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Kutsuna S, Ohbe H, Matsui H, Yasunaga H. Analysis of the effectiveness of combination antimicrobial therapy for Legionnaires' disease: A nationwide inpatient database study. Int J Infect Dis 2024; 142:106965. [PMID: 38367954 DOI: 10.1016/j.ijid.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
OBJECTIVES The effectiveness of monotherapy and combination therapy with quinolones and macrolides for treating Legionnaires' disease remains uncertain; this study aimed to assess the comparative effectiveness of three treatment approaches. METHODS Using a nationwide inpatient database, we analyzed 3560 eligible patients hospitalized for Legionnaires' disease between April 1, 2014, and March 31, 2021; patients were divided into combination therapy, quinolone monotherapy, and macrolide monotherapy groups according to the antibiotics administered within 2 days of admission. We compared in-hospital mortality, total hospitalization costs, and length of stay across these groups using multiple propensity score analysis with inverse probability of treatment weighting. RESULTS Of the 3560 patients, there were 564 (15.8%), 2221 (62.4%), and 775 (21.8%) patients in the combination therapy, quinolone monotherapy, and macrolide monotherapy groups, respectively. No significant differences were observed in in-hospital mortality between combination therapy and quinolone monotherapy groups, and between combination therapy and macrolide monotherapy groups. There were no significant differences in total hospitalization costs or length of stay among the three groups. CONCLUSION The study suggests that there may not be a significant advantage in using a combination of quinolones and macrolides over monotherapy for the treatment of Legionnaires' disease. Given the potential for increased side effects, careful consideration is advised when choosing this combination therapy.
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Affiliation(s)
- Satoshi Kutsuna
- Department of Infection Control, Department of Infection Control, Graduate School of Medicine Faculty of Medicine, Osaka University, Osaka, Japan.
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Aoba-ku, Sendai, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Rello J, Allam C, Ruiz-Spinelli A, Jarraud S. Severe Legionnaires' disease. Ann Intensive Care 2024; 14:51. [PMID: 38565811 PMCID: PMC10987467 DOI: 10.1186/s13613-024-01252-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Legionnaires' disease (LD) is a common but under-diagnosed cause of community-acquired pneumonia (CAP), although rapid detection of urine antigen testing (UAT) and advances in molecular testing have improved the diagnosis. LD entails intensive care unit (ICU) admission in almost one-third of cases, and the mortality rate ranges from 4% to 40%. This review aims to discuss recent advances in the study of this condition and to provide an update on the diagnosis, pathogenesis and management of severe LD. RESULTS The overall incidence of LD has increased worldwide in recent years due to the higher number of patients with risk factors, especially immunosuppression, and to improvements in diagnostic methods. Although LD is responsible for only around 5% of all-cause CAP, it is one of the three most common causes of CAP requiring ICU admission. Mortality in ICU patients, immunocompromised patients or patients with a nosocomial source of LD can reach 40% despite appropriate antimicrobial therapy. Regarding pathogenesis, no Legionella-specific virulence factors have been associated with severity; however, recent reports have found high pulmonary Legionella DNA loads, and impairments in immune response and lung microbiome in the most severe cases. The clinical picture includes severe lung injury requiring respiratory and/or hemodynamic support, extrapulmonary symptoms and non-specific laboratory findings. LD diagnostic methods have improved due to the broad use of UAT and the development of molecular methods allowing the detection of all Lp serogroups. Therapy is currently based on macrolides, quinolones, or a combination of the two, with prolonged treatment in severe cases. CONCLUSIONS Numerous factors influence the mortality rate of LD, such as ICU admission, the underlying immune status, and the nosocomial source of the infection. The host immune response (hyperinflammation and/or immunoparalysis) may also be associated with increased severity. Given that the incidence of LD is rising, studies on specific biomarkers of severity may be of great interest. Further assessments comparing different regimens and/or evaluating host-directed therapies are nowadays needed.
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Affiliation(s)
- Jordi Rello
- Global Health ECore, Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
- Formation Recherche Evaluation (FOREVA) Research Group, CHU Nîmes, Nîmes, France
| | - Camille Allam
- Institut des Agents Infectieux, Centre National de Référence des Légionelles, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Équipe Pathogenèse des Légionelles, Université Lyon, Inserm, U1111,Université Claude Bernard Lyon 1, CNRS, UMR5308,École Normale Supérieure de Lyon, Lyon, France
| | | | - Sophie Jarraud
- Institut des Agents Infectieux, Centre National de Référence des Légionelles, Hospices Civils de Lyon, Lyon, France.
- Centre International de Recherche en Infectiologie (CIRI), Équipe Pathogenèse des Légionelles, Université Lyon, Inserm, U1111,Université Claude Bernard Lyon 1, CNRS, UMR5308,École Normale Supérieure de Lyon, Lyon, France.
- Centre National de Reference des Légionelles, Institut des Agents Infectieux, Hospices Civils de Lyon, 103 Grande rue de la Croix Rousse, 69317, Lyon Cedex 04, France.
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Krause JD. Controlling Legionella pneumophila growth in hot water systems by reducing dissolved oxygen levels. J Occup Environ Hyg 2024; 21:259-269. [PMID: 38447033 DOI: 10.1080/15459624.2024.2313580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Legionella pneumophila, the leading cause of Legionnaires' disease in the United States, is found in lakes, ponds, and streams but poses a health risk when it grows in building water systems. The growth of L. pneumophila in hot water systems of healthcare facilities poses a significant risk to patients, staff, and visitors. Hospitals and long-term care facilities account for 76% of reported Legionnaires' disease cases with mortality rates of 25%. Controlling L. pneumophila growth in hot water systems serving healthcare and hospitality buildings is currently achieved primarily by adding oxidizing chemical disinfectants. Chemical oxidants generate disinfection byproducts and can accelerate corrosion of premise plumbing materials and equipment. Alternative control methods that do not generate hazardous disinfection byproducts or accelerate corrosion are needed. L. pneumophila is an obligate aerobe that cannot sustain cellular respiration, amplify, or remain culturable when dissolved oxygen (DO) concentrations are too low (< 0.3 mg/L). An alternative method of controlling L. pneumophila growth by reducing DO levels in a hot water model system using a gas transfer membrane contactor was evaluated. A hot water model system was constructed and inoculated with L. pneumophila at DO concentrations above 0.5 mg/L. Once the model system was colonized, DO levels were incrementally reduced. Water samples were collected each week to evaluate the effect of reducing dissolved oxygen levels when all other conditions favored Legionella amplification. At DO concentrations below 0.3 mg/L, L. pneumophila concentrations were reduced by 1-log over 7 days. Under conditions in the hot water model system, at favorable temperatures and with no residual chlorine disinfectant, L. pneumophila concentrations were reduced by 1-log, indicating growth inhibition by reducing DO levels as the sole control measure. In sections of the model system where DO levels were not lowered L. pneumophila continued to grow. Reducing dissolved oxygen levels in hot water systems of healthcare and other large buildings to control L. pneumophila could also lower the risk of supplemental chemical treatment methods currently in use.
