be associated with a low percentage (<20%) of positive water samples per semester and with a low contamination level (<10(2) colony-forming units/L). An infection control system for nosocomial LD should, therefore, be based on both environmental and clinical surveillance, together with the appropriate maintenance of the hospital water distribution system.

Severe community-acquired pneumonia due to Legionella pneumophila Serogroup 6

Legionella pneumophila is a common cause of sporadic community-acquired pneumonia, but culture-proven legionellosis is rarely diagnosed. There is no laboratory test for Legionnaires' disease that can detect all patients with the disease. Culture is the standard diagnostic method and should be initiated as soon as possible in suspected cases. We describe a rare case of community-acquired pneumonia caused by L. pneumophila serogroup 6. A 77-year-old man was admitted to a tertiary care hospital because of high fever, productive cough, and progressive dyspnea. Chest radiography showed bilateral pneumonia, which led to respiratory failure necessitating mechanical ventilatory support. Despite antibiotic therapy, his condition continued to deteriorate and acute renal failure also developed. Urine was negative for L. pneumophila. Culture of the sputum yielded L. pneumophila serogroup 6, although there was no elevation of the serum antibody titer. Pneumonia resolved gradually and he was extubated after treatment with levofloxacin followed by erythromycin. L. pneumophila other than serogroup 1 should be included in the differential diagnosis of patients with suspected atypical community-acquired pneumonia.

Clinical and environmental distribution of Legionella pneumophila in a university hospital in Italy: efficacy of ultraviolet disinfection

The molecular epidemiology of Legionella pneumophila in the 'V. Monaldi' University Hospital was studied. Seven cases of nosocomial Legionnaires' disease were diagnosed between 1999 and 2003. Two clinical legionella strains obtained from two patients in the adult cardiac surgery unit (CSU) and 30 environmental legionella strains from the paediatric and adult CSUs, neonatal intensive care unit (NICU) and the cardiorespiratory intensive care unit (CR-ICU) were serotyped and genotyped. L. pneumophila serogroup 1/Philadelphia with an identical pulsed-field gel electrophoresis (PFGE) profile A was isolated from two patients in the adult CSU, and from three and one water samples taken in the adult CSU and the paediatric CSU, respectively, from 2001 to 2002. Furthermore, L. pneumophila serogroup 3 with an identical PFGE profile B was identified in 20 environmental strains from all wards, L. pneumophila serogroup 3 with PFGE profile C was identified in a single environmental strain from the CR-ICU, and non-pneumophila Legionella with identical PFGE profile D was identified in five environmental strains from the adult CSU, paediatric CSU and NICU. Ultraviolet irradiation was effective in disinfection of the hospital water supplies in the adult and paediatric CSUs contaminated by L. pneumophila clone associated with nosocomial Legionnaires' disease. In conclusion, these data demonstrate that two cases of nosocomial legionellosis were caused by the persistence of a single clone of L. pneumophila serogroup 1/Philadelphia in the hospital environment, and that disinfection by ultraviolet irradiation may represent an effective measure to prevent nosocomial Legionnaires' disease.

Multiplication intra-amibienne de Legionella pneumophila et rôle potentiel des amibes dans la transmission de la légionellose

Legionnaires' disease is one of the major infectious risks related to hospital water systems. It is commonly accepted, that the disease is transmitted to man mostly by inhalation of water aerosols contaminated by Legionella pneumophila. The ability of L. pneumophila to multiply intracellularly within some amoebae better explains the ecology, the pathogenicity, and the virulence of this bacterium against human alveolar macrophages. The presence of these amoebae in water systems located where cases of Legionnaire's disease broke out, partly explains the difficulty in eradicating Legionella. Some studies also show that amoebae can play a major role in the transmission of the disease to man. Some other studies point out that inhaled amoebae could be involved in the pathogenesis of Legionnaire's disease. Future strategies to prevent the transmission of Legionella will probably have to include efficient treatments against amoebae.

The global regulatory proteins LetA and RpoS control phospholipase A, lysophospholipase A, acyltransferase, and other hydrolytic activities of Legionella pneumophila JR32

Legionella pneumophila possesses a variety of secreted and cell-associated hydrolytic activities that could be involved in pathogenesis. The activities include phospholipase A, lysophospholipase A, glycerophospholipid:cholesterol acyltransferase, lipase, protease, phosphatase, RNase, and p-nitrophenylphosphorylcholine (p-NPPC) hydrolase. Up to now, there have been no data available on the regulation of the enzymes in L. pneumophila and no data at all concerning the regulation of bacterial phospholipases A. Therefore, we used L. pneumophila mutants in the genes coding for the global regulatory proteins RpoS and LetA to investigate the dependency of hydrolytic activities on a global regulatory network proposed to control important virulence traits in L. pneumophila. Our results show that both L. pneumophila rpoS and letA mutants exhibit on the one hand a dramatic reduction of secreted phospholipase A and glycerophospholipid:cholesterol acyltransferase activities, while on the other hand secreted lysophospholipase A and lipase activities were significantly increased during late logarithmic growth phase. The cell-associated phospholipase A, lysophospholipase A, and p-NPPC hydrolase activities, as well as the secreted protease, phosphatase, and p-NPPC hydrolase activities were significantly decreased in both of the mutant strains. Only cell-associated phosphatase activity was slightly increased. In contrast, RNase activity was not affected. The expression of plaC, coding for a secreted acyltransferase, phospholipase A, and lysophospholipase A, was found to be regulated by LetA and RpoS. In conclusion, our results show that RpoS and LetA affect phospholipase A, lysophospholipase A, acyltransferase, and other hydrolytic activities of L. pneumophila in a similar way, thereby corroborating the existence of the LetA/RpoS regulation cascade.

