Legionella and Legionnaires' disease: 25 years of investigation

Causes, Factors, and Control Measures of Opportunistic Premise Plumbing Pathogens—A Critical Review

This review critically analyses the chemical and physical parameters that influence the occurrence of opportunistic pathogens in the drinking water distribution system, specifically in premise plumbing. A comprehensive literature review reveals significant impacts of water age, disinfectant residual (type and concentration), temperature, pH, and pipe materials. Evidence suggests that there is substantial interplay between these parameters; however, the dynamics of such relationships is yet to be elucidated. There is a correlation between premise plumbing system characteristics, including those featuring water and energy conservation measures, and increased water quality issues and public health concerns. Other interconnected issues exacerbated by high water age, such as disinfectant decay and reduced corrosion control efficiency, deserve closer attention. Some common features and trends in the occurrence of opportunistic pathogens have been identified through a thorough analysis of the available literature. It is proposed that the efforts to reduce or eliminate their incidence might best focus on these common features.

Occurrence of Legionella spp. in Man-Made Water Sources: Isolates Distribution and Phylogenetic Characterization in the Emilia-Romagna Region

Legionella species distribution in the Emilia-Romagna region, involving hospital (H) and community (C) environments, was conducted. Legionella culture, agglutination test, and mip-gene sequencing were applied on 240 isolates. The analysis showed a higher prevalence of non-Legionellapneumophila (n-Lp) species (84.1%) compared with L. pneumophila (Lp) (15.9%), with a higher frequency of n-Lp with respect to Lp species in both environments (77.6% and 96.4%, in H and C, respectively). The Shannon index showed a significant difference in Legionella distribution (p = 0.00017), with a significant abundance of Lp in the H compared with C environment (p = 0.00028). The continuous disinfection treatment in H could contribute to adaptive survival of the Lp species. Phylogenetic analysis revealed a conservative clade distribution between H and C: L. feeleii clade with three subclades in C and the Lp clade with five subclades in H and two in C, respectively. Our findings suggest the importance of Legionella surveillance both in H and C, with a focus on n-Lp species less connected to human disease. The Legionella prevalence and diversity found here indicate that geographical and temporal isolate evolution should be considered during surveillance, particularly in the light of global warming and changes in population risk factors.

Quantification and Comparison of Risks Associated with Wastewater Use in Spray Irrigation

In the U.S., spray irrigation is the most common method used in agriculture and supplementing with animal wastewater has the potential to reduce water demands. However, this could expose individuals to respiratory pathogens such as Legionella pneumophila and nontuberculosis Mycobacteria (NTM). Disinfection with methods like anaerobic digestion is an option but can increase concentrations of cytotoxic ammonia (personal communication). Our study aimed to model the annual risks of infection from these bacterial pathogens and the air concentrations of ammonia and determine if anaerobically digesting this wastewater is a safe option. Air dispersion modeling, conducted in AERMOD, generated air concentrations of water during the irrigation season (May-September) for the years 2013-2018. These values fed into the quantitative microbial risk assessments for the bacteria and allowed calculation of ammonia air concentrations. The outputs of these models were compared to the safety thresholds of 10^-4 infections/year and 0.5 mg/m³ , respectively, to determine their potential for negative health outcomes. It was determined that infection from NTM was not a concern for individuals near active spray irrigators, but that infection with L. pneumophila could be a concern, with a maximum predicted annual risk of infection of 3.5 × 10^-3 infections/year and 25.2% of parameter combinations exceeding the established threshold. Ammonia posed a minor risk, with 1.5% of parameter combinations surpassing the risk threshold of 0.5 mg/m³ . These findings suggest that animal wastewater should be anaerobically digested prior to use in irrigation to remove harmful pathogens.

Assessment of hygienic conditions of recreational facility restrooms: an integrated approach

Introduction

Microbiological quality of recreational environments included restrooms, is generally assessed by water and surface monitoring. In this study, an environmental monitoring, conducted in spring, of swimming pool restrooms of a recreation center located in the Marche region has been carried out. Seven water samples and seven surface swabs were collected. Moreover, six air samples have been included. The aim of this study was to evaluate if air microbiological monitoring, along with molecular detection in real-time PCR, could give additional useful information about the hygienic conditions of the facility.

Methods

Heterotrophic Plate Count (HPC) both at 22°C (psychrophilic) and 37°C (mesophilic) was determined by separate cultures in all samples. The presence of Legionella pneumophila and Pseudomonas aeruginosa was evaluated by both culture and real-time PCR.

Results

The analysis of shower water recorded a HPC load of mesophilic bacteria (37°C) more than 10-fold higher in men restroom, respect to women’s one (> 100 vs < 10 CFU/ml), while in air samples was between < 100 and > 500. Concerning pathogen presence, both species Legionella pneumophila and Pseudomonas aeruginosa were detected only in men restroom, but in different sample types by using different methods (culture and real-time PCR).

Conclusions

Air sampling may offer the advantage of giving more representative data about microbial presence in restrooms, including bacterial species transmitted through aerosol, like Legionella. Moreover, the concurrent use of molecular and microbiological detection in an integrated approach could offer the advantage of greater sensitivity.

Local Adaptation of Legionella pneumophila within a Hospital Hot Water System Increases Tolerance to Copper

In large-building water systems, Legionella pneumophila is exposed to common environmental stressors such as copper. The aim of this study was to evaluate the susceptibility to copper of L. pneumophila isolates recovered from various sites: two clinical and seven environmental isolates from hot water system biofilm and water and from cooling tower water. After a 1-week acclimation in simulated drinking water, strains were exposed to various copper concentrations (0.8 to 5 mg/liter) for over 672 h. Complete loss of culturability was observed for three isolates following copper exposure to 5 mg/liter for 672 h. Two sequence type 1427 (ST1427)-like isolates were highly sensitive to copper, while the other two, isolated from biofilm samples, maintained higher culturability. The expression of the copper resistance gene copA evaluated by reverse transcription-quantitative PCR (RT-qPCR) was significantly higher for the biofilm isolates. All four ST1427-like isolates were recovered from the same water system during an outbreak. Whole-genome sequencing results confirmed that the four isolates are very close phylogenetically, differing by only 29 single nucleotide polymorphisms, suggesting in situ adaptation to microenvironmental conditions, possibly due to epigenetic regulation. These results indicate that the immediate environment within a building water distribution system influences the tolerance of L. pneumophila to copper. Increased contact of L. pneumophila biofilm strains with copper piping or copper alloys in the heat exchanger might lead to local adaptation. The phenotypic differences observed between water and biofilm isolates from the hot water system of a health care facility warrants further investigation to assess the relevance of evaluating disinfection performances based on water sampling alone.IMPORTANCELegionella pneumophila is a pathogen indigenous to natural and large building water systems in the bulk and the biofilm phases. The immediate environment within a system can impact the tolerance of L. pneumophila to environmental stressors, including copper. In health care facilities, copper levels in water can vary, depending on water quality, plumbing materials, and age. This study evaluated the impact of the isolation site (water versus biofilm, hot water system versus cooling tower) within building water systems. Closely related strains isolated from a health care facility hot water system exhibited variable tolerance to copper stress, shown by differential expression of copA, with biofilm isolates displaying highest expression and tolerance. Relying on the detection of L. pneumophila in water samples following exposure to environmental stressors such as copper may underestimate the prevalence of L. pneumophila, leading to inappropriate risk management strategies and increasing the risk of exposure for vulnerable patients.

Detection of targeted bacteria species on filtration membranes

The detection of pathogens in aquatic environments issues a time-consuming challenge, but it is an essential task to prevent the spread of diseases. We have developed a new point-of-care (POC) method for the fast and efficient detection of Legionella pneumophila in water. The method consists first of the generation of immunocomplexes of bacteria species with its corresponding targeted fluorescence-labelled serogroup-specific antibodies, and second a concentration step of pathogens with a membrane filter. Third, on the filtration membrane, our method can detect the fluorescence intensity corresponding to the pathogen concentration. Thus selective and efficient evidence for the presence of bacteria can be evaluated. We tested our system on fluorescent Escherichia coli bacteria and were able to reach an accurate determination of 1000 cells. The technique was furthermore tested on Legionella pneumophila cells, which were labelled with fluorescence-labelled antibodies as a proof of principle. Furthermore, we were able to verify this method in the presence of other bacteria species. We were able to detect bacteria cells within half an hour, a substantial advancement compared to the prevailling state of the art detection method based on the cultivation of Legionella pneumophila. Hence, this system represents the basis for future developments in analysis of pathogens.

