1
|
Yao XH, Shen F, Hao J, Huang L, Keng B. A review of Legionella transmission risk in built environments: sources, regulations, sampling, and detection. Front Public Health 2024; 12:1415157. [PMID: 39131570 PMCID: PMC11309999 DOI: 10.3389/fpubh.2024.1415157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/08/2024] [Indexed: 08/13/2024] Open
Abstract
The risk of Legionella transmission in built environments remains a significant concern. Legionella can spread within buildings through aerosol transmission, prompting the exploration of airborne transmission pathways and proposing corresponding prevention and control measures based on building characteristics. To this end, a comprehensive literature review on the transmission risk of Legionella in built environments was performed. Four electronic databases (PubMed, Web of Science, Google Scholar, and CNKI) were searched from inception to March 2024 for publications reporting the risk of Legionella transmission in built environments. Relevant articles and gray literature reports were hand-searched, and 96 studies were finally included. Legionella pollution comes from various sources, mainly originates in a variety of built environments in which human beings remain for extended periods. The sources, outbreaks, national standards, regulations, and monitoring techniques for Legionella in buildings are reviewed, in addition to increases in Legionella transmission risk due to poor maintenance of water systems and long-distance transmission events caused by aerosol characteristics. Air and water sampling using various analytical methods helps identify Legionella in the environment, recognize sources in the built environments, and control outbreaks. By comparing the standard regulations of national organizations globally, the authors further highlight gaps and deficiencies in Legionella surveillance in China. Such advancements offer essential insights and references for understanding and addressing Legionella transmission risk in the built environment, with the potential to contribute to safeguarding public health and building environment safety.
Collapse
Affiliation(s)
- Xiao Hui Yao
- Department of Environmental Health, Beijing Center for Disease Prevention and Control, Beijing, China
| | - Fan Shen
- Department of Environmental Health, Beijing Center for Disease Prevention and Control, Beijing, China
| | - Jing Hao
- Department of Environmental Health, Beijing Fengtai District Center for Disease Prevention and Control, Beijing, China
| | - Lu Huang
- Department of Environmental Health, Beijing Dongcheng District Center for Disease Prevention and Control, Beijing, China
| | - Bin Keng
- Department of Environmental Health, Beijing Huairou District Center for Disease Prevention and Control, Beijing, China
| |
Collapse
|
2
|
Ortí-Lucas RM, Luciano E. New immunomagnetic separation method to analyze risk factors for Legionella colonization in health care centres. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2022; 32:744-750. [PMID: 35264765 PMCID: PMC8906530 DOI: 10.1038/s41370-022-00421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND It's pivotal to control the presence of legionella in sanitary structures. So, it's important to determine the risk factors associated with Legionella colonization in health care centres. In recent years that is why new diagnostic techniques have been developed. OBJECTIVE To evaluate risks factors for Legionella colonization using a novel and more sensitive Legionella positivity index. METHODS A total of 204 one-litre water samples (102 cold water samples and 102 hot water samples), were collected from 68 different sampling sites of the hospital water system and tested for Legionella spp. by two laboratories using culture, polymerase chain reaction and a method based on immunomagnetic separation (IMS). A Legionella positivity index was defined to evaluate Legionella colonization and associated risk factors in the 68 water samples sites. We performed bivariate analyses and then logistic regression analysis with adjustment of potentially confounding variables. We compared the performance of culture and IMS methods using this index as a new gold standard to determine if rapid IMS method is an acceptable alternative to the use of slower culture method. RESULTS Based on the new Legionella positivity index, no statistically significant differences were found neither between laboratories nor between methods (culture, IMS). Positivity was significantly correlated with ambulatory health assistance (p = 0.05) and frequency of use of the terminal points. The logistic regression model revealed that chlorine (p = 0.009) and the frequency of use of the terminal points (p = 0.001) are predictors of Legionella colonization. Regarding this index, the IMS method proved more sensitive (69%) than culture method (65.4%) in hot water samples. SIGNIFICANCE We showed that the frequency of use of terminal points should be considered when examining environmental Legionella colonization, which can be better evaluated using the provided Legionella positivity index. This study has implications for the prevention of Legionnaires' disease in hospital settings.