lbtA and lbtB are required for production of the Legionella pneumophila siderophore legiobactin

Under iron stress, Legionella pneumophila secretes legiobactin, a nonclassical siderophore that is reactive in the chrome azurol S (CAS) assay. Here, we have optimized conditions for legiobactin expression, shown its biological activity, and identified two genes, lbtA and lbtB, which are involved in legiobactin production. lbtA appears to be iron repressed and encodes a protein that has significant homology with siderophore synthetases, and FrgA, a previously described iron-regulated protein of L. pneumophila. lbtB encodes a protein homologous with members of the major facilitator superfamily of multidrug efflux pumps. Mutants lacking lbtA or lbtB were defective for legiobactin, producing 40 to 70% less CAS reactivity in deferrated chemically defined medium (CDM). In bioassays, mutant CDM culture supernatants, unlike those of the wild type, did not support growth of iron-limited wild-type bacteria in 2',2'-dipyridyl-containing buffered charcoal yeast extract (BCYE) agar and a ferrous iron transport mutant on BCYE agar without added iron. The lbtA mutant was modestly defective for growth in deferrated CDM containing the iron chelator citrate, indicating that legiobactin is required in conditions of severe iron limitation. Complementation of the lbt mutants restored both siderophore expression, as measured by the CAS assay and bioassays, and bacterial growth in deferrated, citrate-containing media. The lbtA mutant replicated as the wild type did in macrophages, amoebae, and the lungs of mice. However, L. pneumophila expresses lbtA in the macrophage, suggesting that legiobactin, though not required, may play a dispensable role in intracellular growth. The discovery of lbtAB represents the first identification of genes required for L. pneumophila siderophore expression.

Flagellin-deficient Legionella mutants evade caspase-1- and Naip5-mediated macrophage immunity

Macrophages from C57BL/6J (B6) mice restrict growth of the intracellular bacterial pathogen Legionella pneumophila. Restriction of bacterial growth requires caspase-1 and the leucine-rich repeat-containing protein Naip5 (Birc1e). We identified mutants of L. pneumophila that evade macrophage innate immunity. All mutants were deficient in expression of flagellin, the primary flagellar subunit, and failed to induce caspase-1-mediated macrophage death. Interestingly, a previously isolated flagellar mutant (fliI) that expresses, but does not assemble, flagellin did not replicate in macrophages, and induced macrophage death. Thus, flagellin itself, not flagella or motility, is required to initiate macrophage innate immunity. Immunity to Legionella did not require MyD88, an essential adaptor for toll-like receptor 5 (TLR5) signaling. Moreover, flagellin of Legionella and Salmonella induced cytotoxicity when delivered to the macrophage cytosol using Escherichia coli as a heterologous host. It thus appears that macrophages sense cytosolic flagellin via a TLR5-independent pathway that leads to rapid caspase-1-dependent cell death and provides defense against intracellular bacterial pathogens.

Legionella pneumophila is a bacterial pathogen that is the cause of a severe form of pneumonia known as Legionnaires' disease. A crucial aspect of the propensity of Legionella to cause disease lies in its ability to survive and multiply inside host immune cells known as macrophages. The intracellular survival and replication of Legionella can be studied using isolated macrophages grown in culture. Macrophages isolated from different laboratory mouse strains are differentially permissive for intracellular Legionella growth. This difference in permissiveness is genetic, and is conferred by differences in a mouse protein known as Naip5. The authors determined that Legionella strains that are unable to produce a protein called flagellin are able to grow inside normally resistant mouse macrophages. In addition, these flagellin⁻ strains are defective in initiating a cell-death response on the part of infected macrophages. Based on these data, the authors suggest that there is an intracellular mechanism for detecting the presence of bacterial flagellin protein, and that a cell-death response is initiated upon the detection of flagellin.

