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Kim P, Deshpande A, Rothberg MB. Urinary Antigen Testing for Respiratory Infections: Current Perspectives on Utility and Limitations. Infect Drug Resist 2022; 15:2219-2228. [PMID: 35510157 PMCID: PMC9058651 DOI: 10.2147/idr.s321168] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
Pneumonia is a leading cause of hospitalization and death due to infection worldwide. Streptococcus pneumoniae and Legionella pneumophila remain among the most commonly identified bacterial pathogens. Unfortunately, more than half of all pneumonia cases today lack an etiologic diagnosis due to limitations in traditional microbiological methods like blood and sputum cultures, which are affected by poor sample collection, prior antibiotic administration, and delayed processing. Urinary antigen tests (UATs) for S. pneumoniae and L. pneumophila have emerged as powerful tools for improving the diagnosis of bacterial respiratory infections, enabling physicians to administer early directed therapy and improve antimicrobial stewardship. UATs are simple, rapid, and non-invasive diagnostic tests with high specificity (>90%) and moderate sensitivity (<80%). The potential impact of urinary antigen testing is especially significant for respiratory infections caused by Legionella. While all recommended community-acquired pneumonia (CAP) therapies are adequate for treating pneumococcal pneumonia, only certain antibiotics are effective against Legionella. Delayed therapy for Legionella is associated with worse clinical outcomes, which underscores the importance of rapid diagnostic methods like UATs. Despite their potential impact, current American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines argue against the routine use of urinary antigen testing for S. pneumoniae and L. pneumophila, except in patients with severe CAP and those with epidemiological risk factors for Legionella. Further research is necessary to evaluate the impact of early targeted treatment due to positive UAT results, as well as optimal strategies for UAT utilization. The purpose of this review is to summarize the UATs available for bacterial respiratory infections, describe current guidelines on their usage, and assess their impact on clinical outcomes and targeted therapy.
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Affiliation(s)
- Priscilla Kim
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Correspondence: Michael B Rothberg, Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, Mail Code G10, Cleveland, OH, 44195, USA, Tel +1 216-445-5556, Email
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Brigmon RL, Turick CE, Knox AS, Burckhalter CE. The Impact of Storms on Legionella pneumophila in Cooling Tower Water, Implications for Human Health. Front Microbiol 2020; 11:543589. [PMID: 33362725 PMCID: PMC7758282 DOI: 10.3389/fmicb.2020.543589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/02/2020] [Indexed: 12/03/2022] Open
Abstract
At the U.S. Department of Energy’s Savannah River Site (SRS) in Aiken, SC, cooling tower water is routinely monitored for Legionella pneumophila concentrations using a direct fluorescent antibody (DFA) technique. Historically, 25–30 operating SRS cooling towers have varying concentrations of Legionella in all seasons of the year, with patterns that are unpredictable. Legionellosis, or Legionnaires’ disease (LD), is a pneumonia caused by Legionella bacteria that thrive both in man-made water distribution systems and natural surface waters including lakes, streams, and wet soil. Legionnaires’ disease is typically contracted by inhaling L. pneumophila, most often in aerosolized mists that contain the bacteria. At the SRS, L. pneumophila is typically found in cooling towers ranging from non-detectable up to 108 cells/L in cooling tower water systems. Extreme weather conditions contributed to elevations in L. pneumophila to 107–108 cells/L in SRS cooling tower water systems in July–August 2017. L. pneumophila concentrations in Cooling Tower 785-A/2A located in SRS A-Area, stayed in the 108 cells/L range despite biocide addition. During this time, other SRS cooling towers did not demonstrate this L. pneumophila increase. No significant difference was observed in the mean L. pneumophila mean concentrations for the towers (p < 0.05). There was a significant variance observed in the 285-2A/A Tower L. pneumophila results (p < 0.05). Looking to see if we could find “effects” led to model development by analyzing 13 months of water chemistry and microbial data for the main factors influencing the L. pneumophila concentrations in five cooling towers for this year. It indicated chlorine and dissolved oxygen had a significant impact (p < 0.0002) on cooling tower 785A/2A. Thus, while the variation in the log count data for the A-area tower is statistically greater than that of the other four towers, the average of the log count data for the A-Area tower was in line with that of the other towers. It was also observed that the location of 785A/2A and basin resulted in more debris entering the system during storm events. Our results suggest that future analyses should evaluate the impact of environmental conditions and cooling tower design on L. pneumophila water concentrations and human health.
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Affiliation(s)
- Robin L Brigmon
- Savannah River National Laboratory, Environmental Science and Biotechnology Group, Aiken, SC, United States
| | - Charles E Turick
- Savannah River National Laboratory, Environmental Science and Biotechnology Group, Aiken, SC, United States
| | - Anna S Knox
- Savannah River National Laboratory, Environmental Science and Biotechnology Group, Aiken, SC, United States
| | - Courtney E Burckhalter
- Savannah River National Laboratory, Environmental Science and Biotechnology Group, Aiken, SC, United States
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Miyashita N, Horita N, Higa F, Aoki Y, Kikuchi T, Seki M, Tateda K, Maki N, Uchino K, Ogasawara K, Kiyota H, Watanabe A. Validation of a diagnostic score model for the prediction of Legionella pneumophila pneumonia. J Infect Chemother 2019; 25:407-412. [PMID: 30935766 DOI: 10.1016/j.jiac.2019.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/22/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) due to Legionella has a high mortality rate in patients who do not receive adequate antibiotic therapy. In a previous study, we developed a simple Legionella Score to distinguish patients with Legionella and non-Legionella pneumonia based on clinical information at diagnosis. In the present study, we validated this Legionella Score for the presumptive diagnosis of Legionella CAP. METHODS This validation cohort included 109 patients with Legionella CAP and 683 patients with non-Legionella CAP. The Legionella Score includes six parameters by assigning one point for each of the following items: being male, absence of cough, dyspnea, C-reactive protein (CRP) ≥ 18 mg/dL, lactate dehydrogenase (LDH) ≥ 260 U/L, and sodium < 134 mmol/L. RESULTS When the Legionella CAP and non-Legionella CAP were compared by univariate analysis, most of the evaluated symptoms and laboratory test results differed substantially. The six parameters that were used for the Legionella Score also indicated clear differences between the Legionella and non-Legionella CAP. All Legionella patients had a score of 2 points or higher. The median Legionella Scores were 4 in the Legionella CAP cases and 2 in the non-Legionella CAP cases. A receiver operating characteristics curve showed that the area under the curve was 0.93. The proposed best cutoff, total score ≥3, had sensitivity of 93% and specificity of 75%. CONCLUSION Our Legionella Score was shown to have good diagnostic ability with a positive likelihood of 3.7 and a negative likelihood of 0.10.
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Affiliation(s)
- Naoyuki Miyashita
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan.
| | - Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Japan
| | - Futoshi Higa
- National Hospital Organization Okinawa National Hospital, Japan
| | - Yosuke Aoki
- Department of Infectious Disease and Hospital Epidemiology, Saga University Hospital, Japan
| | - Toshiaki Kikuchi
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Masafumi Seki
- Division of Infectious Diseases and Infection Control, Tohoku Medical and Pharmaceutical University Hospital, Japan
| | - Kazuhiro Tateda
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Japan
| | - Nobuko Maki
- Taisho Toyama Pharmaceutical Co., Ltd, Japan
| | | | - Kazuhiko Ogasawara
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan
| | - Hiroshi Kiyota
- Department of Urology, The Jikei University Katsushika Medical Center, Japan
| | - Akira Watanabe
- Development of Anti-Infective Agents, Faculty of Medical Science and Welfare, Tohoku Bunka Gakuen University, Japan
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Viasus D, Calatayud L, McBrown MV, Ardanuy C, Carratalà J. Urinary antigen testing in community-acquired pneumonia in adults: an update. Expert Rev Anti Infect Ther 2019; 17:107-115. [PMID: 30618315 DOI: 10.1080/14787210.2019.1565994] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) continues to be a leading cause of hospitalization and mortality worldwide. Streptococcus pneumoniae and Legionella pneumophila remain the major etiological agents and are responsible for a significant proportion of CAP mortality. Among diagnostic tests for CAP, urine antigen detection of S. pneumoniae and L. pneumophila is widely accepted due to the simplicity of collection and the rapidity of the test results. Areas covered: This comprehensive review outlines the urinary antigen tests available, discusses their sensitivity and specificity, and assesses the usefulness of their results as the basis for targeted therapy. Expert commentary: There have been advances in urine antigen detection tests for patients with CAP. New methodologies show greater sensitivity, detect S. pneumoniae and L. pneumophila in a single test, and also detect pneumococcal serotypes. In addition, urine antigen detection tests have shown a high specificity, which means that a positive result practically indicates the causative pathogen of CAP. Therefore, a positive result can lead to a targeted therapy that is likely to improve patient outcomes and reduce the risk of resistance and adverse events. However, well-designed studies are needed to evaluate the usefulness of urine antigen detection tests with regard to clinical outcomes.