Collapse
Affiliation(s)
- Rafael Manuel Ortí-Lucas
- Research group on Public Health and Patient Safety, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain.
- Department of Preventive Medicine, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - Eugenio Luciano
- Department of Preventive Medicine, Hospital Clínico Universitario de Valencia, Valencia, Spain.
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain.
| |
Collapse
|
3
|
Bavari S, Mirkalantari S, Masjedian Jazi F, Darban-Sarokhalil D, Golnari Marani B. Risk assessment and quantitative measurement along with monitoring of Legionella in hospital water sources. New Microbes New Infect 2022; 45:100948. [PMID: 35399198 PMCID: PMC8984627 DOI: 10.1016/j.nmni.2021.100948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/21/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Legionella spp. as a causative agent of Legionnaires' disease (LD) and an opportunistic pathogen creates a public health problem. Isolation and quantification of this bacteria from clinic water sources are essential for hazard appraisal and sickness avoidance. This study aimed at risk assessment and quantitative measurement along with Legionella monitoring in educational hospital water sources in Tehran, Iran. A cross-sectional study was carried out in 1 year. The conventional culture method was used in this study to isolate Legionella from water samples. The polymerase chain reaction (PCR) technique was used to confirm the identity of the isolates and ensure that they were all Legionella. Quantitative PCR (qPCR) was used to determine the count of bacteria, and HeLa cell culture was used to determine the invasion of isolates. A total of 100 water samples were collected and inoculated on GVPC (glycine, vancomycin, polymyxin, and cycloheximide) agar; 12 (12%) and 42 (42%) cases were culture and PCR positive, respectively. Percentage of Legionella presence in PCR-positive samples by the qPCR method in <103 GU/L, in about 103 and lower than 104 GU/L, and in 104 GU/L was 40.47 (17 cases), 4.76% (two cases), and 54.76% (23 cases), respectively. Invasion analysis revealed that five and four isolates had invaded HeLa cells more than twice and equally, respectively, and the others had a lower invasion than the reference strain. The findings revealed that the spread of LD in hospitals was linked to the water system. Given the importance of nosocomial infections in the medical community, establishing a hospital water monitoring system is the most effective way to control these infections, particularly Legionella infections.
Collapse
|
4
|
Bagheri H, Khaledi A, Ghanizadeh G, Esmaeili D. Efficacy of PCR Analysis of Mip, Doth and Gspd Genes with Culture in Detection of Legionella pneumophila. IRANIAN JOURNAL OF PUBLIC HEALTH 2021; 50:1079-1081. [PMID: 34183971 PMCID: PMC8223580 DOI: 10.18502/ijph.v50i5.6130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Hamid Bagheri
- Department of Microbiology and Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Azad Khaledi
- Infectious Diseases Research Center, Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Ghader Ghanizadeh
- Health School, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Davoud Esmaeili
- Department of Microbiology and Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| |
Collapse
|
5
|
Understanding the distribution of positiveLegionellasamples in healthcare-premise water systems: Using statistical analysis to determine a distribution forLegionellaand to support sample size recommendations. Infect Control Hosp Epidemiol 2020; 42:63-68. [DOI: 10.1017/ice.2020.384] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To significantly fit a statistical distribution to the proportion of positiveLegionellasamples in a series of water samples from multiple facility-premise water systems.Design:Statistical fit test.Setting:A hospital and associated long-term care facility (LTCF) in New York State, as well as temporal and culture data from a deidentified hospital site supplied by one of the vendor laboratories.Methods:Culture samples (n = 1,393) were segmented into 139 test cycles with roughly 10 samples in each. The proportion of positive samples was standardized to 25 total samples per test to give a distribution of discrete values. These values were analyzed for fit with the following discrete distributions: Poisson, negative binomial, geometric, and zero-inflated Poisson.Results:The zero-inflated Poisson distribution fitted to the copper–silver ionization (CSI)-treated and untreated test cycles indicates that 88% of the expected positive proportions should occur by the 30% cutoff (rounded up to 8 positive samples among 25 total samples), similar to the 93% expectation for just CSI-treated test cycles. The other treatment in these data (chlorine dioxide) was not effective in treatingLegionellain the sampled buildings, and if there is an underlying distribution to these specific test cycles, it is not the zero-inflated Poisson distribution.Conclusions:In a well-maintained or well-treated premise water distribution system, ~30% or lower proportion of positiveLegionellasamples should occur. Anything above that cutoff is either very unlikely or not expected at all and indicates a problem in the water system.
