Hospital-acquired legionellosis: solutions for a preventable infection

Practices to prevent non-ventilator hospital-acquired pneumonia: a narrative review

Nosocomial infection has significant consequences in health care, both at the individual level due to increased morbidity and mortality, and at the organizational level due to increased costs. Hospital-acquired pneumonia (HAP) is the most common nosocomial infection, and is associated with high excess mortality, frequent use of broad-spectrum antimicrobials and increased length of stay. This review explores the preventative strategies that have been examined in non-ventilator HAP (NV-HAP). The management of aspiration risk, interventions for oral hygiene, role of mobilization and physiotherapy, modification of environmental factors, and vaccination are discussed. Many of these interventions are low risk, acceptable to patients and have good cost-benefit ratios. However, the evidence base for prevention of NV-HAP is weak. This review identifies the lack of a unified research definition, under-recruitment to studies, and variation in intervention and outcome measures as limitations in the existing literature. Given that the core risk factors for acquisition of NV-HAP are increasing, there is an urgent need for research to address the prevention of NV-HAP. This review calls for a unified definition of NV-HAP, and identification of a core outcome set for studies in NV-HAP, and suggests future directions for research in NV-HAP. Improving care for people with NV-HAP will reduce morbidity, mortality and healthcare costs significantly.

A review of Legionella transmission risk in built environments: sources, regulations, sampling, and detection

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.

Legionella pneumophila cell surface RtxA release by LapD/LapG and its role in virulence

BACKGROUND

Legionella pneumophila is a Gram-negative intracellular bacillus and is the causative agent of a severe form of pneumonia called Legionnaires' disease which accounts for 2-9% of cases of community acquired pneumonia. It produces an extremely large protein belonging to the RTX (Repeats in ToXin) family, called RtxA, and we previously reported that RtxA is transported by a dedicated type 1 secretion system (T1SS) to the cell surface. RTX proteins have been shown to participate in the virulence or biofilm formation of various bacteria, the most studied models being the pore forming hemolysin A (HlyA) of Escherichia coli and the biofilm associated protein LapA of P. fluorescens. LapA localization depends on the enzymatic release by LapD/LapG complex activity. This study aimed to elucidate the dual localization (cell surface associated or released state) of L. pneumophila RTX protein (RtxA) and whether this released versus sequestered state of RtxA plays a role in L. pneumophila virulence.

RESULTS

The hereby work reveals that, in vitro, LapG periplasmic protease cleaves RtxA N-terminus in the middle of a di-alanine motif (position 108-109). Consistently, a strain lacking LapG protease maintains RtxA on the cell surface, whereas a strain lacking the c-di-GMP receptor LapD does not exhibit cell surface RtxA because of its continuous cleavage and release, as in the LapA-D-G model of Pseudomonas fluorescens. Interestingly, our data point out a key role of RtxA in enhancing the infection process of amoeba cells, regardless of its location (embedded or released); therefore, this may be the result of a secondary role of this surface protein.

CONCLUSIONS

This is the first experimental identification of the cleavage site within the RTX protein family. The primary role of RtxA in Legionella is still questionable as in many other bacterial species, hence it sounds reasonable to propose a major function in biofilm formation, promoting cell aggregation when RtxA is embedded in the outer membrane and facilitating biofilm dispersion in case of RtxA release. The role of RtxA in enhancing the infection process may be a result of its action on host cells (i.e., PDI interaction or pore-formation), and independently of its status (embedded or released).

Adherence to Legionella control regulations and guidelines in Norwegian nursing homes: a cross-sectional survey

BACKGROUND

Infection by Legionella bacteria is a risk to elderly individuals in health care facilities and should be managed by preventing bacterial proliferation in internal water systems. Norwegian legislation calls for a mandatory Legionella-specific risk assessment with the subsequent introduction of an adapted water management programme. The present study investigates adherence to legislation and guidelines on Legionella control and prevention in Norwegian nursing homes.

METHODS

A cross-sectional survey was distributed to Norwegian municipalities to investigate the status of Legionella specific risk assessments of internal water distribution systems and the introduction of water management programmes in nursing homes.

RESULTS

A total of 55.1% (n = 228) of the participating nursing homes had performed Legionella-specific risk assessments, of which 55.3% (n = 126) stated that they had updated the risk assessment within the last year. 96.5% introduced a water management programme following a risk assessment, whereas 59.6% of the ones without a risk assessment did the same. Nursing homes with risk assessments were more likely to monitor Legionella levels than those without (61.2% vs 38.8%), to remove dead legs (44.7% vs 16.5%), and to select biocidal preventive treatment over hot water flushing (35.5% vs 4.6%).

CONCLUSIONS

This study presents novel insight into Legionella control in Norway, suggesting that adherence to mandatory risk assessment in nursing homes is moderate-low. Once performed, the risk assessment seems to be advantageous as an introduction to future Legionella prevention in terms of the scope and contents of the water management programme.

