Each water outlet is a unique ecological niche for Legionella pneumophila

Existence and control of Legionella bacteria in building water systems: A review

Legionellae are waterborne bacteria which are capable of causing potentially fatal Legionnaires' disease (LD), as well as Pontiac Fever. Public concern about Legionella exploded following the 1976 outbreak at the American Legion conference in Philadelphia, where 221 attendees contracted pneumonia and 34 died. Since that time, a variety of different control methods and strategies have been developed and implemented in an effort to eradicate Legionella from building water systems. Despite these efforts, the incidence of LD has been steadily increasing in the U.S. for more than a decade. Public health and occupational hygiene professionals have maintained an active debate regarding best practices for management and control of Legionella. Professional opinion remains divided with respect to the relative merits of performing routine sampling for Legionella, vs. the passive, reactive approach that has been largely embraced by public health officials and facility owners. Given the potential risks and ramifications associated with waiting to assess systems for Legionella until after disease has been identified and confirmed, a proactive approach of periodic testing for Legionella, along with proper water treatment, is the best approach to avoiding large-scale disease outbreaks.

Modelling characteristics to predict Legionella contamination risk - Surveillance of drinking water plumbing systems and identification of risk areas

For the surveillance of drinking water plumbing systems (DWPS) and the identification of risk factors, there is a need for an early estimation of the risk of Legionella contamination within a building, using efficient and assessable parameters to estimate hazards and to prioritize risks. The precision, accuracy and effectiveness of ways of estimating the risk of higher Legionella numbers (temperature, stagnation, pipe materials, etc.) have only rarely been empirically assessed in practice, although there is a broad consensus about the impact of these risk factors. We collected n = 807 drinking water samples from 9 buildings which had had Legionella spp. occurrences of >100 CFU/100mL within the last 12 months, and tested for Legionella spp., L. pneumophila, HPC 20°C and 36°C (culture-based). Each building was sampled for 6 months under standard operating conditions in the DWPS. We discovered high variability (up to 4 log(10) steps) in the presence of Legionella spp. (CFU/100 mL) within all buildings over a half year period as well as over the course of a day. Occurrences were significantly correlated with temperature, pipe length measures, and stagnation. Logistic regression modelling revealed three parameters (temperature after flushing until no significant changes in temperatures can be obtained, stagnation (low withdrawal, qualitatively assessed), pipe length proportion) to be the best predictors of Legionella contamination (>100 CFU/100 mL) at single outlets (precision = 66.7%; accuracy = 72.1%; F(0.5) score = 0.59).

Presence and Chromosomal Subtyping ofLegionellaSpecies in Potable Water Systems in 20 Hospitals of Catalonia, Spain

Objective:

To investigate the presence and clonal distribution ofLegionellaspecies in the water supply of 20 hospitals in Catalonia, Spain.

Setting:

20 hospitals in Catalonia, an area of 32,000 km2, located in northeast Spain.

Methods:

Environmental cultures of 186 points of potable water supply and 10 cooling towers were performed for the presence ofLegionellaspecies. Following filtration and acid treatment, the samples were seeded in selective MWY (modified Wadowsky Yee)-buffered charcoal yeast extract-a agar. All isolates obtained were characterized microbiologically and genotyped bySfilpulsed-field gel electrophoresis (PFGE).

Results:

73 of 196 water samples, representing 17 of the 20 hospitals included in the study, were positive forLegionella pneumophila(serogroups 1, 2-14, or both). The degree of contamination ranged from 200 to 74,250 colony-forming units/L. Twenty-five chromosomal DNA subtypes were detected by PFGE. A single DNA subtype was identified in 10 hospitals, 2 DNA subtypes were observed in 6 hospitals, and 1 hospital exhibited 3 different DNA subtypes. Each hospital had its ownLegionellaDNA subtype, which was not shared with any other hospitals.

Conclusions:

Legionellawas present in the water of most of the hospitals studied; each such hospital had a unique, dominant chromosomal DNA subtype. The verification of several genomic DNA restriction profiles in such a small geographic area demonstrates the great genetic diversity ofLegionellain the aquatic environment.

Prevalence of Legionella spp. in water systems of hospitals and hotels in South Western Greece

The aim of the present study was to determine the prevalence of Legionella spp. in water systems of hospitals and hotels located in South Western Greece, to study the molecular epidemiology of the isolated strains and their possible association with bacterial contamination (total count and Pseudomonas aeruginosa), the water pH, and temperature. A prevalence survey for Legionella spp. by culturing techniques in water distribution systems of eight hospitals and nine hotels occurred in South Western Greece. Water sampling and microbiological analysis were carried out following the ISO methods. Legionella pneumophila was detected in 33% and 36% of the distribution systems of hospitals and hotels, respectively. Our survey results suggest a frequent prevalence of elevated concentrations of Legionella spp. in water systems of hospitals and hotels. Our investigation has confirmed the need to regularly monitor the microbiological condition of water systems in hospitals and hotels.