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Affiliation(s)
- J David Krause
- Healthcare Consulting and Contracting, Tallahassee, Florida
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Buchholz U, Brodhun B, Lehfeld AS. Incidence of Legionnaires' Disease among Travelers Visiting Hotels in Germany, 2015-2019. Emerg Infect Dis 2024; 30:13-19. [PMID: 38146962 PMCID: PMC10756367 DOI: 10.3201/eid3001.231064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
We determined whether the incidence rates of travel-associated Legionnaires' disease (TALD) in hotels in Germany increased after a previous occurrence and whether control measures required by the European Legionnaires' Disease Surveillance Network after a cluster (>2 cases within 2 years) restored the rate to baseline. We analyzed TALD surveillance data from Germany during 2015-2019; a total of 307 TALD cases (163 domestic, 144 nondomestic) in hotels were reported. The incidence rate ratio was 5.5 (95% CI 3.6-7.9) for a second case and 25 (95% CI 11-50) for a third case after a cluster had occurred, suggesting that control measures initiated after the occurrence of TALD clusters might be inadequate to restore the incidence rate to baseline. Our findings indicate that substantial LD preventive measures should be explored by hotels or other accommodations after the first TALD case occurs to reduce the risk for future infections.
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Donovan CV, MacFarquhar JK, Wilson E, Sredl M, Tanz LJ, Mullendore J, Fleischauer A, Smith JC, Lucas C, Kunz J, Moore Z. Legionnaires' Disease Outbreak Associated With a Hot Tub Display at the North Carolina Mountain State Fair, September 2019. Public Health Rep 2024; 139:79-87. [PMID: 36971250 PMCID: PMC10905752 DOI: 10.1177/00333549231159159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
OBJECTIVES On September 23, 2019, the North Carolina Division of Public Health identified a legionellosis increase in western North Carolina; most patients had recently attended the North Carolina Mountain State Fair. We conducted a source investigation. METHODS Cases were fair attendees with laboratory-confirmed legionellosis and symptom onset within 2 to 14 days (Legionnaires' disease) or ≤3 days (Pontiac fever). We conducted a case-control study matching cases to non-ill fair attendees as control participants and an environmental investigation, and we performed laboratory testing (Legionella bacteria culture and polymerase chain reaction) of 27 environmental samples from fairgrounds and hot tubs and 14 specimens from case patients. We used multivariable unconditional logistic regression models to calculate adjusted odds ratios for potential Legionella exposure sources and risk factors. RESULTS Of 136 people identified with fair-associated legionellosis, 98 (72%) were hospitalized and 4 (3%) died. Case patients were more likely than control participants to report walking by hot tub displays (adjusted odds ratio = 10.0; 95% CI, 4.2-24.1). Complete hot tub water treatment records were not kept, precluding evaluation of water maintenance conducted on display hot tubs. Legionella pneumophila sequence types (STs) were consistent among 10 typed clinical specimens (ST224) but distinct from the only positive environmental sample from the fair (ST7 and ST8). CONCLUSIONS Hot tub displays were identified as the most likely outbreak source, making this the largest hot tub-associated Legionnaires' disease outbreak worldwide. Following the investigation, the North Carolina Division of Public Health and the Centers for Disease Control and Prevention released guidance on mitigating risk of Legionella exposure from hot tub displays. Results highlight the importance of properly maintaining equipment that aerosolizes water, including hot tubs intended for display purposes only.
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Affiliation(s)
- Catherine V. Donovan
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Now with the Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer K. MacFarquhar
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Erica Wilson
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Megan Sredl
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Lauren J. Tanz
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Aaron Fleischauer
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
- Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jessica C. Smith
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Claressa Lucas
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jasen Kunz
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Zack Moore
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
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Szczepanek A, Tyszko P, Kalinowski P, Chmielewski J, Choina P, Nowak-Starz G. Occurrence of Legionella sp. bacteria in hot water systems in hospitals and nursing homes in the Świętokrzyskie Province of south-eastern Poland. Ann Agric Environ Med 2023; 30:654-660. [PMID: 38153068 DOI: 10.26444/aaem/176501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
INTRODUCTION AND OBJECTIVE The occurrence of bacteria of the genus Legionella sp. in hot water supply systems in buildings is a real threat to human health, especially for patients in hospitals and residents of nursing homes. The aim of the study was determination of the degree of colonization of hot water systems in hospitals and nursing homes in the Świętokrzyskie Province in south-east Poland. MATERIAL AND METHODS Between 2014 - 2018, samples were collected from hot water systems in 30 hospitals and 32 nursing homes in order to determine the degree of contamination. 631 samples collected of the bacteria Legionella sp were analyzed. RESULTS Excessive contamination (≥ 100CFU/100 ml) with the bacteria Legionella sp. was detected in 12.12% (n=71) of samples. Contamination was significantly more frequently detected in samples from hot water systems in nursing homes, compared to hospitals (16.48% vs. 10.37%). Above-standard contamination of hot water systems with Legionella sp. bacteria occurred in 34.43% of the facilities, and was more frequent in hospitals (41.38%) than in the nursing homes (28.13%). In 21.3% of the facilities, contamination was detected many times during the study period. CONCLUSIONS Excessive contamination of hot water systems with Legionella sp. bacteria in the examined facilities was a common phenomenon. The presence of the pathogen in the installations of these facilities may constitute a considerable health hazard for patients and residents.
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Affiliation(s)
| | | | | | - Jarosław Chmielewski
- International European University, Kyiv, Ukraine
- Institute of Environmental Protection - National Research Institute (IEP-NRI), Warsaw, Poland
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Montagna MT, Brigida S, Fasano F, Leone CM, D'Ambrosio M, Spagnuolo V, Lopuzzo M, Apollonio F, Triggiano F, Caringella ME, De Giglio O. The role of air temperature in Legionella water contamination and legionellosis incidence rates in southern Italy (2018-2023). Ann Ig 2023; 35:631-640. [PMID: 37724578 DOI: 10.7416/ai.2023.2578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Background Legionnaires' disease is caused by inhalation or aspiration of small water droplets contaminated with Legionella, commonly found in natural and man-made water systems and in moist soil. Over the past 5 years, notification rates of this disease have almost doubled in the European Union (EU) / European Environmental Agency (EEA), from 1.4 in 2015 to 2.2 cases per 100,000 population in 2019. Some studies show that the greater presence of the microorganism in the water network and the increase in cases of legionellosis could be related to the variations in some environmental factors, such as air temperature, which may influence the water temperature. Study design Climate change is currently a prominent topic worldwide because of its significant impact on the natural environment. It is responsible for the increase in numerous waterborne pathologies. The purpose of this study was to correlate the air temperature recorded in Apulia region from January 2018 to April 2023 with the presence of Legionella in the water networks of public and private facilities and the incidence rates of legionellosis during the same period. Methods During the period from January 2018 to April 2023, water samples were collected from facilities involved in legionellosis cases and analyzed for Legionella. During the same period, all the cases notified to the regional epidemiological observatory (OER-Apulia) were included in this study. Statistical analyses were conducted using the Shapiro-Wilk test to determine whether the Legionella load was distributed normally, the Wilcoxon rank sum test to compare the air temperatures (average and range) of the negative and positive samples for Legionella detection, and the multivariate analysis (Poisson regression) to compare the Legionella load with the water sample temperature, average air temperature, and temperature range on the day of sampling. The Wilcoxon test for paired samples was used to compare legionellosis cases between the warmer and colder months. Results Overall, 13,044 water samples were analyzed for Legionella and 460 cases of legionellosis were notified. Legionella was isolated in 20.1% of the samples examined. The difference in the air temperature between negative samples and positive samples was statistically significant (p-value < 0.0001): on days when water samples tested positive for Legionella a higher temperature range was observed than on days when water samples tested negative (p-value = 0.004). Poisson regression showed a direct correlation between Legionella load, water temperature, and average air temperature. The incidence of legionellosis cases in warmer months was higher than in colder months (p-value = 0.03). Conclusions Our study highlights a significant increase in the load of Legionella in the Apulian water network, and an association between warmer temperatures and legionellosis incidence. In our opinion, further investigations are needed in different contexts and territories to characterize the epidemiology of legionellosis, and to explain its extreme variability in different geographical areas and how these data may be influenced by different risk factors.