Effects of climate changes and road exposure on the rapidly rising legionellosis incidence rates in the United States

Legionellosis is an infection acquired through inhalation of aerosols that are contaminated with environmental bacteria Legionella spp. The bacteria require warm temperature for proliferation in bodies of water and moist soil. The legionellosis incidence in the United States has been rising rapidly in the past two decades without a clear explanation. In the meantime, the US has recorded consecutive years of above-norm temperature since 1997 and precipitation surplus since 2008. The present study analyzed the legionellosis incidence in the US during the 20-year period of 1999 to 2018 and correlated with concurrent temperature, precipitation, solar ultraviolet B (UVB) radiation, and vehicle mileage data. The age-adjusted legionellosis incidence rates rose exponentially from 0.40/100,000 in 1999 (with 1108 cases) to 2.69/100,000 in 2018 (with 9933 cases) at a calculated annual increase of 110%. In regression analyses, the rise correlated with an increase in vehicle miles driven and with temperature and precipitation levels that have been above the 1901–2000 mean since 1997 and 2008, respectively, suggesting more road exposure to traffic-generated aerosols and promotive effects of anomalous climate. Remarkably, the regressions with cumulative anomalies of temperature and precipitation were robust (R² ≥ 0.9145, P ≤ 4.7E-11), implying possible changes to microbial ecology in the terrestrial and aquatic environments. An interactive synergy between annual precipitation and vehicle miles was also found in multiple regressions. Meanwhile, the bactericidal UVB radiation has been decreasing, which also contributed to the rising incidence in an inverse correlation. The 2018 legionellosis incidence peak corresponded to cumulative effects of the climate anomalies, vast vehicle miles (3,240 billion miles, 15904 km per capita), record high precipitation (880.1 mm), near record low UVB radiation (7488 kJ/m²), and continued above-norm temperature (11.96°C). These effects were examined and demonstrated in California, Florida, New Jersey, Ohio, and Wisconsin, states that represent diverse incidence rates and climates. The incidence and above-norm temperature both rose most in cold Wisconsin. These results suggest that warming temperature and precipitation surplus have likely elevated the density of Legionella bacteria in the environment, and together with road exposure explain the rapidly rising incidence of legionellosis in the United States. These trends are expected to continue, warranting further research and efforts to prevent infection.

A robust phylogenetic framework for members of the order Legionellales and its main genera (Legionella, Aquicella, Coxiella and Rickettsiella) based on phylogenomic analyses and identification of molecular markers demarcating different clades

The order Legionellales contains several clinically important microorganisms. Although members of this order are well-studied for their pathogenesis, there is a paucity of reliable characteristics distinguishing members of this order and its constituent genera. Genome sequences are now available for 73 Legionellales species encompassing ≈90% of known members from different genera. With the aim of understanding evolutionary relationships and identifying reliable molecular characteristics that are specific for this order and its constituent genera, detailed phylogenetic and comparative analyses were conducted on the protein sequences from these genomes. A phylogenomic tree was constructed based on 393 single copy proteins that are commonly shared by the members of this order to delineate the evolutionary relationships among its members. In parallel, comparative analyses were performed on protein sequences from Legionellales genomes to identify novel molecular markers consisting of conserved signature indels (CSIs) that are specific for different clades and genera. In the phylogenomic tree and in an amino acid identity matrix based on core proteins, members of the genera Aquicella, Coxiella, Legionella and Rickettsiella formed distinct clades confirming their monophyly. In these studies, Diplorickettsia massiliensis exhibited a close relationship to members of the genus Rickettsiella. The results of our comparative genomic analyses have identified 59 highly specific molecular markers consisting of CSIs in diverse proteins that are uniquely shared by different members of this order. Four of these CSIs are specific for all Legionellales species, except the two deeper-branching "Candidatus Berkiella" species, providing means for identifying members of this order in molecular terms. Twenty four, 7 and 6 CSIs are uniquely shared by members of the genera Legionella, Coxiella and Aquicella, respectively, identifying these groups in molecular terms. The descriptions of these three genera are emended to include information for their novel molecular characteristics. We also describe 12 CSIs that are uniquely shared by D. massiliensis and different members of the genus Rickettsiella. Based on these results, we are proposing an integration of the genus Diplorickettsia with Rickettsiella. Three other CSIs suggest that members of the genera Coxiella and Rickettsiella shared a common ancestor exclusive of other Legionellales. The described molecular markers, due to their exclusivity for the indicated taxa/genera, provide important means for the identification of these clinically important microorganisms and for discovering novel properties unique to them.

Sea water whirlpool spa as a source of Legionella infection

Bacterial pneumonia caused by the inhalation of aerosols contaminated with Legionella spp. is also known as Legionnaires' disease. In this study, we report a case of pneumonia caused by Legionella pneumophila sg.1 in a 58-year-old man who visited a sea water-filled whirlpool within a hotel and spa complex. The patient's Legionella urine antigen test was positive for L. pneumophila sg.1. During the field study, samples were taken from both the outdoor and indoor sea water-filled pools. Samples from the whirlpool were culture positive for L. pneumophila sg.1. Typing results indicated sea water isolate belonged to Sequence type ST82 and Allentown/France MAb subgroup. In vitro experiments showed that L. pneumophila strains are able to survive within sea water up to 7 days, and survival time is prolonged with sea water dilution. Also, our results indicate that L. pneumophila Allentown strain was the most resistant to adverse conditions in sea water with the highest values of DT50 (420 min) and DT90 (1,396 min). The possible source of infection was adding potable water for filling up the whirlpool. The survival of the L. pneumophila in additionally conditioned sea water should be considered in a further study.

Trends in the incidence and mortality of legionellosis in Japan: a nationwide observational study, 1999-2017

This study examined temporal trend, seasonality, and geographical variations of legionellosis incidence and mortality in Japan. This nationwide observational study used the Japanese Vital Statistics and Infectious Diseases Weekly Report (1999-2017) data to calculate legionellosis crude and age-adjusted incidence and mortality rates per 100,000 population by age and sex. Incidence was compared among the 4 seasons and regional incidence among 47 prefectures. Of 13,613 (11,194 men) people with legionellosis in Japan, 725 (569 men) were fatal. Increasing incidence trend occurred from 0.0004 (1999) to 1.37 (2017) per 100,000 population. People aged ≥ 70 years accounted for 43.1% overall; men's age-adjusted incidence rate was consistently approximately five times higher than for women. Significantly higher incidence occurred in summer than in winter (p = 0.013). Geographically, highest incidence (≥ 2.0 per 100,000 population) occurred in Hokuriku District, with increasing trends in Hokkaido and middle-part of Japan. Estimated fatality rates decreased consistently at 5.9% (95% confidence interval: - 8.1, - 3.5) annually, from 1999 to 2017, with no trend change point. Increasing legionellosis incidence occurred in Japan during 1999-2017, with declining estimated fatality rates. In this aging society and warming world, disease clinical burden may further deteriorate in future due to increasing incidence trends.

Evaluation of Legiolert™ for the Detection of Legionella pneumophila and Comparison with Spread-Plate Culture and qPCR Methods

Legionella pneumophila, the organism responsible for Legionnaires' disease, a potentially lethal pneumonia, is an opportunistic bacterium spread via inhalation of contaminated, aerosolized water. The detection and control of L. pneumophila is crucial to reduce the risk it poses to human health. L. pneumophila is generally detected and quantified by the plating method, ISO 11731:2017 and by qPCR. ISO 11731 is based on the filtration of the water sample through a membrane, which is placed on selective agar medium, and after colony growth, presumptive Legionella are then confirmed by subculturing, serology, or PCR. Quantitative Polymerase Chain Reaction (qPCR) is based on the amplification of a DNA sequence specific to L. pneumophila, usually within the mip gene. The objective of this study was to compare these methods to a new, liquid culture method based on the Most Probable Number (MPN) technique, Legiolert™/Quanti-Tray® with data obtained with ISO 11731 and a viability quantitative qPCR (v-qPCR), for quantification of L. pneumophila in potable and non-potable waters. Data showed that the Legiolert method revealed concentrations of L. pneumophila greater than ISO 11731 and generally similar results to those of v-qPCR. The Legiolert method was highly specific and easy to use, representing a significant advancement in the quantification of L. pneumophila from potable and non-potable waters.

Take my breath away: studying pathogen invasion of the human lung using primary tissue models

The human pulmonary environment is complex, containing a matrix of cells, including fibroblasts, epithelial cells, interstitial macrophages, alveolar macrophages and neutrophils. When confronted with foreign material or invading pathogens, these cells mount a robust response. Nevertheless, many bacterial pathogens with an intracellular lifecycle stage exploit this environment for replication and survival. These include, but are not limited to, Coxiella burnetii, Legionella pneumophila, Yersinia pestis, Mycobacterium tuberculosis and Staphylococcus aureus. Currently, few human disease-relevant model systems exist for studying host-pathogen interactions during these bacterial infections in the lung. Here, we present two novel infection platforms, human alveolar macrophages (hAMs) and human precision-cut lung slices (hPCLS), along with an up-to-date synopsis of research using said models. Additionally, alternative uses for these systems in the absence of pathogen involvement are presented, such as tissue banking and further characterization of the human lung environment. Overall, hAMs and hPCLS allow novel human disease-relevant investigations that other models, such as cell lines and animal models, cannot completely provide.