Occurrence of Legionella in hot water systems of single-family residences in suburbs of two German cities with special reference to solar and district heating

A total of 452 samples from hot water systems of randomly selected single family residences in the suburbs of two German cities were analysed for the occurrence of Legionella. Technical data were documented using a standardized questionnaire to evaluate possible factors promoting the growth of the bacterium in these small plumbing systems. All houses were supplied with treated groundwater from public water works. Drinking water quality was within the limits specified in the German regulations for drinking water and the water was not chlorinated. The results showed that plumbing systems in private houses that provided hot water from instantaneous water heaters were free of Legionella compared with a prevalence of 12% in houses with storage tanks and recirculating hot water where maximum counts of Legionella reached 100,000 CFU/100ml. The presence of L. pneumophila accounted for 93.9% of all Legionella positive specimens of which 71.8% belonged to serogroup 1. The volume of the storage tank, interrupting circulation for several hours daily and intermittently raising hot water temperatures to >60 degrees C had no influence on Legionella counts. Plumbing systems with copper pipes were more frequently contaminated than those made of synthetic materials or galvanized steel. An inhibitory effect due to copper was not present. Newly constructed systems (<2 years) were not colonized. The type of hot water preparation had a marked influence. More than 50% of all houses using district heating systems were colonized by Legionella. Their significantly lower hot water temperature is thought to be the key factor leading to intensified growth of Legionella. Although hot water systems using solar energy to supplement conventional hot water supplies operate at temperatures 3 degrees C lower than conventional systems, this technique does not seem to promote proliferation of the bacterium. Our data show convincingly that the temperature of the hot water is probably the most important or perhaps the only determinant factor for multiplication of Legionella. Water with a temperature below 46 degrees C was most frequently colonized and contained the highest concentrations of legionellae. It is evident that the same factors affecting colonization by Legionella in large buildings also exist in small residential water systems. If temperatures are low there is no difference between large and small systems and Legionella counts are high in both. Since private residences are an important source of community-acquired legionellosis, these findings emphasize the need for preventive control measures in small residential buildings. In some situations it may be necessary to install filtration devices at the point-of-use.

Genetic diversity of Legionella pneumophila in hospital water systems

It has been shown that different patients who had acquired legionellosis in a hospital setting were infected with the same strain even years apart. However, there are no longitudinal data describing the molecular epidemiology of Legionella pneumophila strains that contaminate a water system. This raised the question if there are any shifts of L. pneumophila strains over time, or after carrying out control measures. Using genotyping on a large collection of isolates, we investigated in a retrospective study the distribution of L. pneumophila serogroups and PFGE types in six different hospitals of the University of Heidelberg between 1991 and 2001. A total of 2012 water samples were drawn for routine testing and for evaluation of control measures, 747 samples were positive for L. pneumophila. Serogroups were determined by latex agglutination or by direct fluorescence assay; and 515 L. pneumophila isolates from water systems and six from patients underwent PFGE typing after SfiI-restriction. We identified seven serogroups and 19 genotypes among the water isolates. Each hospital had one to four predominating PFGE types that were stable over the investigation period. The oldest buildings in hospitals 4 and 5 (built 1876 and 1907) had more types than the newest one (built 1986). In all hospitals PFGE types were identified that could be found only sporadically. Although each hospital had its own warm water supply, we identified types that could be found in more than one hospital. However, there was no overlap of types in buildings that were fed from different wells. Infrequently occurring nosocomial legionellosis (n=3) were only caused by predominant strains. Contamination of water supplies seemed to be dominated by stable genotypes, even after various control measures. Additional genotypes could be isolated sporadically, however, their pathogenetic relevance seemed to be questionable.

Real-time PCR assay for the detection and quantification of Legionella pneumophila in environmental water samples: utility for daily practice

We developed a quantitative real-time PCR assay targeting the mip gene of Legionella pneumophila for a prospective study from September 2004 to April 2005. It was compared with a standard culture method (French guideline AFNOR T90-431), analysing 120 water samples collected to monitor the risk related to Legionellae at Nantes hospital and to investigate a case of legionellosis acquired from hospital environment. Samples from six distinct water distribution systems were analysed by DNA extraction, amplification and detection with specific primers and FRET probes. The detection limit was 100 genomic units of L. pneumophila per liter (GU/l), the positivity threshold about 600 GU/l and the quantification limit 800 GU/l. PCR results were divided into three groups: negative (n=63), positive but non-quantifiable (n=22) or positive (n=35). PCR showed higher sensitivity than culture, whereas four culture-positive samples appeared negative by PCR (PCR inhibitor detected for two of them). Although no correlation was observed between both methods and real-time PCR cannot substitute for the reference method, it represents an interesting complement. Its sensitivity, reproducibility and rapidity appear particularly interesting in epidemic contexts in order to identify the source of contamination or to evaluate critical points of contamination in water distribution systems.