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Affiliation(s)
- M T Montagna
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - S Brigida
- Department of Biological and Environmental Sciences and Technologies, University of Salento, Campus Ecotekne, Monteroni di Lecce, Lecce, Italy
| | - F Fasano
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - C M Leone
- Azienda Ospedaliero Universitaria Policlinico di Bari, Bari, Italy
| | - M D'Ambrosio
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - V Spagnuolo
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - M Lopuzzo
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - F Apollonio
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - F Triggiano
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - M E Caringella
- Azienda Ospedaliero Universitaria Policlinico di Bari, Bari, Italy
| | - O De Giglio
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
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Allam C, Mouton W, Testaert H, Ginevra C, Fessy N, Ibranosyan M, Descours G, Beraud L, Guillemot J, Chapalain A, Albert-Vega C, Richard JC, Argaud L, Friggeri A, Labeye V, Jamilloux Y, Freymond N, Venet F, Lina G, Doublet P, Ader F, Trouillet-Assant S, Jarraud S. Hyper-inflammatory profile and immunoparalysis in patients with severe Legionnaires' disease. Front Cell Infect Microbiol 2023; 13:1252515. [PMID: 37965258 PMCID: PMC10641404 DOI: 10.3389/fcimb.2023.1252515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/28/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Severe Legionnaires' disease (LD) can lead to multi-organ failure or death in 10%-30% of patients. Although hyper-inflammation and immunoparalysis are well described in sepsis and are associated with high disease severity, little is known about the immune response in LD. This study aimed to evaluate the immune status of patients with LD and its association with disease severity. Methods A total of 92 hospitalized LD patients were included; 19 plasmatic cytokines and pulmonary Legionella DNA load were measured in 84 patients on the day of inclusion (day 0, D0). Immune functional assays (IFAs) were performed from whole blood samples collected at D2 and stimulated with concanavalin A [conA, n = 19 patients and n = 21 healthy volunteers (HV)] or lipopolysaccharide (LPS, n = 14 patients and n = 9 HV). A total of 19 cytokines (conA stimulation) and TNF-α (LPS stimulation) were quantified from the supernatants. The Sequential Organ Failure Assessment (SOFA) severity score was recorded at D0 and the mechanical ventilation (MV) status was recorded at D0 and D8. Results Among the 84 patients, a higher secretion of plasmatic MCP-1, MIP1-β, IL-6, IL-8, IFN-γ, TNF-α, and IL-17 was observed in the patients with D0 and D8 MV. Multiparametric analysis showed that these seven cytokines were positively associated with the SOFA score. Upon conA stimulation, LD patients had a lower secretion capacity for 16 of the 19 quantified cytokines and a higher release of IL-18 and MCP-1 compared to HV. IL-18 secretion was higher in D0 and D8 MV patients. TNF-α secretion, measured after ex vivo LPS stimulation, was significantly reduced in LD patients and was associated with D8 MV status. Discussion The present findings describe a hyper-inflammatory phase at the initial phase of Legionella pneumonia that is more pronounced in patients with severe LD. These patients also present an immunoparalysis for a large number of cytokines, except IL-18 whose secretion is increased. An assessment of the immune response may be relevant to identify patients eligible for future innovative host-directed therapies.
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Affiliation(s)
- Camille Allam
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - William Mouton
- Unité Mixte de Recherche Hospices Civils de Lyon-bioMérieux, Pierre-Bénite, France
- Centre International de Recherche en Infectiologie (CIRI), Virpath Team Inserm U1111, CNRS UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hugo Testaert
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Christophe Ginevra
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Noémie Fessy
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Marine Ibranosyan
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Ghislaine Descours
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Laetitia Beraud
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Johann Guillemot
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Annelise Chapalain
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Chloé Albert-Vega
- Centre International de Recherche en Infectiologie (CIRI), Virpath Team Inserm U1111, CNRS UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive-Réanimation - Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation - Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Friggeri
- Département d’Anesthésie Réanimation - Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Vanessa Labeye
- Service des urgences - Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Yvan Jamilloux
- Département de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Nathalie Freymond
- Service de Pneumologie, Centre Hospitalier Lyon Sud - Hospices Civils de Lyon, Pierre-Bénite, France
| | - Fabienne Venet
- Laboratoire d’Immunologie - Hôpital Edouard Herriot - Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), NLRP3 Inflammation and Immune Response to Sepsis, Inserm U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Gérard Lina
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Patricia Doublet
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Florence Ader
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Département des Maladies Infectieuses et Tropicales - Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Sophie Trouillet-Assant
- Unité Mixte de Recherche Hospices Civils de Lyon-bioMérieux, Pierre-Bénite, France
- Centre International de Recherche en Infectiologie (CIRI), Virpath Team Inserm U1111, CNRS UMR5308, ENS Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Sophie Jarraud
- Centre National de Référence des Légionelles, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Legiopath team, Inserm, U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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Kunz JM, Hannapel E, Vander Kelen P, Hils J, Hoover ER, Edens C. Effects of the COVID-19 Pandemic on Legionella Water Management Program Performance across a United States Lodging Organization. Int J Environ Res Public Health 2023; 20:6885. [PMID: 37835155 PMCID: PMC10572137 DOI: 10.3390/ijerph20196885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023]
Abstract
Legionella, the bacterium that causes Legionnaires' disease, can grow and spread in building water systems and devices. The COVID-19 pandemic impacted building water systems through reductions in water usage. Legionella growth risk factors can be mitigated through control measures, such as flushing, to address stagnation, as part of a water management program (WMP). A national lodging organization (NLO) provided WMP data, including Legionella environmental testing results for periods before and during the pandemic. The statistical analysis revealed an increased risk of water samples testing positive for Legionella during the pandemic, with the greatest increase in risk observed at the building's cold-water entry test point. Sample positivity did not vary by season, highlighting the importance of year-round Legionella control activities. The NLO's flushing requirements may have prevented an increased risk of Legionella growth during the pandemic. However, additional control measures may be needed for some facilities that experience Legionella detections. This analysis provides needed evidence for the use of flushing to mitigate the impacts of building water stagnation, as well as the value of routine Legionella testing for WMP validation. Furthermore, this report reinforces the idea that WMPs remain the optimal tool to reduce the risk of Legionella growth and spread in building water systems.
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Affiliation(s)
- Jasen M. Kunz
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H24-11, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Elizabeth Hannapel
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-6, 1600 Clifton Road, Atlanta, GA 30333, USA; (E.H.); (C.E.)
| | - Patrick Vander Kelen
- Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA; (P.V.K.); (E.R.H.)
| | - Janie Hils
- Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA; (P.V.K.); (E.R.H.)
- Oak Ridge Institute for Science and Education, P.O. Box 117, Oak Ridge, TN 37830, USA
| | - Edward Rickamer Hoover
- Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Mailstop S106-5, 4770 Buford Highway, Atlanta, GA 30341, USA; (P.V.K.); (E.R.H.)
| | - Chris Edens
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop H24-6, 1600 Clifton Road, Atlanta, GA 30333, USA; (E.H.); (C.E.)