Occurrence and genetic diversity of uncultured Legionella spp. in drinking water treated at temperatures below 15 degrees C

Representatives of the genus Legionella were detected by use of a real-time PCR method in all water samples collected directly after treatment from 16 surface water (SW) supplies prior to postdisinfection and from 81 groundwater (GW) supplies. Legionella concentrations ranged from 1.1 x 10(3) to 7.8 x 10(5) cells liter(-1) and were significantly higher in SW treated with multiple barriers at 4 degrees C than in GW treated at 9 to 12 degrees C with aeration and filtration but without chemical disinfection. No Legionellae (<50 CFU liter(-1)) were detected in treated water by the culture method. Legionella was also observed in untreated SW and in untreated aerobic and anaerobic GW. Filtration processes in SW and GW treatment had little effect or increased the Legionella concentration, but ozonation in SW treatment caused about 1-log-unit reduction. A phylogenetic analysis of 16S rRNA gene sequences of 202 clones, obtained from a selection of samples, showed a high similarity (>91%) with Legionella sequences in the GenBank database. A total of 40 (33%) of the 16S rRNA gene sequences obtained from treated water were identified as described Legionella species and types, including L. bozemanii, L. worsleiensis, Legionella-like amoebal pathogen types, L. quateirensis, L. waltersii, and L. pneumophila. 16S rRNA gene sequences with a similarity of below 97% from described species were positioned all over the phylogenetic tree of Legionella. Hence, a large diversity of yet-uncultured Legionellae are common members of the microbial communities in SW and GW treated at water temperatures of below 15 degrees C.

Introduction of monochloramine into a municipal water system: impact on colonization of buildings by Legionella spp

Legionnaires' disease (LD) outbreaks are often traced to colonized potable water systems. We collected water samples from potable water systems of 96 buildings in Pinellas County, Florida, between January and April 2002, during a time when chlorine was the primary residual disinfectant, and from the same buildings between June and September 2002, immediately after monochloramine was introduced into the municipal water system. Samples were cultured for legionellae and amoebae using standard methods. We determined predictors of Legionella colonization of individual buildings and of individual sampling sites. During the chlorine phase, 19 (19.8%) buildings were colonized with legionellae in at least one sampling site. During the monochloramine phase, six (6.2%) buildings were colonized. In the chlorine phase, predictors of Legionella colonization included water source (source B compared to all others, adjusted odds ratio [aOR], 6.7; 95% confidence interval [CI], 2.0 to 23) and the presence of a system with continuously circulating hot water (aOR, 9.8; 95% CI, 1.9 to 51). In the monochloramine phase, there were no predictors of individual building colonization, although we observed a trend toward greater effectiveness of monochloramine in hotels and single-family homes than in county government buildings. The presence of amoebae predicted Legionella colonization at individual sampling sites in both phases (OR ranged from 15 to 46, depending on the phase and sampling site). The routine introduction of monochloramine into a municipal drinking water system appears to have reduced colonization by Legionella spp. in buildings served by the system. Monochloramine may hold promise as community-wide intervention for the prevention of LD.

Retrospective study of 30 cases of Legionella pneumonia in the Kansai region

Thirty Legionella pneumonia cases were clinically investigated retrospectively from 1999 to 2005 at the Respiratory Medicine Department of Kyoto University and affiliated hospitals. Twenty-eight cases were sporadic and two cases were part of an outbreak. The patients consisted of 28 men and 2 women, with a mean age of 58.8 years (range 25-87). Nineteen cases were smokers and 19 had some underlying disease. The mean period from the disease occurrence to presenting at a hospital was 4.8 days (range 1-15). The mean period from presenting at hospital to Legionella pneumonia diagnosis was 4.6 days (range 0-22). Urinary antigen detection tests for Legionella pneumophilla were performed for 25 cases, and resulted in the diagnosis of 22 cases. Other diagnostic tests with positive findings were culture (buffered charcoal-yeast extract agar, BCYE), the polymerase chain reaction (PCR) test, and serological diagnosis (enzyme immunoassay and microagglutination test). Legionella species diagnosis was obtained by culture and serology for 13 cases: 10 cases had Legionella pneumophila serogroup 1, 2 cases had Legionella pneumophila serogroup 6, and 1 case had Legionella longbeachea. Fluoloquinolones (Fq) are most often used for therapy, especially in recent cases, and were predominantly the chosen treatment (70%). Death due to Legionella pneumonia occurred in 4 cases: 3 cases had severe underlying diseases, and 1 case took 18 days to diagnose (doctors' delay). To detect the majority of Legionella pneumonia cases, a combination of diagnostic examinations is still needed. Regarding the management of community-acquired pneumonia, both the cost and the indication of diagnostic examinations for Legionella infection should be considered simultaneously.