Water Safety Plan, Monochloramine Disinfection and Extensive Environmental Sampling Effectively Control Legionella and Other Waterborne Pathogens in Nosocomial Settings: The Ten-Year Experience of an Italian Hospital

Legionella contamination control is crucial in healthcare settings where patients suffer an increased risk of disease and fatal outcome. To ensure an effective management of this health hazard, the accurate application of a hospital-specific Water Safety Plan (WSP), the choice of a suitable water disinfection system and an extensive monitoring program are required. Here, the ten-year experience of an Italian hospital is reported: since its commissioning, Legionellosis risk management has been entrusted to a multi-disciplinary Working Group, applying the principles of the World Health Organization's WSP. The disinfection strategy to prevent Legionella and other waterborne pathogens relies on the treatment of domestic hot water with a system ensuring the in situ production and dosage of monochloramine. An average of 250 samples/year were collected and analyzed to allow an accurate assessment of the microbiological status of water network. With the aim of increasing the monitoring sensitivity, in addition to the standard culture method, an optimized MALDI-ToF MS-based strategy was applied, allowing the identification of Legionella species and other relevant opportunistic pathogens. Data collected so far confirmed the effectiveness of this multidisciplinary approach: the fraction of positive samples never overcame 1% on a yearly basis and Legionnaires' Disease cases never occurred.

Systematic active environmental surveillance successfully identified and controlled the Legionella contamination in the hospital

INTRODUCTION

Legionella disease can manifest as severe respiratory tract infection with a high mortality rate and is sometimes associated with a hospital outbreak by a contaminated water supply. A patient with breast cancer admitted about a month before. High fever was observed 18 days after admission and the Legionella antigen test showed the positive result.

METHODS

Due to the incidence of Legionella infection, we demonstrated the active surveillance of Legionella contamination in the entire hospital.

RESULTS

Cultures of her environmental samples revealed that hot water in two bathrooms were contaminated with Legionella. In our hospital, the hot water is heated and pumped up on the roof and distributed to each room. The contaminated bathrooms were related to the same plumbing. Therefore, we further collected samples throughout the hot water system. Legionella was not detected in the central part of the system. However, we detected Legionella in the hot water sampled from other five rooms, which were also associated with the same plumbing of the two bathrooms. The temperature and chlorine concentration of the hot water were not high enough to inactivate Legionella at the end of the plumbing. After the adjustment of the water temperature and chlorine concentration, Legionella became undetectable. Our prompt and active surveillance successfully identified the plumbing of the hot water system as the source of Legionella contamination and took precautions against future outbreaks.

CONCLUSIONS

Monitoring of water temperature and chloride concentration at the end of the hot water circulation is important to prevent nosocomial Legionella disease.

Proteome Exploration of Legionella pneumophila To Identify Novel Therapeutics: a Hierarchical Subtractive Genomics and Reverse Vaccinology Approach

Legionella pneumophila is the causative agent of a severe type of pneumonia (lung infection) called Legionnaires' disease. It is emerging as an antibiotic-resistant strain day by day. Hence, identifying novel drug targets and vaccine candidates is essential to fight against this pathogen. Here, attempts were taken through a subtractive genomics approach on the complete proteome of L. pneumophila to address the challenges of multidrug resistance. A total of 2,930 proteins from L. pneumophila proteome were investigated through diverse subtractive proteomics approaches, e.g., identification of human nonhomologous and pathogen-specific essential proteins, druggability and "anti-target" analysis, subcellular localization prediction, human microbiome nonhomology screening, and protein-protein interaction studies to find out effective drug and vaccine targets. Only three fulfilled these criteria and were proposed as novel drug targets against L. pneumophila. Furthermore, outer membrane protein TolB was identified as a potential vaccine target with a better antigenicity score. Antigenicity and transmembrane topology screening, allergenicity and toxicity assessment, population coverage analysis, and a molecular docking approach were adopted to generate the most potent epitopes. The final vaccine was constructed by the combination of highly immunogenic epitopes, along with suitable adjuvant and linkers. The designed vaccine construct showed higher binding interaction with different major histocompatibility complex (MHC) molecules and human immune TLR-2 receptors with minimum deformability at the molecular level. The present study aids the development of novel therapeutics and vaccine candidates for efficient treatment and prevention of L. pneumophila infections. However, further wet-lab-based phenotypic and genomic investigations and in vivo trials are highly recommended to validate our prediction experimentally. IMPORTANCE Legionella pneumophila is a human pathogen distributed worldwide, causing Legionnaires' disease (LD), a severe form of pneumonia and respiratory tract infection. L. pneumophila is emerging as an antibiotic-resistant strain, and controlling LD is now difficult. Hence, developing novel drugs and vaccines against L. pneumophila is a major research priority. Here, the complete proteome of L. pneumophila was considered for subtractive genomics approaches to address the challenge of antimicrobial resistance. Our subtractive proteomics approach identified three potential drug targets that are promising for future application. Furthermore, a possible vaccine candidate, "outer membrane protein TolB," was proposed using reverse vaccinology analysis. The constructed vaccine candidate showed higher binding interaction with MHC molecules and human immune TLR-2 receptors at the molecular level. Overall, the present study aids in developing novel therapeutics and vaccine candidates for efficient treatment of the infections caused by L. pneumophila.

Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems

Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).

Experiences of infection prevention and control in clinical practice of nursing students in the Greater Accra Region, Ghana: An exploratory qualitative study

INTRODUCTION

Globally, infections acquired from hospitals pose a major obstacle to patients' safety. Health care workers, especially, nursing students are at high risk for Hospital Acquired Infections (HAIs) as they are always in contact with clients. Therefore, this study aims to explore experiences of infection prevention and control in the clinical practice of nursing students in the Greater Accra Region, Ghana.

METHODS

The study utilized a qualitative exploratory design to interview 42 participants (7 focus groups, comprising of 6 members each). A purposive sampling technique was employed to select the participants, who were engaged in 50-90 min' focus group discussions. Data collection lasted for 3 months and was analyzed using content analysis. NVivo version 12 Software was used to identify recurrent themes from the transcribed data.

