Spatial distribution of Legionella pneumophila MLVA-genotypes in a drinking water system

Lessons learned from a one-year study of Legionella spp. cultivation from activated sludge samples

Risk assessment and management of Legionella spp. contamination in activated sludge in wastewater treatment plants is carried out using the culture method. Underestimation of Legionella spp. is frequently reported in the literature, but a comprehensive long-term study of the performance of the method under comparable conditions is still lacking. The aim of this study is to evaluate the recovery rate and limit of detection of the culture method for Legionella spp. from activated sludge samples collected during the different seasons of the year. Activated sludge samples spiked with Legionella pneumophila subsp. pneumophila strain Philadelphia-1 (mean concentration 5.2 ± 0.35 logCFU/mL) were analysed monthly for one year using the culture method. Three different sample pre-treatments were compared, namely filtration, acid treatment and thermal treatment, and the recovery rate and limit of detection were assessed for each. The recovery rate of the culture method for Legionella spp. depended on the type of sample pre-treatment and the season of activated sludge sampling, while the limit of detection depended only on the sample pre-treatment. The best performance of the culture method, defined as the combination of the highest recovery rate and lowest limit of detection, was obtained for the filtered acid pre-treated samples (recovery rate: 89 ± 4 %; limit of detection: 1.3 logCFU/mL in 83 % of the samples). The lowest limit of detection was observed for the filtered thermally pre-treated samples (1.0 logCFU/mL in 93 % of the samples). Simultaneously, both thermally pre-treated samples showed up to a third lower recovery rates than the other pre-treatments in winter, while untreated and acid pre-treated samples showed consistently high recovery rates (>80%, logCFU/mL). The recovery rates of the unfiltered and filtered thermally pre-treated samples showed significant weak to strong positive correlations with the organic and phosphorus load in the influent as well as with the water and atmospheric temperatures, indicating that the recovery rate depends on the seasonal variation of the wastewater composition. This study presents new insights into the detection and quantification of Legionella spp. in activated sludge samples and considers seasonal dependencies in analytical results.

Legionella pneumophila Presence in Dental Unit Waterlines: A Cultural and Molecular Investigation in the West Bank, Palestine

A Legionella pneumophila bacterium is ubiquitous in water distribution systems, including dental unit waterlines (DUWLs). Legionellosis is atypical pneumonia, including Legionnaires' disease (LD) and the less acute form of Pontiac fever. Legionellosis occurs as a result of inhalation/aspiration of aerosolized Legionella-contaminated water by susceptible patients, health workers, and dentists. In this study, we undertook to determine the prevalence of Legionella in water and biofilm samples from Tap and DUWLs collected from five sites of dental clinics and faculties across the West Bank. Water samples were tested for physical and chemical parameters. The study samples included 185 samples, 89 (48%) water samples, and 96 (52%) biofilm swabs, which were analyzed by cultivation-dependent analysis (CDA) and by the cultivation-independent technique (CIA). Also, partial sequencing of the 16S rRNA gene for fifteen L. pneumophila isolates was performed for quality assurance and identification. L. pneumophila was isolated from 28 (15%) of 185 samples using CDA and was detected in 142 (77%) of 185 samples using CIA. The abundance of culturable L. pneumophila was low in DUWL of the sampling sites (range: 27-115 CFU/Liter). PCR was 5× more sensitive than the culture technique. L. pneumophila Sg 1 was detected in (75%) of the isolates, while (25%) isolates were L. pneumophila Sg 2-14. All fifteen sequenced Legionella isolates were identified as L. pneumophila ≥ 94.5%. The analysis of phylogenetic tree showed that L. pneumophila branch clearly identified and distinguished from other branches. These results show that DUWLs of the examined dental clinics and faculties are contaminated with L. pneumophila. This finding reveals a serious potential health risk for infection of immunocompromised patients and dentists' post-exposure.

Persistent contamination of a hospital hot water network by Legionellapneumophila

OBJECTIVES

We assessed the contamination with Legionella pneumophila (Lp) of the hot water network (HWN) of a hospital, mapped the risk of contamination, and evaluated the relatedness of isolates. We further validated phenotypically the biological features that could account for the contamination of the network.

METHODS

We collected 360 water samples from October 2017 to September 2018 in 36 sampling points of a HWN of a building from a hospital in France. Lp were quantified and identified with culture-based methods and serotyping. Lp concentrations were correlated with water temperature, date and location of isolation. Lp isolates were genotyped by pulsed-field gel electrophoresis and compared to a collection of isolates retrieved in the same HWN two years later, or in other HWN from the same hospital.

RESULTS

207/360 (57.5%) samples were positive with Lp. In the hot water production system, Lp concentration was negatively associated with water temperature. In the distribution system, the risk of recovering Lp decreased when temperature was >55 °C (p < 10^-3), the proportion of samples with Lp increased with distance from the production network (p < 10^-3), and the risk of finding high loads of Lp increased 7.96 times in summer (p = 0.001). All Lp isolates (n = 135) were of serotype 3, and 134 (99.3%) shared the same pulsotype which is found two years later (Lp G). In vitro competition experiments showed that a 3-day culture of Lp G on agar inhibited the growth of a different pulsotype of Lp (Lp O) contaminating another HWN of the same hospital (p = 0.050). We also found that only Lp G survived to a 24h-incubation in water at 55 °C (p = 0.014).