Collapse
|
6
|
Burillo A, Pedro-Botet ML, Bouza E. Microbiology and Epidemiology of Legionnaire's Disease. Infect Dis Clin North Am 2017; 31:7-27. [PMID: 28159177 DOI: 10.1016/j.idc.2016.10.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Legionnaire's disease (LD) is the pneumonic form of legionellosis caused by aerobic gram-negative bacilli of the genus Legionella. Individuals become infected when they inhale aerosolized water droplets contaminated with Legionella species. Forty years after the identification of Legionella pneumophila as the cause of the 1976 pneumonia outbreak in a hotel in Philadelphia, we have non-culture-based diagnostic tests, effective antibiotics, and preventive measures to handle LD. With a mortality rate still around 10%, underreporting, and sporadic outbreaks, there is still much work to be done. In this article, the authors review the microbiology, laboratory diagnosis, and epidemiology of LD.
Collapse
Affiliation(s)
- Almudena Burillo
- Division of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
| | - María Luisa Pedro-Botet
- Infectious Diseases Unit, Hospital Universitario German Trías i Pujol, Carretera de Canyet s/n, 08916 Badalona, Spain; Departamento de Medicina, Area de Medicina, Universidad Autónoma de Barcelona, Plaza Cívica, Campus de la UAB, 08193 Bellaterra, Sardañola del Vallés (Barcelona), Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/1089), Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellón 11, 28029 Madrid, Spain
| | - Emilio Bouza
- Division of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellón 11, 28029 Madrid, Spain.
| |
Collapse
|
7
|
Agarwal S, Abell V, File TM. Nosocomial (Health Care–Associated) Legionnaire's Disease. Infect Dis Clin North Am 2017; 31:155-165. [DOI: 10.1016/j.idc.2016.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
8
|
Hung TL, Li MC, Wang LR, Liu CC, Li CW, Chen PL, Syue LS, Lee NY, Ko WC. Legionnaires' disease at a medical center in southern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 51:352-358. [PMID: 28094205 DOI: 10.1016/j.jmii.2016.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/03/2016] [Accepted: 08/08/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE Legionella pneumophila had been recognized as a pathogen for both healthcare-associated and community-acquired pneumonia. We aimed to evaluate clinical features and outcomes of patients with Legionnaires' disease at a tertiary medical center in southern Taiwan. METHODS From January 2005 to December 2013, a retrospective study of adult cases of Legionnaires' disease was conducted in a 1200-bed tertiary hospital. Their medical records were reviewed for further evaluation and analysis. RESULTS A total of 61 cases of Legionnaires' disease were identified during the study period. Their mean age was 61.1 years, with male predominance (43, 70.5%). Among them, 30 (49.2%) had healthcare-associated pneumonia (HCAP), 20 (32.8%) had community-acquired pneumonia, and notably 11 (18.0%) were caregivers. Patients with healthcare-associated pneumonia tend to have higher Charlson comorbidity scores than those with community-acquired pneumonia (3.6±2.4 vs. 1.9±1.9, p=0.008) and caregivers (0.5±0.5, p<0.001). Six patients died, resulting in an in-hospital mortality rate of 9.8%. Underlying cancer (66.7% vs. 20.0%, p=0.028) and a higher Charlson comorbidity score (4.7±2.6 vs. 2.2±2.2, p=0.013) were related to a fatal outcome. CONCLUSION L. pneumophila remains an important pathogen for pneumonia acquired from the community or associated with healthcare facility. Healthy caregivers may potentially be at risk for Legionella infection in certain clinical settings.