RESULTS

The results revealed two main themes: preventive practices against hospital-acquired infections and barriers toward infection prevention practices. The subthemes under the preventive practices were as follows: views on HAIs preventive practices, barrier nursing, hand washing and use of sanitizers, aseptic techniques, and sterilization. Increased workload, lack of superior support, and inadequate resources emerged under the barriers toward infection prevention practices.

CONCLUSION

It was concluded from the study that most of the student nurses had adequate information about HAIs and wish to adhere to the Infection prevention protocols. However, the participants observed poor infection prevention practices among the staff they were learning from. It is therefore recommended that more attention is focused on infection prevention and control in clinical practice among nurses.

Outbreaks in Health Care Settings

Outbreaks and pseudo-outbreaks in health care settings are complex and should be evaluated systematically using epidemiologic and molecular tools. Outbreaks result from failures of infection prevention practices, inadequate staffing, and undertrained or overcommitted health care personnel. Contaminated hands, equipment, supplies, water, ventilation systems, and environment may also contribute. Neonatal intensive care, endoscopy, oncology, and transplant units are areas at particular risk. Procedures, such as bronchoscopy and endoscopy, are sources of infection when cleaning and disinfection processes are inadequate. New types of equipment can be introduced and lead to contamination or equipment and medications can be contaminated at the manufacturing source.

Can Copper Products and Surfaces Reduce the Spread of Infectious Microorganisms and Hospital-Acquired Infections?

Pathogen transfer and infection in the built environment are globally significant events, leading to the spread of disease and an increase in subsequent morbidity and mortality rates. There are numerous strategies followed in healthcare facilities to minimize pathogen transfer, but complete infection control has not, as yet, been achieved. However, based on traditional use in many cultures, the introduction of copper products and surfaces to significantly and positively retard pathogen transmission invites further investigation. For example, many microbes are rendered unviable upon contact exposure to copper or copper alloys, either immediately or within a short time. In addition, many disease-causing bacteria such as E. coli O157:H7, hospital superbugs, and several viruses (including SARS-CoV-2) are also susceptible to exposure to copper surfaces. It is thus suggested that replacing common touch surfaces in healthcare facilities, food industries, and public places (including public transport) with copper or alloys of copper may substantially contribute to limiting transmission. Subsequent hospital admissions and mortality rates will consequently be lowered, with a concomitant saving of lives and considerable levels of resources. This consideration is very significant in times of the COVID-19 pandemic and the upcoming epidemics, as it is becoming clear that all forms of possible infection control measures should be practiced in order to protect community well-being and promote healthy outcomes.

Healthcare-Associated Legionnaires' Disease, Europe, 2008-2017

Healthcare-associated Legionnaires’ disease (HCA LD) can cause nosocomial outbreaks with high death rates. We compared community-acquired LD cases with HCA LD cases in Europe during 2008−2017 using data from The European Surveillance System. A total of 29 countries reported 40,411 community-acquired and 4,315 HCA LD cases. Of the HCA LD cases, 2,937 (68.1%) were hospital-acquired and 1,378 (31.9%) were linked to other healthcare facilities. The odds of having HCA LD were higher for women, children and persons <20 years of age, and persons >60 years of age. Out of the cases caused by Legionella pneumophila with a known serotype, community-acquired LD was more likely to be caused by L. pneumophila serogroup 1 (92.3%) than was HCA LD (85.1%). HCA LD patients were more likely to die. HCA LD is associated with specific patient demographics, causative strains, and outcomes. Healthcare facilities should consider these characteristics when designing HCA LD prevention strategies.

Legionella spp. in Polish hospitals in 2009–2013 and 2014–2016: An epidemiological analysis

Introduction: Bacteria of the genus Legionella cause Legionnaires’ disease (atypical pneumonia, often with a severe clinical course) and Pontiac fever (self-limiting infection with flu-like symptoms). Legionella spp. are commonly found in natural aquatic environments and artificial water distribution systems. Material&Methods: An epidemiological analysis of Legionella spp. in hospital water supply systems was based on the results obtained from Sanitary-Epidemiological Stations of Poland. The materials for this study were hot water samples collected from 346 hospitals in 2009–2013 and from 221 hospitals in 2014–2016. Results: Between 2014 and 2016, there was a decrease in the percentage of the number of water samples in Group A (<100 CFU/100 ml). In other groups: B (>100 CFU/100 ml), C (>1000 CFU/100 ml), D (>10 000 CFU/100 ml) was observed an increase in the percentage of the number of water samples, which was a negative phenomenon. The mean number of L. pneumophila colonies in analyzed periods 2009–2013 and 2014–2016 were different. In 2009–2013, the most virulent L. pneumophila serogroup 1 (SG 1) was detected in 3 hospitals (0.9%), and L. pneumophila SG 2-14 were isolated in 20 (5.5%). Between 2014 and 2016, L. pneumophila SG 1 and L. pneumophila SG 2-14 were found in 5 hospitals (2.2%) and 18 hospitals (8.1%), respectively. Disscusion: In this study a comparative epidemiological analysis was performed on the prevalence of L. pneumophila in hospital water supply systems in Poland in the following two periods: 2009 –2013 and 2014–2016. The study demonstrated that the water supply systems of Polish hospitals were colonized by L. pneumophila at different levels. However, between 2014 and 2016 an upward trend was observed in comparison with 2009–2013.