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

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

Presence and chromosomal subtyping of Legionella species in potable water systems in 20 hospitals of Catalonia, Spain

OBJECTIVE

To investigate the presence and clonal distribution of Legionella species in the water supply of 20 hospitals in Catalonia, Spain.

SETTING

20 hospitals in Catalonia, an area of 32,000 km2, located in northeast Spain.

METHODS

Environmental cultures of 186 points of potable water supply and 10 cooling towers were performed for the presence of Legionella species. Following filtration and acid treatment, the samples were seeded in selective MWY (modified Wadowsky Yee)-buffered charcoal yeast extract-alpha agar. All isolates obtained were characterized microbiologically and genotyped by SfiI pulsed-field gel electrophoresis (PFGE).

RESULTS

73 of 196 water samples, representing 17 of the 20 hospitals included in the study, were positive for Legionella pneumophila (serogroups 1, 2-14, or both). The degree of contamination ranged from 200 to 74,250 colony-forming units/L. Twenty-five chromosomal DNA subtypes were detected by PFGE. A single DNA subtype was identified in 10 hospitals, 2 DNA subtypes were observed in 6 hospitals, and 1 hospital exhibited 3 different DNA subtypes. Each hospital had its own Legionella DNA subtype, which was not shared with any other hospitals.

CONCLUSIONS

Legionella was present in the water of most of the hospitals studied; each such hospital had a unique, dominant chromosomal DNA subtype. The verification of several genomic DNA restriction profiles in such a small geographic area demonstrates the great genetic diversity of Legionella in the aquatic environment.

Persistence of Legionella pneumophila in a hospital's water system: a 13-year survey

OBJECTIVE

To describe the molecular epidemiology of Legionella pneumophila infections in the University of Iowa Hospitals and Clinics (UIHC).

DESIGN

Molecular epidemiological study using pulsed-field gel electrophoresis (PFGE).

SETTING

A large university teaching hospital. ISOLATES: All surviving isolates obtained from culture-proven nosocomial L. pneumophila infections and all surviving isolates obtained from the University of Iowa Hospital and Clinics' water supply between 1981 and 1993.

RESULTS

Thirty-three isolates from culture-proven nosocomial cases of L. pneumophila pneumonia were available for typing. PFGE of genomic DNA from the clinical isolates identified six different strains. However, only strain C (16 cases) and strain D (13 cases) caused more than 1 case. Strain C caused clusters of nosocomial infection in 1981, 1986, and 1993 and also caused 4 sporadic cases. Strain D caused a cluster in 1987 and 1988 plus 4 sporadic cases. Of the six strains causing clinical infections, only strains C and D were identified in water samples. PFGE identified three strains in the water supply, of which strains C and D caused clinical disease and also persisted in the water supply during most of the study period.

CONCLUSION

Specific strains of L. pneumophila can colonize hospital water supplies and cause nosocomial infections over long periods of time.

Legionella: from environmental habitats to disease pathology, detection and control

Studies on Legionella show a continuum from environment to human disease. Legionellosis is caused by Legionella species acquired from environmental sources, principally water sources such as cooling towers, where Legionella grows intracellularly in protozoa within biofilms. Aquatic biofilms, which are widespread not only in nature, but also in medical and dental devices, are ecological niches in which Legionella survives and proliferates and the ultimate sources to which outbreaks of legionellosis can be traced. Invasion and intracellular replication of L. pneumophila within protozoa in the environment play a major role in the transmission of Legionnaires' disease. Protozoa provide the habitats for the environmental survival and reproduction of Legionella species. L. pneumophila proliferates intracellularly in various species of protozoa within vacuoles studded with ribosomes, as it also does within macrophages. Growth within protozoa enhances the environmental survival capability and the pathogenicity (virulence) of Legionella. The growth requirements of Legionella, the ability of Legionella to enter a viable non-culturable state, the association of Legionella with protozoa and the occurrence of Legionella within biofilms complicates the detection of Legionella and epidemiological investigations of legionellosis. Polymerase chain reaction (PCR) methods have been developed for the molecular detection of Legionella and used in environmental and epidemiological studies. Various physical and chemical disinfection methods have been developed to eliminate Legionella from environmental sources, but gaining control of Legionella in environmental waters, where they are protected from disinfection by growing within protozoa and biofilms, remains a challenge, and one that must be overcome in order to eliminate sporadic outbreaks of legionellosis.