CONCLUSION

We report here a persistent contamination with Lp of a hospital HWN. Lp concentrations were correlated with water temperature, season, and distance from the production system. Such persistent contamination could be due to biotic parameters such as intra-Legionella inhibition and tolerance to high temperature, but also to the non-optimal configuration of the HWN that prevented the maintenance of high temperature and optimal water circulation.

Host-Endosymbiont Relationship Impacts the Retention of Bacteria-Containing Amoeba Spores in Porous Media

Amoebae are protists that are commonly found in water, soil, and other habitats around the world and have complex interactions with other microorganisms. In this work, we investigated how host-endosymbiont interactions between amoebae and bacteria impacted the retention behavior of amoeba spores in porous media. A model amoeba species, Dictyostelium discoideum, and a representative bacterium, Burkholderia agricolaris B1qs70, were used to prepare amoeba spores that carried bacteria. After interacting with B. agricolaris, the retention of D. discoideum spores was enhanced compared to noninfected spores. Diverse proteins, especially proteins contributing to the looser exosporium structure and cell adhesion functionality, are secreted in higher quantities on the exosporium surface of infected spores compared to that of noninfected ones. Comprehensive examinations using a quartz crystal microbalance with dissipation (QCM-D), a parallel plate chamber, and a single-cell force microscope present coherent evidence that changes in the exosporium of D. discoideum spores due to infection by B. agricolaris enhance the connections between spores in the suspension and the spores that were previously deposited on the collector surface, thus resulting in more retention compared to the uninfected ones in porous media. This work provides novel insight into the retention of amoeba spores after bacterial infection in porous media and suggests that the host-endosymbiont relationship regulates the fate of biocolloids in drinking water systems, groundwater, and other porous environments.

Is a Proactive Approach to Controlling Legionella in the Environment Justified?

Research background

Legionella are Gram-negative bacteria that are ubiquitous in the natural environment. Contaminated water in man-made water systems is a potential source of transmission of legionnaires’ disease. The aim of this study is to explore the prevalence of Legionella pneumophila in the drinking water distribution system (DWDS) of Primorje-Gorski Kotar (PGK) County, Croatia, for the period 2013-2019, coupled with the incidence of legionnaires’ disease. A number of L. pneumophila-positive samples (>100 CFU/L), serogroup distribution and the degree of contamination of specific facilities (health and aged care, tourism, and sports) were assessed. Based on the obtained results, the reasoning for the implementation of a mandatory Legionella environmental surveillance program was assessed.

Experimental approach

Sample testing for Legionella was carried out according to the standard method for enumeration of this bacterium. A heterotrophic plate count (HPC) and Pseudomonas aeruginosa number were analysed along with the basic physicochemical indicators of drinking water quality. The research period was divided into two parts, namely, the 2013-2018 period (before implementation of the prevention program, after the outbreak of legionnaires’ disease), and the year 2019 (proactive approach, no disease cases recorded).

Results and conclusion

During the 7-year observation period in PGK County, an increase in the number of samples tested for Legionella was found. An increase in Legionella-positive samples (particularly pronounced during the warmer part of the year) was recorded, along with a growing trend in the number of reported legionnaires’ disease cases. In addition to hot water systems, the risk of Legionella colonisation also applies to cold water systems. Health and aged care facilities appear to be at highest risk. In addition to the higher proportion of positive samples and a higher degree of microbiological load in these facilities, the highest proportion of L. pneumophila SGs 2-14 was identified. Due to the diagnostic limitations of the applied tests, the number of legionnaires’ disease cases is underdiagnosed.

Novelty and scientific contribution

The introduction of a mandatory preventive approach to monitoring Legionella in DWDS water samples, along with the definition of national criteria for the interpretation of the results will create the preconditions for diagnosis and adequate treatment of larger numbers of legionnaires’ disease cases.

Environmental surveillance of Legionella pneumophila in hot water systems of hotels in Morocco

OBJECTIVE

Environmental monitoring of Legionella in hot water systems of hotels in Morocco was performed during the period from January 2016 to April 2018. A total of 149 water samples from 118 different hotels were analyzed.

METHODS

A total of 149 water samples from 118 different hotels were analyzed. Possible risk factors were prospectively recorded, and data were analyzed in connection with building and plumbing systems characteristics. Data about building and risk factors were collected through a questionnaire survey.

RESULTS

Out of the 149 samples, 77(51.7%) were positive for L. pneumophila. Serological typing of the isolates revealed that 54 (70.1%) are L. pneumophila serogroup 2-15 and 23 (29.9%) are L. pneumophila serogroup 1. 56.8% of all buildings were colonized by L. pneumophila. Counts were over 1,000 CFU/L in 44%. Contamination was strongly correlated with temperature in the circulation, the age of the premise plumbing and the size of the building.

CONCLUSIONS

The results showed a relevant exposure to L. pneumophila in the community and the identified risk factors can serve as indicators for risk assessment and relevant actions.