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10
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Fischer FB, Bigler M, Mäusezahl D, Hattendorf J, Egli A, Julian TR, Rölli F, Gaia V, Wymann M, Fridez F, Bertschi S. Legionnaires' disease in Switzerland: rationale and study protocol of a prospective national case-control and molecular source attribution study (SwissLEGIO). Infection 2023; 51:1467-1479. [PMID: 36905400 PMCID: PMC10545568 DOI: 10.1007/s15010-023-02014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/23/2023] [Indexed: 03/12/2023]
Abstract
Switzerland has one of the highest annual Legionnaires' disease (LD) notification rates in Europe (7.8 cases/100,000 population in 2021). The main sources of infection and the cause for this high rate remain largely unknown. This hampers the implementation of targeted Legionella spp. control efforts. The SwissLEGIO national case-control and molecular source attribution study investigates risk factors and infection sources for community-acquired LD in Switzerland. Over the duration of one year, the study is recruiting 205 newly diagnosed LD patients through a network of 20 university and cantonal hospitals. Healthy controls matched for age, sex, and residence at district level are recruited from the general population. Risk factors for LD are assessed in questionnaire-based interviews. Clinical and environmental Legionella spp. isolates are compared using whole genome sequencing (WGS). Direct comparison of sero- and sequence types (ST), core genome multilocus sequencing types (cgMLST), and single nucleotide polymorphisms (SNPs) between clinical and environmental isolates are used to investigate the infection sources and the prevalence and virulence of different Legionella spp. strains detected across Switzerland. The SwissLEGIO study innovates in combining case-control and molecular typing approaches for source attribution on a national level outside an outbreak setting. The study provides a unique platform for national Legionellosis and Legionella research and is conducted in an inter- and transdisciplinary, co-production approach involving various national governmental and national research stakeholders.
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Affiliation(s)
- Fabienne B Fischer
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Melina Bigler
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Daniel Mäusezahl
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Jan Hattendorf
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Adrian Egli
- Institute for Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Timothy R Julian
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | - Franziska Rölli
- Lucerne University of Applied Sciences and Arts, Lucerne, Switzerland
| | - Valeria Gaia
- Service of Microbiology, Institute of Laboratory Medicine, National Reference Centre for Legionella, EOC, Bellinzona, Switzerland
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11
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Ayesha A, Chow FWN, Leung PHM. Role of Legionella pneumophila outer membrane vesicles in host-pathogen interaction. Front Microbiol 2023; 14:1270123. [PMID: 37817751 PMCID: PMC10561282 DOI: 10.3389/fmicb.2023.1270123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Legionella pneumophila is an opportunistic intracellular pathogen that inhabits artificial water systems and can be transmitted to human hosts by contaminated aerosols. Upon inhalation, it colonizes and grows inside the alveolar macrophages and causes Legionnaires' disease. To effectively control and manage Legionnaires' disease, a deep understanding of the host-pathogen interaction is crucial. Bacterial extracellular vesicles, particularly outer membrane vesicles (OMVs) have emerged as mediators of intercellular communication between bacteria and host cells. These OMVs carry a diverse cargo, including proteins, toxins, virulence factors, and nucleic acids. OMVs play a pivotal role in disease pathogenesis by helping bacteria in colonization, delivering virulence factors into host cells, and modulating host immune responses. This review highlights the role of OMVs in the context of host-pathogen interaction shedding light on the pathogenesis of L. pneumophila. Understanding the functions of OMVs and their cargo provides valuable insights into potential therapeutic targets and interventions for combating Legionnaires' disease.
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Affiliation(s)
| | | | - Polly Hang-Mei Leung
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
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12
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Park J, Bae JM. Trends of legionellosis reported in Jeju Province, Republic of Korea, 2015-2022. Osong Public Health Res Perspect 2023; 14:321-327. [PMID: 37652687 PMCID: PMC10493698 DOI: 10.24171/j.phrp.2023.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The number of reported cases of Legionnaires' disease (LD) in the Republic of Korea surged nationally in 2016; however, in 2022, this number was higher in Jeju Province than the previous national peak. A descriptive epidemiological study was conducted to analyze trends in the incidence of reported LD cases in Jeju Island from 2015 to 2022. METHODS The data for this study were obtained from case reports submitted to the Korea Disease Control and Prevention Agency through its Disease and Health Integrated Management System. The selection criteria were cases or suspected cases of LD reported among Jeju residents between 2015 and 2022. The 95% confidence interval of the crude incidence rate was calculated using the Poisson distribution. RESULTS Since 2020, the incidence rate of LD in Jeju has risen sharply, showing a statistically significant difference from the national incidence rate. A particular medical institution in Jeju reported a significant number of LD cases. Screening with the urine antigen test (UAT) also increased significantly. CONCLUSION Our findings indicate that the rapid increase in cases of LD in Jeju Province since 2020 was due to the characteristics of medical-care use among Jeju residents, which were focused on a specific medical institution. According to their clinical practice guidelines, this medical institution conducted UATs to screen patients suspected of pneumonia.
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Affiliation(s)
- Juyoung Park
- Department of Medicine, Graduate School, Jeju National University, Jeju, Republic of Korea
- Jeju Center for Infectious Disease Control and Prevention, Jeju, Republic of Korea
| | - Jong-Myon Bae
- Jeju Center for Infectious Disease Control and Prevention, Jeju, Republic of Korea
- Department of Preventive Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
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13
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Riccò M, Ferraro P, Ranzieri S, Boldini G, Zanella I, Marchesi F. Legionnaires' Disease in Occupational Settings: A Cross-Sectional Study from Northeastern Italy (2019). Trop Med Infect Dis 2023; 8:364. [PMID: 37505660 PMCID: PMC10384770 DOI: 10.3390/tropicalmed8070364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/09/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023] Open
Abstract
In Italy, Legionnaires' Disease (LD) causes >1000 hospital admissions per year, with a lethality rate of 5 to 10%. Occupational exposures could reasonably explain a substantial share of total cases, but the role of Occupational Physicians (OPs) in management and prevention of LD has been scarcely investigated. The present survey therefore evaluates the knowledge, attitudes and practices (KAP) regarding LD from a convenience sample of Italian OPs, focusing on their participation in preventive interventions. A total of 165 OPs were recruited through a training event (Parma, Northeastern Italy, 2019), and completed a specifically designed structured questionnaire. The association between reported participation in preventive interventions and individual factors was analyzed using a binary logistic regression model, calculating corresponding multivariable Odds Ratio (aOR). Overall, participants exhibited satisfactory knowledge of the clinical and diagnostic aspects of LD, while substantial uncertainties were associated epidemiological factors (i.e., notification rate and lethality). Although the majority of participating OPs reportedly assisted at least one hospital (26.7%) and/or a nursing home (42.4%) and/or a wastewater treatment plant, only 41.8% reportedly contributed to the risk assessment for LD and 18.8% promoted specifically designed preventive measures. Working as OPs in nursing homes (aOR 8.732; 95% Confidence Intervals [95%CI] 2.991 to 25.487) and wastewater treatment plants (aOR 8.710; 95%CI 2.844 to 26.668) was associated with participation in the risk assessment for LD, while the promotion of preventive practice was associated with working as an OP in hospitals (aOR 6.792; 95%CI 2.026 to 22.764) and wastewater treatment plants (aOR 4.464, 95%CI 1.363 to 14.619). In other words, the effective participation of the OP in the implementation of preventive measures appears uncommon and is limited to certain occupational settings. Collectively, these results highlight the importance of tailoring specifically designed information campaigns aimed to raise the involvement of OPs in the prevention of LD in occupational settings other than healthcare.