Novel Endosymbionts in Rhizarian Amoebae Imply Universal Infection of Unrelated Free-Living Amoebae by Legionellales

Legionellales-infected water is a frequent cause of local outbreaks of Legionnaires’ disease and Pontiac fever. Decontaminations are difficult because Legionellales reproduce in eukaryotic microorganisms (protists). Most often, Legionellales have been isolated from amoebae; however, the culture-based sampling methods are taxonomically biased. Sequencing studies show that amoebae in the cercozoan class Thecofilosea are dominant in soils and wastewater treatment plants, prompting us to screen their capability to serve as potential hosts of endosymbiotic bacteria. Environmental isolates of Thecofilosea contained a surprising richness of endosymbiotic Legionellales, including Legionella. Considering the widespread dispersal of Legionellales in apparently unrelated amoeboid protist taxa, it appears that the morphotype and not the evolutionary origin of amoebae determines their suitability as hosts for Legionellales. We further provide a protocol for gnotobiotic cultivation of Legionellales and their respective hosts, facilitating future genomic and transcriptomic research of host–symbiont relationships.

Microbiological Health Risk Assessment of Water Conservation Strategies: A Case Study in Amsterdam

The aim of this study was to assess the health risks that may arise from the implementation of greywater reuse and rainwater harvesting for household use, especially for toilet flushing. In addition, the risk of cross connections between these systems and the drinking water system was considered. Quantitative microbial risk assessment (QMRA) is a method that uses mathematical modelling to estimate the risk of infection when exposure to pathogens happens and was used in this study to assess the health risks. The results showed that using rainwater without prior treatment for toilet flushing poses an annual infection risk from L. pneumophila at 0.64 per-person-per-year (pppy) which exceeds the Dutch standard of 10-4 pppy. The use of untreated greywater showed a risk that is below the standard. However, treatment is recommended due to the ability of P. aeruginosa to grow in the reuse system. Moreover, showering and drinking with cross-connected water has a high annual infection risk that exceeds the standard due to contact with Staphylococcus aureus and E. coli O157:H7. Several measures can be implemented to mitigate the risks such as treating the greywater and rainwater with a minimum of 5-log removal, closing the toilet lid while flushing, good design of greywater and rainwater collection systems, and rigorous plumbing installation procedures.

Comparison of BCYEα+AB agar and MWY agar for detection and enumeration of Legionella spp. in hospital water samples

Background

This study illustrates for the first time the performance (sensitivity and selectivity) of the selective medium BCYEα +AB suggested by the new edition of ISO 11731 for legionella isolation and enumeration. We compared the efficacy of the selective BCYEα +AB medium with that of the highly selective MWY medium.

Results

Legionella spp. was detected in 48.2 and 47.1% of the samples by BCYEα +AB and MWY agar, respectively. For optimal detection of Legionella spp., most protocols recommend using selective media to reduce the number of non-Legionella bacteria. Agreement between the two media was 86.7%.

Conclusions

According to the results, both media have a very similar performance and they both have advantages and disadvantages over each other. In AB medium there is the risk of being less selective so more interfering microbiota may grow but in MWY medium there is the risk of being too selective. The low selectivity of the AB medium could be resolved if other treatments are applied after filtration, e.g. acid and/or heat treatment, but it must be taken into account that these treatments still reduce the number of viable Legionella. In conclusion, we recommend using MWY as a selective medium for the detection of Legionella spp. as it is easier discern suspected colonies and facilitate the final Legionella spp. count.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-021-02109-1.

An Indispensable Role for the MavE Effector of Legionella pneumophila in Lysosomal Evasion

Intracellular proliferation of Legionella pneumophila within a vacuole in human alveolar macrophages is essential for manifestation of Legionnaires’ pneumonia. Intravacuolar growth of the pathogen is totally dependent on remodeling the L. pneumophila-containing vacuole (LCV) by the ER and on its evasion of the endosomal-lysosomal degradation pathway.

Diversion of the Legionella pneumophila-containing vacuole (LCV) from the host endosomal-lysosomal degradation pathway is one of the main virulence features essential for manifestation of Legionnaires’ pneumonia. Many of the ∼350 Dot/Icm-injected effectors identified in L. pneumophila have been shown to interfere with various host pathways and processes, but no L. pneumophila effector has ever been identified to be indispensable for lysosomal evasion. While most single effector mutants of L. pneumophila do not exhibit a defective phenotype within macrophages, we show that the MavE effector is essential for intracellular growth of L. pneumophila in human monocyte-derived macrophages (hMDMs) and amoebae and for intrapulmonary proliferation in mice. The mavE null mutant fails to remodel the LCV with endoplasmic reticulum (ER)-derived vesicles and is trafficked to the lysosomes where it is degraded, similar to formalin-killed bacteria. During infection of hMDMs, the MavE effector localizes to the poles of the LCV membrane. The crystal structure of MavE, resolved to 1.8 Å, reveals a C-terminal transmembrane helix, three copies of tyrosine-based sorting motifs, and an NPxY eukaryotic motif, which binds phosphotyrosine-binding domains present on signaling and adaptor eukaryotic proteins. Two point mutations within the NPxY motif result in attenuation of L. pneumophila in both hMDMs and amoeba. The substitution defects of P⁷⁸ and D⁶⁴ are associated with failure of vacuoles harboring the mutant to be remodeled by the ER and results in fusion of the vacuole to the lysosomes leading to bacterial degradation. Therefore, the MavE effector of L. pneumophila is indispensable for phagosome biogenesis and lysosomal evasion.

The Role of Lipids in Legionella-Host Interaction

Legionella are Gram-stain-negative rods associated with water environments: either natural or man-made systems. The inhalation of aerosols containing Legionella bacteria leads to the development of a severe pneumonia termed Legionnaires' disease. To establish an infection, these bacteria adapt to growth in the hostile environment of the host through the unusual structures of macromolecules that build the cell surface. The outer membrane of the cell envelope is a lipid bilayer with an asymmetric composition mostly of phospholipids in the inner leaflet and lipopolysaccharides (LPS) in the outer leaflet. The major membrane-forming phospholipid of Legionella spp. is phosphatidylcholine (PC)-a typical eukaryotic glycerophospholipid. PC synthesis in Legionella cells occurs via two independent pathways: the N-methylation (Pmt) pathway and the Pcs pathway. The utilisation of exogenous choline by Legionella spp. leads to changes in the composition of lipids and proteins, which influences the physicochemical properties of the cell surface. This phenotypic plasticity of the Legionella cell envelope determines the mode of interaction with the macrophages, which results in a decrease in the production of proinflammatory cytokines and modulates the interaction with antimicrobial peptides and proteins. The surface-exposed O-chain of Legionella pneumophila sg1 LPS consisting of a homopolymer of 5-acetamidino-7-acetamido-8-O-acetyl-3,5,7,9-tetradeoxy-l-glycero-d-galacto-non-2-ulosonic acid is probably the first component in contact with the host cell that anchors the bacteria in the host membrane. Unusual in terms of the structure and function of individual LPS regions, it makes an important contribution to the antigenicity and pathogenicity of Legionella bacteria.

Healthcare-Associated Legionella Disease: A Multi-Year Assessment of Exposure Settings in a National Healthcare System in the United States

Healthcare facilities are high-risk environments for Legionella disease (LD), including Legionnaires' disease, but transmission in these settings is often overlooked. We used the LD database at the U.S. Department of Veterans Affairs (VA) national healthcare system to assess the type of healthcare exposure for LD cases. Cases were extracted from the database for 1 September 2012 through 31 July 2019, focusing on cases with an overnight stay at a VA facility during the 10-day exposure window prior to symptom onset. Patient medical charts were reviewed for demographics and types of healthcare setting exposure(s). There were 99 LD cases in the cohort: 31.3% were classified as having definite VA exposure, 37.4% were classified as possible VA with inpatient exposure, and 31.3% were classified as possible VA with both inpatient and outpatient exposure. For definite VA LD cases, 67.7% had some type of exposure in the long-term care setting. While 63% of the 99 cases had exposure in the acute care setting only, both the long-term care and acute care settings contributed substantially to the total number of exposure days. A review of patient movement during the exposure period showed the variable and sometimes extensive use of the VA system, and it provides insights useful for epidemiologic investigations and potential preventive actions.

A Hospital-based Study on the Local Epidemiology of Pneumonia Including the Contribution of Legionella Pneumonia

Background

In real-life practice, only 20% of hospitalised pneumonia cases have an identified etiology. The usage of Legionella urine antigen test (LUAT) in developed nations revolutionised case detection rates. Accordingly, our objectives were to study the microbiological etiology for hospitalised pneumonia patients and the diagnosis of Legionella pneumonia.

Methods

A prospective, observational single-centre study was conducted where all 504 cases that were consecutively admitted for pneumonia were enrolled. Blood and sputum samples obtained were used to identify pathogens using standard microbiological culture methods. The urine samples collected were tested using the Immunocatch^TMLegionella immunochromatographic (ICT) urine antigen test.