Both viable and inactivated amoeba spores protect their intracellular bacteria from drinking water disinfection

In drinking water systems, waterborne pathogens constitute a significant threat. While most studies focus on a single infectious agent, such as bacteria, fungi, viruses, and protists, the effect of interactions among these infectious agents on disinfection treatment has largely been ignored. In this study, we find that dormant amoeba spores, a frequently found protist in drinking water systems, can protect their intracellular bacteria from drinking water disinfection. Bacteria-containing amoeba spores were constructed and treated with various disinfection techniques (Cl₂, ClO_2, and UV₂₅₄). The three disinfection methods could kill the bacteria alone efficiently (6-log inactivation). However, the inactivation efficiency of bacteria that hid within amoeba spore was significantly inhibited (2-3-log inactivation). We also found that inactivated amoeba spores can still protect their intracellular bacteria. This study provides direct evidence that viable and inactivated amoeba spores can protect their hitchhiking bacteria from disinfection treatment, which is crucial for future decision-making about the dosage for sufficient bacterial disinfection in drinking water systems.

Cytotoxicity, Intracellular Replication, and Contact-Dependent Pore Formation of Genotyped Environmental Legionella pneumophila Isolates from Hospital Water Systems in the West Bank, Palestine

Legionella pneumophila is the causative agent of Legionnaires’ disease. Due to the hot climate and intermittent water supply, the West Bank, Palestine, can be considered a high-risk area for this often fatal atypical pneumonia. L. pneumophila occurs in biofilms of natural and man-made freshwater environments, where it infects and replicates intracellularly within protozoa. To correlate the genetic diversity of the bacteria in the environment with their virulence properties for protozoan and mammalian host cells, 60 genotyped isolates from hospital water systems in the West Bank were analyzed. The L. pneumophila isolates were previously genotyped by high resolution Multi Locus Variable Number of Tandem Repeat Analysis (MLVA-8(12)) and sorted according to their relationship in clonal complexes (VACC). Strains of relevant genotypes and VACCs were compared according to their capacity to infect Acanthamoeba castellanii and THP-1 macrophages, and to mediate pore-forming cytotoxicity in sheep red blood cells (sRBCs). Based on a previous detailed analysis of the biogeographic distribution and abundance of the MLVA-8(12)-genotypes, the focus of the study was on the most abundant L. pneumophila- genotypes Gt4(17), Gt6 (18) and Gt10(93) and the four relevant clonal complexes [VACC1, VACC2, VACC5 and VACC11]. The highly abundant genotypes Gt4(17) and Gt6(18) are affiliated with VACC1 and sequence type (ST)1 (comprising L. pneumophila str. Paris), and displayed seroroup (Sg)1. Isolates of these two genotypes exhibited significantly higher virulence potentials compared to other genotypes and clonal complexes in the West Bank. Endemic for the West Bank was the clonal complex VACC11 (affiliated with ST461) represented by three relevant genotypes that all displayed Sg6. These genotypes unique for the West Bank showed a lower infectivity and cytotoxicity compared to all other clonal complexes and their affiliated genotypes. Interestingly, the L. pneumophila serotypes ST1 and ST461 were previously identified by in situ-sequence based typing (SBT) as main causative agents of Legionnaires’ disease (LD) in the West Bank at a comparable level. Overall, this study demonstrates the site-specific regional diversity of L. pneumophila genotypes in the West Bank and suggests that a combination of MLVA, cellular infection assays and hierarchical agglomerative cluster analysis allows an improved genotype-based risk assessment.

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.

Biogeography and Environmental Drivers of Legionella pneumophila Abundance and Genotype Composition Across the West Bank: Relevance of a Genotype-Based Ecology for Understanding Legionella Occurrence

The West Bank can be considered as a high-risk area for Legionella prevalence in drinking water due to high ambient temperature, intermittent water supply, frequent pressure loss, and storage of drinking water in roof containers. To assess occurrence of Legionella species, especially L. pneumophila, in the drinking water of the West Bank, the drinking water distribution systems of eight hospitals were sampled over a period of 2.3 years covering the seasonal cycle and the major geographic regions. To gain insight into potential environmental drivers, a set of physico-chemical and microbiological parameters was recorded. Sampling included drinking water and biofilm analyzed by culture and PCR-based methods. Cultivation led to the isolation of 180 strains of L. pneumophila that were genotyped by Multi-Locus Variable Number of Tandem Repeat Analysis (MLVA). Surprisingly, the abundance of culturable L. pneumophila was low in drinking water of the sampling sites, with only three out of eight sites where Legionella was observed at all (range: 30–500 CFU/Liter). By contrast, biofilm and PCR-based analyses showed a higher prevalence. Statistical analyses with physico-chemical parameters revealed a decrease of L. pneumophila abundance for water and biofilm with increasing magnesium concentrations (>30 mg/L). MLVA-genotype analysis of the L. pneumophila isolates and their spatial distribution indicated three niches characterized by distinct physico-chemical parameters and inhabited by specific consortia of genotypes. This study provides novel insights into mechanisms shaping L. pneumophila populations and triggering their abundance leading to an understanding of their genotype-specific niches and ecology in support of improved prevention measures.