Analysis of the genetic diversity of Legionella by sequencing the 23S-5S ribosomal intergenic spacer region: from phylogeny to direct identification of isolates at the species level from clinical specimens

This study focuses on the interest of the hypervariable 23S-5S ribosomal intergenic spacer region (ISR) of the genus Legionella to analyze the phylogenic diversity of Legionella at the species and subspecies levels and to identify isolates directly from clinical specimens. The method, using a real-time PCR assay with a single primer pair followed by sequencing, was able to identify correctly 49 reference strains of Legionella belonging to 37 different species, including those implicated in human infections, and to clearly differentiate the three subspecies of L. pneumophila. Based on sequence similarities, the 23S-5S ISR sequences were much more variable than the rpoB and mip sequences (P<0.0001 by the Wilcoxon signed rank test). The 23S-5S ISR method was able to cluster Legionella species in accordance with phenotypic traits, such as autofluorescence or fatty acid membrane composition. Using maximum parsimony methods, the rpoB and 23S-5S ISR data sets were shown to be incongruent (P<0.001). In contrast, the 23S-5S ISR and the mip data sets were found to be congruent (P=0.313), suggesting the interest of combining these two regions to demonstrate phylogenetic links between Legionella species. This molecular assay was shown able to both detect Legionella DNA directly in respiratory specimens from patients exhibiting a Legionella infection and provide accurate identification of the bacterium at the species level in the tested specimens. These properties open a wide range of applications to the 23S-5S ISR sequencing method, from taxonomic analyses to clinical and epidemiological investigations.

Community-acquired pneumonia caused by Legionella longbeachae in an immunocompetent patient

Reported here is the case of a previously healthy 67-year-old man who was admitted to the intensive care unit with pneumonia caused by Legionella longbeachae. The organism was identified in sputum and serum by 16S rRNA-based PCR assay and sequence-based typing. One acute serum sample produced a single elevated IgM antibody titer of 1:512 against non-pneumophila Legionella spp. The patient fully recovered following the initiation of appropriate antibiotic treatment. Since most current laboratory tests for Legionella spp. cannot detect infections caused by non-pneumophila Legionella spp., culture on Legionella-selective media or PCR should be considered when diagnosing severe pneumonia of unknown etiology.

No evidence of Legionella infection in general practice patients presenting with acute respiratory infections in The Netherlands

The role of Legionella spp. in the aetiology of acute respiratory infections (ARIs) is largely unknown. In this case-control study, conducted in a general practitioner setting during 2000 and 2001, nose and throat samples from patients presenting with ARIs (n = 230) and controls (n = 200) were analysed for the presence of Legionella spp. by real-time PCR. Legionella DNA was not detected in any of the cases or controls. Thus, Legionella spp. do not seem to play a role in patients presenting with ARIs, nor were they present in patients who visited their general practitioner for complaints other than ARIs.

Legionella contamination in hot water of Italian hotels

A cross-sectional multicenter survey of Italian hotels was conducted to investigate Legionella spp. contamination of hot water. Chemical parameters (hardness, free chlorine concentration, and trace element concentrations), water systems, and building characteristics were evaluated to study risk factors for colonization. The hot water systems of Italian hotels were strongly colonized by Legionella; 75% of the buildings examined and 60% of the water samples were contaminated, mainly at levels of > or =10(3) CFU liter(-1), and Legionella pneumophila was the most frequently isolated species (87%). L. pneumophila serogroup 1 was isolated from 45.8% of the contaminated sites and from 32.5% of the hotels examined. When a multivariate logistic model was used, only hotel age was associated with contamination, but the risk factors differed depending on the contaminating species and serogroup. Soft water with higher chlorine levels and higher temperatures were associated with L. pneumophila serogroup 1 colonization, whereas the opposite was observed for serogroups 2 to 14. In conclusion, Italian hotels, particularly those located in old buildings, represent a major source of risk for Legionnaires' disease due to the high frequency of Legionella contamination, high germ concentration, and major L. pneumophila serogroup 1 colonization. The possible role of chlorine in favoring the survival of Legionella species is discussed.

Detection of Legionella pneumophila in water samples by species-specific real-time and nested PCR assays

AIMS

Legionella pneumophila is a contaminant of man-made water systems, including potable water, cooling towers, water systems of large buildings, etc. It is the most common causative agent of legionellosis, a respiratory infection, which may give rise to restricted outbreaks. To survey environmental water samples from hospitals and private habitations in Bologna, we developed a species-specific nested and a TaqMan real-time PCR for the detection of L. pneumophila. We compared the two assays and both to cultural isolation.

METHODS AND RESULTS

The targeted gene was macrophage infectivity potentiator (mip), conserved in L. pneumophila, and divergent in other legionellae. One assay was based on a nested PCR and the other on a TaqMan real-time PCR protocol. Their sensitivities were 14 % or 5% higher than that of cultural isolation respectively. The detection limits were 1-2 genome equivalents per 50-microl reaction. Specificity was assessed using DNA from nine target and 20 nontarget organisms.

CONCLUSIONS

When applied to water samples, both assays detected L. pneumophila at 80% or higher frequency.

SIGNIFICANCE AND IMPACT OF THE STUDY

The species-specific molecular diagnosis of L. pneumophila by means of nested PCR does not require a specific instrumentation, exhibits a high sensitivity, and is advantageous over the cultural isolation and real-time PCR detection. It allows to quickly monitor water samples for the risk assessment of environmental contaminations.