The impact of pipeline changes and temperature increase in a hospital historically colonised with Legionella

Healthcare-related Legionnaires’ disease has a devastating impact on high risk patients, with a case fatality rate of 30–50%. Legionella prevention and control in hospitals is therefore crucial. To control Legionella water colonisation in a hospital setting we evaluated the effect of pipeline improvements and temperature increase, analysing 237 samples over a 2-year period (first year: 129, second year: 108). In the first year, 25.58% of samples were positive for Legionella and 16.67% for amoeba. Assessing the distance of the points analysed from the hot water tank, the most distal points presented higher proportion of Legionella colonisation and lower temperatures (nearest points: 6.4% colonised, and temperature 61.4 °C; most distal points: 50% and temperature 59.1 °C). After the first year, the hot water system was repaired and the temperature stabilised. This led to a dramatic reduction in Legionella colonisation, which was negative in all the samples analysed; however, amoeba colonisation remained stable. This study shows the importance of keeping the temperature stable throughout the circuit, at around 60 °C. Special attention should be paid to the most distal points of the circuit; a fall in temperature at these weak points would favour the colonisation and spread of Legionella, because amoeba (the main Legionella reservoir) are not affected by temperature.

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.

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.

Legionnaires' Disease in Pediatric Patients, Control Measures and 5-Year Follow-up

BACKGROUND

Legionnaires' disease (LD) occurs predominantly in adults and elderly people. Its incidence in Europe has been increasing in recent years. It is rare in younger age groups and prone to be reported as healthcare-associated infection with a higher risk of fatal outcome. Hospital-acquired LD is mostly associated with a colonized hospital water system. We describe 5 LD cases in a children's hospital in Slovakia, subsequent environmental investigation, control measures, and 5-year monitoring of Legionella colonization in hospital's water system.

METHODS

In 2014-2019, we tested clinical specimens from 75 hospitalized patients. Respiratory samples were cultured for Legionella, patient's urine was tested for Legionella urinary antigens, and the microagglutination test was used for serologic testing. Samples of water were collected in 2015-2019 and processed according ISO11731.

RESULTS

We identified 5 Legionella infections in 2014-2015. Median age of patients was 15 years. All were high-risk patients hospitalized for their underlying diseases. All patients required admission to intensive care unit, and artificial ventilation due to general deterioration and respiratory failure. Legionella pneumophila was isolated from 72% of water samples. Chlorine dioxide dosing into water system above 0.3 ppm caused significant decrease of Legionella concentration in water samples. Samples taken from outlets with antimicrobial filter installed were legionellae-negative.

CONCLUSIONS

Control measures led to decreased risk of infection, but not to eradication of Legionellae. It is necessary to extend the diagnostics for Legionella infection in hospitalized children with pneumonia, especially in hospitals with colonized water system.

Long-Term Monitoring of Noxious Bacteria for Construction of Assurance Management System of Water Resources in Natural Status of the Republic of Korea

Climate change is expected to affect not only availability and quality of water, the valuable resource of human life on Earth, but also ultimately public health issue. A six-year monitoring (total 20 times) of Escherichia coli O157, Salmonella enterica, Legionella pneumophila, Shigella sonnei, Campylobacter jejuni, and Vibrio cholerae was conducted at five raw water sampling sites including two lakes, Hyundo region (Geum River) and two locations near Water Intake Plants of Han River (Guui region) and Nakdong River (Moolgeum region). A total 100 samples of 40 L water were tested. Most of the targeted bacteria were found in 77% of the samples and at least one of the target bacteria was detected (65%). Among all the detected bacteria, E. coli O157 were the most prevalent with a detection frequency of 22%, while S. sonnei was the least prevalent with a detection frequency of 2%. Nearly all the bacteria (except for S. sonnei) were present in samples from Lake Soyang, Lake Juam, and the Moolgeum region in Nakdong River, while C. jejuni was detected in those from the Guui region in Han River. During the six-year sampling period, individual targeted noxious bacteria in water samples exhibited seasonal patterns in their occurrence that were different from the indicator bacteria levels in the water samples. The fact that they were detected in the five Korea's representative water environments make it necessary to establish the chemical and biological analysis for noxious bacteria and sophisticated management systems in response to climate change.

Legionellosis and Recent Advances in Technologies for Legionella Control in Premise Plumbing Systems: A Review

This review discusses Legionella, among the most prolific and publicly well-known waterborne pathogens, and advances in potential treatment technologies. The number of cases associated with Legionella continues to rise, as does its public awareness. Currently, cases associated with premise plumbing account for the largest number of legionellosis cases in the United States. So, while it is important to understand Legionella as such, it is also important to investigate how to treat drinking water in premise plumbing for Legionella and other waterborne pathogens. While there are currently several methods recognized as potential means of inactivating waterborne pathogens, several shortcomings continue to plague its implementation. These methods are generally of two types. Firstly, there are chemical treatments such as chlorine, chlorine dioxide, monochloramine, ozone, and copper-silver ionization. Secondly, there are physical treatments such as thermal inactivation and media filtration. Their shortcomings range from being labor-intensive and costly to having negative health effects if not properly operated. Recently developed technologies including ultraviolet (UV) irradiation using light emitting diodes (LEDs) and innovative carbon nanotube (CNT) filters can better control waterborne pathogens by allowing for the simultaneous use of different treatment measures in plumbing systems.