Results

A microbiological diagnosis was only achieved in 104 cases (20.6%) and a Gram-negative infection predominance was observed. Culture-positive cases required longer hospitalisation (8.46 days versus 5.53 days; P < 0.001) and the higher usage of antipseudomonal antibiotics (23.1% versus 8.3%; P < 0.001). Only 3 cases (0.6%) were diagnosed with Legionella pneumonia.

Conclusion

The local pathogen distribution is diverse compared to other regions. Culture-negative pneumonia is common and significantly differs from culture-positive pneumonia. Legionella pneumophila serotype 1 is not a common cause of pneumonia and LUAT did not help demystify the cause of culture-negative pneumonia.

Legionellosis in Japan: A Self-inflicted Wound?

Legionellosis is a serious bacterial infection characterized by atypical pneumonia primarily due to infection with Legionella pneumophila, and bathing can be a potential cause of this infection. Legionellosis was first identified in 1977, and it is caused by Gram-negative bacteria belonging to the genus Legionella. Legionellosis remains an important public health threat, particularly in Japan, where the population is rapidly aging, thereby becoming more at risk of developing severe disease and accompanying life-threatening pneumonia. The bacteria are most commonly transmitted via the inhalation of contaminated aerosols produced and broadcast via water sprays, jets or mists. Infection can also occur via the aspiration of contaminated water or ice, or through inhalation of contaminated dust. Because the signs and symptoms of Legionnaires' disease (LD), as well as radiographic imaging are similar to pneumonia caused by other pathogens, a specific diagnostic test is required, such as a urine antigen detection test. Six clinical and laboratory parameters, a high body temperature, a non-productive cough, low serum sodium and platelet counts, and high lactate dehydrogenase (LDH) and c-reactive protein concentrations can be used to reliably predict the likelihood of LD. The first choices for chemotherapy are fluoroquinolone and macrolide antibiotic drugs. The main goals of LD prevention measures are 1) the prevention of microbial growth and biofilm formation, 2) the removal of all biofilm formed on equipment and in facilities, 3) minimizing aerosol splash and spread, and 4) minimizing bacterial contamination from external sources. It is apparent that, in Japan, where hot spring (onsen) bathing is common among aged people, strict regulations need to be in place - and enforced - to ensure that all Japanese onsens and spas provide a safe environment and undertake regular, effective infection control practices.

Differential Bacterial Predation by Free-Living Amoebae May Result in Blooms of Legionella in Drinking Water Systems

Intracellular growth of pathogenic Legionella in free-living amoebae (FLA) results in the critical concentrations that are problematic in engineered water systems (EWS). However, being amoeba-resistant bacteria (ARB), how Legionella spp. becomes internalized within FLA is still poorly understood. Using fluorescent microscopy, we investigated in real-time the preferential feeding behavior of three water-related FLA species, Willaertia magna, Acanthamoeba polyphaga, and Vermamoeba vermiformis regarding Legionella pneumophila and two Escherichia coli strains. Although all the studied FLA species supported intracellular growth of L. pneumophila, they avoided this bacterium to a certain degree in the presence of E. coli and mostly fed on it when the preferred bacterial food-sources were limited. Moreover, once L. pneumophila were intracellular, it inhibited digestion of co-occurring E. coli within the same trophozoites. Altogether, based on FLA–bacteria interactions and the shifts in microbial population dynamics, we propose that FLA’s feeding preference leads to an initial growth of FLA and depletion of prey bacteria, thus increases the relative abundance of Legionella and creates a “forced-feeding” condition facilitating the internalization of Legionella into FLA to initiate the cycles of intracellular multiplication. These findings imply that monitoring of FLA levels in EWS could be useful in predicting possible imminent high occurrence of Legionella.

Transposon Insertion Sequencing in a Clinical Isolate of Legionella pneumophila Identifies Essential Genes and Determinants of Natural Transformation

Legionella pneumophila is the etiologic agent of a severe form of nosocomial and community-acquired pneumonia in humans. The environmental life traits of L. pneumophila are essential to its ability to accidentally infect humans.

Legionella pneumophila is a Gram-negative bacterium ubiquitous in freshwater environments which, if inhaled, can cause a severe pneumonia in humans. The emergence of L. pneumophila is linked to several traits selected in the environment, the acquisition of some of which involved intra- and interkingdom horizontal gene transfer events. Transposon insertion sequencing (TIS) is a powerful method to identify the genetic basis of selectable traits as well as to identify fitness determinants and essential genes, which are possible antibiotic targets. TIS has not yet been used to its full power in L. pneumophila, possibly because of the difficulty of obtaining a high-saturation transposon insertion library. Indeed, we found that isolates of sequence type 1 (ST1), which includes the commonly used laboratory strains, are poorly permissive to saturating mutagenesis by conjugation-mediated transposon delivery. In contrast, we obtained high-saturation libraries in non-ST1 clinical isolates, offering the prospect of using TIS on unaltered L. pneumophila strains. Focusing on one of them, we then used TIS to identify essential genes in L. pneumophila. We also revealed that TIS could be used to identify genes controlling vertical transmission of mobile genetic elements. We then applied TIS to identify all the genes required for L. pneumophila to develop competence and undergo natural transformation, defining the set of major and minor type IV pilins that are engaged in DNA uptake. This work paves the way for the functional exploration of the L. pneumophila genome by TIS and the identification of the genetic basis of other life traits of this species.

IMPORTANCELegionella pneumophila is the etiologic agent of a severe form of nosocomial and community-acquired pneumonia in humans. The environmental life traits of L. pneumophila are essential to its ability to accidentally infect humans. A comprehensive identification of their genetic basis could be obtained through the use of transposon insertion sequencing. However, this powerful approach had not been fully implemented in L. pneumophila. Here, we describe the successful implementation of the transposon-sequencing approach in a clinical isolate of L. pneumophila. We identify essential genes, potential drug targets, and genes required for horizontal gene transfer by natural transformation. This work represents an important step toward identifying the genetic basis of the many life traits of this environmental and pathogenic species.

Effect of organic micropollutants on biofouling in a forward osmosis process integrating seawater desalination and wastewater reclamation

This study systematically investigated the effect of organic micropollutants (OMPs) on biofouling in forward osmosis (FO) integrating wastewater treatment and seawater dilution. Synthetic seawater (0.6 M sodium chloride) was used as a draw solution and synthetic municipal wastewater as a feed solution. To evaluate the impact of OMPs in a replicate parallel study, wastewater was supplemented with a mixture of 7 OMPs (OMPs-feed) and without OMPs (control) during 8 batch filtration cycles with feed and draw solution replacement after each filtration. The FO performance (water flux), development and microbial composition properties of biofilm layers on the wastewater side of the FO membrane were studied. Compared to the control without OMPs, the FO fed with OMPs containing wastewater showed (i) initially the same water flux and flux decline during the first filtration cycle, (ii) with increasing filtration cycle a lower flux decline and (iii) lower concentrations for the total cells, ATP, EPS carbohydrates and proteins in biofilm layers, and (iv) a lower diversity of the biofilm microbial community composition (indicating selective pressure) and (v) increasing rejection of 6 of the 7 OMPs. In essence, biofouling on the FO membrane showed (i) a lower flux decline in the presence of OMPs in the feed water and (ii) a higher OMPs rejection, both illustrating better membrane performance. This study has a significant implication for optimizing osmotic dilution in terms of FO operation and OMPs rejection.

Evaluation of MALDI-TOF Mass Spectrometry in Diagnostic and Environmental Surveillance of Legionella Species: A Comparison With Culture and Mip-Gene Sequencing Technique

Legionella spp. are widespread bacteria in aquatic environments with a growing impact on human health. Between the 61 species, Legionella pneumophila is the most prevalent in human diseases; on the contrary, Legionella non-pneumophila species are less detected in clinical diagnosis or during environmental surveillance due to their slow growth in culture and the absence of specific and rapid diagnostic/analytical tools. Reliable and rapid isolate identification is essential to estimate the source of infection, to undertake containment measures, and to determine clinical treatment. Matrix-assisted laser desorption ionization–time-of-flight mass spectrometry (MALDI–TOF MS), since its introduction into the routine diagnostics of laboratories, represents a widely accepted method for the identification of different bacteria species, described in a few studies on the Legionella clinical and environmental surveillance. The focus of this study was the improvement of MALDI–TOF MS on Legionella non-pneumophila species collected during Legionella nosocomial and community surveillance. Comparative analysis with cultural and mip-gene sequencing results was performed. Moreover, a phylogenetic analysis was carried out to estimate the correlations amongst isolates. MALDI–TOF MS achieved correct species-level identification for 45.0% of the isolates belonging to the Legionella anisa, Legionella rubrilucens, Legionella feeleii, and Legionella jordanis species, displaying a high concordance with the mip-gene sequencing results. In contrast, less reliable identification was found for the remaining 55.0% of the isolates, corresponding to the samples belonging to species not yet included in the database. The phylogenetic analysis showed relevant differences inside the species, regruped in three main clades; among the Legionella anisa clade, a subclade with a divergence of 3.3% from the main clade was observed. Moreover, one isolate, identified as Legionella quinlivanii, displayed a divergence of 3.8% from the corresponding reference strain. However, these findings require supplementary investigation. The results encourage the implementation of MALDI–TOF MS in routine diagnostics and environmental Legionella surveillance, as it displays a reliable and faster identification at the species level, as well as the potential to identify species that are not yet included in the database. Moreover, phylogenetic analysis is a relevant approach to correlate the isolates and to track their spread, especially in unconventional reservoirs, where Legionella prevention is still underestimated.