Impact of non-Legionella bacteria on the uptake and intracellular replication of Legionella pneumophila in Acanthamoeba castellanii and Naegleria lovaniensis

In aquatic environments, Legionella pneumophila survives, in association with other bacteria, within biofilms by multiplying in free-living amoebae. The precise mechanisms underlying several aspects of the uptake and intracellular replication of L. pneumophila in amoebae, especially in the presence of other bacteria, remain unknown. In the present study, we examined the competitive effect of selected non-Legionella bacteria (Escherichia coli, Aeromonas hydrophila, Flavobacterium breve, and Pseudomonas aeruginosa) on the uptake of L. pneumophila serogroup 1 by the amoebae Acanthamoeba castellanii and Naegleria lovaniensis. We also investigated their possible influence on the intracellular replication of L. pneumophila in both amoeba species. Our results showed that the non-Legionella bacteria did not compete with L. pneumophila for uptake, suggesting that the amoeba hosts took in L. pneumophila through a specific and presumably highly efficient uptake mechanism. Living and heat-inactivated P. aeruginosa best supported the replication of L. pneumophila in N. lovaniensis and A. castellanii, respectively, whereas for both amoeba species, E. coli yielded the lowest number of replicated L. pneumophila. Furthermore, microscopic examination showed that 100% of the A. castellanii and only 2% of the N. lovaniensis population were infected with L. pneumophila at the end of the experiment. This study clearly shows the influence of some non-Legionella bacteria on the intracellular replication of L. pneumophila in A. castellanii and N. lovaniensis. It also demonstrates the different abilities of the two tested amoeba species to serve as a proper host for the replication and distribution of the human pathogen in man-made aquatic environments such as cooling towers, shower heads, and air conditioning systems with potential serious consequences for human health.

Isolation and characterization of aStaphylococcus warneristrain producing an anti-Legionellapeptide

Legionella pneumophila is a pathogenic bacterium found in freshwater environments that is responsible for pneumonia. People become infected through inhalation of contaminated droplets from water devices, such as cooling towers and showers. It is important to find new treatments that decrease the development of Legionella. We found a Staphylococcus warneri strain that inhibits Legionella growth. This activity is due to a molecule secreted by S. warneri. This molecule displayed a high heat-stability and its activity was lost after protease treatments, suggesting that it might be a bacteriocin. Its purification led us to conclude that this anti-Legionella molecule is an highly hydrophobic peptide. It has an original and very specific spectrum of activity, directed only toward the Legionella genus. This is the first description of an antibacterial peptide active against Legionella.

Isolation of pathogenic Legionella species and legionella-laden amoebae in dental unit waterlines

Legionella released into the air during treatment are a potential source of infection. Water stagnation in dental unit waterlines (DUWLs) creates biofilms and promotes the proliferation of these micro-organisms. This study investigated the presence of amoeba infected with legionella, L. pneumophila and other pathogenic Legionella species in a dental teaching hospital. Water samples were collected in the morning and afternoon from 99 dental units and 16 taps connected to the municipal water supply. Samples were plated on selective media and tested for legionella using the direct immunofluorescent antibody technique and the latex agglutination test. Legionella were found in 33% of the DUWLs and in 47% of the mains taps supplying these units. Legionella-laden amoebae occurred in one mains tap sample and in 20% of DUWLs in a clinic of the teaching hospital. L. micdadei was the predominant species isolated from this clinic. L. pneumophila serogroups 2-14 predominated in the mains water, whereas L. pneumophila serogroup 1 was found in approximately half of the contaminated DUWLs and mains taps irrespective of the time of sampling. Pathogenic Legionella species seeded by municipal water into DUWLs is a potential source of legionella infection for both dental personnel and patients during prolonged dental treatment. This problem is compounded by the presence of legionella-laden amoebae which may contain levels of organism well within the infective dose. The interaction of legionella with amoebae is an important ecological factor that may significantly increase the risk of legionellosis, and thus should be given further consideration in the refinement of risk assessment models.

Legionnaires' disease associated with macular rash: two cases

Legionnaires' disease is an acute bacterial infection, generally sustained by Legionella pneumophila, which involves primarily the lower respiratory tract, although it is often associated with multi-systemic extrapulmonary manifestations. Afflicted patients may sometimes have gastrointestinal symptoms, liver function abnormalities, renal failure or central nervous system complications, while cutaneous manifestations are very uncommon and may include erythematous, maculopapular or petechial skin lesions. Pathogenesis of skin involvement in the setting of Legionnaires' disease is still uncertain, but may involve toxic or immunological mechanisms. Two exceptional cases of Legionella pneumonia complicated by diffuse, macular rash in two adult women are described, in association with severe peripheral polyneuropathy and flaccid quadriplegia in one case.

Legionella waltersii--a novel cause of pneumonia?

A 5-y-old girl was admitted to our hospital with fever, cough, respiratory distress and rapidly increasing oxygen requirements. A chest radiograph showed bilateral central infiltrates. PCR was performed with pharyngeal washings and revealed Legionella DNA, while no genetic materials of other pathogens such as respiratory viruses, Mycoplasma and Chlamydia were detected. The clinical condition improved gradually after administration of steroids and therapy with clarithromycin. Further sequencing of Legionella DNA led to the identification of Legionella waltersii. This Legionella species has never been described as a human pathogen before.