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Affiliation(s)
- Matteo Riccò
- Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), AUSL-IRCCS di Reggio Emilia, Via Amendola n.2, I-42122 Reggio Emilia, Italy
| | - Pietro Ferraro
- Occupational Medicine Unit, Direzione Sanità, Italian Railways' Infrastructure Division, RFI SpA, I-00161 Rome, Italy
| | - Silvia Ranzieri
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
| | - Giorgia Boldini
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
- Servizio di Igiene Pubblica, AUSL di Parma, Via Vasari n.13/a, I-43123 Parma, Italy
| | - Ilaria Zanella
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, Via Gramsci, 14, I-43126 Parma, Italy
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14
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See XY, Ahmed O, Nand N, Quwatli W. Legionnaires' Disease Complicated with Rhabdomyolysis and Acute Kidney Injury. Eur J Case Rep Intern Med 2023; 10:003940. [PMID: 37554481 PMCID: PMC10405870 DOI: 10.12890/2023_003940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/21/2023] [Indexed: 08/10/2023] Open
Abstract
UNLABELLED Legionnaire's disease can cause rare and severe complications such as rhabdomyolysis and acute kidney injury. This case report details a 45-year-old male patient who presented with features of Legionnaire's disease. Laboratory results showed a significantly elevated serum creatinine kinase level and an increased creatinine level. Imaging showed right lower lobe consolidation, and a positive urine antigen test confirmed Legionnaire's disease. The patient was administered azithromycin and underwent fluid repletion to manage the rhabdomyolysis and acute kidney injury, resulting in improved creatinine kinase levels and kidney function. He was discharged and continued on azithromycin for 10 days. His outpatient follow-up showed that creatinine kinase levels had further decreased. This case report emphasises the importance of early recognition and management of Legionnaire's disease and its rare but severe complications. LEARNING POINTS Legionnaire's disease is a severe form of pneumonia caused by Legionella bacteria that can lead to rare complications such as rhabdomyolysis and acute kidney injury, which have high morbidity and mortality rates.The treatment for Legionnaire's disease complicated with rhabdomyolysis and acute kidney injury involves early fluid repletion, antibiotics and close monitoring of creatinine kinase levels, electrolytes and kidney function.For patients with creatinine kinase levels over 5000 U/l without hypocalcaemia or alkalaemia, urinary alkalinisation with bicarbonate therapy may be considered as a treatment option.
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Affiliation(s)
- Xin Ya See
- Department of Medicine, Unity Hospital, Rochester Regional Health, Rochester, NY, USA
| | - Omer Ahmed
- Department of Medicine, Unity Hospital, Rochester Regional Health, Rochester, NY, USA
| | - Nikita Nand
- Department of Medicine, Unity Hospital, Rochester Regional Health, Rochester, NY, USA
| | - Waleed Quwatli
- Department of Medicine, Unity Hospital, Rochester Regional Health, Rochester, NY, USA
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15
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Jun H, Scott-Thomas A, Slow S, Williman J, Murdoch DR, Chambers ST. The inhibitory effect of copper, zinc and manganese on Legionella longbeachae and other Legionella spp. in vitro. Lett Appl Microbiol 2023:ovad074. [PMID: 37403323 DOI: 10.1093/lambio/ovad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Legionella longbeachae is an important cause of Legionnaires' disease in Australasia and is associated with exposure to potting soils. Our aim was to identify ways to reduce the load of L. longbeachae in potting soils. Inductively-coupled plasma optical emission spectrometry (ICP-OES) of an all-purpose potting mix showed copper (Cu) concentrations (mg/kg) range from 15.8-23.6. Zinc (Zn) and manganese (Mn) were significantly higher than Cu ranging from 88.6-106 and 171-203 respectively. Minimal inhibitory and bactericidal concentrations of 10 salts used in the horticultural industry were determined for Legionella species in buffered yeast extract (BYE) broth. For L. longbeachae (n = 9) the median (range) minimum inhibitory concentration (MIC) (mg/L) of copper sulfate was 31.25 (15.6-31.25), zinc sulfate 31.25 (7.81-31.25) and manganese sulfate 31.25 (7.81-62.5). The MIC and minimum bactericidal concentration (MBC) were within one dilution of each other. Susceptibility to Cu and Zn salts increased as the concentration of pyrophosphate iron in the media decreased. The MIC values for these three metals against L. pneumophila (n = 3) and L. micdadei (n = 4) were similar. Combinations of Cu, Zn and Mn were additive. L. longbeachae has similar susceptibility to Cu and other metal ions in comparison to L. pneumophila.
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Affiliation(s)
- Hyunwoo Jun
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8011, New Zealand
| | - Amy Scott-Thomas
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8011, New Zealand
| | - Sandy Slow
- Department of Agricultural Sciences, Lincoln University, Lincoln 7674, New Zealand
| | - Jonathan Williman
- Department Population Health, University of Otago, Christchurch 8011, New Zealand
| | - David R Murdoch
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8011, New Zealand
| | - Stephen T Chambers
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8011, New Zealand
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Gerdes ME, Miko S, Kunz JM, Hannapel EJ, Hlavsa MC, Hughes MJ, Stuckey MJ, Francois Watkins LK, Cope JR, Yoder JS, Hill VR, Collier SA. Estimating Waterborne Infectious Disease Burden by Exposure Route, United States, 2014. Emerg Infect Dis 2023; 29:1357-1366. [PMID: 37347505 PMCID: PMC10310388 DOI: 10.3201/eid2907.230231] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases.
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Affiliation(s)
| | | | - Jasen M. Kunz
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Elizabeth J. Hannapel
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Michele C. Hlavsa
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Michael J. Hughes
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Matthew J. Stuckey
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Louise K. Francois Watkins
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Jennifer R. Cope
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Jonathan S. Yoder
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Vincent R. Hill
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
| | - Sarah A. Collier
- Chenega Corporation, Atlanta, Georgia, USA (M.E. Gerdes)
- Centers for Disease Control and Prevention, Atlanta (M.E. Gerdes, S. Miko, J.M. Kunz, E.J. Hannapel, M.C. Hlavsa, M.J. Hughes, M.J. Stuckey, L.K. Francois Watkins, J.R. Cope, J.S. Yoder, V.R. Hill, S.A. Collier)
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17
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Gea-Izquierdo E, Gil-Prieto R, Hernández-Barrera V, Rodríguez-Caravaca G, Gil-de-Miguel Á. Legionellosis-Associated Hospitalization in Spain from 2002 to 2021. Microorganisms 2023; 11:1693. [PMID: 37512866 PMCID: PMC10385138 DOI: 10.3390/microorganisms11071693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Legionellosis is a respiratory disease of bacterial and environmental origin that usually presents two distinct clinical entities, "Legionnaires' disease" (LD) and "Pontiac fever". LD is an important cause of hospital-acquired pneumonia (HAP). The objective of this study is to describe the epidemiology of legionellosis-associated hospitalization (L-AH) in Spain from 2002 to 2021 and the burden of hospitalization due to legionellosis. Discharge reports from the Minimum Basic Data Set (MBDS) were used to retrospectively analyze hospital discharge data with a diagnosis of legionellosis, based on the ICD-9-CM and ICD-10-CM diagnosis codes, from 2002 to 2021. 21,300 L-AH occurred throughout the year during 2002-2021. The incidence of hospitalization associated per 100,000 inhabitants by month showed a similar trend for the 2002-2011, 2012-2021, and 2002-2021 periods. In Spain, during 2002-2021, the hospitalization rate (HR) in the autonomous communities ranged from 4.57 (2002-2011) to 0.24 (2012-2021) cases per 100,000 inhabitants. The HR of legionellosis in Spain has substantially increased across the 2002-2021 period, and the estimate is consistent with available European data. It is considered that in-depth epidemiological surveillance studies of legionellosis and improvements in the prevention and control of the disease are required in Spain.