Characterization of Legionella pneumophila Populations by Multilocus Variable Number of Tandem Repeats (MLVA) Genotyping from Drinking Water and Biofilm in Hospitals from Different Regions of the West Bank

The West Bank can be considered a high-risk area for Legionnaires' disease (LD) due to its hot climate, intermittent water supply and roof storage of drinking water. Legionella, mostly L. pneumophila, are responsible for LD, a severe, community-acquired and nosocomial pneumonia. To date, no extensive assessment of Legionella spp and L. pneumophila using cultivation in combination with molecular approaches in the West Bank has been published. Two years of environmental surveillance of Legionella in water and biofilms in the drinking water distribution systems (DWDS) of eight hospitals was carried out; 180 L. pneumophila strains were isolated, mostly from biofilms in DWDS. Most of the isolates were identified as serogroup (Sg) 1 (60%) and 6 (30%), while a minor fraction comprised Sg 8 and 10. Multilocus Variable number of tandem repeats Analysis using 13 loci (MLVA-8(12)) was applied as a high-resolution genotyping method and compared to the standard Sequence Based Typing (SBT). The isolates were genotyped in 27 MLVA-8(12) genotypes (Gt), comprising four MLVA clonal complexes (VACC 1; 2; 5; 11). The major fraction of isolates constituted Sequence Type (ST)1 and ST461. Most of the MLVA-genotypes were highly diverse and often unique. The MLVA-genotype composition showed substantial regional variability. In general, the applied MLVA-method made it possible to reproducibly genotype the isolates, and was consistent with SBT but showed a higher resolution. The advantage of the higher resolution was most evident for the subdivision of the large strain sets of ST1 and ST461; these STs were shown to be highly pneumonia-relevant in a former study. This shows that the resolution by MLVA is advantageous for back-tracking risk sites and for the avoidance of outbreaks of L. pneumophila. Overall, our results provide important insights into the detailed population structure of L. pneumophila, allowing for better risk assessment for DWDS.

Chlorine Disinfection of Legionella spp., L. pneumophila, and Acanthamoeba under Warm Water Premise Plumbing Conditions

Premise plumbing conditions can contribute to low chlorine or chloramine disinfectant residuals and reactions that encourage opportunistic pathogen growth and create risk of Legionnaires' Disease outbreaks. This bench-scale study investigated the growth of Legionella spp. and Acanthamoeba in direct contact with premise plumbing materials-glass-only control, cross-linked polyethylene (PEX) pipe, magnesium anode rods, iron pipe, iron oxide, pH 10, or a combination of factors. Simulated glass water heaters (SGWHs) were colonized by Legionella pneumophila and exposed to a sequence of 0, 0.1, 0.25, and 0.5 mg/L chlorine or chloramine, at two levels of total organic carbon (TOC), over 8 weeks. Legionella pneumophila thrived in the presence of the magnesium anode by itself and or combination with other factors. In most cases, 0.5 mg/L Cl2 caused a significant rapid reduction of L. pneumophila, Legionella spp., or total bacteria (16S rRNA) gene copy numbers, but at higher TOC (>1.0 mg C/L), a chlorine residual of 0.5 mg/L Cl2 was not effective. Notably, Acanthamoeba was not significantly reduced by the 0.5 mg/L chlorine dose.

Legionella Diversity and Spatiotemporal Variation in The Occurrence of Opportunistic Pathogens within a Large Building Water System

Understanding Legionella survival mechanisms within building water systems (BWSs) is challenging due to varying engineering, operational, and water quality characteristics unique to each system. This study aimed to evaluate Legionella, mycobacteria, and free-living amoebae occurrence within a BWS over 18-28 months at six locations differing in plumbing material and potable water age, quality, and usage. A total of 114 bulk water and 57 biofilm samples were analyzed. Legionella culturability fluctuated seasonally with most culture-positive samples being collected during the winter compared to the spring, summer, and fall months. Positive and negative correlations between Legionella and L. pneumophila occurrence and other physiochemical and microbial water quality parameters varied between location and sample types. Whole genome sequencing of 19 presumptive Legionella isolates, from four locations across three time points, identified nine isolates as L. pneumophila serogroup (sg) 1 sequence-type (ST) 1; three as L. pneumophila sg5 ST1950 and ST2037; six as L. feeleii; and one as Ochrobactrum. Results showed the presence of a diverse Legionella population with consistent and sporadic occurrence at four and two locations, respectively. Viewed collectively with similar studies, this information will enable a better understanding of the engineering, operational, and water quality parameters supporting Legionella growth within BWSs.

Assessing the transition effects in a drinking water distribution system caused by changing supply water quality: an indirect approach by characterizing suspended solids

Worldwide, it is common that the drinking water distribution systems (DWDSs) may be subjected to changes of supply water quality due to the needs of upgrading the treatment processes or switching the source water. However, the potential impacts of quality changed supply water on the stabilized ecological niches within DWDSs and the associated water quality deterioration risks were poorly documented. In the present study, such transition effects caused by changing the supply water quality that resulted from destabilization of biofilm and loose deposits in DWDS were investigated by analyzing the physiochemical and microbiological characteristics of suspended particles before (T₀), during (T_3-weeks) and after upgrading the treatments (T_6-months) in an unchlorinated DWDS in the Netherlands. Our results demonstrated that after 6 months' time the upgraded treatments significantly improved the water quality. Remarkably, water quality deterioration was observed at the initial stage when the quality-improved treated water distributed into the network at T_3-weeks, observed as a spike of total suspended solids (TSS, 50-260%), active biomass (ATP, 95-230%) and inorganic elements (e.g. Mn, 130-250%). Furthermore, pyrosequencing results revealed sharp differences in microbial community composition and structure for the bacteria associated with suspended particles between T₀ and T_3-weeks, which re-stabilized after 6 months at T_6-months. The successful capture of transition effects was especially confirmed by the domination of Nitrospira spp. and Polaromonas spp. in the distribution system at T_3-weeks, which were detected at rather low relative abundance at treatment plant. Though the transitional effects were captured, this study shows that the introduction of softening and additional filtration did not have an effect on the water quality for the consumer which improved considerably after 6-months' period. The methodology of monitoring suspended particles with MuPFiSs and additional analysis is capable of detecting transitional effects by monitoring the dynamics of suspended particles and its physiochemical and microbiological composition.