CONCLUSION

For the first time, L. waltersii was identified as a cause of severe pneumonia. Since L. waltersii is not detected by routine laboratory tests, it may be speculated that these bacteria, like other Legionella species, are underestimated as a probable cause of community-acquired pneumonia.

Value of serological testing for diagnosis of legionellosis in outbreak patients

Serum antibody detection tests and a urine antigen detection technique were compared in samples from 116 patients epidemiologically characterized as belonging to a legionellosis outbreak. Sera were tested by enzyme-linked immunosorbent assays (ELISAs) for immunoglobulin M (IgM) and IgG plus IgM and by immunofluorescent assays (IFAs) for IgG, IgM, IgA, and polyimmunoglobulin using commercial kits (Vircell); concentrated urines were tested with the Binax NOW Legionella test. ELISA for IgM, ELISA for IgG plus IgM, antigenuria detection, and IFA for IgM were able to diagnose 72.3%, 60.5%, 53.3%, and 51.4%, respectively, of patients. Antigenuria was present in 53.8% of first samples, ELISA detected IgM in 29.7%, ELISA detected IgG plus IgM in 7.9%, and IFA detected IgM in 3.9%. Ten antigenuria-negative first samples tested serologically positive, 9 of them to IgM by ELISA. Despite the single source of the samples included in the study, detection of IgM using a sensitive technique such as ELISA seems to be a suitable complement to antigenuria detection for the diagnosis of legionellosis.

Phylogenetic relationships and species differentiation of 39 Legionella species by sequence determination of the RNase P RNA gene rnpB

The rnpB gene is ubiquitous in Bacteria, Archaea and Eucarya and encodes the RNA component of RNase P, an endoribonuclease P that consists of one RNA and one protein subunit (C5). In this study, partial rnpB genes were sequenced from 39 type strains and 16 additional strains of the genus Legionella. Models of the putative secondary structures of the RNase P RNA in the genus Legionella are proposed and possible interactions between RNase P RNA and C5 are discussed. The phylogenetic relationships within the genus Legionella were examined and rnpB sequences indicated six main clades that together comprised 27 of the 39 species examined. The phylogenetic relationships were further inferred by analysing combined datasets of sequences from the rnpB, mip, 16S rRNA and rpoB genes. It is concluded that rnpB is suitable for use in phylogenetic studies of closely related species and that it exhibits the potential to discriminate between Legionella species.

Development and evaluation of Chlamylege, a new commercial test allowing simultaneous detection and identification of Legionella, Chlamydophila pneumoniae, and Mycoplasma pneumoniae in clinical respiratory specimens by multiplex PCR

This study describes the development and evaluation of a new commercial test, Chlamylege (Argene Inc.), which allows the simultaneous detection in respiratory samples of Chlamydophila pneumoniae, Mycoplasma pneumoniae, and most Legionella species, as well as PCR inhibitors, by using a multiplex PCR and microplate hybridization. The sensitivities of Chlamylege were 1 x 10(-3) IFU, 5 x 10(-2) color-changing units, and 1 CFU per reaction tube for C. pneumoniae, M. pneumoniae, and Legionella pneumophila, respectively. A cohort of 154 clinical samples from patients with documented respiratory infections was analyzed by the kit, including 2 samples from patients with C. pneumoniae infection, 9 samples from patients with M. pneumoniae infection, 19 samples from patients with Legionella species infection, and 114 samples that tested negative for the three pathogens. All the positive specimens were correctly detected and identified by the Chlamylege kit, and no false-positive result was observed with the negative samples. The kit was then evaluated in a pediatric prospective study that included 220 endotracheal aspirates, and the results were compared with those obtained by three single in-house PCR assays. Four specimens were found to be positive for C. pneumoniae and six were found to be positive for M. pneumoniae by using both strategies. The Chlamylege kit detected two additional samples positive for M. pneumoniae and one additional sample positive for a Legionella species other than L. pneumophila; these three samples were shown to be true positive by other techniques. These overall results demonstrate that the Chlamylege assay is sensitive, specific, and convenient for the rapid detection and identification of atypical pathogens in clinical samples from patients with respiratory infections.

Coevolution between nonhomologous but functionally similar proteins and their conserved partners in the Legionella pathogenesis system

Legionella pneumophila, the causative agent of Legionnaires' disease, and other pathogenic Legionella species multiply inside protozoa and human macrophages by using the intracellular multiplication (Icm)/defect in organelle trafficking (Dot) type-IV secretion system. The IcmQ protein, which possesses pore-forming activity, and IcmR, which regulates the IcmQ activity, are two essential components of this system. Analysis of the region expected to contain these two genes from 29 Legionella species revealed the presence of a conserved icmQ gene and a large hypervariable gene family [functional homologues of icmR (fir) genes], located at the icmR genomic position. Although hypervariable in their sequence, the fir genes from all 29 Legionella species were found, together with their corresponding icmQ genes, to function similarly during infection. In addition, all FIR proteins we examined were found to interact with their corresponding IcmQ proteins. Detailed bioinformatic, biochemical, and genetic analysis of the interaction between the variable FIR proteins and conserved IcmQ proteins revealed that their interaction depends on a variable region located between two conserved domains of IcmQ. This variable region was also found to be critical for IcmQ self-interaction, and the region probably coevolved with the corresponding FIR protein. A FIR-IcmQ pair was also found in Coxiella burnetii, the only known non-Legionella bacterium that contains an Icm/Dot system, indicating the significance of this protein pair for the function of this type-IV secretion system. We hypothesize that this gene variation, which is probably mediated by positive selection, plays an important role in the evolutionary arms race between the protozoan host cell and the pathogen.