Can incorporation of UVC LEDs into showerheads prevent opportunistic respiratory pathogens? - Microbial behavior and device design considerations

Respiratory infections from opportunistic bacterial pathogens (OBPs) have heightened research interests in drinking water distribution systems, premise plumbing, and point-of-use technologies. In particular, biofilm growth in showerheads increases OBP content, and inhalation of shower aerosols is a major exposure route for Legionellae and Mycobacteria infections. Incorporation of UVC LEDs into showerheads has thus been proposed as a point-of-use option for healthcare facilities. Herein we have examined incongruities between the nature of OBP contamination in shower water and the hypothetical application of conventional UV disinfection engineering concepts. Effective UV dosing within showerheads must overcome significant shielding effects imparted by the biological matrices in which common OBPs reside, including biofilm particles and protozoan hosts. Furthermore, prevention of biofilm growth in showerhead interiors requires a different UV irradiation approach and is lacking in established design parameters. Development of showerhead devices is also likely to face a trade-off between bathing functionality and simpler form factors that are more conducive to internal UV irradiation.

Comparison of Whole-Genome Sequences of Legionella pneumophila in Tap Water and in Clinical Strains, Flint, Michigan, USA, 2016

During the water crisis in Flint, Michigan, USA (2014-2015), 2 outbreaks of Legionnaires' disease occurred in Genesee County, Michigan. We compared whole-genome sequences of 10 clinical Legionella pneumophila isolates submitted to a laboratory in Genesee County during the second outbreak with 103 water isolates collected the following year. We documented a genetically diverse range of L. pneumophila strains across clinical and water isolates. Isolates belonging to 1 clade (3 clinical isolates, 3 water isolates from a Flint hospital, 1 water isolate from a Flint residence, and the reference Paris strain) had a high degree of similarity (2-1,062 single-nucleotide polymorphisms), all L. pneumophila sequence type 1, serogroup 1. Serogroup 6 isolates belonging to sequence type 2518 were widespread in Flint hospital water samples but bore no resemblance to available clinical isolates. L. pneumophila strains in Flint tap water after the outbreaks were diverse and similar to some disease-causing strains.

Advances in Legionella Control by a New Formulation of Hydrogen Peroxide and Silver Salts in a Hospital Hot Water Network

Legionella surveillance is an important issue in public health, linked to the severity of disease and the difficulty associated with eradicating this bacterium from the water environment. Different treatments are suggested to reduce Legionella risk, however long-term studies of their efficiency are lacking. This study focused on the activity of a new formulation of hydrogen peroxide and silver salts, WTP828, in the hospital hot water network (HWN) to contain Legionella contamination during two years of treatment. The effectiveness of WTP828 was tested measuring physical-chemical and microbiological parameters such as Legionella, Pseudomonas aeruginosa (P. aeruginosa), and a heterotopic plate count (HPC) at 36 °C. Legionella isolates were identified by serotyping and genotyping. WTP 828 induced a reduction in Legionella–positive sites (60% to 36%) and contamination levels (2.12 to 1.7 log₁₀ CFU/L), with isolates belonging to L. pneumophila SG1 (ST1 and ST104), L. anisa and L. rubrilucens widely distributed in HWN. No relevant contamination was found for other parameters tested. The long-term effect of WTP828 on Legionella containment suggest the easy and safe application of this disinfectant, that combined with knowledge of building characteristics, an adequate environmental monitoring and risk assessment plan, become the key elements in preventing Legionella contamination and exposure.

Viewing Legionella pneumophila Pathogenesis through an Immunological Lens

Legionella pneumophila is the causative agent of the severe pneumonia Legionnaires' disease. L. pneumophila is ubiquitously found in freshwater environments, where it replicates within free-living protozoa. Aerosolization of contaminated water supplies allows the bacteria to be inhaled into the human lung, where L. pneumophila can be phagocytosed by alveolar macrophages and replicate intracellularly. The Dot/Icm type IV secretion system (T4SS) is one of the key virulence factors required for intracellular bacterial replication and subsequent disease. The Dot/Icm apparatus translocates more than 300 effector proteins into the host cell cytosol. These effectors interfere with a variety of cellular processes, thus enabling the bacterium to evade phagosome-lysosome fusion and establish an endoplasmic reticulum-derived Legionella-containing vacuole, which facilitates bacterial replication. In turn, the immune system has evolved numerous strategies to recognize intracellular bacteria such as L. pneumophila, leading to potent inflammatory responses that aid in eliminating infection. This review aims to provide an overview of L. pneumophila pathogenesis in the context of the host immune response.

Evaluation of the prevalence of Legionella pneumophila in Iranian clinical samples: A systematic review and meta-analysis

BACKGROUND

Legionella pneumophila is the main cause for community-acquired pneumonia especially in hospital environments. In this systematic review and meta-analysis, we evaluated the prevalence of L. pneumophila in clinical samples obtained from Iranian patients.

METHODS

The studies reporting L. pneumophila prevalence in Iranian clinical samples that were published between January 2000 and July 2016 were recruited. Comprehensive Meta-Analysis Software (version 3.3.070) was used for quantitative data analysis. Because of high heterogeneity between the studies according to the Cochrane Q and I² statistics, a random-effects model was used for meta-analysis.

RESULTS

Sixteen studies encompassing 1956 subjects were included in the meta-analysis. The overall prevalence of L. pneumophila was 9.6% in clinical samples obtained from the Iranian patients. The age spectrum ranged from 6 months to 80 years old. Dyspnea and cough comprised the most common clinical manifestations. In the subgroup analysis, the prevalence of L. pneumophila was higher in studies with sample size ≤100 (12.9%) in comparison with studies with sample size >100 (8.4%). In addition, the prevalence of L. pneumophila was higher in the years 2009-2016 (9.2%) compared with 2000-2008 (0.7%).

CONCLUSION

L. pneumophila is a major cause of community- and hospital-acquired pneumonia. It is of pivotal importance to implement sensitive and reliable molecular and culture-based techniques to detect and control this infection in healthcare environments.