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Affiliation(s)
- Enrique Gea-Izquierdo
- Preventive Medicine and Public Health, Rey Juan Carlos University, 28922 Madrid, Spain
- María Zambrano Program, European Union, Spain
| | - Ruth Gil-Prieto
- Preventive Medicine and Public Health, Rey Juan Carlos University, 28922 Madrid, Spain
| | | | - Gil Rodríguez-Caravaca
- Preventive Medicine and Public Health, Rey Juan Carlos University, 28922 Madrid, Spain
- Department of Preventive Medicine, Hospital Universitario Fundación Alcorcón, Rey Juan Carlos University, 28922 Madrid, Spain
| | - Ángel Gil-de-Miguel
- Preventive Medicine and Public Health, Rey Juan Carlos University, 28922 Madrid, Spain
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Lehfeld AS, Reber F, Lewandowsky MM, Jahn HJ, Lück C, Petzold M, Schaefer B, Germelmann AR, Lorenz K, Buchholz U. Could oral hygiene prevent cases of at-home-acquired Legionnaires' disease? - Results of a comprehensive case-control study on infection sources, risk, and protective behaviors. Front Microbiol 2023; 14:1199572. [PMID: 37396377 PMCID: PMC10311500 DOI: 10.3389/fmicb.2023.1199572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/12/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction The "LeTriWa study" on community-acquired cases of Legionnaires' disease (LD) found that most cases likely acquired their infection at home (AHALD). However, which sources confer the infection is largely unknown. We therefore analyzed the data set from the LeTriWa study to find out if individual sources were associated with AHALD and if specific behavioral habits may increase or lower the risk for AHALD. Methods During the study we had used two comparison groups: (i) controls matched for age group and hospital ("controls"), (ii) household members of cases with AHALD ("AHALD-HHM"). We inquired about exposure to water sources, such as showering or wearing dentures, as well as behavioral factors and habits related to oral hygiene. We took standardized household bathroom water and biofilm samples of both cases with AHALD and controls, and in addition from households of cases with AHALD only samples from suspect residential (non-)drinking water sources. We first conducted bivariate analyses for infection sources and behaviors, followed by multivariable analyses. Results There were 124 cases with AHALD, 217 controls and 59 AHALD-HHM. In bivariate analyses using controls for comparison, wearing dentures was the only variable significantly positively associated (odds ratio (OR) = 1.7, 95% confidence interval (CI) = 1.1-2.7, p-value = 0.02). Behavioral factors such as showering, letting water run before use and not being alcohol abstinent were significantly negatively associated, smoking was significantly positively associated. In a multivariable analysis, we identified good oral hygiene as a preventive factor for both denture wearers (OR = 0.33, 95% CI = 0.13-0.83, p-value = 0.02) and non-denture wearers (OR = 0.32, 95% CI = 0.10-1.04, p-value = 0.06). Analyses of comparisons with AHALD-HHM showed similar effects but lacked statistical power. We identified Legionella in 16 residential (non-)drinking water sources, one of which was a PCR-positive scratch sample of dentures. Discussion Wearing (inadequately cleaned) dentures or poor oral hygiene might confer an increased risk for AHALD, and oral hygiene may prevent AHALD. The hypothesis that Legionella in oral biofilm or dental plaque may be the cause of cases with AHALD should be examined further. If confirmed this may open new and simple avenues for the prevention of LD.
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Affiliation(s)
- Ann-Sophie Lehfeld
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Franziska Reber
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Marina M. Lewandowsky
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Heiko J. Jahn
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Christian Lück
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Virology, National Consulting Laboratory for Legionella, Technische Universität Dresden, Dresden, Germany
| | - Markus Petzold
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Virology, National Consulting Laboratory for Legionella, Technische Universität Dresden, Dresden, Germany
| | - Benedikt Schaefer
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | | | - Katrin Lorenz
- Department of Periodontology, Technische Universität Dresden, Dresden, Germany
| | - Udo Buchholz
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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Nisar MA, Ros KE, Brown MH, Bentham R, Best G, Xi J, Hinds J, Whiley H. Stagnation arising through intermittent usage is associated with increased viable but non culturable Legionella and amoeba hosts in a hospital water system. Front Cell Infect Microbiol 2023; 13:1190631. [PMID: 37351181 PMCID: PMC10282743 DOI: 10.3389/fcimb.2023.1190631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
Hospital water systems are a significant source of Legionella, resulting in the potentially fatal Legionnaires' disease. One of the biggest challenges for Legionella management within these systems is that under unfavorable conditions Legionella transforms itself into a viable but non culturable (VBNC) state that cannot be detected using the standard methods. This study used a novel method (flow cytometry-cell sorting and qPCR [VFC+qPCR] assay) concurrently with the standard detection methods to examine the effect of temporary water stagnation, on Legionella spp. and microbial communities present in a hospital water system. Water samples were also analyzed for amoebae using culture and Vermamoeba vermiformis and Acanthamoeba specific qPCR. The water temperature, number and duration of water flow events for the hand basins and showers sampled was measured using the Enware Smart Flow® monitoring system. qPCR analysis demonstrated that 21.8% samples were positive for Legionella spp., 21% for L. pneumophila, 40.9% for V. vermiformis and 4.2% for Acanthamoeba. All samples that were Legionella spp. positive using qPCR (22%) were also positive for VBNC Legionella spp.; however, only 2.5% of samples were positive for culturable Legionella spp. 18.1% of the samples were positive for free-living amoebae (FLA) using culture. All samples positive for Legionella spp. were also positive for FLA. Samples with a high heterotrophic plate count (HPC ≥ 5 × 103 CFU/L) were also significantly associated with high concentrations of Legionella spp. DNA, VBNC Legionella spp./L. pneumophila (p < 0.01) and V. vermiformis (p < 0.05). Temporary water stagnation arising through intermittent usage (< 2 hours of usage per month) significantly (p < 0.01) increased the amount of Legionella spp. DNA, VBNC Legionella spp./L. pneumophila, and V. vermiformis; however, it did not significantly impact the HPC load. In contrast to stagnation, no relationship was observed between the microbes and water temperature. In conclusion, Legionella spp. (DNA and VBNC) was associated with V. vermiformis, heterotrophic bacteria, and stagnation occurring through intermittent usage. This is the first study to monitor VBNC Legionella spp. within a hospital water system. The high percentage of false negative Legionella spp. results provided by the culture method supports the use of either qPCR or VFC+qPCR to monitor Legionella spp. contamination within hospital water systems.
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Affiliation(s)
- Muhammad Atif Nisar
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Kirstin E. Ros
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Melissa H. Brown
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
- Australian Research Council Training Centre for Biofilm Research and Innovation, Flinders University, Bedford Park, SA, Australia
| | - Richard Bentham
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Giles Best
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- Flow Cytometry Facility, Flinders University, Bedford Park, SA, Australia
| | - James Xi
- Enware Australia Pty Ltd., Caringbah, NSW, Australia
| | - Jason Hinds
- Enware Australia Pty Ltd., Caringbah, NSW, Australia
| | - Harriet Whiley
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
- Australian Research Council Training Centre for Biofilm Research and Innovation, Flinders University, Bedford Park, SA, Australia
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Graham FF, Harte D, Zhang J, Fyfe C, Baker MG. Increased Incidence of Legionellosis after Improved Diagnostic Methods, New Zealand, 2000-2020. Emerg Infect Dis 2023; 29:1173-1182. [PMID: 37209673 DOI: 10.3201/eid2906.221598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
Legionellosis, notably Legionnaires' disease, is recognized globally and in New Zealand (Aotearoa) as a major cause of community-acquired pneumonia. We analyzed the temporal, geographic, and demographic epidemiology and microbiology of Legionnaires' disease in New Zealand by using notification and laboratory-based surveillance data for 2000‒2020. We used Poisson regression models to estimate incidence rate ratios and 95% CIs to compare demographic and organism trends over 2 time periods (2000-2009 and 2010-2020). The mean annual incidence rate increased from 1.6 cases/100,000 population for 2000-2009 to 3.9 cases/100,000 population for 2010-2020. This increase corresponded with a change in diagnostic testing from predominantly serology with some culture to almost entirely molecular methods using PCR. There was also a marked shift in the identified dominant causative organism, from Legionella pneumophila to L. longbeachae. Surveillance for legionellosis could be further enhanced by greater use of molecular typing of isolates.