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Affiliation(s)
- Diego Viasus
- a Department of Medicine, Health Sciences Division , Universidad del Norte and Hospital Universidad del Norte , Barranquilla , Colombia
| | - Laura Calatayud
- b Department of Microbiology , Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), University of Barcelona , Barcelona , Spain.,c Research Network for Respiratory Diseases (CIBERES) , Instituto de Salud Carlos III (ISCIII) , Madrid , Spain
| | - María V McBrown
- a Department of Medicine, Health Sciences Division , Universidad del Norte and Hospital Universidad del Norte , Barranquilla , Colombia
| | - Carmen Ardanuy
- b Department of Microbiology , Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), University of Barcelona , Barcelona , Spain.,c Research Network for Respiratory Diseases (CIBERES) , Instituto de Salud Carlos III (ISCIII) , Madrid , Spain
| | - Jordi Carratalà
- d Department of Infectious Diseases , Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), University of Barcelona , Barcelona , Spain.,e Spanish Network for Research in Infectious Diseases (REIPI) , Instituto de Salud Carlos III (ISCIII) , Madrid , Spain
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5
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Ruiz-Moreno JS, Hamann L, Shah JA, Verbon A, Mockenhaupt FP, Puzianowska-Kuznicka M, Naujoks J, Sander LE, Witzenrath M, Cambier JC, Suttorp N, Schumann RR, Jin L, Hawn TR, Opitz B. The common HAQ STING variant impairs cGAS-dependent antibacterial responses and is associated with susceptibility to Legionnaires' disease in humans. PLoS Pathog 2018; 14:e1006829. [PMID: 29298342 PMCID: PMC5770077 DOI: 10.1371/journal.ppat.1006829] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 01/16/2018] [Accepted: 12/18/2017] [Indexed: 11/23/2022] Open
Abstract
The cyclic GMP-AMP synthase (cGAS)-STING pathway is central for innate immune sensing of various bacterial, viral and protozoal infections. Recent studies identified the common HAQ and R232H alleles of TMEM173/STING, but the functional consequences of these variants for primary infections are unknown. Here we demonstrate that cGAS- and STING-deficient murine macrophages as well as human cells of individuals carrying HAQ TMEM173/STING were severely impaired in producing type I IFNs and pro-inflammatory cytokines in response to Legionella pneumophila, bacterial DNA or cyclic dinucleotides (CDNs). In contrast, R232H attenuated cytokine production only following stimulation with bacterial CDN, but not in response to L. pneumophila or DNA. In a mouse model of Legionnaires’ disease, cGAS- and STING-deficient animals exhibited higher bacterial loads as compared to wild-type mice. Moreover, the haplotype frequency of HAQ TMEM173/STING, but not of R232H TMEM173/STING, was increased in two independent cohorts of human Legionnaires’ disease patients as compared to healthy controls. Our study reveals that the cGAS-STING cascade contributes to antibacterial defense against L. pneumophila in mice and men, and provides important insight into how the common HAQ TMEM173/STING variant affects antimicrobial immune responses and susceptibility to infection. Interferons (IFNs) and pro-inflammatory cytokines are key regulators of gene expression and antibacterial defense during Legionella pneumophila infection. Here we demonstrate that production of these mediators was largely or partly dependent on the cyclic GMP-AMP synthase (cGAS)-STING pathway in human and murine cells. Cells of individuals carrying the common HAQ allele of TMEM173/STING were strongly impaired in their ability to respond to L. pneumophila, bacterial DNA or cyclic dinucleotides (CDNs), whereas the R232H allele was only attenuated in sensing of exogenous CDNs. Importantly, cGAS and STING contributed to antibacterial defense in mice during L. pneumophila lung infection, and the allele frequency of HAQ TMEM173/STING, but not of R232H TMEM173/STING, was increased in two independent cohorts of human Legionnaires’ disease patients as compared to healthy controls. Hence, sensing of bacterial DNA by the cGAS/STING pathway contributes to antibacterial defense against L. pneumophila infection, and the hypomorphic variant HAQ TMEM173/STING is associated with increased susceptibility to Legionnaires’ disease in humans.
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Affiliation(s)
- Juan S. Ruiz-Moreno
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lutz Hamann
- Institute of Microbiology and Hygiene, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin, Berlin, Germany
| | - Javeed A. Shah
- Department of Medicine, University of Washington, Seattle, Washington, United states of America
- VA Puget Sound Health Care System, Seattle, Washington, United states of America
| | - Annelies Verbon
- Department of Medical Microbiology and Infectious diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank P. Mockenhaupt
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Monika Puzianowska-Kuznicka
- Department of Human Epigenetics, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
- Department of Geriatrics and Gerontology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Jan Naujoks
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Leif E. Sander
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- German Center for Lung Research (DZL), Germany
| | - Martin Witzenrath
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- German Center for Lung Research (DZL), Germany
- CAPNETZ STIFTUNG, Hannover, Germany
| | - John C. Cambier
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Norbert Suttorp
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- German Center for Lung Research (DZL), Germany
- CAPNETZ STIFTUNG, Hannover, Germany
| | - Ralf R. Schumann
- Institute of Microbiology and Hygiene, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health Berlin, Berlin, Germany
| | - Lei Jin
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Thomas R. Hawn
- Department of Medicine, University of Washington, Seattle, Washington, United states of America
| | - Bastian Opitz
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- German Center for Lung Research (DZL), Germany
- * E-mail:
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Groeneveld GH, Dalhuijsen A, Kara-Zaïtri C, Hamilton B, de Waal MW, van Dissel JT, van Steenbergen JE. ICARES: a real-time automated detection tool for clusters of infectious diseases in the Netherlands. BMC Infect Dis 2017; 17:201. [PMID: 28279150 PMCID: PMC5345172 DOI: 10.1186/s12879-017-2300-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/01/2017] [Indexed: 01/16/2023] Open
Abstract
Background Clusters of infectious diseases are frequently detected late. Real-time, detailed information about an evolving cluster and possible associated conditions is essential for local policy makers, travelers planning to visit the area, and the local population. This is currently illustrated in the Zika virus outbreak. Methods In the Netherlands, ICARES (Integrated Crisis Alert and Response System) has been developed and tested on three syndromes as an automated, real-time tool for early detection of clusters of infectious diseases. From local general practices, General Practice Out-of-Hours services and a hospital, the numbers of routinely used syndrome codes for three piloted tracts i.e., respiratory tract infection, hepatitis and encephalitis/meningitis, are sent on a daily basis to a central unit of infectious disease control. Historic data combined with information about patients’ syndromes, age cohort, gender and postal code area have been used to detect clusters of cases. Results During the first 2 years, two out of eight alerts appeared to be a real cluster. The first was part of the seasonal increase in Enterovirus encephalitis and the second was a remarkably long lasting influenza season with high peak incidence. Conclusions This tool is believed to be the first flexible automated, real-time cluster detection system for infectious diseases, based on physician information from both general practitioners and hospitals. ICARES is able to detect and follow small regional clusters in real time and can handle any diseases entity that is regularly registered by first line physicians. Its value will be improved when more health care institutions agree to link up with ICARES thus improving further the signal-to-noise ratio.