Multiplex polymerase chain reaction of genetic markers for detection of potentially pathogenic environmental Legionella pneumophila isolates

Background & objectives:

Genomic constitution of the bacterium Legionella pneumophila plays an important role in providing them a pathogenic potential. Here, we report the standardization and application of multiplex polymerase chain reaction (PCR) for the detection of molecular markers of pathogenic potential in L. pneumophila in hospital environment.

Methods:

Culture of the standard strains of L. pneumophila was performed in buffered charcoal-yeast extract agar with L-cysteine at pH 6.9. Primers were designed for multiplex PCR, and standardization for the detection of five markers annotated to L. pneumophila plasmid pLPP (11A2), lipopolysaccharide synthesis (19H4), CMP-N-acetylneuraminic acid synthetase (10B12), conjugative coupling factor (24B1) and hypothetical protein (8D6) was done. A total of 195 water samples and 200 swabs were collected from the hospital environment. The bacterium was isolated from the hospital environment by culture and confirmed by 16S rRNA gene PCR and restriction enzyme analysis. A total of 45 L. pneumophila isolates were studied using the standardized multiplex PCR.

Results:

The PCR was sensitive to detect 0.1 ng/μl DNA and specific for the two standard strains used in the study. Of the 45 hospital isolates tested, 11 isolates had four markers, 12 isolates had three markers, 10 isolates had two markers, nine isolates had one marker and three isolates had none of the markers. None of the isolates had all the five markers.

Interpretation & conclusions:

The findings of this study showed the presence of gene markers of pathogenic potential of the bacterium L. pneumophila. However, the genomic constitution of the environmental isolates should be correlated with clinical isolates to prove their pathogenic potential. Rapid diagnostic methods such as multiplex PCR reported here, for elucidating gene markers, could help in future epidemiological studies of bacterium L. pneumophila.

New system for the detection of Legionella pneumophila in water samples

Waterborne pathogens are a global concern for public health worldwide. Despite continuing efforts to maintain water safety, water quality is still affected by deterioration and pollution. Legionella pneumophila colonizes man-made water systems and can infect humans causing Legionnaire's disease (LD), pneumonia. The prevention of LD is a public health issue and requires specific systems to control and detect these microorganisms. Culture plate is the only technique currently approved, but requires more than 10 days to obtain results. A rapid test that inform in hours about the presence of Legionella pneumophila in water samples will improve the control of this pathogen colonization. In order to control colonization by L. pneumophila we developed a membrane filter method to capture and immunodetect this microorganism in water samples. This membrane filter is used to retain the bacteria using a nitrocellulose disc inside a home-made cartridge. Subsequently we perform the immunodetection of the bacteria retained in the nitrocellulose (blocking, antibody incubation, washings and developing). On comparing our test with the gold-standard, the most important finding is the considerably reduction in time maintaining the same detection limit. This rapid test is easily automated for L. pneumophila detection allowing a comprehensive surveillance of L. pneumophila in water facilities and reducing the variability in the analyses due to the low need for manipulation. Moreover, corrective measures may be applied the same day of the analysis. This method considerably reduces the detection time compared with the conventional, gold-standard detection culture method that requires more than 10 days, being decisive to prevent outbreaks.

Legionella pneumophila Serogroup 1 in the Water Facilities of a Tertiary Healthcare Center, India

Proactive environmental surveillance for Legionella pneumophila in hospitals that treat immunocompromised patients is a useful strategy for preventing nosocomial Legionnaires’ disease. We report the presence of L. pneumophila serogroup 1 in 15.2% of the water systems of our tertiary healthcare center, which should prompt health officials to formulate mitigation policies.

Legionella pneumonia appeared during hospitalization in a patient with hematological malignancy confirmed by sputum culture after negative urine antigen test

Legionella pneumophila is recognized as a common causative organism for community-acquired pneumonia, but it is rarely a causative organism for hospital-acquired pneumonia, except in cases of hospital outbreak. Recently, most of the Legionella cases have been diagnosed using the urine antigen test. However, this test can reliably detect only L. pneumophila serogroup 1. Here we report a 63-year-old male patient who was recently diagnosed with acute leukemia and treated with chemotherapy and who developed pneumonia on hospital day 8 during the nadir phase. He was later diagnosed with Legionella pneumonia by culture despite a negative urine antigen test. This case suggests that Legionella pneumonia is an important differential diagnosis for pneumonia in inpatients in the early phase of hospitalization and that when Legionella infection is clinically suspected, culture using selective media or molecular tests should be performed even if the urine antigen test is negative.

Legionella: virulence factors and host response

PURPOSE OF REVIEW

Legionella pneumophila is a facultative intracellular pathogen and an important cause of community-acquired and nosocomial pneumonia. This review focuses on the latest literature examining Legionella's virulence strategies and the mammalian host response.

RECENT FINDINGS

Recent studies identify novel virulence strategies used by L. pneumophila and new aspects of the host immune response to this pathogen. Legionella prevents acidification of the phagosome by recruiting Rab1, a host protein. Legionella also blocks a conserved endoplasmic reticulum stress response. To access iron from host stores, L. pneumophila upregulates more regions allowing vacuolar colocalization N. In response to Legionella, the host cell may activate caspase-1, caspase-11 (mice) or caspase-4 (humans). Caspase-3 and apoptosis are activated by a secreted, bacterial effector. Infected cells send signals to their uninfected neighbors, allowing the elaboration of inflammatory cytokines in trans. Antibody subclasses provide robust protection against Legionella.