A Methodology for Classifying Root Causes of Outbreaks of Legionnaires' Disease: Deficiencies in Environmental Control and Water Management

We piloted a methodology for collecting and interpreting root cause—or environmental deficiency (ED)—information from Legionnaires’ disease (LD) outbreak investigation reports. The methodology included a classification framework to assess common failures observed in the implementation of water management programs (WMPs). We reviewed reports from fourteen CDC-led investigations between 1 January 2015 and 21 June 2019 to identify EDs associated with outbreaks of LD. We developed an abstraction guide to standardize data collection from outbreak reports and define relevant parameters. We categorized each ED according to three criteria: ED type, WMP-deficiency type, and source of deficiency. We calculated the prevalence of EDs among facilities and explored differences between facilities with and without WMPs. A majority of EDs identified (81%) were classified as process failures. Facilities with WMPs (n = 8) had lower prevalence of EDs attributed to plumbed devices (9.1%) and infrastructure design (0%) than facilities without WMPs (n = 6; 33.3% and 24.2%, respectively). About three quarters (72%) of LD cases and 81% of the fatalities in our sample originated at facilities without a WMP. This report highlights the importance of WMPs in preventing and mitigating outbreaks of LD. Building water system process management is a primary obstacle toward limiting the root causes of LD outbreaks. Greater emphasis on the documentation, verification, validation, and continuous program review steps will be important in maximizing the effectiveness of WMPs.

The Impact of Storms on Legionella pneumophila in Cooling Tower Water, Implications for Human Health

At the U.S. Department of Energy’s Savannah River Site (SRS) in Aiken, SC, cooling tower water is routinely monitored for Legionella pneumophila concentrations using a direct fluorescent antibody (DFA) technique. Historically, 25–30 operating SRS cooling towers have varying concentrations of Legionella in all seasons of the year, with patterns that are unpredictable. Legionellosis, or Legionnaires’ disease (LD), is a pneumonia caused by Legionella bacteria that thrive both in man-made water distribution systems and natural surface waters including lakes, streams, and wet soil. Legionnaires’ disease is typically contracted by inhaling L. pneumophila, most often in aerosolized mists that contain the bacteria. At the SRS, L. pneumophila is typically found in cooling towers ranging from non-detectable up to 10⁸ cells/L in cooling tower water systems. Extreme weather conditions contributed to elevations in L. pneumophila to 10⁷–10⁸ cells/L in SRS cooling tower water systems in July–August 2017. L. pneumophila concentrations in Cooling Tower 785-A/2A located in SRS A-Area, stayed in the 10⁸ cells/L range despite biocide addition. During this time, other SRS cooling towers did not demonstrate this L. pneumophila increase. No significant difference was observed in the mean L. pneumophila mean concentrations for the towers (p < 0.05). There was a significant variance observed in the 285-2A/A Tower L. pneumophila results (p < 0.05). Looking to see if we could find “effects” led to model development by analyzing 13 months of water chemistry and microbial data for the main factors influencing the L. pneumophila concentrations in five cooling towers for this year. It indicated chlorine and dissolved oxygen had a significant impact (p < 0.0002) on cooling tower 785A/2A. Thus, while the variation in the log count data for the A-area tower is statistically greater than that of the other four towers, the average of the log count data for the A-Area tower was in line with that of the other towers. It was also observed that the location of 785A/2A and basin resulted in more debris entering the system during storm events. Our results suggest that future analyses should evaluate the impact of environmental conditions and cooling tower design on L. pneumophila water concentrations and human health.

Legionella pneumophila in Patients with Pneumonia at a Referral Hospital, New Delhi, India, 2015-2020

Legionnaires' disease (LD) is an established cause of pneumonia, and the disease remains largely underdiagnosed. Even though LD has been reported from many parts of the world, only sporadic cases have been reported in India. During February 2015-January 2020, we enrolled 597 patients with radiographically confirmed pneumonia and tested respiratory secretions for Legionella spp. by using real-time PCR, and culture. A commercial urinary antigen test (UAT) was also used to detect the Legionella pneumophila (Lp) serogroup 1 antigen in urine. An LD case was defined as a patient with pneumonia and positive results for Legionella spp. infections determined by real-time PCR (from any respiratory specimen) or culture or UAT. Demographic data, risk factors, clinical, radiological, and outcome data of Lp-positive and Lp-negative patients were compared using logistic regression. Over the study period, 14 (2.3%) patients were positive for Legionella spp. infections by real-time PCR and UAT; eight (57%) were admitted to the intensive care unit, and four (28.6%) in-hospital deaths occurred. Bivariate analysis showed that renal disease, neurological conditions, confusion, leukocytosis, and requirement of oxygen support were more common in the Lp-positive group than in the Lp-negative group. However, multivariate analysis failed to confirm most of these differences; renal disease was the only independent variable remaining significant. All test methods have intrinsic limitations in identifying Legionella; therefore, more than one testing method should be used. Application of molecular assays including real-time PCR has great value because of its high sensitivity, specificity, and rapid diagnostic potency. Increased awareness and improved diagnostic testing could facilitate early detection of cases, pathogen-directed therapy, and improved outcomes for patients.

CD8+ T Cells Directed Against a Peptide Epitope Derived From Peptidoglycan-Associated Lipoprotein of Legionella pneumophila Confer Disease Protection

Legionella pneumophila, an intracellular bacterium, may cause life-threatening pneumonia in immunocompromised individuals. Mononuclear cells and antibodies have been reported to be associated with the host defense response against L. pneumophila. This study is to determine whether Legionella peptidoglycan-associated lipoprotein (PAL)-specific CD8⁺ T cells are directly associated with protection against L. pneumophila, with a focus on potential epitopes. Synthetic peptides derived from PAL of L. pneumophila were obtained and tested through in vitro and in vivo cytotoxic T lymphocyte (CTL) assays for immunogenicity. PAL DNA vaccines or a peptide epitope with or without CpG-oligodeoxynucleotides (ODN) was evaluated for protection against L. pneumophila infection in animal models. When mice were immunized with DNA vaccines expressing the PAL of L. pneumophila, they were significantly protected against a lethal challenge with L. pneumophila through induction of antigen-specific CD8⁺ CTLs. Of the 13 PAL peptides tested, PAL_92-100 (EYLKTHPGA) was the most immunogenic and induced the strongest CTL responses. When mice were immunized with the PAL_92-100 peptide plus CpG-ODN, they were protected against the lethal challenge, while control mice died within 3–6 days after the challenge. Consistent with lung tissue histological data, bacterial counts in the lungs of immunized mice were significantly lower than those in control mice. Also, the amino acid sequence of PAL_92-100 peptides is conserved among various Legionella species. To our knowledge, this study is the first to demonstrate that PAL_92-100-specific CD8⁺ T cells play a central role in the host defense response against L. pneumophila.

Cost-benefit analysis of point-of-use devices for health risks reduction from pathogens in drinking water

Microbial contamination of drinking water post-municipal treatment is difficult to predict as a risk factor for human health. One method to reduce morbidity or mortality from unpredictable exposures is through point-of-use (POU) treatment devices. The goal of this project was to assess the cost-benefit of POU water treatment at the tap in terms of protection from microbes in drinking water. This project estimated: (1) incidence of acute illness (AI), sequela, and mortality associated with waterborne pathogens; (2) illness reduction rates from using POU devices; and (3) healthcare cost reductions associated with POU devices. Infection rates and costs associated with 10 of the most common waterborne pathogens were identified and used to calculate national annual costs. We estimated 9M AI, 0.6M sequela, and 1,400 mortality cases that occur annually in the USA from these pathogens. The greatest cost-benefit was seen when considering the totality of disease burden reduction (AI, sequela, and mortality) including all pathogens at a national level and applying a 35% infection reduction, resulting in a total cost per averted disease case of $1,815. This study suggests that it is cost-beneficial to prevent water-related illness using POU devices.

The mysterious illness that drove them to their knees - Ah, that Legionnaires' disease - A historical reflection of the work in Legionnaires' disease in New Zealand (1978 to mid-1990s) and the 'One Health' paradigm

And so, formed the basis for the song Legionnaires' disease (LD) composed by the legendry musician Bob Dylan shortly after this mysterious illness dramatically entered the clinical and epidemiological scene in July 1976 at an American hotel. Now more than forty years have passed since Legionella pneumophila, the causative agent of LD, was formally identified in 1977. Once the publicity associated with the outbreak subsided, there was the challenge to science and health professionals of what was an extremely complex and intriguing health concern. In the United States, the outbreak investigation that eventually solved the mystery had taken an array of surprising twists and turns. Globally, it revealed the strengths and weakness of countries' health systems in response to the outbreak from an unknown agent. Extensive international coverage of the outbreak also marked a turning point in journalism's efforts to hold officials accountable for their response to epidemics that had the potential to threaten the lives of hundreds of people. In 1979, New Zealand became an active participant in the international efforts towards increasing the understanding of infection caused by Legionella species and set up a centralized laboratory diagnostic service. By 1980 LD had become a notifiable disease making New Zealand one of the first countries globally to do so. This historical narrative in the decade or so from its recognition, provides a unique insight into how the One Health paradigm was instrumental in New Zealand's early response to LD in tandem with control strategies. The findings show that from 1979 the distribution of the Legionella species in New Zealand did not follow patterns observed in studies carried out globally.