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Affiliation(s)
- Geert H Groeneveld
- Department of Internal Medicine and Infectious Diseases, Leiden University Medical Center, P.O. box 9600, 2300 RC, Leiden, The Netherlands.
| | - Anton Dalhuijsen
- Unit for Infectious Disease Control, Public Health Service Hollands Midden, Leiden, The Netherlands
| | - Chakib Kara-Zaïtri
- Faculty of Engineering and Informatics, University of Bradford, Bradford, UK
| | | | - Margot W de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap T van Dissel
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, The Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Jim E van Steenbergen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, The Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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7
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Farida H, Rondags A, Gasem MH, Leong K, Adityana A, van den Broek PJ, Keuter M, Natsch S. Development of quality indicators to evaluate antibiotic treatment of patients with community-acquired pneumonia in Indonesia. Trop Med Int Health 2015; 20:501-9. [DOI: 10.1111/tmi.12452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Helmia Farida
- Department of Microbiology; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | - Angelique Rondags
- Department of General Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - M. Hussein Gasem
- Department of Internal Medicine; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | - Katharina Leong
- Department of Anesthesiology; Radboud University Medical Centre; Nijmegen The Netherlands
| | - A. Adityana
- Department of Internal Medicine; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | | | - Monique Keuter
- Department of General Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Stephanie Natsch
- Department of Pharmacy; Radboud University Medical Centre; Nijmegen The Netherlands
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Mercante JW, Winchell JM. Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clin Microbiol Rev 2015; 28:95-133. [PMID: 25567224 PMCID: PMC4284297 DOI: 10.1128/cmr.00029-14] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Legionnaires' disease (LD) is an often severe and potentially fatal form of bacterial pneumonia caused by an extensive list of Legionella species. These ubiquitous freshwater and soil inhabitants cause human respiratory disease when amplified in man-made water or cooling systems and their aerosols expose a susceptible population. Treatment of sporadic cases and rapid control of LD outbreaks benefit from swift diagnosis in concert with discriminatory bacterial typing for immediate epidemiological responses. Traditional culture and serology were instrumental in describing disease incidence early in its history; currently, diagnosis of LD relies almost solely on the urinary antigen test, which captures only the dominant species and serogroup, Legionella pneumophila serogroup 1 (Lp1). This has created a diagnostic "blind spot" for LD caused by non-Lp1 strains. This review focuses on historic, current, and emerging technologies that hold promise for increasing LD diagnostic efficiency and detection rates as part of a coherent testing regimen. The importance of cooperation between epidemiologists and laboratorians for a rapid outbreak response is also illustrated in field investigations conducted by the CDC with state and local authorities. Finally, challenges facing health care professionals, building managers, and the public health community in combating LD are highlighted, and potential solutions are discussed.
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Affiliation(s)
- Jeffrey W Mercante
- Pneumonia Response and Surveillance Laboratory, Respiratory Diseases Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas M Winchell
- Pneumonia Response and Surveillance Laboratory, Respiratory Diseases Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Chen NT, Chen MJ, Guo CY, Chen KT, Su HJ. Precipitation increases the occurrence of sporadic legionnaires' disease in Taiwan. PLoS One 2014; 9:e114337. [PMID: 25474539 PMCID: PMC4256405 DOI: 10.1371/journal.pone.0114337] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 11/07/2014] [Indexed: 11/25/2022] Open
Abstract
Legionnaires' disease (LD) is an acute form of pneumonia, and changing weather is considered a plausible risk factor. Yet, the relationship between weather and LD has rarely been investigated, especially using long-term daily data. In this study, daily data was used to evaluate the impacts of precipitation, temperature, and relative humidity on LD occurrence in Taiwan from 1995-2011. A time-stratified 2:1 matched-period case-crossover design was used to compare each case with self-controlled data using a conditional logistic regression analysis, and odds ratios (ORs) for LD occurrence was estimated. The city, gender and age were defined as a stratum for each matched set to modify the effects. For lag day- 0 to 15, the precipitation at lag day-11 significantly affected LD occurrence (p<0.05), and a 2.5% (95% CIs = 0.3-4.7%) increased risk of LD occurrence was associated with every 5-mm increase in precipitation. In addition, stratified analyses further showed that positive associations of precipitation with LD incidence were only significant in male and elderly groups and during the warm season ORs = 1.023-1.029). However, such an effect was not completely linear. Only precipitations at 21-40 (OR = 1.643 (95% CIs = 1.074-2.513)) and 61-80 mm (OR = 2.572 (1.106-5.978)) significantly increased the risk of LD occurrence. Moreover, a negative correlation between mean temperature at an 11-day lag and LD occurrence was also found (OR = 0.975 (0.953-0.996)). No significant association between relative humidity and LD occurrence was identified (p>0.05). In conclusion, in warm, humid regions, an increase of daily precipitation is likely to be a critical weather factor triggering LD occurrence where the risk is found particularly significant at an 11-day lag. Additionally, precipitation at 21-40 and 61-80 mm might make LD occurrence more likely.
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Affiliation(s)
- Nai-Tzu Chen
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mu-Jean Chen
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- National Environmental Health Research Center, National Health Research Institutes, Miaoli, Taiwan
| | - Chao-Yu Guo
- Institution of Public Health & Department of Public Health, College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kow-Tong Chen
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huey-Jen Su
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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10
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Irons JF, Dunn MJG, Kefala K, Thorn S, Lakha F, Caesar D, Cameron DD, McCormick D, McCallum A, Helgason KO, Laurenson IF, Paterson RL, Greening A, Fried M, Hill AT, Hanson M, Gillies MA. The effect of a large Legionnaires' disease outbreak in Southwest Edinburgh on acute and critical care services. QJM 2013; 106:1087-94. [PMID: 23970183 DOI: 10.1093/qjmed/hct167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The largest outbreak of Legionnaires Disease (LD) in the UK for a decade occurred in Edinburgh in June 2012. We describe the clinical and public health management of the outbreak. SETTING Three acute hospitals covering an urban area of ~480,000. METHODS Data were collected on confirmed and suspected cases and minutes of the Incident Management Team meetings were reviewed to identify key actions. RESULTS Over 1600 urine samples and over 600 sputum samples were tested during the outbreak. 61 patients with pneumonia tested positive for Legionella pneumophila serogroup 1 by urinary antigen detection, culture, respiratory PCR or serology. A further 23 patients with pneumonia were treated as suspected cases on clinical and epidemiological grounds but had no microbiological diagnosis. 36% of confirmed and probable cases required critical care admission. Mean ICU length of stay was 11.3 (±7.6) days and mean hospital length of stay for those who were admitted to ICU was 23.0 (±17.2) days. For all hospitalized patients the mean length of stay was 15.7 (±14) days. In total there were four deaths associated with this outbreak giving an overall case fatality of 6.5%. Hospital and critical care mortality was 6.1% and 9.1%, respectively. CONCLUSION A significant proportion of patients required prolonged multiple organ support or complex ventilation. Case fatality compared favourably to other recent outbreaks in Europe. Access to rapid diagnostic tests and prompt antibiotic therapy may have mitigated the impact of pre-existing poor health among those affected.
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Affiliation(s)
- J F Irons
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK.
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St-Martin G, Uldum S, Mølbak K. Incidence and Prognostic Factors for Legionnaires' Disease in Denmark 1993–2006. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/847283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives. To describe the incidence of Legionnaires’ disease and factors affecting survival in Denmark from 1993 to 2006. Methods. Retrospective register study using data on episodes of Legionnaires’ disease from notification forms and the National Reference Laboratory, and information on comorbidity from national registers on discharge diagnoses and mortality. Results. The average annual incidence of laboratory confirmed cases was 1.5 per 100000 people. The 30-day case fatality was 19%, ranging from 7% in travellers to 37% in hospital-acquired cases. Patients older than 60 years and patients with underlying disease were more likely-to die, as were patients infected with L. pneumophila serogroup 6. The lowest mortality was seen for L. pneumophila serogroup 1. Conclusion. Increased awareness of the disease, better diagnostics, and appropriate testing and treatment strategies are needed to improve survival. In particular, we focus on the relevance of diagnostic methods, such as polymerase chain reaction (PCR), that detect other serogroups than the urinary antigen tests used that will only reliably detect antigen from L. pneumophila serogroup 1. PCR is faster and more sensitive than culture.