Quantitative microbial risk assessment of Legionella pneumophila in a drinking water supply system in Israel

Legionella pneumophila cause human infections via inhalation of contaminated water aerosols, resulting in severe pneumonia. Legionella spp. prevalence was monitored in a drinking-water distribution system (DWDS) in Northern Israel. Five points (toilet faucets and showers) were sampled seasonally along a three years period. Toilet faucets and shower use, both generating aerosols, are known transmission routes for this pathogen and thus, present a potential health risk. Quantitative Microbial Risk Assessment (QMRA) was applied in order to assess the health risks posed by Legionella for these two exposure scenarios, while considering Legionella seasonality. The obtained results were compared with estimated tolerable risk levels of infection and of disease set by the USEPA and WHO. Both limits were expressed as Disability-Adjusted Life Years index (DALY) being 1 × 10^-4 and 1 × 10^-6, respectively. The QMRA revealed that the annual risk levels for both faucets and showers use exceeded the acceptable risk of infection with an average of 5.52 × 10^-4 and 2.37 × 10^-3 DALY'S per person per year, respectively. Annual risk levels were stable with no significant differences between the three years. Risk levels varied significantly between seasons by up to three orders of magnitude. Risk levels were highest during summer, autumn, and lowest during winter. The highest seasonal infection risk values were found in summer for both faucets and showers, which corresponded to 8.09 × 10^-4 and 2.75 × 10^-3 DALY'S per person per year, respectively. In conclusion, during summer and autumn there is a significant increase of the infection risk associated with exposure to Legionella-contaminated aerosols, in the studied water system. Public health assessment and prevention measures should focus on these seasons.

Antimicrobial agent susceptibilities of Legionella pneumophila MLVA-8 genotypes

Legionella pneumophila causes human lung infections resulting in severe pneumonia. High-resolution genotyping of L. pneumophila isolates can be achieved by multiple-locus variable-number tandem-repeat analysis (MLVA-8). Legionella infections in humans occur as a result of inhalation of bacteria-containing aerosols, thus, our aim was to study the antimicrobial susceptibilities of different MLVA-8 genotypes to ten commonly used antimicrobial agents in legionellosis therapy. Epidemiological cut-off values were determined for all antibiotics. Significant differences were found between the antimicrobial agents' susceptibilities of the three studied environmental genotypes (Gt4, Gt6, and Gt15). Each genotype exhibited a significantly different susceptibility profile, with Gt4 strains (Sequence Type 1) significantly more resistant towards most studied antimicrobial agents. In contrast, Gt6 strains (also Sequence Type 1) were more susceptible to six of the ten studied antimicrobial agents compared to the other genotypes. Our findings show that environmental strains isolated from adjacent points of the same water system, exhibit distinct antimicrobial resistance profiles. These differences highlight the importance of susceptibility testing of Legionella strains. In Israel, the most extensively used macrolide for pneumonia is azithromycin. Our results point at the fact that clarithromycin (another macrolide) and trimethoprim with sulfamethoxazole (SXT) were the most effective antimicrobial agents towards L. pneumophila strains. Moreover, legionellosis can be caused by multiple L. pneumophila genotypes, thus, the treatment approach should be the use of combined antibiotic therapy. Further studies are needed to evaluate specific antimicrobial combinations for legionellosis therapy.

Comparison of in situ sequence type analysis of Legionella pneumophila in respiratory tract secretions and environmental samples of a hospital in East Jerusalem

Legionella pneumophila genotyping is important for epidemiological investigation of nosocomial and community-acquired outbreaks of legionellosis. The prevalence of legionellosis in pneumonia patients in the West Bank was monitored for the first time, and the sequence types (STs) from respiratory samples were compared with STs of environmental samples from different wards of the hospital. Sputum (n = 121) and bronchoalveolar lavage (BAL) (n = 74) specimens were cultured for L. pneumophila; genomic DNA was tested by 16S rRNA polymerase chain reaction (PCR) amplification. Nested PCR sequence-based typing (NPSBT) was implemented on DNA of the respiratory and environmental PCR-positive samples. Only one respiratory specimen was positive for L. pneumophila by culture. BAL gave a higher percentage of L. pneumophila-positive samples, 35% (26/74) than sputum, 15% (18/121) by PCR. NPSBT revealed the following STs: ST 1 (29%, 7/24), ST 461 (21%, 5/24), ST 1037 (4%, 1/24) from respiratory samples, STs from environmental samples: ST 1 (28.5%, 4/14), ST 187 (21.4%, 3/14) and ST 2070, ST 461, ST 1482 (7.1%, 1/14) each. This study emphasises the advantage of PCR over culture for the detection of L. pneumophila in countries where antibiotics are indiscriminately used prior to hospital admission. ST 1 was the predominant ST in both respiratory and environmental samples.