Distribution of Virulence Genes and Sequence-Based Types Among Legionella pneumophila Isolated From the Water Systems of a Tertiary Care Hospital in India

Background: Legionnaires' disease (LD) is a potentially fatal pneumonia predominantly caused by infection due to Legionella pneumophila although more than 50 other Legionella species are described. Water systems contaminated with Legionella spp. are the implicated sources of Legionnaires' disease. In this study, we aimed to assess Legionella contamination in the water sources of a tertiary care hospital and to determine the virulence properties and molecular characteristics of L. pneumophila environmental isolates.

Methods: During May 2015 through August 2018, a total of 201 hospital water samples were tested for L. pneumophila by standardized culture procedures; environmental isolates were examined for the presence of two virulence genes: Legionella vir homolog (lvh) and repeats in structural toxin (rtxA) by PCR. The genotyping of isolates was performed by sequence-based typing (SBT) according to the protocol of the European Study Group for Legionella Infections (ESGLI).

Results:L. pneumophila was isolated from 38/201 (18.9%) water samples; among the 46 isolates, the lvh locus was present in 45 (97.8%), the rtxA locus was found in 45 (97.8%), and both loci were found in 44 (95.7%) isolates. A total of 23 sequence types (STs) were identified among the 44 isolates (index of discrimination [IOD] of 0.929), and 11/23 (47.8%) STs were new to the ESGLI database.

Conclusions: The study results showed genetic diversity in L. pneumophila isolates from the hospital environment along with a high percentage of pathogenicity loci. Besides, certain STs may have an increased ability to cause legionellosis, thus requires specific infection control and prevention strategies whenever identified.

Persistence of Legionella in Routinely Disinfected Heater-Cooler Units and Heater Units assessed by Propidium Monoazide qPCR

BACKGROUND

Evidence to date indicates that heater-cooler units (HCUs) and heater units (HUs) can generate potentially infectious aerosols containing a range of opportunistic pathogens such as Mycobacterium chimaera, other non-tuberculous mycobacterial (NTM) species, Pseudomonas aeruginosa and Legionella spp. Our purpose was to determine the extent of Legionella contamination and total viable count (TVC) in HCUs and HUs and to analyze the relationship by water system design of devices of two different brands (LivaNova vs. Maquet).

METHODS

Legionella spp. were detected and quantified by our optimized PMA-qPCR protocol; TVCs were assessed according to ISO protocol 6222. Analyses were performed in the first sampling round and after six months of surveillance.

RESULTS

Overall, Legionella spp. was detected in 65.7% of devices. In the second sampling round, Legionella positivity rates were significantly lower in water samples from the Maquet devices compared to the LivaNova ones (27.3% vs. 61.5%). LivaNova HCUs also yielded more Legionella, and aquatic bacteria counts than Maquet in both first and second-round samples.

CONCLUSIONS

We recommend that all surgical patients and staff exposed to aerosols from thermoregulatory devices should be followed up for Legionella infection and that microbiological surveillance on such devices should be conducted regularly as precautionary principle.

Roadblocks to Low Temperature District Heating

Energy usage in buildings is coming increasingly under the spotlight as carbon policy focus shifts towards the utilization of thermal energy. In the UK, heating and hot water accounts for around 40% of energy consumption and 20% of greenhouse gas emissions. Heating is typically produced onsite, making widescale carbon or energetic improvements challenging. District heating networks (DHNs) can offer significant carbon reduction for many users but can only be implemented if the end user buildings have good thermal energy efficiency. This greatly limits the ability to implement advancing 4th and 5th generation DHNs, which are the most advanced systems available. We elucidate the current state of thermal efficiency in buildings in the UK and provide recommendations for necessary building requirements and modifications in order to accommodate 4th and 5th generation district heating. We conclude that key sectors must be addressed including creating a skilled workforce, producing relevant metrics and benchmarks, and providing financial support for early stage design exploration.

Evaluation of a novel urinary antigen test kit for diagnosing Legionella pneumonia

OBJECTIVES

The aim of this study was to evaluate the diagnostic utility of a novel test kit that could theoretically detect all serogroups of Legionella pneumophila for diagnosing Legionella pneumonia, in comparison with existing kits.

METHODS

This study was conducted in 16 hospitals in Japan from April 2016 to December 2018. Three urinary antigen test kits were used: the novel kit (LAC-116), BinaxNOW Legionella (Binax), and Q-line Kyokutou Legionella (Q-line). In addition, sputum culture and nucleic acid detection tests and serum antibody tests were performed where possible. The diagnostic accuracy and correlations of the novel kit with the two existing kits were analyzed.

RESULTS

In total, 56 patients were diagnosed with Legionella pneumonia. The sensitivities of LAC-116, Binax, and Q-line were 79%, 84%, and 71%, respectively. The overall match rate between LAC-116 and Binax was 96.8% and between LAC-116 and Q-line was 96.4%. One patient had L. pneumophila serogroup 2, and only LAC-116 showed a positive result, whereas Binax and Q-line did not.

CONCLUSIONS

The novel Legionella urinary antigen test kit was useful for diagnosing Legionella pneumonia. In addition, it could detect Legionella pneumonia caused by non-L. pneumophila serogroup 1.

Sit bath systems: A new source of Legionella infection

Sit Bath Systems (SBSs) are the most common hygiene method for patients who are not self-sufficient. Therefore, the water quality of SBSs in the nosocomial environment plays a fundamental role in controlling infections for both patients and health-care workers. A long-term study on Legionella and Pseudomonas aeruginosa (P. aeruginosa) contamination was performed in SBSs (n = 20) of six Health Care Facilities (HCFs). A total of 254 water samples were analyzed following ISO procedures. The samples were positive for P. aeruginosa (46.85%) and Legionella (53.54%), respectively, both over the directive limits. Legionella isolates were identified as: Legionella pneumophila (L. pneumophila) serogroups 1, 3, and 6 and Legionella non-pneumophila species (L. anisa, L. londiniensis, L. rubrilucens, and L. nagelii). Moreover, the contamination found was studied with respect to median temperature measured (42 °C), from which two groups (A and B) could be distinguished. P. aeruginosa was found in both groups (100% of SBSs), while a higher percentage of Legionella positive samples was found in group A (75% of SBSs), compared to group B (50% of SBSs), showing how Legionella control could be carried out by using temperatures above 42 °C. An analysis of SBS water pipelines, maintenance, and disinfection treatments indicates SBSs as a new source of infection risk for both patients and health-care workers.

Interplay between bacterial deubiquitinase and ubiquitin E3 ligase regulates ubiquitin dynamics on Legionella phagosomes

Legionella pneumophila extensively modulates the host ubiquitin network to create the Legionella-containing vacuole (LCV) for its replication. Many of its virulence factors function as ubiquitin ligases or deubiquitinases (DUBs). Here, we identify Lem27 as a DUB that displays a preference for diubiquitin formed by K6, K11, or K48. Lem27 is associated with the LCV where it regulates Rab10 ubiquitination in concert with SidC and SdcA, two bacterial E3 ubiquitin ligases. Structural analysis of the complex formed by an active fragment of Lem27 and the substrate-based suicide inhibitor ubiquitin-propargylamide (PA) reveals that it harbors a fold resembling those in the OTU1 DUB subfamily with a Cys-His catalytic dyad and that it recognizes ubiquitin via extensive hydrogen bonding at six contact sites. Our results establish Lem27 as a DUB that functions to regulate protein ubiquitination on L. pneumophila phagosomes by counteracting the activity of bacterial ubiquitin E3 ligases.

Case report: fatal pneumonia caused by new sequence type Legionella pneumophilia serogroup 1

INTRODUCTION

Legionnaires' disease is caused by Legionella bacteria, and commonly manifests as pneumonia and has a high fatality rate.

PATIENT CONCERNS

This case study reports on the fatal incident of a patient, initially diagnosed with pneumonia, and subsequently diagnosed with Legionnaires' disease caused by a new sequence type (ST) of Legionella.

DIAGNOSIS

It is speculated that the patient acquired Legionnaires' disease from a contaminated water source. Legionnaires' disease was diagnosed using the Legionella urinary antigen assay and bacterial cultures of respiratory secretions; Legionella pneumophilia Type 1 was also identified through serological testing. Sequence-based typing of the cultured bacterium revealed it to be a previously unidentified species, and it was named ST2345 new-type.