Collapse
Affiliation(s)
- Tzu-Lun Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Li-Rong Wang
- Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ching-Chuan Liu
- Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| |
Collapse
|
9
|
Almeida D, Cristovam E, Caldeira D, Ferreira JJ, Marques T. Are there effective interventions to prevent hospital-acquired Legionnaires' disease or to reduce environmental reservoirs of Legionella in hospitals? A systematic review. Am J Infect Control 2016; 44:e183-e188. [PMID: 27524259 DOI: 10.1016/j.ajic.2016.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/21/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Legionnaires' disease (LD) is recognized as an important hospital-acquired disease. Despite the several methods available, the optimal method to control hospital-acquired LD is not well established and their overall efficacy requires further evaluation. OBJECTIVE To systematically review all controlled trials evaluating the efficacy of interventions to prevent hospital-acquired LD in patients at high risk of developing the disease and its effects on environmental colonization. METHODS A database search was performed through PubMed and the Cochrane Central Register of Controlled Trials (inception-November 2014). Eligible studies included all controlled studies evaluating interventions to prevent hospital-acquired LD in patients at high risk or evaluating the effect on environmental colonization. Both individual and pooled risk estimates were reported using risk ratio (RR) and 95% confidence intervals (95% CIs). RESULTS There were no studies evaluating the risk reduction in hospital-acquired LD, but 4 studies evaluated the influence of copper-silver ionization and ultraviolet light in the reduction of environmental reservoirs of Legionella. The meta-analysis showed a significant 95% risk reduction of Legionella positivity in environmental samples using copper-silver ionization (RR, 0.05; 95% CI, 0.01-0.17) and 97% risk reduction with ultraviolet light (RR, 0.03; 95% CI, 0.002-0.41). CONCLUSIONS The best available evidence suggests that copper-silver ionization and ultraviolet light are effective in reducing Legionella positivity in environmental samples. Nevertheless, the low quality of evidence weakens the robustness of conclusions.
Collapse
|
10
|
Legionella and risk management in hospitals—A bibliographic research methodology for people responsible for built environment and facility management. Int J Hyg Environ Health 2016; 219:890-897. [DOI: 10.1016/j.ijheh.2016.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/27/2016] [Accepted: 07/01/2016] [Indexed: 01/06/2023]
|
11
|
Ghanizadeh G, Mirmohamadlou A, Esmaeli D. Predictive parameters of Legionella pneumophila occurrence in hospital water: HPCs and plumbing system installation age. ENVIRONMENTAL MONITORING AND ASSESSMENT 2016; 188:536. [PMID: 27573071 DOI: 10.1007/s10661-016-5554-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/24/2016] [Indexed: 06/06/2023]
Abstract
Occurrence of Legionella pneumophila can be relevant to the installation age and the presence of heterotrophic plate counts (HPCs). This research illustrates L. pneumophila contamination of hospital water in accordance with the installation age and the presence of HPCs. One hundred and fifty samples were collected from hot and cold water systems and cultured on R2A and BCYE agar. L. pneumophila identification was done via specific biochemical tests. HPCs and L. pneumophila were detected in 96 and 37.3 % of the samples, respectively. The mean of HPCs density was 947 ± 998 CFU/ml; therefore, 52 % of the samples had higher densities than 500 CFU/ml. High densities of HPCs (>500 CFU/ml) led to colonization of L. pneumophila (≥1000 CFU/ml), mainly observed in cooling systems, gynecological, sonography, and NICU wards. Chi(2) test demonstrated that higher densities (>500 CFU/ml) of HPCs and L. pneumophila contamination in cold water were more frequent than warm water (OR: 2.3 and 1.49, respectively). Univariate regressions implied a significant difference between HPCs density and installation age in positive and negative tests of L. pneumophila (OR = 1.1, p < 0.001, OR = 1.2, p < 0.001). Mann-Whitney U test implied the significant effects of HPCs and installation age on L. pneumophila occurrences (p < 0.001). Spearman correlation and multivariate linear regression revealed significant differences between L. pneumophila and HPCs densities (r s = 0.33, p < 0.001 and ß = 0.11, p = 0.02), but nonsignificant difference with installation age (r s = 0.33, p < 0.001 and ß = 0.0, p = 0.91). The occurrence of L. pneumophila, HPCs, and installation age are relevant; so, plumbing system renovation with appropriate materials and promotion of the effective efforts for hospital's water quality assurance is highly recommended.