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Affiliation(s)
- G. St-Martin
- Department of Epidemiology, Statens Serum Institut, Ørestads Boulevard 5, 2300 Copenhagen S, Denmark
| | - S. Uldum
- Department of Microbiological Surveillance and Research, Statens Serum Institut, Ørestads Boulevard 5, 2300 Copenhagen S, Denmark
| | - K. Mølbak
- Department of Epidemiology, Statens Serum Institut, Ørestads Boulevard 5, 2300 Copenhagen S, Denmark
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Bryner B, Miskulin J, Smith C, Cooley E, Grams R, Bartlett R, Annich G, Mychaliska GB. Extracorporeal life support for acute respiratory distress syndrome due to severe Legionella pneumonia. Perfusion 2013; 29:39-43. [PMID: 23863490 DOI: 10.1177/0267659113497229] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Legionella is a common cause of community-acquired pneumonia (CAP) and is second only to Pneumococcal pneumonia as a cause of severe CAP that requires treatment in an intensive care unit. We report a case series of patients with severe Legionella pneumonia who developed the acute respiratory distress syndrome (ARDS), failed to improve with mechanical ventilation alone and required extracorporeal life support (ECLS). METHODS We performed a retrospective study of all patients treated with ECLS at our institution for severe ARDS as a result of Legionella pneumonia from 1994 to 2006. RESULTS A total of twelve patients with a diagnosis of Legionella pneumonia were treated with veno-venous (VV) ECLS over this time period. Nine of these twelve (75%) were successfully treated and weaned off ECLS and 8 patients (67%) survived to hospital discharge. Two (13%) died of multisystem organ failure, one patient (8%) died from global hypoxic encephalopathy and one (8%) was weaned from ECLS, but ultimately died of liver failure. Renal failure requiring some form of continuous dialysis occurred in seven patients (58%) and the survival for this sub-set of patients was 43%. CONCLUSIONS Extracorporeal life support for severe ARDS associated with Legionella pneumonia is an effective treatment option when mechanical ventilation fails, especially when introduced early in the course.
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Affiliation(s)
- B Bryner
- 1Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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A TLR6 polymorphism is associated with increased risk of Legionnaires' disease. Genes Immun 2013; 14:420-6. [PMID: 23823019 PMCID: PMC3791179 DOI: 10.1038/gene.2013.34] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/10/2013] [Accepted: 05/21/2013] [Indexed: 02/03/2023]
Abstract
Legionella pneumophila (Lp), the etiologic agent of Legionnaires’ Disease (LD), is an important cause of community-acquired and nosocomial pneumonia. However, the host immune and genetic determinants of human susceptibility to Lp are poorly understood. Here we show that both TLR6 and TLR1 cooperate with TLR2 to recognize Lp in transfected HEK293 cells. We also perform a human genetic association study of 14 candidate single nucleotide polymorphisms in Toll-like receptors (TLRs) 1, 2, and 6 in 98 LD cases and 268 controls from the Netherlands. No polymorphisms in TLR1 or TLR2 were associated with LD. A TLR6 polymorphism, 359T>C (rs5743808), was associated with an elevated risk of LD in genotypic and dominant (OR 5.83, p=7.9×10−5) models. The increased risk in persons with 359 TC or CC genotypes was further enhanced among smokers. In a multivariate model, 359T>C was associated with a higher risk of LD (OR 4.24, p=0.04), than any other variable, including age and smoking. Together, these data suggest that the human TLR6 variant, 359T>C, is an independent risk factor for LD.
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14
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Engel MF, van Manen L, Hoepelman AIM, Thijsen S, Oosterheert JJ. Diagnostic, therapeutic and economic consequences of a positive urinary antigen test forLegionellaspp. in patients admitted with community-acquired pneumonia: a 7-year retrospective evaluation. J Clin Pathol 2013; 66:797-802. [DOI: 10.1136/jclinpath-2012-201209] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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15
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Abu Khweek A, Fernández Dávila NS, Caution K, Akhter A, Abdulrahman BA, Tazi M, Hassan H, Novotny LA, Bakaletz LO, Amer AO. Biofilm-derived Legionella pneumophila evades the innate immune response in macrophages. Front Cell Infect Microbiol 2013; 3:18. [PMID: 23750338 PMCID: PMC3664316 DOI: 10.3389/fcimb.2013.00018] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 04/27/2013] [Indexed: 01/11/2023] Open
Abstract
Legionella pneumophila, the causative agent of Legionnaire's disease, replicates in human alveolar macrophages to establish infection. There is no human-to-human transmission and the main source of infection is L. pneumophila biofilms established in air conditioners, water fountains, and hospital equipments. The biofilm structure provides protection to the organism from disinfectants and antibacterial agents. L. pneumophila infection in humans is characterized by a subtle initial immune response, giving time for the organism to establish infection before the patient succumbs to pneumonia. Planktonic L. pneumophila elicits a strong immune response in murine, but not in human macrophages enabling control of the infection. Interactions between planktonic L. pneumophila and murine or human macrophages have been studied for years, yet the interface between biofilm-derived L. pneumophila and macrophages has not been explored. Here, we demonstrate that biofilm-derived L. pneumophila replicates significantly more in murine macrophages than planktonic bacteria. In contrast to planktonic L. pneumophila, biofilm-derived L. pneumophila lacks flagellin expression, do not activate caspase-1 or -7 and trigger less cell death. In addition, while planktonic L. pneumophila is promptly delivered to lysosomes for degradation, most biofilm-derived bacteria were enclosed in a vacuole that did not fuse with lysosomes in murine macrophages. This study advances our understanding of the innate immune response to biofilm-derived L. pneumophila and closely reproduces the natural mode of infection in human.
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Affiliation(s)
- Arwa Abu Khweek
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, College of Medicine, The Ohio State University Columbus, OH, USA
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16
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Bruin JP, Diederen BMW, Ijzerman EPF, Den Boer JW, Mouton JW. Correlation of MIC value and disk inhibition zone diameters in clinical Legionella pneumophila serogroup 1 isolates. Diagn Microbiol Infect Dis 2013; 76:339-42. [PMID: 23583350 DOI: 10.1016/j.diagmicrobio.2013.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 03/01/2013] [Accepted: 03/01/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Routine use of disk diffusion tests for detecting antibiotic resistance in Legionella pneumophila has not been described. The goal of this study was to determine the correlation of MIC values and inhibition zone diameter (MDcorr) in clinical L. pneumophila isolates. METHODS Inhibition zone diameter of 183 L. pneumophila clinical isolates were determined for ten antimicrobials. Disk diffusion results were correlated with MICs as determined earlier with E-tests. RESULTS Overall the correlation of MIC values and inhibition zone diameters (MDcorr) of the tested antimicrobials is good, and all antimicrobials showed a WT distribution. Of the tested fluoroquinolones levofloxacin showed the best MDcorr. All macrolides showed a wide MIC distribution and good MDcorr. The MDcorr for cefotaxim, doxycycline and tigecycline was good, while for rifampicin and moxifloxacin, they were not. CONCLUSION Overall good correlation between MIC value and disk inhibition zone were found for the fluoroquinolones, macrolides and cefotaxim.
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Affiliation(s)
- Jacob P Bruin
- Regional Laboratory of Public Health, Haarlem, The Netherlands.