SUMMARY

L. pneumophila is a significant human pathogen that lives in amoebae in the environment but may opportunistically infect the alveolar macrophage. To maintain its intracellular lifestyle, Legionella extracts essential iron from the cell, blocks inflammatory responses and manipulates trafficking to avoid fusion with the lysosome. The mammalian host has counter strategies, which include the release of proinflammatory cytokines, the activation of caspases and antibody-mediated immunity.

Ten Questions Concerning the Aerosolization and Transmission of Legionella in the Built Environment

Legionella is a genus of pathogenic Gram-negative bacteria responsible for a serious disease known as legionellosis, which is transmitted via inhalation of this pathogen in aerosol form. There are two forms of legionellosis: Legionnaires' disease, which causes pneumonia-like symptoms, and Pontiac fever, which causes influenza-like symptoms. Legionella can be aerosolized from various water sources in the built environment including showers, faucets, hot tubs/swimming pools, cooling towers, and fountains. Incidence of the disease is higher in the summertime, possibly because of increased use of cooling towers for air conditioning systems and differences in water chemistry when outdoor temperatures are higher. Although there have been decades of research related to Legionella transmission, many knowledge gaps remain. While conventional wisdom suggests that showering is an important source of exposure in buildings, existing measurements do not provide strong support for this idea. There has been limited research on the potential for Legionella transmission through heating, ventilation, and air conditioning (HVAC) systems. Epidemiological data suggest a large proportion of legionellosis cases go unreported, as most people who are infected do not seek medical attention. Additionally, controlled laboratory studies examining water-to-air transfer and source tracking are still needed. Herein, we discuss ten questions that spotlight current knowledge about Legionella transmission in the built environment, engineering controls that might prevent future disease outbreaks, and future research that is needed to advance understanding of transmission and control of legionellosis.

Are there effective interventions to prevent hospital-acquired Legionnaires' disease or to reduce environmental reservoirs of Legionella in hospitals? A systematic review

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.

Discriminatory usefulness of pulsed-field gel electrophoresis and sequence-based typing in Legionella outbreaks

Aim: To compare the discriminatory power of pulsed-field gel electrophoresis (PFGE) and sequence-based typing (SBT) in Legionella outbreaks for determining the infection source. Materials & methods: Twenty-five investigations of Legionnaires’ disease were analyzed by PFGE, SBT and Dresden monoclonal antibody. Results: The results suggested that monoclonal antibody could reduce the number of Legionella isolates to be characterized by molecular methods. The epidemiological concordance PFGE–SBT was 100%, while the molecular concordance was 64%. Adjusted Wallace index (AW) showed that PFGE has better discriminatory power than SBT (AWSBT→PFGE = 0.767; AWPFGE→SBT = 1). The discrepancies appeared mostly in sequence type (ST) 1, a worldwide distributed ST for which PFGE discriminated different profiles. Conclusion: SBT discriminatory power was not sufficient verifying the infection source, especially in worldwide distributed STs, which were classified into different PFGE patterns.

Use of copper-silver ionization for the control of legionellae in alkaline environments at health care facilities

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.

Nosocomial neonatal legionellosis associated with water in infant formula, Taiwan

We report 2 cases of neonatal Legionella infection associated with aspiration of contaminated water used in hospitals to make infant formula. The molecular profiles of Legionella strains isolated from samples from the infants and from water dispensers were indistinguishable. Our report highlights the need to consider nosocomial legionellosis among neonates who have respiratory symptoms.

Environmental surveillance and molecular epidemiology of waterborne pathogen Legionella pneumophila in health-care facilities of Northeastern Greece: a 4-year survey

A 4-year proactive environmental surveillance of Legionella spp. in the water distribution and cooling systems of five health-care facilities was carried out as part of the strategy for the prevention of hospital-acquired Legionnaires' disease in Northeastern Greece. Legionella spp. were detected in 71 out of 458 collected samples. The majority of strains belonged to Legionella pneumophila serogroups 2-15 (75.0%), while all L. pneumophila serogroup 1 strains (23.6%) were isolated from a single hospital. The highest percentage of positive samples was found in distal sites (19.4%), while no Legionella strains were detected in cooling systems. Each hospital was colonized at least once with L. pneumophila, while remedial actions resulted in significant reduction of Legionella concentration. The molecular epidemiology of environmental L. pneumophila strains was also investigated using random amplified polymorphic DNA (RAPD) and multi-gene sequence-based analysis. Based on RAPD patterns, L. pneumophila serogroups 2-15 and serogroup 1 strains were classified into 24 and 9 operational taxonomic units (OTUs), respectively. Sequencing of housekeeping and diversifying pressure-related genes recommended by European Working Group for Legionella Infections (EWGLI) revealed not only a high intraspecies variability but also the circulation and persistence of one specific genotyping profile in the majority of hospitals. This study highlights the necessity for diachronic surveillance of Legionella in health-care facilities by adopting both cultural and molecular methods.

Environmental Cultures and Hospital-Acquired Legionnaires' Disease: A 5-Year Prospective Study in 20 Hospitals in Catalonia, Spain

Objective:

To determine whether environmental cultures forLegionellaincrease the index of suspicion for legionnaires' disease (LD).

Design:

Five-year prospective study.

Setting:

Twenty hospitals in Catalonia, Spain.

Methods:

From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested forLegionella, Cases of hospital-acquired LD and availability of an “in-house”Legionellatest in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing.

Results:

Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and usedLegionellatests includingLegionellaurinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals,Legionellatests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) usedLegionellaurinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD.