Collapse
Affiliation(s)
- Ghader Ghanizadeh
- Environmental Health Department, Health School, Baqiyatallah University of Medical Sciences, South Sheykhbahaee Ave, Nosrat Alley, Tehran, Iran.
| | - Ali Mirmohamadlou
- Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Davoud Esmaeli
- Medical Bacteriology Department, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| |
Collapse
|
12
|
Culture positivity and bacterial burden thresholds for Legionella in hospital water: Proceed with caution. Am J Infect Control 2016; 44:730. [PMID: 26851195 DOI: 10.1016/j.ajic.2015.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/23/2022]
|
13
|
Abstract
Since first identified in early 1977, bacteria of the genus Legionella are recognised as a common cause of community-acquired pneumonia and a rare cause of hospital-acquired pneumonia. Legionella bacteria multisystem manifestations mainly affect susceptible patients as a result of age, underlying debilitating conditions, or immunosuppression. Water is the major natural reservoir for Legionella, and the pathogen is found in many different natural and artificial aquatic environments such as cooling towers or water systems in buildings, including hospitals. The term given to the severe pneumonia and systemic infection caused by Legionella bacteria is Legionnaires' disease. Over time, the prevalence of legionellosis or Legionnaires' disease has risen, which might indicate a greater awareness and reporting of the disease. Advances in microbiology have led to a better understanding of the ecological niches and pathogenesis of the condition. Legionnaires' disease is not always suspected because of its non-specific symptoms, and the diagnostic tests routinely available do not offer the desired sensitivity. However, effective antibiotics are available. Disease notification systems provide the basis for initiating investigations and limiting the scale and recurrence of outbreaks. This report reviews our current understanding of this disease.
Collapse
Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, NY, USA; School of Medicine, State University of New York, Stony Brook, NY, USA.
| | - Almudena Burillo
- Division of Clinical Microbiology and Infectious Disease, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - Emilio Bouza
- Division of Clinical Microbiology and Infectious Disease, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| |
Collapse
|
14
|
Bartley PB, Ben Zakour NL, Stanton-Cook M, Muguli R, Prado L, Garnys V, Taylor K, Barnett TC, Pinna G, Robson J, Paterson DL, Walker MJ, Schembri MA, Beatson SA. Hospital-wide Eradication of a NosocomialLegionella pneumophilaSerogroup 1 Outbreak. Clin Infect Dis 2015; 62:273-279. [DOI: 10.1093/cid/civ870] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 09/18/2015] [Indexed: 12/11/2022] Open
|
15
|
Dziewulski DM, Ingles E, Codru N, Strepelis J, Schoonmaker-Bopp D. Use of copper-silver ionization for the control of legionellae in alkaline environments at health care facilities. Am J Infect Control 2015; 43:971-6. [PMID: 26149750 DOI: 10.1016/j.ajic.2015.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 05/12/2015] [Accepted: 05/12/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are multiple treatment options for the control of legionellae in premise hot water systems. Water chemistry plays a role in the efficacy of these treatments and should be considered when selecting a treatment. This study demonstrated the efficacy of copper-silver ionization (CSI) under alkaline water conditions in 2 health care facilities. METHODS Monitoring for copper (Cu) and silver (Ag) ions was performed, and the corresponding percentage of positive Legionella cultures was monitored. Low Legionella colony forming units (CFU), with a mean <10 CFU/100 mL, and ≤30% positive culture for each sampling period, along with no recurrent disease, were considered indicative of control. RESULTS CSI treatment was shown to reduce both the number of CFU found and the percentage of samples found to be culture positive. After treatment was established, culture positivity was, for example, reduced from 70% (>10(3) CFU/100 mL) to consistently <30% (38 CFU/100 mL). CONCLUSION Control of legionellae in premise water systems may be a complex process requiring long-term assessments for adequate control. This work found that CSI could be successful in controlling Legionella under alkaline water conditions, and the evidence suggests that Ag ions are responsible for the control of Legionella pneumophila 1, L pneumophila 6, and L anisa.