Comparison of large restriction fragments of Mycobacterium avium isolates recovered from AIDS and non-AIDS patients with those of isolates from potable water

We examined potable water in Los Angeles, California, as a possible source of infection in AIDS and non-AIDS patients. Nontuberculous mycobacteria were recovered from 12 (92%) of 13 reservoirs, 45 (82%) of 55 homes, 31 (100%) of 31 commercial buildings, and 15 (100%) of 15 hospitals. Large-restriction-fragment (LRF) pattern analyses were done with AseI. The LRF patterns of Mycobacterium avium isolates recovered from potable water in three homes, two commercial buildings, one reservoir, and eight hospitals had varying degrees of relatedness to 19 clinical isolates recovered from 17 patients. The high number of M. avium isolates recovered from hospital water and their close relationship with clinical isolates suggests the potential threat of nosocomial spread. This study supports the possibility that potable water is a source for the acquisition of M. avium infections.

Analysis of Legionella pneumophila serogroup 1 isolates by pulsed-field gel electrophoresis

At a hospital in Halifax, Nova Scotia, Canada, three strains of Legionella pneumophila were detectable based on plasmid content, while the isolates collected at another hospital in Halifax had no plasmids. Genomic DNA was digested with BssHII, SalI, and SpeI and subjected to pulsed-field gel electrophoresis (PFGE). We found no relationship between plasmid profile and PFGE pattern.

Potable water and nosocomial Legionnaires' disease--check water from all rooms in which patient has stayed

We studied 7 patients with nosocomial Legionnaires' disease to determine the relationship between isolates of Legionella pneumophila recovered from potable water and those recovered from patients. Potable water was cultured from all rooms in which patients had stayed prior to the diagnosis of Legionnaires' disease. The 38 isolates of L. pneumophila (31 environmental, 7 patient) were resolved into 9 distinct patterns by pulse-field gel electrophoresis (PFGE), 3 by plasmid content and 2 each with monoclonal antibodies and conventional agarose gel electrophoresis of small fragments of DNA. Using PFGE it was determined that 4 of the 7 patients were infected with L. pneumophila identical to an isolate recovered from the potable water supply in one of the rooms each had occupied prior to the diagnosis of Legionnaires' disease. Patients had resided in a mean of 3.57 rooms before a diagnosis of nosocomial Legionnaires' disease. We conclude that in the setting of contaminated potable water and nosocomial Legionnaires' disease water from all the rooms which the patient has occupied prior to this diagnosis should be cultured. PFGE of large DNA fragments discriminated best among the isolates of L. pneumophila.

Nosocomial legionellosis in three heart-lung transplant patients: case reports and environmental observations

Organ transplant recipients are at high risk of contracting Legionnaires' disease in a hospital environment contaminated with legionellae. This study describes the first cases of culture-verified Legionella infections with an established link to potable hospital water in Denmark; three patients operated on at the Cardiopulmonary Transplant Unit, Rigshospitalet, Copenhagen, became infected with legionellae. Environmental and clinical isolates of Legionella pneumophila serogroups 1 and 6 were investigated by restriction enzyme analysis and ribotyping. An ice machine located in the kitchen of the intensive care unit was implicated as a source of infection in two of the three cases.

Legionnaires' disease outbreak, Fairfield 1992: public health aspects

An investigation of an outbreak of Legionnaires' disease in 1992 in Fairfield, a municipality of Sydney, was carried out to determine the source of the outbreak. Cases of Legionnaires' disease with onset of symptoms between 11 and 20 April 1992 were included. Definite cases were individuals with a history consistent with Legionnaires' disease, confirmed by direct fluorescent antibody testing plus serology or culture. There were two control groups: patients admitted to the same hospital as the cases, matched for age and sex, and patients admitted to hospital with a presumptive diagnosis of legionnaires' disease, in whom the diagnosis was subsequently excluded. There were 26 definite cases with onset of symptoms between 11 and 20 April 1992. Six (23 per cent) died. Twenty-two cases (85 per cent) reported visiting the Fairfield business district during the ten days prior to the onset of symptoms. They were 20 times more likely to have visited Fairfield than were matched controls. Matching of Legionella pneumophila serogroup 1 from environmental and clinical samples was achieved by cytogenetic fingerprinting. Fourteen cases were linked to a single environmental sample. The epidemiological findings were consistent with a point source of Legionella in the Fairfield business district. It is most likely that the exposure occurred on 10 April 1992.