Conclusions:

The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using theLegionellaurinary antigen test in their laboratories.

Fatal NosocomialLegionella pneumophilaInfection Due to Exposure to Contaminated Water From a Washbasin in a Hematology Unit

A fatal nosocomial infection withLegionella pneumophilaserogroup 5 occurred in a patient with leukemia. Isolates recovered from both the potable water supply and the patient showed an identical genomic profile. With no other exposure identified, the water from the washbasin was evidently the source of infection.

Environmental Cultures and Hospital-Acquired Legionnaires' Disease: A 5-Year Prospective Study in 20 Hospitals in Catalonia, Spain

Objective:

To determine whether environmental cultures forLegionellaincrease the index of suspicion for legionnaires' disease (LD).

Design:

Five-year prospective study.

Setting:

Twenty hospitals in Catalonia, Spain.

Methods:

From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested forLegionella, Cases of hospital-acquired LD and availability of an “in-house”Legionellatest in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing.

Results:

Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and usedLegionellatests includingLegionellaurinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals,Legionellatests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) usedLegionellaurinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD.

Conclusions:

The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using theLegionellaurinary antigen test in their laboratories.

Current preventive measures for health-care associated surgical site infections: a review

Healthcare-associated infections (HAIs) continue to be a tremendous issue today. It is estimated 1.7 million HAIs occur per year, and cost the healthcare system up to $45 billion annually. Surgical site infections (SSIs) alone account for 290,000 of total HAIs and approximately 8,000 deaths. In today's rapidly changing world of medicine, it is ever important to remain cognizant of this matter and its impact both globally and on the individual lives of our patients. This review aims to impress upon the reader the unremitting significance of HAIs in the daily practice of medicine. Further, we discuss the etiology of HAIs and review successful preventive measures that have been demonstrated in the literature. In particular, we highlight preoperative, intraoperative, and postoperative interventions to combat SSIs. Finally, we contend that current systems in place are often insufficient, and emphasize the benefits of institution-wide adoption of multiple preventive interventions. We hope this concise update and review can inspire additional dialogue for the continuing progress towards improving patient care and patient lives.

Legionella control in the water system of antiquated hospital buildings by shock and continuous hyperchlorination: 5 years experience

Background

To control the presence of Legionella in an old hospital water system, an integrated strategy of water disinfection-filtration was implemented in the university hospital Umberto I in Rome.

Methods

Due to antiquated buildings, hospital water system design and hospital extension (38 buildings), shock hyperchlorination (sodium hypochlorite, 20–50 ppm of free chlorine at distal points for 1–2 h) followed by continuous hyperchlorination (0.5-1.0 mg/L at distal points) were adopted, and microbiological and chemical monitoring of the water supply was carried out in the university hospital (December 2006-December 2011).

Results

Overall, 1308 samples of cold <20°C (44.5%), mixed ≥20°C ≤ 45°C (37.7%) and hot >45°C (17.8%) water were collected, determining residual free chlorine (0.43 ± 0.44 mg/L), pH (7.43 ± 0.29) and trihalomethanes (8.97 ± 18.56 μg/L). Legionella was isolated in 102 (9.8%) out of 1.041 water samples without filters (L. pneumophila sg 1 17.6%, L. pneumophila sg 2–14 28.4%, L. non pneumophila 53.9%), and in none of the 267 samples with filters. Legionella was recovered in 23 buildings out of 38 and 29 samples (28.4%) exceeded 10³ cfu/L. When considering the disinfection treatment Legionella was isolated: before shock hyperchlorination (21.1%), 15 days after shock hyperchlorination (7.8%), 30 days after shock hyperchlorination (3.5%), during continuous hyperchlorination (5.5%) and without continuous hyperchlorination (27.3%). Continuous hyperchlorination following the shock treatment achieved >70% reduction of positive samples, whereas no continuous hyperchlorination after shock treatment was more frequently associated to Legionella isolation (OR 6.41; 95% CI 3.10–13.26; p <0.001). Independent risk factors for Legionella isolation were: residual free chlorine <0.5 mg/L (OR 13.0; 95% CI 1.37 – 123.2; p <0.03), water T° ≥20°C ≤ 45°C (OR 12.0; 95% CI 1.28 – 111.48; p <0.03) and no continuous hyperchlorination after shock treatment (OR 10.3; 95% CI 1.06 – 100.05; p <0.05).

Conclusions

Shock and continuous hyperchlorination achieved significant Legionella reduction, but effective chlorine levels (>0.5 < 1.0 mg/L) deteriorated water quality (organoleptic and chemical). However, shock and continuous hyperchlorination remains a valid-term option in old buildings with no water system rational design, managing problems due to hospital extension and absence of a proper hot water recirculation system.

Classifying infectious disease outbreaks to improve timeliness and efficiency of response

Following the intentional dissemination of B.anthracis through the U.S. Postal Service in 2001, use of the term "naturally occurring" to classify some infectious disease outbreaks has become more evident. However, this term is neither a scientific nor an epidemiologic classification that is helpful in describing either the source or the mode of transmission in outbreaks. In this paper, the authors provide examples of how and when the public health community has recognized potentially flawed or misleading taxonomy in the past and taken steps to improve the taxonomy's accuracy and usefulness. We also offer examples of alternative terms for classifying outbreaks since inaccurate descriptions of outbreaks could potentially lead to a flawed or incomplete set of underlying assumptions about the outbreak's causal factors. This, in turn, could lead to implementing a flawed or incomplete intervention or response strategy which could extend the duration of the outbreak, resulting in avoidable morbidity and mortality.