INTERVENTIONS

In addition to the treatment of Legionnaires' disease, blood samples taken on the second day of admission showed a co-infection of Candida tropicalis, which was treated with anti-fungal treatment. The patient improved after a week, however, on the seventh day of administration lower respiratory secretions showed the growth of Klebsiella pneumonia, indicative of ventilator-associated pneumonia.

OUTCOMES

Despite active treatment, the patient passed away due to multiple organ failure. As this was a fatal case, further research is needed to determine whether the critical condition of this case was related to the virulence of the novel Legionella strain.

CONCLUSION

A key finding of this study is that treatment for suspected Legionnaires' disease must be administered rapidly, as infection with Legionella may give rise to secondary pathogenic infections.

Enhancement of Culture of Legionella longbeachae from Respiratory Samples by Use of Immunomagnetic Separation and Antimicrobial Decontamination

Legionella longbeachae is the commonest Legionella species identified in patients with community-acquired pneumonia in New Zealand. Isolation of the organism on culture is the gold standard for the diagnosis of Legionnaires disease, but it has poor sensitivity (40%) compared with quantitative PCR (qPCR). We have developed a selective decontamination process using glycine, vancomycin, polymyxin, and cycloheximide (GVPC) with immunomagnetic separation (IMS) for culturing L. longbeachae A polyclonal antibody specific for L. longbeachae was produced from New Zealand White rabbits and coupled to tosyl-activated magnetic beads. Stored L. longbeachae qPCR-positive respiratory samples were retrieved from -80°C storage for testing. One portion of test samples was mixed with GVPC and the antibody bead complex, separated, washed, and cultured on modified Wadowsky and Yee agar (MWY) agar. Another portion was exposed to HCl-KCl acidic buffer (pH 2.2) before incubation on MWY agar. qPCR used probes specific for the ITS (internal transcribed spacer) region of the L. longbeachae genome. Cultures were positive in 10/53 (19%) samples after acid wash and 26/53 (49%) after GVPC-IMS (P = 0.001). Growth of contaminants was rare. The mean qPCR threshold cycle values were lower in culture-positive samples after acid wash than in the culture-negative samples (mean, 29.9 versus 34.8; difference, 4.9; 95% confidence interval [CI], ±2.9; P = 0.001) but not after GVPC-IMS (mean, 33.0 versus 34.7; difference, 1.7; 95% CI, ±2.48; P = 0.16). The sensitivity of culture for L. longbeachae in respiratory specimens may be improved by using GVPC-IMS rather than acid wash for decontamination, but this should be confirmed in a prospective study of fresh specimens.

Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience

CONTEXT

The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories.

PROGRAM

The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations.

IMPLEMENTATION

Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness.

EVALUATION

It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program.

DISCUSSION

Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

Isolation and identification of Legionella spp. from hot spring water in Algeria by culture and molecular methods

AIMS

Due to infectious risk associated with the presence of Legionella in warm water, we determined the prevalence of living Legionella spp. in hot spring water in Algeria.

METHODS AND RESULTS

Detection of Legionella by culture was done by using two methods, direct culture on agar plates and co-culture with amoeba. Fifty samples were taken from different hot springs in northern Algeria, including swimming pools, showers and thermal sources. Legionella pneumophila serotypes were predominant, accounting for 60% of positive samples. Direct method allowed the isolation of 13 L. pneumophila only of 50 samples (26%), whereas co-culture using a panel of three free living amoeba allowed the isolation of 119 Legionella species from the same samples (80%) CONCLUSIONS: Amoeba co-culture allowed the isolation of several Legionella sp., while direct culture allowed the isolation of L. pneumophila only. Remarkably, Legionella longbeachae, usually isolated from soil and compost, was isolated for the first time in thermal water in three samples using Vermamoeba vermiformis co-culture.

SIGNIFICANCE AND IMPACT OF THE STUDY

The presence of Legionella in the water of hot springs in Algeria, which are mainly frequented by individuals at risk of Legionellosis, requires urgent control measures.

Identification of differentially expressed Legionella genes during its intracellular growth in Acanthamoeba

Legionella grows intracellularly in free-living amoeba as well as in mammalian macrophages. Until now, the overall gene expression pattern of intracellular Legionella in Acanthamoeba was not fully explained. Intracellular bacteria are capable of not only altering the gene expression of its host, but it can also regulate the expression of its own genes for survival. In this study, differentially expressed Legionella genes within Acanthamoeba during the 24 h intracellular growth period were investigated for comparative analysis. RNA sequencing analysis revealed 3,003 genes from the intracellular Legionella. Among them, 115 genes were upregulated and 1,676 genes were downregulated more than 2 fold compared to the free Legionella. Gene ontology (GO) analysis revealed the suppression of multiple genes within the intracellular Legionella, which were categorized under 'ATP binding' and 'DNA binding' in the molecular function domain. Gene expression of alkylhydroperoxidase, an enzyme involved in virulence and anti-oxidative stress response, was strongly enhanced 24 h post-intracellular growth. Amino acid ABC transporter substrate-binding protein that utilizes energy generation was also highly expressed. Genes associated with alkylhydroperoxidase, glucose pathway, and Dot/Icm type IV secretion system were shown to be differentially expressed. These results contribute to a better understanding of the survival strategies of intracellular Legionella within Acanthamoeba.

Legionnaires' Disease on the Rise in Switzerland: A Denominator-Based Analysis of National Diagnostic Data, 2007-2016

The risk of falling ill with Legionnaires' disease (LD) is suggested to increase, but the global burden of disease is unknown due to a lack of appropriate diagnosis and surveillance systems. In Switzerland, the number of LD cases, captured by the National Notification System for Infectious Diseases, has more than doubled since 2008. This study aims to investigate this increase, contextualizing disease surveillance data with denominator data, which is not routinely available, i.e., the number of tests performed for Legionella spp. We collected the testing data for Legionella spp. of 14 Swiss diagnostic laboratories and calculated the positivity, defined as the proportion of the number of positive tests to the number of tests performed. The number of positive tests increased proportionally to the number of tests performed; hence, the positivity remained stable. However, the cause of the increase in test volume is unclear and has a large impact on the interpretation of the positivity curve. Further, the test outcome was found to be dependent on regional determinants, and the diagnostic method applied. The lack of understanding if and at which stage LD is considered in current case management of pneumonia patients limits the interpretation of observed heterogeneities in incidence or underestimation of LD in Switzerland. The absence of (or non-adherence to) existing guidelines and the heterogeneity in diagnostic testing hampers the comparison of data in the Swiss public health context. Therefore, diagnostic procedures should be harmonised across Switzerland and adherence to national LD management guidelines supported.

Corroding copper and steel exposed to intermittently flowing tap water promote biofilm formation and growth of Legionella pneumophila

The information about the impact of copper pipes on the growth of Legionella pneumophila in premise plumbing is controversial. For this reason, pipe segments of copper, stainless steel (SS), mild steel (MS), polyethylene, chlorinated polyvinylchloride (CPVC) and glass (controls) were exposed to intermittently flowing (20 min stagnation time) nonchlorinated tap water of 37 °C or 16 °C (ambient temperature) during six months to study the impact of metals on biofilm formation and growth of L. pneumophila. Biofilm concentrations (BfC, measured as ATP) on copper were 3 (at 37 °C) to 6 (at 16 °C) times higher than on SS. The maximum colony counts of L. pneumophila on the materials tested at 37 °C showed a quadratic relationship with the associated BfCs, with highest values on copper and MS. The average Cu concentration on the glass control of copper (glass-copper) was more than two log units lower than the Fe concentration on glass-MS, suggesting that copper released less corrosion by-products than MS. The release of corrosion by-products with attached biomass from MS most likely enhanced biofilm formation on glass-MS. Cloning and 16S RNA gene sequence analysis of the predominating biofilm bacteria revealed that an uncultured Xanthobacteraceae bacterium and Reyranella accounted for 75% of the bacterial community on copper at 37 °C. The nitrite-oxidizing Nitrospira moscoviensis, which can also utilize hydrogen (H₂) and formate, accounted for >50% of the bacterial abundance in the biofilms on MS and glass-MS at 37 °C. The predominating presence of the strictly anaerobic non-fermentative Fe(III)-reducing Geobacter and the Fe(II)-oxidizing Gallionella on MS exposed to tap water of 16 °C indicated anoxic niches and the availability of H₂, low molecular weight carboxylic acids (LMWCAs) and Fe(II) at the MS surface. LMWCAs likely also promoted bacterial growth on copper, but the release mechanisms from natural organic matter at the surface of corroding metals are unclear. The effects of water stagnation time and flow dynamics on biofilm formation on copper requires further investigation.