Occurrence of Legionella spp. in Water-Main Biofilms from Two Drinking Water Distribution Systems

The maintenance of a chlorine or chloramine residual to suppress waterborne pathogens in drinking water distribution systems is common practice in the United States but less common in Europe. In this study, we investigated the occurrence of Bacteria and Legionella spp. in water-main biofilms and tap water from a chloraminated distribution system in the United States and a system in Norway with no residual using real-time quantitative polymerase chain reaction (qPCR). Despite generally higher temperatures and assimilable organic carbon levels in the chloraminated system, total Bacteria and Legionella spp. were significantly lower in water-main biofilms and tap water of that system ( p < 0.05). Legionella spp. were not detected in the biofilms of the chloraminated system (0 of 35 samples) but were frequently detected in biofilms from the no-residual system (10 of 23 samples; maximum concentration = 7.8 × 10⁴ gene copies cm^-2). This investigation suggests water-main biofilms may serve as a source of Legionella for tap water and premise plumbing systems, and residual chloramine may aid in reducing their abundance.

Virulence Traits of Environmental and Clinical Legionella pneumophila Multilocus Variable-Number Tandem-Repeat Analysis (MLVA) Genotypes

Legionella pneumophila causes water-based infections resulting in severe pneumonia. Recently, we showed that different MLVA-8 (multilocus variable-number tandem-repeat analysis using 8 loci) genotypes dominated different sites of a drinking-water distribution system. Each genotype displayed a unique temperature-dependent growth behavior. Here we compared the pathogenicity potentials of different MLVA-8 genotypes of environmental and clinical strains. The virulence traits studied were hemolytic activity and cytotoxicity toward amoebae and macrophages. Clinical strains were significantly more hemolytic than environmental strains, while their cytotoxicity toward amoebae was significantly lower at 30°C. No significant differences were detected between clinical and environmental strains in cytotoxicity toward macrophages. Significant differences in virulence were observed between the environmental genotypes (Gt). Gt15 strains showed a significantly higher hemolytic activity. In contrast, Gt4 and Gt6 strains were more infective toward Acanthamoeba castellanii Moreover, Gt4 strains exhibited increased cytotoxicity toward macrophages and demonstrated a broader temperature range of amoebal lysis than Gt6 and Gt15 strains. Understanding the virulence traits of Legionella genotypes may improve the assessment of public health risks of Legionella in drinking water.IMPORTANCELegionella pneumophila is the causative agent of a severe form of pneumonia. Here we demonstrated that clinical strains were significantly more cytotoxic toward red blood cells than environmental strains, while their cytotoxicity toward macrophages was similar. Genotype 4 (Gt4) strains were highly cytotoxic toward amoebae and macrophages and lysed amoebae in a broader temperature range than to the other studied genotypes. The results can explain the relatively high success of Gt4 in the environment and in clinical samples; thus, Gt4 strains should be considered a main factor for the assessment of public health risks of Legionella in drinking water. Our findings shed light on the ecology, virulence, and pathogenicity potential of different L. pneumophila genotypes, which can be a valuable parameter for future modeling and quantitative microbial risk assessment of Legionella in drinking-water systems.

Greywater reuse - Assessment of the health risk induced by Legionella pneumophila

Greywater (GW), domestic wastewater excluding the streams generated by toilets and kitchens, can serve as an alternative water source. The main options for GW reuse are toilet flushing and garden irrigation, both generating aerosols. These may transmit inhalable pathogens like Legionella and present a potential health risk. This study quantified the health risk that may arise from inhalation of Legionella-contaminated aerosols due to non-potable GW reuse. Data on Legionella concentrations in potable water and GW was collected. Then, Quantitative Microbial Risk Assessment (QMRA) was performed for two possible exposure scenarios: garden irrigation and toilet flushing. This was performed while considering Legionella seasonality. In order to determine the safety of GW reuse regarding Legionella transmission, the obtained results were compared with estimated tolerable risk levels of infection and of disease. Both limits were expressed as Disability-Adjusted Life Years index (DALY) being 10^-4 and 10^-5, respectively. The QMRA revealed that the annual risk associated with reuse of treated and chlorinated GW for garden irrigation and toilet flushing was not significantly higher than the risk associated with using potable water for the same two purposes. In all studied scenarios, the health risk stemming from reusing treated and chlorinated GW was acceptable regarding Legionella infection. In contrast, reuse of untreated or treated but unchlorinated GW should not be practiced, as these are associated with significantly higher health risks.

Benefits of Genomic Insights and CRISPR-Cas Signatures to Monitor Potential Pathogens across Drinking Water Production and Distribution Systems

The occurrence of pathogenic bacteria in drinking water distribution systems (DWDSs) is a major health concern, and our current understanding is mostly related to pathogenic species such as Legionella pneumophila and Mycobacterium avium but not to bacterial species closely related to them. In this study, genomic-based approaches were used to characterize pathogen-related species in relation to their abundance, diversity, potential pathogenicity, genetic exchange, and distribution across an urban drinking water system. Nine draft genomes recovered from 10 metagenomes were identified as Legionella (4 draft genomes), Mycobacterium (3 draft genomes), Parachlamydia (1 draft genome), and Leptospira (1 draft genome). The pathogenicity potential of these genomes was examined by the presence/absence of virulence machinery, including genes belonging to Type III, IV, and VII secretion systems and their effectors. Several virulence factors known to pathogenic species were detected with these retrieved draft genomes except the Leptospira-related genome. Identical clustered regularly interspaced short palindromic repeats-CRISPR-associated proteins (CRISPR-Cas) genetic signatures were observed in two draft genomes recovered at different stages of the studied system, suggesting that the spacers in CRISPR-Cas could potentially be used as a biomarker in the monitoring of Legionella related strains at an evolutionary scale of several years across different drinking water production and distribution systems. Overall, metagenomics approach was an effective and complementary tool of culturing techniques to gain insights into the pathogenic characteristics and the CRISPR-Cas signatures of pathogen-related species in DWDSs.