Collapse
Affiliation(s)
- David M Dziewulski
- Bureau of Water Supply Protection, New York State Department of Health, Albany, NY; School of Public Health, Department of Environmental Health Sciences, State University at Albany, Rensselaer, NY.
| | - Erin Ingles
- Central Regional Office, New York State Department of Health, Syracuse, NY
| | - Neculai Codru
- Bureau of Water Supply Protection, New York State Department of Health, Albany, NY
| | - John Strepelis
- Central Regional Office, New York State Department of Health, Syracuse, NY
| | | |
Collapse
|
16
|
Mancini B, Scurti M, Dormi A, Grottola A, Zanotti A, Cristino S. Effect of monochloramine treatment on colonization of a hospital water distribution system by Legionella spp.: a 1 year experience study. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2015; 49:4551-4558. [PMID: 25723867 DOI: 10.1021/es506118e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Contamination of hot water distribution systems by Legionella represents a great challenge due to difficulties associated with inactivating microorganisms, preserving the water characteristics. The aim of this study was to examine over the course of 1 year in 11 fixed sites, the impact of monochloramine disinfection on Legionella, heterotrophic bacteria (36 °C), Pseudomonas aeruginosa contamination, and chemical parameters of a plumbing system in an Italian hospital. Three days after installation (T0), in the presence of monochloramine concentration between 1.5 and 2 mg/L, 10/11 sites (91%) were contaminated by L. pneumophila serogroups 3 and 10. After these results, the disinfectant dosage was increased to between 6 and 10 mg/L, reducing the level of Legionella by three logarithmic unit by 2 months postinstallation (T2) until 6 months later (T3). One year later (T4), there was a significant reduction (p = 0.0002) at 8/11 (73%) sites. Our data showed also a significant reduction of heterotrophic bacteria (36 °C) in 6/11 (55%) sites at T4 (p = 0.0004), by contrast the contamination of P. aeruginosa found at T0 in two sites persisted up until T4. The results of the present study show that monochloramine is a promising disinfectant that can prevent Legionella contamination of hospital water supplies.
Collapse
Affiliation(s)
| | | | | | - Antonella Grottola
- §Regional Reference Laboratory for Clinical Diagnosis of Legionellosis, Unit of Microbiology and Virology, Modena University Hospital, via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Zanotti
- ⊥ITACA srl ITACA s.r.l., via Remigia, 19, 40068, San Lazzaro di Savena (BO), Italy
| | | |
Collapse
|
17
|
Bédard E, Fey S, Charron D, Lalancette C, Cantin P, Dolcé P, Laferrière C, Déziel E, Prévost M. Temperature diagnostic to identify high risk areas and optimize Legionella pneumophila surveillance in hot water distribution systems. WATER RESEARCH 2015; 71:244-56. [PMID: 25622002 DOI: 10.1016/j.watres.2015.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 12/22/2014] [Accepted: 01/05/2015] [Indexed: 05/08/2023]
Abstract
Legionella pneumophila is frequently detected in hot water distribution systems and thermal control is a common measure implemented by health care facilities. A risk assessment based on water temperature profiling and temperature distribution within the network is proposed, to guide effective monitoring strategies and allow the identification of high risk areas. Temperature and heat loss at control points (water heater, recirculation, representative points-of-use) were monitored in various sections of five health care facilities hot water distribution systems and results used to develop a temperature-based risk assessment tool. Detailed investigations show that defective return valves in faucets can cause widespread temperature losses because of hot and cold water mixing. Systems in which water temperature coming out of the water heaters was kept consistently above 60 °C and maintained above 55 °C across the network were negative for Legionella by culture or qPCR. For systems not meeting these temperature criteria, risk areas for L. pneumophila were identified using temperature profiling and system's characterization; higher risk was confirmed by more frequent microbiological detection by culture and qPCR. Results confirmed that maintaining sufficiently high temperatures within hot water distribution systems suppressed L. pneumophila culturability. However, the risk remains as shown by the persistence of L. pneumophila by qPCR.