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17
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Caterino U. Instability of gait as an extrapulmonary sequela in acute Legionella pneumonia: a case report. J Emerg Med 2013; 44:e13-e15. [PMID: 21911280 DOI: 10.1016/j.jemermed.2011.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 02/18/2011] [Accepted: 06/01/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND Legionnaires disease is a potentially fatal infection often associated with permanent pulmonary fibrosis in survivors. Although neurological complications are not infrequent, chronic peripheral neuropathy in the absence of pulmonary abnormalities is an uncommon consequence of Legionnaires disease. CASE REPORT A 51-year-old woman was admitted to the Emergency Department due to acute respiratory failure. Chest computed tomographic (CT) scan revealed bilateral consolidation shadows suggestive of acute respiratory disease syndrome (ARDS). Urine culture was evaluated and empiric therapy was administered due to a clinical suspicion of acute legionella pneumonia. Acute flaccid paralysis of the limbs and cutaneous rash complicated the clinical course. Treatment with appropriate antibiotics and steroids resulted in complete recovery of pulmonary damage, whereas mild ataxic gait was present at 1-year follow-up. CONCLUSIONS The outcome of this case confirms that the early exudative phase of ARDS in the absence of bronchial dilatation on chest CT scan is not always related to pulmonary fibrosis in survivors at follow-up. It also demonstrates that peripheral neuropathy can persist despite tailored treatment.
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Affiliation(s)
- Umberto Caterino
- Department of Respiratory Disease, Physiopathology and Rehabilitation, Second University of Naples (SUN), AORN Monaldi Hospital, Naples, Italy
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18
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Bruin JP, Ijzerman EP, den Boer JW, Mouton JW, Diederen BM. Wild-type MIC distribution and epidemiological cut-off values in clinical Legionella pneumophila serogroup 1 isolates. Diagn Microbiol Infect Dis 2012; 72:103-8. [DOI: 10.1016/j.diagmicrobio.2011.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 10/15/2022]
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19
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Légionelles et légionellose : qu’a-t-on découvert depuis 30 ans ? ACTA ACUST UNITED AC 2011; 59:134-6. [DOI: 10.1016/j.patbio.2009.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 04/03/2009] [Indexed: 11/20/2022]
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20
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Progress in the surveillance and control of Legionella infection in France, 1998–2008. Int J Infect Dis 2011; 15:e30-7. [DOI: 10.1016/j.ijid.2010.09.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 09/01/2010] [Accepted: 09/05/2010] [Indexed: 01/28/2023] Open
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21
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Khweek AA, Amer A. Replication of Legionella Pneumophila in Human Cells: Why are We Susceptible? Front Microbiol 2010; 1:133. [PMID: 21687775 PMCID: PMC3109522 DOI: 10.3389/fmicb.2010.00133] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 11/16/2010] [Indexed: 11/13/2022] Open
Abstract
Legionella pneumophila is the causative agent of Legionnaires’ disease, a serious and often fatal form of pneumonia. The susceptibility to L. pneumophila arises from the ability of this intracellular pathogen to multiply in human alveolar macrophages and monocytes. L. pneumophila also replicates in several professional and non-professional phagocytic human-derived cell lines. With the exception of the A/J mouse strain, most mice strains are restrictive, thus they do not support L. pneumophila replication. Mice lacking the NOD-like receptor Nlrc4 or caspase-1 are also susceptible to L. pneumophila. On the other hand, in the susceptible human hosts, L. pneumophila utilizes several strategies to ensure intracellular replication and protect itself against the host immune system. Most of these strategies converge to prevent the fusion of the L. pneumophila phagosome with the lysosome, inhibiting host cell apoptosis, activating survival pathways, and sequestering essential nutrients for replication and pathogenesis. In this review, we summarize survival mechanisms employed by L. pneumophila to maintain its replication in human cells. In addition, we highlight different human-derived cell lines that support the multiplication of this intracellular bacterium. Therefore, these in vitro models can be applicable and are reproducible when investigating L. pneumophila/phagocyte interactions at the molecular and cellular levels in the human host.
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Affiliation(s)
- Arwa Abu Khweek
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Center for Microbial Interface Biology and the Department of Internal Medicine, Ohio State University Columbus, OH, USA
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22
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Abstract
The genus Legionella contains more than 50 species, of which at least 24 have been associated with human infection. The best-characterized member of the genus, Legionella pneumophila, is the major causative agent of Legionnaires' disease, a severe form of acute pneumonia. L. pneumophila is an intracellular pathogen, and as part of its pathogenesis, the bacteria avoid phagolysosome fusion and replicate within alveolar macrophages and epithelial cells in a vacuole that exhibits many characteristics of the endoplasmic reticulum (ER). The formation of the unusual L. pneumophila vacuole is a feature of its interaction with the host, yet the mechanisms by which the bacteria avoid classical endosome fusion and recruit markers of the ER are incompletely understood. Here we review the factors that contribute to the ability of L. pneumophila to infect and replicate in human cells and amoebae with an emphasis on proteins that are secreted by the bacteria into the Legionella vacuole and/or the host cell. Many of these factors undermine eukaryotic trafficking and signaling pathways by acting as functional and, in some cases, structural mimics of eukaryotic proteins. We discuss the consequences of this mimicry for the biology of the infected cell and also for immune responses to L. pneumophila infection.
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Carr R, Warren R, Towers L, Bartholomew A, Duggal HV, Rehman Y, Harrison TG, Olowokure B. Investigating a cluster of Legionnaires’ cases: Public health implications. Public Health 2010; 124:326-31. [PMID: 20483439 DOI: 10.1016/j.puhe.2010.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Revised: 02/04/2010] [Accepted: 03/02/2010] [Indexed: 11/18/2022]
Affiliation(s)
- R Carr
- Health Protection Agency, Shropshire and Staffordshire Health Protection Unit, Shropshire, UK
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24
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A cluster of Legionnaires' disease and associated Pontiac fever morbidity in office workers, Dublin, June-July 2008. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2010; 2010:463926. [PMID: 20414339 PMCID: PMC2855950 DOI: 10.1155/2010/463926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 02/09/2010] [Accepted: 02/15/2010] [Indexed: 11/21/2022]
Abstract
In June and July 2008, two office workers were admitted to a Dublin hospital with Legionnaires' disease. Investigations showed that cooling towers in the basement car park were the most likely source of infection. However, positive results from cooling tower samples by polymerase chain reaction (PCR) did not correlate with subsequent culture results. Also, many employees reported Pontiac fever-like morbidity following notification of the second case of Legionnaires' disease. In total, 54 employees attended their general practitioner or emergency department with symptoms of Legionnaires' disease or Pontiac fever. However, all laboratory tests for Legionnaires' disease or Pontiac fever were negative. In this investigation, email was used extensively for active case finding and provision of time information to employees and medical colleagues. We recommend clarification of the role of PCR in the diagnosis of legionellosis and also advocate for a specific laboratory test for the diagnosis of the milder form of legionellosis as in Pontiac fever.
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25
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Blyth CC, Adams DN, Chen SCA. Diagnostic and typing methods for investigating Legionella infection. NSW PUBLIC HEALTH BULLETIN 2010; 20:157-61. [PMID: 19917208 DOI: 10.1071/nb08062] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Legionella infection is an important cause of community-acquired pneumonia in Australia. Morbidity and mortality is significant. Diagnosis remains a challenge with infection often unrecognised, particularly early in the course of illness. An understanding of available diagnostic methods and their limitations is important to public health practitioners and clinicians alike.
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Affiliation(s)
- Christopher C Blyth
- Centre for Infectious Diseases and Microbiology Laboratory Services, Sydney West Area Health Service
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Palusińska-Szysz M, Cendrowska-Pinkosz M. Pathogenicity of the family Legionellaceae. Arch Immunol Ther Exp (Warsz) 2009; 57:279-90. [DOI: 10.1007/s00005-009-0035-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 01/30/2009] [Indexed: 10/20/2022]
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Abstract
Given the nonspecific clinical manifestations of Legionnaires' disease and the high mortality of untreated Legionnaires' disease, we recommend routine use of Legionella testing, especially the Legionella urinary antigen test, for all patients with community-acquired pneumonia. This includes patients with ambulatory pneumonia and hospitalized children. Legionella cultures should be more widely available, especially in hospitals where the drinking water is colonized with Legionella. Azithromycin or levofloxacin can be considered as first-line therapy. Other antibiotics including tetracyclines, tigecycline, other fluoroquinolones and other macrolides (especially clarithromycin) are also effective. The clinical response of quinolones may be somewhat more favorable compared to macrolides, but the outcome is similar. If the Legionnaires' disease is hospital-acquired, culturing of the hospital drinking water for Legionella is indicated.