Legionella Persistence in Manufactured Water Systems: Pasteurization Potentially Selecting for Thermal Tolerance

Legionella is an opportunistic waterborne pathogen of increasing public health significance. Pasteurization, otherwise known as super-heat and flush (increasing water temperature to above 70°C and flushing all outlets), has been identified as an important mechanism for the disinfection of Legionella in manufactured water systems. However, several studies have reported that this procedure was ineffective at remediating water distribution systems as Legionella was able to maintain long term persistent contamination. Up to 25% of L. pneumophila cells survived heat treatment of 70°C, but all of these were in a viable but non-culturable state. This demonstrates the limitations of the culture method of Legionella detection currently used to evaluate disinfection protocols. In addition, it has been demonstrated that pasteurization and nutrient starvation can select for thermal tolerant strains, where L. pneumophila was consistently identified as having greater thermal tolerance compared to other Legionella species. This review demonstrates that further research is needed to investigate the effectiveness of pasteurization as a disinfection method. In particular, it focuses on the potential for pasteurization to select for thermal tolerant L. pneumophila strains which, as the primary causative agent of Legionnaires disease, have greater public health significance compared to other Legionella species.

Domestic wastewaters reuse reclaimed by an improved horizontal subsurface-flow constructed wetland: A case study in the southeast of Spain

The aim of this case study was to assess the performance of a horizontal subsurface flow constructed wetland (HF-CW) located in southeastern Spain, filled with blast furnace slags (BFS), planted with Phragmites australis and designed to treat artificially aerated domestic wastewater to produce effluents suitable for agriculture reuse. The water quality parameters, included in the Spanish regulations for reclaimed wastewater reuse as agricultural quality 2.1, were monitored for one year. Data for all studied parameters, except electrical conductivity (EC) and sodium adsorption ratio (SAR), met the Spanish standards for reclaimed wastewater reuse due to the high evapotranspiration (ET) during the summer. The introduced improvements were effective for turbidity, total suspended solids (TSS), total nitrogen (TN), Escherichia coli (E. coli) and, specially, for total phosphorus (TP) with an average abatement of 96.9±1.7%. The improved HF-CW achieved similar or better percentage abatements than those reported using some hybrid systems.

Temperature-Dependent Growth Modeling of Environmental and Clinical Legionella pneumophila Multilocus Variable-Number Tandem-Repeat Analysis (MLVA) Genotypes

Legionella pneumophila causes waterborne infections resulting in severe pneumonia. High-resolution genotyping of L. pneumophila isolates can be achieved by multiple-locus variable-number tandem-repeat analysis (MLVA). Recently, we found that different MLVA genotypes of L. pneumophila dominated different sites in a small drinking-water network, with a genotype-related temperature and abundance regime. The present study focuses on understanding the temperature-dependent growth kinetics of the genotypes that dominated the water network. Our aim was to model mathematically the influence of temperature on the growth kinetics of different environmental and clinical L. pneumophila genotypes and to compare it with the influence of their ecological niches. Environmental strains showed a distinct temperature preference, with significant differences among the growth kinetics of the three studied genotypes (Gt4, Gt6, and Gt15). Gt4 strains exhibited superior growth at lower temperatures (25 and 30°C), while Gt15 strains appeared to be best adapted to relatively higher temperatures (42 and 45°C). The temperature-dependent growth traits of the environmental genotypes were consistent with their distribution and temperature preferences in the water network. Clinical isolates exhibited significantly higher growth rates and reached higher maximal cell densities at 37°C and 42°C than the environmental strains. Further research on the growth preferences of L. pneumophila clinical and environmental genotypes will result in a better understanding of their ecological niches in drinking-water systems as well as in the human body.IMPORTANCELegionella pneumophila is a waterborne pathogen that threatens humans in developed countries. The bacteria inhabit natural and man-made freshwater environments. Here we demonstrate that different environmental L. pneumophila genotypes have different temperature-dependent growth kinetics. Moreover, Legionella strains that belong to the same species but were isolated from environmental and clinical sources possess adaptations for growth at different temperatures. These growth preferences may influence the bacterial colonization at specific ecological niches within the drinking-water network. Adaptations for growth at human body temperatures may facilitate the abilities of some L. pneumophila strains to infect and cause illness in humans. Our findings may be used as a tool to improve Legionella monitoring in drinking-water networks. Risk assessment models for predicting the risk of legionellosis should take into account not only Legionella concentrations but also the temperature-dependent growth kinetics of the isolates.

Comparison of sputum microbiome of legionellosis-associated patients and other pneumonia patients: indications for polybacterial infections

Bacteria of the genus Legionella cause water-based infections resulting in severe pneumonia. Here we analyze and compare the bacterial microbiome of sputum samples from pneumonia patients in relation to the presence and abundance of the genus Legionella. The prevalence of Legionella species was determined by culture, PCR, and Next Generation Sequencing (NGS). Nine sputum samples out of the 133 analyzed were PCR-positive using Legionella genus-specific primers. Only one sample was positive by culture. Illumina MiSeq 16S rRNA gene sequencing analyses of Legionella-positive and Legionella-negative sputum samples, confirmed that indeed, Legionella was present in the PCR-positive sputum samples. This approach allowed the identification of the sputum microbiome at the genus level, and for Legionella genus at the species and sub-species level. 42% of the sputum samples were dominated by Streptococcus. Legionella was never the dominating genus and was always accompanied by other respiratory pathogens. Interestingly, sputum samples that were Legionella positive were inhabited by aquatic bacteria that have been observed in an association with amoeba, indicating that amoeba might have transferred Legionella from the drinking water together with its microbiome. This is the first study that demonstrates the sputum major bacterial commensals and pathogens profiles with regard to Legionella presence.