Efficacy of pazufloxacin mesilate in Legionnaires' disease: a case report and in vitro study of the isolate

We report here a case of culture-proven Legionnaires' disease successfully treated with intravenous injection of pazufloxacin mesilate (PZFX), a fluoroquinolone newly approved in Japan. The patient was a 51-year-old man hospitalized after a diagnosis of community-acquired pneumonia. Legionella pneumophila SG1 was isolated from the patient's bronchoalveolar lavage (BAL) fluid, and the soluble antigen of the bacterium was detected in the fluid as well. Subsequently, intravenous PZFX was administered for a week and proved markedly effective. An in vitro study confirmed that PZFX had excellent extracellular and intracellular activity against the isolate from the patient. This case suggests that PZFX is an option for treating Legionnaires' disease.

Outbreak of travel-related pontiac fever among hotel guests illustrating the need for better diagnostic tests

BACKGROUND

Pontiac fever (PF), a legionellosis with influenza-like symptoms and high attack rates, is rarely reported. Travel-related outbreaks can elude detection because infected persons are often widely removed geographically from the transmission source before illness onset. Thirty-one persons staying at an Illinois hotel during August 9 to 11, 2002, reported influenza-like symptoms to local health departments within 24 to 48 hours of checkout. We investigated to identify the cause and source of illness to guide control measures.

METHODS

Hotel water samples were collected for culture. A telephone questionnaire detailing illness symptoms and exposures was administered to all who were guests at the hotel from August 9 to 15 (n = 380). A case was defined as onset of fever, headache, and myalgia in a guest in the 14 days following the hotel stay. Patient sera were tested by hemagglutination assay for antibodies to Legionella species.

RESULTS

Among 204 questionnaire respondents from 15 states and Canada, 50 met the case definition. Among persons exposed to the swimming pool/whirlpool spa area, 63% (47 of 75) became ill versus 3% (3 of 110) of unexposed persons (relative risk 23.0, 95% CI 7.4-71.1). Illness risk increased with increasing time exposed to the pool/spa. Approximately 95 to 115 bathers per day, two to three times above the usual number, used the spa during August 9 to 11. Three Legionella species, L. dumoffii, L. maceachernii, and L. micdadei, were isolated from spa filter backwash cultures. Two of 15 ill persons with acute- and convalescent-phase sera had a greater than fourfold rise in antibody titer to L. micdadei.

CONCLUSIONS

PF was associated with exposure to a hotel pool/spa area. Heavy bather usage likely contributed to a decreased effectiveness of the disinfectant in the whirlpool spa, possibly promoting bacterial aerosolization. Linking case information from many states is essential in identifying and eliminating the source of disease transmission in travel-related outbreaks of PF. Clinicians should be aware of PF in the differential diagnosis of patients with influenza-like symptoms following recent travel, particularly with exposure to a communal-use whirlpool spa.

Identification of a novel adhesion molecule involved in the virulence of Legionella pneumophila

Legionella pneumophila is an intracellular bacterium, and its successful parasitism in host cells involves two reciprocal phases: transmission and intracellular replication. In this study, we sought genes that are involved in virulence by screening a genomic DNA library of an L. pneumophila strain, 80-045, with convalescent-phase sera of Legionnaires' disease patients. Three antigens that reacted exclusively with the convalescent-phase sera were isolated. One of them, which shared homology with an integrin analogue of Saccharomyces cerevisiae, was named L. pneumophila adhesion molecule homologous with integrin analogue of S. cerevisiae (LaiA). The laiA gene product was involved in L. pneumophila adhesion to and invasion of the human lung alveolar epithelial cell line A549 during in vitro coculture. However, its presence did not affect multiplication of L. pneumophila within a U937 human macrophage cell line. Furthermore, after intranasal infection of A/J mice, the laiA mutant was eliminated from lungs and caused reduced mortality compared to the wild isolate. Thus, we conclude that the laiA gene encodes a virulence factor that is involved in transmission of L. pneumophila 80-045 and may play a role in Legionnaires' disease in humans.