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Herpers BL, Yzerman EPF, de Jong BAW, Bruin JP, Lettinga KD, Kuipers S, Den Boer JW, van Hannen EJ, Rijkers GT, van Velzen-Blad H, de Jongh BM. Deficient mannose-binding lectin-mediated complement activation despite mannose-binding lectin-sufficient genotypes in an outbreak of Legionella pneumophila pneumonia. Hum Immunol 2008; 70:125-9. [PMID: 19073229 DOI: 10.1016/j.humimm.2008.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Revised: 11/07/2008] [Accepted: 11/13/2008] [Indexed: 02/01/2023]
Abstract
Polymorphisms leading to deficiency of mannose-binding lectin (MBL) are associated with predisposition to infection. However, MBL deficiency can be protective against intracellular pathogens that use MBL to enter host cells. The role of MBL genotype and activity in infection with the intracellular pathogen Legionella pneumophila was studied in a large outbreak of legionellosis at a Dutch flower show. A total of 141 patients, 65 exposed asymptomatic exhibition staff members and 670 unexposed blood bank donors were included for the study of MBL2 genotypes and MBL-mediated complement activation. Genotypic MBL deficiency was equally prevalent in patients and controls. Deficient MBL-mediated complement activation was more prevalent in patients. Even in patients with genotypes that confer MBL sufficiency, 20.6% lacked MBL-mediated complement activation. In most patients with MBL-sufficient genotypes who lacked MBL-mediated activation at the acute phase of disease, lectin pathway functionality was restored at convalescence. In conclusion, genotypic MBL deficiency was not a risk factor for legionellosis. However, patients with legionellosis displayed deficient MBL-mediated complement activation even with MBL-sufficient genotypes. Together, these genotypical and functional data suggest that the observed deficiency of lectin pathway activation is an effect of legionellosis rather than a risk factor for acquiring it.
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Affiliation(s)
- Bjorn L Herpers
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein, The Netherlands.
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Randhawa AK, Hawn TR. Toll-like receptors: their roles in bacterial recognition and respiratory infections. Expert Rev Anti Infect Ther 2008; 6:479-95. [PMID: 18662115 DOI: 10.1586/14787210.6.4.479] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Although respiratory infections cause significant morbidity and mortality throughout the world, the immunologic factors that mediate host susceptibility to these infections remain poorly understood. The lung contains a vast surface at the host-environment interface and acts as a crucial barrier to invading pathogens. The lung is equipped with specialized epithelial and hematopoietic cells, which express pattern recognition receptors that act as both sentinels and mediators of pulmonary innate immunity. Toll-like receptors (TLRs) mediate a particularly critical role in pathogen recognition and subsequent initiation of the host immune response. In this review, we will summarize current knowledge of TLRs and their bacterial ligands and explore their role in respiratory infections. Moreover, we will highlight recent advances in the role of TLRs in pulmonary infections from a human immunogenetics perspective.
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Affiliation(s)
- April Kaur Randhawa
- Department of Medicine/Division of Allergy & Infections Diseases, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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Abstract
PURPOSE OF REVIEW Respiratory tract infections are a common reason for prescribing antibiotics, although not all of these infections require such therapy. Rapid diagnosis of etiology using point-of-care tests is a potentially useful way of reducing prescriptions of both unnecessary and unnecessarily broad-spectrum antibiotics. This can also lead to the facilitation of appropriate infection control measures to prevent spread of respiratory viruses within institutions. RECENT FINDINGS Point-of-care tests are available for diagnosing influenza, respiratory syncytial virus, Streptococcus pneumoniae, and Legionella infections using easily obtainable specimens. Their main benefit is that results can be obtained in about 15 min with reasonable accuracy. In many situations, however, it is still important to confirm diagnosis with more accurate but slower tests such as bacterial cultures with antibacterial susceptibility testing or viral polymerase chain reaction testing. SUMMARY Although the sensitivities of many of the rapid diagnostic tests are moderate, when used at the time of initial consultation, they have the potential to reduce costs, length of stay, secondary spread of respiratory viruses, and inappropriate antibiotic prescribing.
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von Baum H, Ewig S, Marre R, Suttorp N, Gonschior S, Welte T, Lück C. Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia. Clin Infect Dis 2008; 46:1356-64. [PMID: 18419436 DOI: 10.1086/586741] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The Competence Network for Community Acquired Pneumonia (CAPNETZ) offers a unique opportunity to study the epidemiology of legionellosis throughout Germany, applying sophisticated diagnostic tools. METHODS The incidence, clinical characteristics, and outcome of Legionella pneumonia in 2503 adult patients with community-acquired pneumonia, participating in the German Multicenter Study of the CAPNETZ, were studied. RESULTS Legionella pneumonia was diagnosed in 94 patients (3.8%), thus identifying Legionella species as one of the most common pathogens to cause community-acquired pneumonia. It was equally common among ambulatory and hospitalized patients (3.7% and 3.8%, respectively). The predominant species causing community-acquired pneumonia was Legionella pneumophila; however, 10% of cases were caused by other species not detectable by the urinary antigen test. Patients whose disease was diagnosed by urinary antigen testing experienced a more severe clinical course. Compared with hospitalized patients, ambulatory patients with Legionella pneumonia showed an equal sex distribution, were younger, had fewer comorbidities, fewer cases of discordant initial antimicrobial treatment, and a milder clinical course without fatalities. Thirty percent of patients with Legionella pneumonia received discordant initial antimicrobial treatment without increased mortality. CONCLUSIONS Legionella is a leading cause of community-acquired pneumonia in Germany. It needs to be considered equally in hospitalized and ambulatory patients. A positive result of a urine antigen test is associated with a more severe clinical course and leads to a potentially relevant underrecognition of species other than L. pneumophila. Legionella pneumonia in outpatients differs significantly from that in hospitalized patients in terms of clinical presentation and outcome. There was an unacceptably high rate of discordant initial antimicrobial treatment.
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Affiliation(s)
- Heike von Baum
- Institute for Medical Microbiology and Hygiene, University Hospital of Ulm, Germany.
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Cytopathogenicity and molecular subtyping ofLegionella pneumophilaenvironmental isolates from 17 hospitals. Epidemiol Infect 2008; 137:188-93. [DOI: 10.1017/s0950268808000691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
SUMMARYThe cytopathogenicity of 22Legionella pneumophilaisolates from 17 hospitals was determined by assessing the dose of bacteria necessary to produce 50% cytopathic effect (CPED50) in U937 human-derived macrophages. All isolates were able to infect and grow in macrophage-like cells (range log10CPED50: 2·67–6·73 c.f.u./ml). Five groups were established and related to the serogroup, the number of PFGE patterns coexisting in the same hospital water distribution system, and the possible reporting of hospital-acquired Legionnaires' disease cases.L. pneumophilaserogroup 1 isolates had the highest cytopathogenicity (P=0·003). Moreover, a trend to more cytopathogenic groups (groups 1–3) in hospitals with more than one PFGE pattern ofL. pneumophilain the water distribution system (60%vs. 17%) and in hospitals reporting cases of hospital-acquired Legionnaires' disease (36·3%vs. 16·6%) was observed. We conclude that the cytopathogenicty of environmentalL. pneumophilashould be taken into account in evaluating the risk of a contaminated water reservoir in a hospital and hospital acquisition of Legionnaires' disease.