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Gumá M, Drasar V, Santandreu B, Cano R, Afshar B, Nicolau A, Bennassar M, del Barrio J, Crespi P, Crespi S. A community outbreak of Legionnaires' disease caused by outdoor hot tubs for private use in a hotel. Front Microbiol 2023; 14:1137470. [PMID: 37180254 PMCID: PMC10167275 DOI: 10.3389/fmicb.2023.1137470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/30/2023] [Indexed: 05/16/2023] Open
Abstract
During the period October-November 2017, an outbreak of Legionnaires' disease involving 27 cases occurred in the tourist area of Palmanova (Mallorca, Spain). The majority of cases were reported by the European Centre of Disease Prevention and Control (ECDC) as travel associated cases of Legionnaires' disease (TALD). Most cases belonged to different hotel cluster alerts. No cases were reported among the local population residing in the area. All tourist establishments associated with one or more TALD cases were inspected and sampled by public health inspectors. All relevant sources of aerosol emission detected were investigated and sampled. The absence of active cooling towers in the affected area was verified, by documents and on-site. Samples from hot tubs for private use located on the terraces of the penthouse rooms of a hotel in the area were included in the study. Extremely high concentrations (> 106 CFU/l) of Legionella pneumophila, including the outbreak strain, were found in the hot tubs of vacant rooms of this hotel thus identifying the probable source of infection. Meteorological situation may have contributed to the geographical distribution pattern of this outbreak. In conclusion, hot tubs for private use located outdoors should be considered when investigating community outbreaks of Legionnaires' disease of unclear origin.
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Affiliation(s)
- Mercedes Gumá
- Conselleria de Salut i Consum, Govern Balear, Palma de Mallorca, Spain
| | - Vladimir Drasar
- Public Health Institute Ostrava, National Legionella Reference Laboratory, Ostrava, Czechia
| | - Beatriz Santandreu
- Environmental Health and Laboratory Services, Biolinea Int., Palma de Mallorca, Spain
| | - Rosa Cano
- Centro Nacional de Epidemiología and CIBERESP, Instituto de Salud Carlos III, Madrid, Spain
| | - Baharak Afshar
- Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU), UK Health Security Agency (UKHSA), London, United Kingdom
| | - Antonio Nicolau
- Conselleria de Salut i Consum, Govern Balear, Palma de Mallorca, Spain
| | - Magdalena Bennassar
- Environmental Health and Laboratory Services, Biolinea Int., Palma de Mallorca, Spain
| | - Jorge del Barrio
- Environmental Health and Laboratory Services, Biolinea Int., Palma de Mallorca, Spain
| | - Pau Crespi
- Environmental Health and Laboratory Services, Biolinea Int., Palma de Mallorca, Spain
| | - Sebastian Crespi
- Environmental Health and Laboratory Services, Biolinea Int., Palma de Mallorca, Spain
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Vormittag S, Ende RJ, Derré I, Hilbi H. Pathogen vacuole membrane contact sites - close encounters of the fifth kind. Microlife 2023; 4:uqad018. [PMID: 37223745 PMCID: PMC10117887 DOI: 10.1093/femsml/uqad018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 05/25/2023]
Abstract
Vesicular trafficking and membrane fusion are well-characterized, versatile, and sophisticated means of 'long range' intracellular protein and lipid delivery. Membrane contact sites (MCS) have been studied in far less detail, but are crucial for 'short range' (10-30 nm) communication between organelles, as well as between pathogen vacuoles and organelles. MCS are specialized in the non-vesicular trafficking of small molecules such as calcium and lipids. Pivotal MCS components important for lipid transfer are the VAP receptor/tether protein, oxysterol binding proteins (OSBPs), the ceramide transport protein CERT, the phosphoinositide phosphatase Sac1, and the lipid phosphatidylinositol 4-phosphate (PtdIns(4)P). In this review, we discuss how these MCS components are subverted by bacterial pathogens and their secreted effector proteins to promote intracellular survival and replication.
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Affiliation(s)
| | | | - Isabelle Derré
- Corresponding author. Department of Microbiology, Immunology and Cancer Biology, University of Virginia, 1340 Jefferson Park Ave, Charlottesville, VA 22908, United States. Tel: +1-434-924-2330; E-mail:
| | - Hubert Hilbi
- Corresponding author. Institute of Medical Microbiology, University of Zürich, Gloriastrasse 30, 8006 Zürich, Switzerland. Tel: +41-44-634-2650; E-mail:
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23
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Leenheer D, Moreno AB, Paranjape K, Murray S, Jarraud S, Ginevra C, Guy L. Rapid adaptations of Legionella pneumophila to the human host. Microb Genom 2023; 9. [PMID: 36947445 PMCID: PMC10132064 DOI: 10.1099/mgen.0.000958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Legionella pneumophila are host-adapted bacteria that infect and reproduce primarily in amoeboid protists. Using similar infection mechanisms, they infect human macrophages, and cause Legionnaires' disease, an atypical pneumonia, and the milder Pontiac fever. We hypothesized that, despite the similarities in infection mechanisms, the hosts are different enough that there exist high-selective value mutations that would dramatically increase the fitness of Legionella inside the human host. By comparing a large number of isolates from independent infections, we identified two genes, mutated in three unrelated patients, despite the short duration of the incubation period (2-14 days). One is a gene coding for an outer membrane protein (OMP) belonging to the OmpP1/FadL family. The other is a gene coding for an EAL-domain-containing protein involved in cyclic-di-GMP regulation, which in turn modulates flagellar activity. The clinical strain, carrying the mutated EAL-domain-containing homologue, grows faster in macrophages than the wild-type strain, and thus appears to be better adapted to the human host. As human-to-human transmission is very rare, fixation of these mutations into the population and spread into the environment is unlikely. Therefore, parallel evolution - here mutations in the same genes observed in independent human infections - could point to adaptations to the accidental human host. These results suggest that despite the ability of L. pneumophila to infect, replicate in and exit from macrophages, its human-specific adaptations are unlikely to be fixed in the population.