Required water temperature in hotel plumbing to control Legionella growth

Legionella spp. occurring in hotel hot water systems, in particular Legionella pneumophila, are causing serious pneumonic infections, and water temperature is a key factor to control their occurrence in plumbing systems. We performed a systematic review and meta-analyses of the available evidence on the association between water temperature and Legionella colonization to identify the water temperature in hotel hot water systems required for control of Legionella. Qualitative synthesis and quantitative analysis were performed on 13 studies that met our inclusion criteria to identify the effect of temperature. The Receiver Operating Characteristic (ROC) curve identified 55 °C as a cutoff point for hotel hot water temperature with an Area Under the Curve (AUC) value of 0.914. The odds ratios (OR) for detecting Legionella at temperatures >55 °C compared to lower temperatures from a meta-analysis of three studies was 0.17 [95% CI: 0.11, 0.25], which indicates a strong negative association between temperature and Legionella colonization. A logistic regression on results from multiple studies using both molecular and culture methods found a temperature of 59 °C associated with an 8% probability of detectable Legionella. Only two studies reported sufficiently detailed data to allow a model of concentration vs. temperature to be fit, and this model was not statistically significant. Additional research or more detailed reporting of existing datasets is required to assess if Legionella growth can be limited below particular concentration targets at different temperatures.

Legionella pneumophila Infection Rewires the Acanthamoeba castellanii Transcriptome, Highlighting a Class of Sirtuin Genes

Legionella pneumophila is an environmental bacterium that has evolved to survive predation by soil and water amoebae such as Acanthamoeba castellanii, and this has inadvertently led to the ability of L. pneumophila to survive and replicate in human cells. L. pneumophila causes Legionnaire's Disease, with human exposure occurring via the inhalation of water aerosols containing both amoebae and the bacteria. These aerosols originate from aquatic biofilms found in artifical water sources, such as air-conditioning cooling towers and humidifiers. In these man-made environments, A. castellanii supports L. pneumophila intracellular replication, thereby promoting persistence and dissemination of the bacteria and providing protection from external stress. Despite this close evolutionary relationship, very little is known about how A. castellanii responds to L. pneumophila infection. In this study, we examined the global transcriptional response of A. castellanii to L. pneumophila infection. We compared A. castellanii infected with wild type L. pneumophila to A. castellanii infected with an isogenic ΔdotA mutant strain, which is unable to replicate intracellularly. We showed that A. castellanii underwent clear morphological and transcriptional rewiring over the course of L. pneumophila infection. Through improved annotation of the A. castellanii genome, we determined that these transcriptional changes primarily involved biological processes utilizing small GTPases, including cellular transport, signaling, metabolism and replication. In addition, a number of sirtuin-encoding genes in A. castellanii were found to be conserved and upregulated during L. pneumophila infection. Silencing of sirtuin gene, sir6f (ACA1_153540) resulted in the inhibition of A. castellanii cell proliferation during infection and reduced L. pneumophila replication. Overall our findings identified several biological pathways in amoebae that may support L. pneumophila replication and A. castellanii proliferation in environmental conditions.

Potent T-cell mediated immune response against Legionella pneumophila in mice following vaccination with detoxified lipopolysaccharide non-covalently combined with recombinant flagellin A and peptidoglycan-associated lipoprotein

BACKGROUND

Legionella pneumophila is a Gram-negative intracellular bacterium and the cause of an atypical pneumonia in humans - legionnaire's disease. Immunological assessment of bacterial antigens clarifies the way that host may develop protection against the pathogen. Lipopolysaccharide (LPS) is the main antigen of Gram-negative bacteria but is less studied because of its carbohydrate nature. Here, we immunized mice with detoxified LPS in combination with immunogenic proteins and looked into the result of bacterial challenge.

METHODS

LPS of L. pneumophila was extracted by hot phenol-water method. Purified LPS was detoxified by sodium hydroxide alkaline procedure. BALB/c mice were immunized mainly with non-covalent combination of detoxified LPS (dLPS) and either of recombinant FlaA or PAL separately. Afterwards, specific serum IgG was assessed by ELISA. Mice were challenged intravenously with sublethal dose of L. pneumpphila then splenocytes were cultured. Cytokine responses of splenocytes were analyzed by ELISA.

RESULTS

Polysaccharide antigen did not elicit significant serum IgG. Combination of the dLPS with recombinant FlaA and PAL led to risen IgG and its subclasses (IgG1, IgG2a and IgG2b) against polysaccharide. Mice immunized with combination of the dLPS and recombinant proteins showed significant elevation of cytokine responses in splenocyte culture after being challenged with L. pneumophila.

CONCLUSIONS

Our results suggest that combination of polysaccharide antigen derived from Legionella LPS may confer raised cell-mediated responses against the pathogen when combined with Th-1 stimulating protein antigens. Although not covalently bond, Legionella detoxified LPS combination with recombinant FlaA and PAL effectively elicited Th-1 type cytokines and humoral responses against L. pneumophila in BALB/c mice.

Parasite-bacteria interrelationship

Parasites and bacteria have co-evolved with humankind, and they interact all the time in a myriad of ways. For example, some bacterial infections result from parasite-dwelling bacteria as in the case of Salmonella infection during schistosomiasis. Other bacteria synergize with parasites in the evolution of human disease as in the case of the interplay between Wolbachia endosymbiont bacteria and filarial nematodes as well as the interaction between Gram-negative bacteria and Schistosoma haematobium in the pathogenesis of urinary bladder cancer. Moreover, secondary bacterial infections may complicate several parasitic diseases such as visceral leishmaniasis and malaria, due to immunosuppression of the host during parasitic infections. Also, bacteria may colonize the parasitic lesions; for example, hydatid cysts and skin lesions of ectoparasites. Remarkably, some parasitic helminths and arthropods exhibit antibacterial activity usually by the release of specific antimicrobial products. Lastly, some parasite-bacteria interactions are induced as when using probiotic bacteria to modulate the outcome of a variety of parasitic infections. In sum, parasite-bacteria interactions involve intricate processes that never cease to intrigue the researchers. However, understanding and exploiting these interactions could have prophylactic and curative potential for infections by both types of pathogens.

Insight into natural inhibitors and bridging docking to dynamic simulation against sugar Isomerase (SIS) domain protein

The pathogen Legionella longbeachae is a causative agent of legionellosis. The antibiotic resistance is the major problem of this modern world. Thus, selective pressure warrants the need for identification of newer drug target. In current study, subtractive proteomics approach screen out SIS (sugar isomerase) domain protein as an attractive receptor molecule for rational drug design. This protein is involved in lipopolysaccharide biosynthesis and catalyzes the isomerization of sedoheptulose 7-phosphate in D-glycero-D-manno-heptose 7-phosphate. Molecular docking revealed compound 1 (2-(6-(N,N-dimethyl sulfamoyl)pipridin-4-yl)pyrazin-2-yl)imidazol-3-ium-1-ide) as the potent inhibitor having GOLD fitness score of 69. The complex is affirmed by half-site effect via simulation analysis. Complex stability was investigated via several approaches that follows dynamic simulation and binding energies. Trajectory analysis revealed slight change in ring positioning of inhibitor inside the active pocket during 130 ns (nanosecond). Interestingly, it was affirmed via binding interactions' density distribution. Hence, radial distribution function (RDF) inferred that SER55 and SER83 are the major residues that take part in hydrogen bonding and complex stability. Furthermore, an indigenously developed method axial frequency distribution (AFD) has revealed that ligand moved closer to the active site with both the residues SER55 and SER83 binding to the ligand. The phenomena was observed via rotating motion with respect to receptor center cavity. Thus, inhibitor movement towards allosteric site was observed at the end of simulations. Finally, binding free energy calculations by MMPB/GBSA predicts high compound affinity for the complex. Hence, findings from the current study will aid in the novel drug discovery and future experimental studies. Graphical abstract.

Cationic Porphyrins as Effective Agents in Photodynamic Inactivation of Opportunistic Plumbing Pathogen Legionella pneumophila

Legionella pneumophila is an environmental bacterium, an opportunistic premise plumbing pathogen that causes the Legionnaires’ disease. L. pneumophila presents a serious health hazard in building water systems, due to its high resistance to standard water disinfection methods. Our aim was to study the use of photodynamic inactivation (PDI) against Legionella. We investigated and compared the photobactericidal potential of five cationic dyes. We tested toluidine blue (TBO) and methylene blue (MB), and three 3-N-methylpyridylporphyrins, one tetra-cationic and two tri-cationic, one with a short (CH₃) and the other with a long (C₁₇H₃₅) alkyl chain, against L. pneumophila in tap water and after irradiation with violet light. All tested dyes demonstrated a certain dark toxicity against L. pneumophila; porphyrins with lower minimal effective concentration (MEC) values than TBO and MB. Nanomolar MEC values, significantly lower than with TBO and MB, were obtained with all three porphyrins in PDI experiments, with amphiphilic porphyrin demonstrating the highest PDI activity. All tested dyes showed increasing PDI with longer irradiation (0–108 J/cm²), especially the two hydrophilic porphyrins. All three porphyrins caused significant changes in cell membrane permeability after irradiation and L. pneumophila, co-cultivated with Acanthamoeba castellanii after treatment with all three porphyrins and irradiation, did not recover in amoeba. We believe our results indicate the considerable potential of cationic porphyrins as effective anti-Legionella agents.