Collapse
Affiliation(s)
- Emilie Bédard
- Department of Civil Engineering, Polytechnique Montréal, Montréal, QC, Canada; INRS-Institut Armand-Frappier, Laval, QC, Canada.
| | - Stéphanie Fey
- Department of Civil Engineering, Polytechnique Montréal, Montréal, QC, Canada
| | - Dominique Charron
- Department of Civil Engineering, Polytechnique Montréal, Montréal, QC, Canada
| | | | - Philippe Cantin
- Centre d'expertise en analyse environnementale du Québec, Québec, QC, Canada
| | - Patrick Dolcé
- Department of Medical Microbiology and Infectious Diseases, Centre Hospitalier Régional de Rimouski, Rimouski, QC, Canada
| | - Céline Laferrière
- Department of Microbiology and Immunology (Infection Control), CHU Ste-Justine, Université de Montréal, Montréal, QC, Canada
| | - Eric Déziel
- INRS-Institut Armand-Frappier, Laval, QC, Canada
| | - Michèle Prévost
- Department of Civil Engineering, Polytechnique Montréal, Montréal, QC, Canada
| |
Collapse
|
18
|
Demirjian A, Lucas CE, Garrison LE, Kozak-Muiznieks NA, States S, Brown EW, Wortham JM, Beaudoin A, Casey ML, Marriott C, Ludwig AM, Sonel AF, Muder RR, Hicks LA. The Importance of Clinical Surveillance in Detecting Legionnaires' Disease Outbreaks: A Large Outbreak in a Hospital With a Legionella Disinfection System—Pennsylvania, 2011–2012. Clin Infect Dis 2015; 60:1596-602. [DOI: 10.1093/cid/civ153] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/15/2015] [Indexed: 11/13/2022] Open
|
19
|
Mercante JW, Winchell JM. Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clin Microbiol Rev 2015; 28:95-133. [PMID: 25567224 PMCID: PMC4284297 DOI: 10.1128/cmr.00029-14] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Legionnaires' disease (LD) is an often severe and potentially fatal form of bacterial pneumonia caused by an extensive list of Legionella species. These ubiquitous freshwater and soil inhabitants cause human respiratory disease when amplified in man-made water or cooling systems and their aerosols expose a susceptible population. Treatment of sporadic cases and rapid control of LD outbreaks benefit from swift diagnosis in concert with discriminatory bacterial typing for immediate epidemiological responses. Traditional culture and serology were instrumental in describing disease incidence early in its history; currently, diagnosis of LD relies almost solely on the urinary antigen test, which captures only the dominant species and serogroup, Legionella pneumophila serogroup 1 (Lp1). This has created a diagnostic "blind spot" for LD caused by non-Lp1 strains. This review focuses on historic, current, and emerging technologies that hold promise for increasing LD diagnostic efficiency and detection rates as part of a coherent testing regimen. The importance of cooperation between epidemiologists and laboratorians for a rapid outbreak response is also illustrated in field investigations conducted by the CDC with state and local authorities. Finally, challenges facing health care professionals, building managers, and the public health community in combating LD are highlighted, and potential solutions are discussed.
Collapse
Affiliation(s)
- Jeffrey W Mercante
- Pneumonia Response and Surveillance Laboratory, Respiratory Diseases Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas M Winchell
- Pneumonia Response and Surveillance Laboratory, Respiratory Diseases Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
20
|
Pierre D, Stout JE, Yu VL. Editorial commentary: risk assessment and prediction for health care-associated Legionnaires' disease: percent distal site positivity as a cut-point. Am J Infect Control 2014; 42:1248-50. [PMID: 25444274 DOI: 10.1016/j.ajic.2014.06.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 06/07/2014] [Accepted: 06/23/2014] [Indexed: 11/27/2022]
|
21
|
Allen JG, Gessesse B, Myatt TA, MacIntosh DL, Ludwig JF, Minegishi T, Stewart JH, Connors BF, Grant MP, Fragala MA, McCarthy JF. Response to commentary on "Assessing risk of health care-acquired Legionnaires' disease from environmental sampling: the limits of using a strict percent positivity approach". Am J Infect Control 2014; 42:1250-3. [PMID: 25444275 DOI: 10.1016/j.ajic.2014.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/17/2014] [Indexed: 10/24/2022]
|