Legionella Risk Management and Control in Potable Water Systems: Argument for the Abolishment of Routine Testing

Legionella is an opportunistic pathogen of public health significance. One of the main sources of Legionella is potable water systems. As a consequence of aging populations there is an increasing demographic considered at high risk for Legionellosis and, as such, a review of the guidelines is required. Worldwide, Legionella has been detected from many potable water sources, suggesting it is ubiquitous in this environment. Previous studies have identified the limitations of the current standard method for Legionella detection and the high possibility of it returning both false negative and false positive results. There is also huge variability in Legionella test results for the same water sample when conducted at different laboratories. However, many guidelines still recommend the testing of water systems. This commentary argues for the removal of routine Legionella monitoring from all water distribution guidelines. This procedure is financially consuming and false negatives may result in managers being over-confident with a system or a control mechanism. Instead, the presence of the pathogen should be assumed and focus spent on managing appropriate control measures and protecting high-risk population groups.

Legionella species diversity and dynamics from surface reservoir to tap water: from cold adaptation to thermophily

Water samples of the Drinking Water Supply System (DWSS) of the city of Braunschweig were analysed for its Legionella species composition using genus-specific PCR amplicons and single-strand conformation polymorphism (SSCP) fingerprint analyses based on 16S rRNA genes. These analyses comprised the whole supply chain including raw water, treatment process and large-scale storage, and a seasonal study of finished drinking water sampled monthly from cold and hot tap water. Treatment of raw water had a major impact on Legionella species by reducing their diversity and abundances. The Legionella species composition of the tap water was highly distinct from that of both source waters. In cold water, 8-14 different phylotypes of Legionella (PTLs) were observed per sample with relative abundances ranging from >1% to 53%. In hot water, L. pneumophila was present during all seasons at high relative abundances (8-40%) accompanied by 5-14 other PTLs of which 6 PTLs were in common with cold water. This thermophilic Legionella community, including L. pneumophila, was able to grow in the hot water above 50 °C. Such thermophilic Legionella populations are of general relevance for drinking water management and public health, but also for the ecology and evolution of the genus Legionella.

Prevalence and distribution of Legionella spp in potable water systems in Germany, risk factors associated with contamination, and effectiveness of thermal disinfection

BACKGROUND

Worldwide, Legionella spp are a common cause of community-acquired pneumonia. Potable water systems are a main reservoir; however, exposure in the community is unknown.

METHODS

Water samples from 718 buildings in Germany were collected. Possible risk factors were prospectively recorded. All samples were tested for Legionella spp using cultural microbiologic methods. Samples were assigned to 1 of 5 levels of contamination. Statistical analysis was performed to determine the influence of risk factors for contamination and, in a subgroup of buildings, for unsuccessful thermal disinfection.

RESULTS

In total, 4,482 water samples from 718 different water supply systems were analyzed. In 233 buildings (32.7%), Legionella spp were identified, 148 (63.5%) of which had a medium or higher level of contamination. The most common species was Legionella pneumophila (94%). Contamination was strongly associated with temperature in the circulation, but not with the size of the building, time of the year, or transport time to the laboratory. Thermal disinfection was successful in fewer than half of the buildings.

CONCLUSIONS

There is relevant exposure to Legionella spp in the community. Water systems are not always up to current technical standards. Although microbiological risk assessment remains a challenge, there is a case for monitoring for Legionella spp outside of hospitals.

Legionella pneumophila: From potable water to treated greywater; quantification and removal during treatment

Greywater is an alternative water source that can help alleviate stress on depleted water resources. The main options for greywater reuse are toilet flushing and garden irrigation, both producing aerosols. For that reason transmission of inhalable pathogens like Legionella present a potential risk. To improve the understanding about Legionella in greywater, we traced the pathogen seasonally from the potable water system to the final steps of the greywater treatment in four houses in northern Israel. Physicochemical and microbiological parameters were analyzed in order to assess background greywater quality and to establish possible associations with Legionella. The mean concentrations of Legionella pneumophila isolated from the potable water system were 6.4×10(2) and 5.9×10(3) cfu/l in cold and hot water respectively. By amending the ISO protocol for Legionella isolation from drinking water, we succeeded in quantifying Legionella in greywater. The mean Legionella concentrations that were found in raw, treated and treated chlorinated greywater were 1.2×10(5), 2.4×10(4) and 5.7×10(3) cfu/l respectively. While Legionella counts in potable water presented a seasonal pattern with high concentrations in summer, its counts in greywater presented an almost inversed pattern. Greywater treatment resulted in 95% decrease in Legionella counts. No significant difference was found between Legionella concentrations in potable water and the treated chlorinated greywater. These findings indicate that regarding Legionella, reusing treated chlorinated greywater would exhibit a risk that is very similar to the risk associated with using potable water for the same non-potable uses.