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An outbreak of Legionnaires' disease associated with a circulating bathwater system at a public bathhouse. II: radiological findings of pneumonia. J Infect Chemother 2008; 14:123-9. [PMID: 18622675 DOI: 10.1007/s10156-008-0591-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 01/23/2008] [Indexed: 01/15/2023]
Abstract
In July 2002, one of the largest outbreaks of Legionnaires' disease associated with a public bathhouse in Japan occurred in Miyazaki. The local government and the University of Miyazaki performed a retrospective investigation of those persons who were considered to have been exposed to Legionella. This investigation provided a unique opportunity to analyze the clinical presentation of patients with outbreak-associated Legionnaires' disease. The purpose of the present study was to analyze high-resolution computerized tomography (HRCT) scans for the characteristic findings of Legionnaires' disease and to evaluate the correlation between the radiological severity on the initial chest X-ray and the outcome of the patients. Radiological findings of HRCT were analyzed in 35 patients. The radiological severity on chest X-ray was evaluated in 69 patients, utilizing the pneumonia scoring system proposed by the Research Committee on Legionnaires' Disease of the Ministry of Health, Labour and Welfare of the Japanese Government. Air-space consolidation, ground-glass opacity, and pleural effusion were common features on HRCT in patients with Legionnaires' disease. Typical HRCT findings showed bilateral multilobar infiltrates in the subpleural areas without centrilobular opacities. Multivariate logistic regression analysis identified male sex, short incubation period, high serum C-reactive protein, high serum alanine aminotransferase, hyponatremia, and positive Legionella urinary antigen test results as independent risk factors for high pneumonia scores. Patients with high pneumonia scores required significantly longer hospitalization and showed poor prognoses.
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Roberts M, Macfarlane J, George R, Harrison T. Microbiology investigations in community acquired pneumonia – Most laboratories in England and Wales do not offer all those recommended in the British Thoracic Society guideline. J Infect 2008; 56:291-4. [DOI: 10.1016/j.jinf.2008.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 02/02/2008] [Accepted: 02/05/2008] [Indexed: 11/16/2022]
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Van Hest NAH, Hoebe CJPA, Den Boer JW, Vermunt JK, Ijzerman EPF, Boersma WG, Richardus JH. Incidence and completeness of notification of Legionnaires' disease in The Netherlands: covariate capture-recapture analysis acknowledging regional differences. Epidemiol Infect 2008; 136:540-50. [PMID: 17588278 PMCID: PMC2870841 DOI: 10.1017/s0950268807008977] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2007] [Indexed: 11/07/2022] Open
Abstract
To estimate incidence and completeness of notification of Legionnaires' disease (LD) in The Netherlands in 2000 and 2001, we performed a capture-recapture analysis using three registers: Notifications, Laboratory results and Hospital admissions. After record-linkage, 373 of the 780 LD patients identified were notified. Ascertained under-notification was 52.2%. Because of expected and observed regional differences in the incidence rate of LD, alternatively to conventional log-linear capture-recapture models, a covariate (region) capture-recapture model, not previously used for estimating infectious disease incidence, was specified and estimated 886 LD patients (95% confidence interval 827-1022). Estimated under-notification was 57.9%. Notified, ascertained and estimated average annual incidence rates of LD were 1.15, 2.42 and 2.77/100 000 inhabitants respectively, with the highest incidence in the southern region of The Netherlands. Covariate capture-recapture analysis acknowledging regional differences of LD incidence appears to reduce bias in the estimated national incidence rate.
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Affiliation(s)
- N A H Van Hest
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands.
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Prevotat A, Bure M, Bergoin C, Tavernier JY, Van Grunderbeeck N, Yazdanpanah Y, Lamblin C. Épidémie de légionellose dans le Pas-de-Calais (2003-2004) : analyse descriptive et facteurs prédictifs d’une évolution défavorable. Rev Mal Respir 2008; 25:285-94. [DOI: 10.1016/s0761-8425(08)71547-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sporadic community-acquired Legionnaires' disease in France: a 2-year national matched case-control study. Epidemiol Infect 2008; 136:1684-90. [PMID: 18211725 DOI: 10.1017/s0950268807000283] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Legionnaires' disease (LD) is an aetiology of community-acquired bacterial pneumonia in adults, with a high case-fatality ratio (CFR). We conducted a matched case-control study to identify risk factors for sporadic, community-acquired LD. Cases of sporadic, community-acquired and biologically confirmed LD, in metropolitan France from 1 September 2002 to 31 September 2004, were matched with a control subject according to age, sex, underlying illness and location of residence within 5 km. We performed a conditional logistic regression on various host-related factors and exposures. Analysis was done on 546 matched pairs. The CFR was 3.5%. Age ranged from 18-93 years (mean 57 years), with a 3.6 male:female sex ratio. Cases were more likely to have smoked with the documentation of a dose-effect relation, to have travelled with a stay in a hotel (OR 6.1, 95% CI 2.6-14.2), or to have used a wash-hand basin for personal hygiene (OR 3.5, 95% CI 1.6-7.7) than controls. Tobacco and travel have been previously described as risk factors for LD, but this is the first time that such a dose-effect for tobacco has been documented among sporadic cases. These findings will provide helpful knowledge about LD and help practitioners in identifying patients at high risk.
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An outbreak of Legionnaires’ disease associated with a circulating bathwater system at a public bathhouse. I: a clinical analysis. J Infect Chemother 2008; 14:117-22. [DOI: 10.1007/s10156-008-0592-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 01/23/2008] [Indexed: 11/26/2022]
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Community-Acquired Pneumonia—Back to Basics. ANTIBIOTIC POLICIES: FIGHTING RESISTANCE 2008. [PMCID: PMC7121559 DOI: 10.1007/978-0-387-70841-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Lower respiratory tract infections are among the most common infectious diseases worldwide and are caused by the inflammation and consolidation of lung tissue due to an infectious agent.1 The clinical criteria for the diagnosis include chest pain, cough, auscultatory findings such as rales or evidence of pulmonary consolidation, fever, or leukocytosis.
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Unterer Respirationstrakt. KLINISCHE INFEKTIOLOGIE 2008. [PMCID: PMC7152301 DOI: 10.1016/b978-343721741-8.50016-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Strålin K. Usefulness of aetiological tests for guiding antibiotic therapy in community-acquired pneumonia. Int J Antimicrob Agents 2008; 31:3-11. [DOI: 10.1016/j.ijantimicag.2007.06.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 06/26/2007] [Indexed: 11/30/2022]
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Piso R, Caruso A, Nebiker M. Hose as a source of Legionella pneumonia. A new risk factor for gardeners? J Hosp Infect 2007; 67:396-7. [DOI: 10.1016/j.jhin.2007.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 09/27/2007] [Indexed: 10/22/2022]
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Charles PGP, Grayson ML. Point‐of‐care tests for lower respiratory tract infections. Med J Aust 2007; 187:36-9. [PMID: 17605701 DOI: 10.5694/j.1326-5377.2007.tb01112.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 02/22/2007] [Indexed: 11/17/2022]
Abstract
Many lower respiratory tract infections (LRTIs) are caused by organisms that do not require antibiotics or could be safely treated with narrow-spectrum antibiotics. Reducing the unnecessary use of antibiotics, particularly broad-spectrum agents, could reduce costs and side effects and delay the emergence of antibiotic-resistant organisms. Various point-of-care tests are becoming available to help clinicians identify the cause of LRTIs at the time of consultation. Point-of-care tests can be used to diagnose influenza, pneumococcal infections, Legionella and respiratory syncytial virus infections, thus allowing early decisions to be made on appropriate management.