Hospital water point-of-use filtration: a complementary strategy to reduce the risk of nosocomial infection

Cholera, hepatitis and typhoid are well-recognized water-borne illnesses that take the lives of many every year in areas of uncontrollable flood, but far less attention is afforded to the allegedly safe potable water in affluent nations and the presumed healthful quality of water in communities and hospitals. Recent literature, however, points to increasing awareness of serious clinical sequelae particularly experienced by immunocompromised patients at high risk for disease and death from exposure to water-borne microbes in hospitals. This review reflects the literature indicting hospital water as an important source for nosocomial infections, examines patient populations at greatest risk, uncovers examples of failures in remedial water treatment methods and the reasons for them, and introduces point-of-use water filtration as a practical alternative or complementary component of an infection control strategy that may reduce the risk of nosocomial infections.

Evaluation of the effectiveness of the Pastormaster method for disinfection of legionella in a hospital water distribution system

The Pastormaster method consists of heating the water of hospital distribution systems at a specific point to a sufficient temperature for a minimum amount of time to eradicate legionella. The object of this study was to evaluate the effectiveness of the Pastormaster method for legionella disinfection in a hospital environment. A two-phase procedure was performed: hydraulic optimization of the water supply circuit, and implementation of the Pastormaster method. Water samples were taken at 10 representative points in the hospital hot-water system and cultured microbiologically. Other physical and chemical measurements were also determined. Implementation of the Pastormaster method and correction of the deficiencies identified during a hydraulic system audit confirmed the absence of legionella in the hospital water distribution system. The combination of implementation of the Pastormaster method and conduction of a hydraulic audit designed to identify and remedy any possible problems in water circulation is effective in minimizing the risk of legionella contamination in hospital water distribution systems.

Legionella waterline colonization: detection of Legionella species in domestic, hotel and hospital hot water systems

AIMS

An evaluation was made of the prevalence of Legionella species in hot water distribution systems in the city of Bologna (Italy) and their possible association with bacterial contamination (total counts and Pseudomonadaceae) and the chemical characteristics of the water (pH, Ca, Mg, Fe, Mn, Cu, Zn and Total Organic Carbon, TOC).

METHODS AND RESULTS

A total of 137 hot water samples were analysed: 59 from the same number of private apartments, 46 from 11 hotels and 32 from five hospitals, all using the same water supply. Legionella species were detected in 40.0% of the distribution systems, L. pneumophila in 33.3%. The highest colonization was found in the hot water systems of hospitals (93.7% of samples positive for L. pneumophila, geometric mean: 2.4 x 10(3) CFU l(-1)), followed by the hotels (60.9%, geometric mean: 127.3 CFU l(-1)) and the apartments with centralized heating (41.9%, geometric mean: 30.5 CFU l(-1)). The apartments with independent heating systems showed a lower level of colonization (3.6% for Legionella species), with no evidence of L. pneumophila. Correlation analysis suggests that copper exerts an inhibiting action, while the TOC tends to favour the development of L. pneumophila. No statistically significant association was seen with Pseudomonadaceae, which were found at lower water temperatures than legionellae and in individual distribution points rather than in the whole network.

CONCLUSIONS

The water recirculation system used by centralized boilers enhances the spreading of legionellae throughout the whole network, both in terms of the number of colonized sites and in terms of CFU count.

SIGNIFICANCE AND IMPACT OF THE STUDY

Differences in Legionella colonization between types of buildings are not due to a variation in water supply but to other factors. Besides the importance of water recirculation, the study demonstrates the inhibiting action of copper and the favourable action of TOC on the development of L. pneumophila.

The challenges were legion

The search for the cause of the large outbreak of severe pneumonia that affected attendees of a convention of war veterans in Philadelphia in 1976 was complicated by a number of factors. The 2-10 day incubation period meant that cases were dispersed across Pennsylvania at time of onset, and matters were further complicated by the lack of a centralised record of attendance of the convention. Known methods for culture, serology, tissue staining, and toxicology gave negative results. The reliance on a clinical case definition, and the need to coordinate local, state, and federal jurisdictions both hindered efforts. Intense public scrutiny, anxiety, and promotion of implausible theories, researchers' memories of prior unsolved major investigations, and the inherent difficulty of documenting airborne spread also had an impact. The novel bacterial agent Legionella pneumophila was identified and its spread defined by persistent application of basic epidemiological and laboratory principles, including the willingness to re-examine one's assumptions.

Cytochrome c maturation proteins are critical for in vivo growth of Legionella pneumophila

Legionella pneumophila, an intracellular parasite of macrophages and protozoa, requires iron for extra- and intracellular growth. In a new screen of a mutant library of L. pneumophila for strains defective for growth on agar media lacking supplemental iron, seven mutants were obtained. All of the mutants had a disruption in the cytochrome c maturation (ccm) locus; two had insertions in ccmB, two in ccmC, and three in ccmF. The ccm mutants were unable to multiply within macrophage-like cells (i.e., U937 and THP-1 cells) and Hartmannella vermiformis amoebae. A competition assay in A/J mice revealed that ccm mutants are severely defective for growth within the lung. Taken together, these data confirm that ccm and cytochrome c maturation proteins are required for L. pneumophila growth in low iron, intracellular infection, and virulence.