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Affiliation(s)
- Patrick G P Charles
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
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Poupard M, Campèse C, Bernillon P, Che D. [Factors associated with mortality in Legionnaires' disease, France, 2002-2004]. Med Mal Infect 2007; 37:325-30. [PMID: 17512152 DOI: 10.1016/j.medmal.2007.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/12/2007] [Indexed: 11/22/2022]
Abstract
UNLABELLED Risk factors for Legionnaires' disease are well known (older age, smoking, or immunosuppression), however, the factors associated with mortality are less documented. A retrospective analysis based on cases notified between 2002 and 2004 was conducted in France to identify these factors. METHOD Cases were identified through mandatory notifications sent to the Institut de veille sanitaire, France. Factors associated with mortality were identified using a logistic regression analysis. RESULTS Three thousand two hundred sixty-seven cases of Legionnaire's disease were notified during the study period and the evolution was documented for 85% of the cases (2.791). Three hundred seventy-seven deaths (13.5%) were notified. 72.5% of the patients were men and the median age was 61. The multivariate analysis applied to patients under 60 years revealed that cancer or hemopathy (OR=6.4 CI95% 3.6-11.2), underlying renal disease (OR=3.2 CI95% 1.0-9.9), or alcohol abuse (OR=2.2 CI95% 1.1-4.4) were associated with mortality. For older patients (>60 years) factors linked to mortality were: cancer/hemopathy (OR=1.8 CI95% 1.2-2.6), underlying renal disease (OR=3 CI95% 1.4-6.4), underlying cardiac disease (OR=2.4 CI95% 1.4-4), alcohol abuse (OR=2.4 CI95% 1.2-5.2), immunosuppression (OR=1.7 CI95% 1.1-2.6), nosocomial acquisition of the disease (OR=2.0 CI95% 1.3-3), or infection acquired in nursing home residents (OR=2.4 IC 95% 1.6-3.6). CONCLUSION These preliminary results further describe Legionnaires' disease and its mortality. However, they should be confirmed by carefully conducted prospective analysis. The description of LD patients at high risk of death will contribute to better prevention measures.
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Affiliation(s)
- M Poupard
- Institut de veille sanitaire, 12, rue du Val-d'Osne, 94415 Saint-Maurice cedex, France
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Telford D, Partridge S, Cumming I, Smith A, Calvert N. The legionnaires' outbreak in Barrow-in-Furness, summer 2002. J Epidemiol Community Health 2007; 60:464-6. [PMID: 16698973 PMCID: PMC2563949 DOI: 10.1136/jech.2005.037127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Faure K. Comment évaluer, orienter et suivre un patient ayant une pneumonie aiguë communautaire ? Une exacerbation de bronchopneumopathie chronique obstructive ? Med Mal Infect 2006; 36:734-83. [PMID: 17092675 PMCID: PMC7133787 DOI: 10.1016/j.medmal.2006.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
L'objectif de cette revue est de présenter une analyse bibliographique de la littérature de ces cinq dernières années concernant les pneumonies aiguës communautaires (PAC) et les exacerbations aiguës de bronchopneumopathies chroniques obstructives (EABPCO). La PAC et l'EABPCO sont des pathologies fréquentes grevées d'une mortalité et/ou morbidité encore élevée de nos jours. La connaissance des facteurs de risque d'évolution compliquée et l'identification des signes de gravité souvent liés au risque de mortalité permettent d'orienter le patient pour un traitement ambulatoire, en hospitalisation conventionnelle ou en secteur de réanimation ; des règles prédictives ont été établies dans ce sens. La littérature concernant les critères de sortie d'hospitalisation et le suivi des patients est plus pauvre.
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Affiliation(s)
- K Faure
- Service de réanimation médicale et maladies infectieuses, centre hospitalier de Tourcoing, 135, rue du Président-Coty, 59208 Tourcoing, France.
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Abstract
Lower respiratory tract infection is easily suggested on clinical signs (cough and sputum) associated with fever. To discriminate between pneumonia and acute bronchitis is crucial because of the mortality associated with pneumonia and of its specific management. Chest X-ray is a key exam for the diagnosis and should be performed on the basis of validated clinical signs that are however of weak diagnostic value. Clinical as well as radiological signs cannot be reliably used to identify the causative germ. Sputum examination, the search for pneumococcal and legionella urinary antigens are of good diagnostic value. An associated COPD may lead to an acute respiratory failure. Acute exacerbation of chronic bronchitis results from various causes but infection is involved in about 50% of the cases, mostly viral and most often due to a rhinovirus. Viral infection can be associated to bacterial infection and the most frequently isolated germs are Streptococcus pneumoniae, Haemophilus influenzae, and B. catarrhalis. Severity assessment relies on the value of basal FEV1 that is often non available. Therefore Afssaps suggests using a dyspnea index to assess exacerbation severity.
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Affiliation(s)
- B Housset
- Service de pneumologie et pathologie professionnelle, CHI de Créteil, 40, avenue de Verdun, 94000 Créteil, France.
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Archer KA, Roy CR. MyD88-dependent responses involving toll-like receptor 2 are important for protection and clearance of Legionella pneumophila in a mouse model of Legionnaires' disease. Infect Immun 2006; 74:3325-33. [PMID: 16714560 PMCID: PMC1479235 DOI: 10.1128/iai.02049-05] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Legionella pneumophila is a gram-negative facultative intracellular parasite of macrophages. Although L. pneumophila is the causative agent of a severe pneumonia known as Legionnaires' disease, it is likely that most infections caused by this organism are cleared by the host innate immune system. It is predicted that host pattern recognition proteins belonging to the Toll-like receptor (TLR) family are involved in the protective innate immune responses. We examined the role of TLR-mediated responses in L. pneumophila detection and clearance using genetically altered mouse hosts in which the macrophages are permissive for L. pneumophila intracellular replication. Our data demonstrate that cytokine production by bone marrow-derived macrophages (BMMs) in response to L. pneumophila infection requires the TLR adapter protein MyD88 and is reduced in the absence of TLR2 but not in the absence of TLR4. Bacterial growth ex vivo in BMMs from MyD88-deficient mice was not enhanced compared to bacterial growth ex vivo in BMMs from heterozygous littermate controls. Wild-type mice were able to clear L. pneumophila from the lung, whereas respiratory infection of MyD88-deficient mice caused death that resulted from robust bacterial replication and dissemination. In contrast to an infection with virulent L. pneumophila, MyD88-deficient mice were able to clear infections with L. pneumophila dotA mutants, indicating that MyD88-independent responses in the lung are sufficient to clear bacteria that are unable to replicate intracellularly. In vivo growth of L. pneumophila was enhanced in the lungs of TLR2-deficient mice, which resulted in a delay in bacterial clearance. No significant differences were observed in the growth and clearance of L. pneumophila in the lungs of TLR4-deficient mice and heterozygous littermate control mice. Our data indicate that MyD88 is crucial for eliciting a protective innate immune response against virulent L. pneumophila and that TLR2 is one of the pattern recognition receptors involved in initiating this MyD88-dependent response.
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Affiliation(s)
- Kristina A Archer
- Section of Microbial Pathogenesis, Yale University School of Medicine, Boyer Center for Molecular Medicine, 295 Congress Avenue, New Haven, CT 06536, USA
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Smith AF, Oakey RJ. Incidence and significance of errors in a patient 'track and trigger' system during an epidemic of Legionnaires' disease: retrospective casenote analysis. Anaesthesia 2006; 61:222-8. [PMID: 16480345 DOI: 10.1111/j.1365-2044.2005.04513.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early warning scoring is designed to be an objective tool to aid identification of hospital patients at risk of deterioration. 'Track and trigger' systems using such scores are widely used but many aspects of scoring have not been clarified. We aimed to document how observations and scores are used in practice as part of a typical track and trigger system. We extracted patient observations and early warning scores from the casenotes of 189 patients admitted to Furness General Hospital during a large outbreak of Legionnaires' disease in 2002. We used these 3739 sets of primary observations to recalculate scores, and compared them with those recorded in the casenotes. Recording of patient observations was variable. Early warning scores were derived from 2607 sets of observations (69.7%), of which 571 (21.9%) had been incorrectly calculated. Incorrect scoring meant that 66 of 270 patients (24.4%) whose observations should have reached the trigger value did not. Patients with more abnormal observations were more likely to be misscored. Scoring errors were more likely to lead to underscoring as the degree of physiological abnormality increased. Patients with confirmed Legionnaires' disease were more likely to be incorrectly scored. We conclude that the assignment of early warning scores is prone to error and this may delay referral of at-risk patients for critical care management.
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Affiliation(s)
- A F Smith
- Department of Anaesthesia, University Hospitals of Morecambe Bay NHS Trust, Royal Lancaster Infirmary, Lancaster LA1 4RR, UK
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Antimony porphyrin complexes as visible-light driven photocatalyst. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY C-PHOTOCHEMISTRY REVIEWS 2005. [DOI: 10.1016/j.jphotochemrev.2005.12.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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