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Affiliation(s)
- Daniël Leenheer
- Department of Medical Biochemistry and Microbiology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
- Ph.D. Program in Human Biology, School of Integrative and Global Majors, University of Tsukuba, Tsukuba, Japan
| | - Anaísa B Moreno
- Department of Medical Biochemistry and Microbiology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Kiran Paranjape
- Department of Medical Biochemistry and Microbiology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Susan Murray
- Department of Medical Biochemistry and Microbiology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Sophie Jarraud
- French National Reference Center of Legionella, Institute of Infectious Agents, Hospices Civils de Lyon, Lyon, France
- CIRI, Centre International de Recherche en Infectiologie, Legionella Pathogenesis Team, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | - Christophe Ginevra
- French National Reference Center of Legionella, Institute of Infectious Agents, Hospices Civils de Lyon, Lyon, France
- CIRI, Centre International de Recherche en Infectiologie, Legionella Pathogenesis Team, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | - Lionel Guy
- Department of Medical Biochemistry and Microbiology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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Samuelsson J, Payne Hallström L, Marrone G, Gomes Dias J. Legionnaires' disease in the EU/EEA*: increasing trend from 2017 to 2019. Euro Surveill 2023; 28:2200114. [PMID: 36927719 PMCID: PMC10021471 DOI: 10.2807/1560-7917.es.2023.28.11.2200114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
BackgroundThe burden of Legionnaires' disease (LD) in the European Union/European Economic Area (EU/EEA) has increased during the last decade, with notification rates increasing from 1.2 to 1.4/100,000 population in 2012-16, to 1.8-2.2 within 2017-19.AimTo measure weekly excess cases during 2017-19 based on previous trends and determine whether a significant change in trend occurred, and to examine any differences in age, sex or level of imported infections.MethodsWe collated 2012-19 annual surveillance data from The European Surveillance System (TESSy) reported by EU/EEA countries. A retrospective prediction by a dynamic regression model was created from 2012-16 data to assess excess cases in 2017-19. Interrupted time series (ITS) analysis was performed to determine if a significant change in trend occurred in 2017-19 compared with the previous 5 years.ResultsWe found a 33.9% increase in cases in 2017-19 compared with the number predicted. The ITS also found a significant trend increase in 2017-19 compared with 2012-16. A significant trend increase was observed from 2017 most strongly among older age groups (> 60 years) and non-imported cases.ConclusionOur study showed a significant increasing trend in LD cases in the EU/EEA during 2017-19 compared with the previous 5 years. The distribution of cases per week suggests an overall amplification of the seasonal trends. These findings underscore that LD continues to be an infectious disease of public health concern in the EU/EEA, warranting further research into determinants of the increase.
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Affiliation(s)
- Jonas Samuelsson
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Gaetano Marrone
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Joana Gomes Dias
- European Centre for Disease Prevention and Control, Stockholm, Sweden
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25
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Nisar MA, Ross KE, Brown MH, Bentham R, Best G, Whiley H. Detection and quantification of viable but non-culturable Legionella pneumophila from water samples using flow cytometry-cell sorting and quantitative PCR. Front Microbiol 2023; 14:1094877. [PMID: 36793878 PMCID: PMC9922708 DOI: 10.3389/fmicb.2023.1094877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 02/03/2023] Open
Abstract
Legionella pneumophila is a waterborne pathogen and, as the causative agent of Legionnaires' disease, a significant public health concern. Exposure to environmental stresses, and disinfection treatments, promotes the formation of resistant and potentially infectious viable but non-culturable (VBNC) Legionella. The management of engineered water systems to prevent Legionnaires' disease is hindered by the presence of VBNC Legionella that cannot be detected using the standard culture (ISO11731:2017-05) and quantitative polymerase reaction (ISO/TS12869:2019) methods. This study describes a novel method to quantify VBNC Legionella from environmental water samples using a "viability based flow cytometry-cell sorting and qPCR" (VFC + qPCR) assay. This protocol was then validated by quantifying the VBNC Legionella genomic load from hospital water samples. The VBNC cells were unable to be cultured on Buffered Charcoal Yeast Extract (BCYE) agar; however, their viability was confirmed through their ATP activity and ability to infect amoeba hosts. Subsequently, an assessment of the ISO11731:2017-05 pre-treatment procedure demonstrated that acid or heat treatment cause underestimation of alive Legionella population. Our results showed that these pre-treatment procedures induce culturable cells to enter a VBNC state. This may explain the observed insensitivity and lack of reproducibility often observed with the Legionella culture method. This study represents the first time that flow cytometry-cell sorting in conjunction with a qPCR assay has been used as a rapid and direct method to quantify VBNC Legionella from environmental sources. This will significantly improve future research evaluating Legionella risk management approaches for the control of Legionnaires' disease.
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Affiliation(s)
- Muhammad Atif Nisar
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Kirstin E. Ross
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Melissa H. Brown
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Richard Bentham
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | - Giles Best
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia,Flow Cytometry Facility, Flinders University, Bedford Park, SA, Australia
| | - Harriet Whiley
- College of Science and Engineering, Flinders University, Bedford Park, SA, Australia,*Correspondence: Harriet Whiley, ✉
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Huang PH, Huang YT, Lee PH, Tseng CH, Liu PY, Liu CW. Diagnosis of Legionnaires' Disease Assisted by Next-Generation Sequencing in a Patient with COVID-19. Infect Drug Resist 2023; 16:355-362. [PMID: 36714349 PMCID: PMC9880021 DOI: 10.2147/idr.s396254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
Coinfection in COVID-19 patients is associated with worsening outcome. Among patients with COVID-19, Legionella pneumophila, a common cause of pneumonia, has been reported as a co-occurring respiratory infection. A nonspecific clinical presentation, however, makes an early diagnosis difficult. Bronchoalveolar lavage fluid was collected from a patient suffering from COVID-19 and presenting with pneumonia and sent for metagenomic analysis. Differential abundance analysis was carried out by comparing each taxon reads per million between the bronchoalveolar lavage fluid sample and the negative control. Two replicates of metagenomic sequencing were conducted on bronchoalveolar lavage fluid samples. Within each replicated sequencing, one negative control was sequenced for comparison of taxon abundance in the BALF sample. In both replicates, Legionella pneumophila was the only taxon with significantly higher abundance when compared with the negative control. PCR of the bronchoalveolar further confirmed the presence of L. pneumophila. Several studies have estimated that the incidence of Legionnaires' disease co-infection in patients with COVID-19 infection is approximately 0% to 1.5%. There are some common characteristics of COVID-19 and co-infection with Legionnaires' disease, making it difficult to diagnose bacterial infection early. The diagnosis of these cases is important due to the different treatments used. Current diagnostic tests for Legionnaires' disease include conventional culture, urinary antigen for L. pneumophila serogroup 1, polymerase chain reaction, direct fluorescent antibody stain, and paired serology. The current study demonstrated that metagenomics is a promising approach that facilitated the diagnosis of Legionnaires' disease.
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Affiliation(s)
- Po-Hsiu Huang
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yao-Ting Huang
- Department of Computer Science and Information Engineering, National Chung Cheng University, Chia-Yi, Taiwan
| | - Po-Hsin Lee
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chien-Hao Tseng
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yu Liu
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan,Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Correspondence: Po-Yu Liu; Chia-Wei Liu, Tel +886 4 2359 2525, Fax +886 4 2359 2525 2111, Email ;
| | - Chia-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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27
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Cipolla L, Rocca F, Armitano R, López B, Prieto M. [Legionnaires' disease in Argentina: Evolution of the laboratory diagnostic strategy]. Rev Argent Microbiol 2023:S0325-7541(22)00103-1. [PMID: 36604301 DOI: 10.1016/j.ram.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/16/2022] [Accepted: 10/18/2022] [Indexed: 01/04/2023] Open
Abstract
Legionnaires' disease (LD) is severe acute pneumonia that occurs in sporadic or epidemic form, and generally requires hospitalization. The objective of this work was to describe the experience in the LD laboratory diagnostic approach in Argentina during the period 2016-2021. The laboratory analyzed 168 clinical specimens from 93 cases of suspected LD pneumonia. Laboratory tests included the detection of the soluble antigen of Legionella pneumophila serogroup 1 in urine sample, detection of DNA of Legionella spp. in lower respiratory secretions by conventional and commercial molecular methods and isolation in selective medium. LD was confirmed in 12 patients. The urinary antigen allowed the diagnosis for 8 patients. L. pneumophila was isolated from the respiratory material of 6 patients suffering from health care-associated pneumonia, who had been previously diagnosed using the commercial molecular method. Fifty percent of these cases did not show detectable urinary antigen. A single patient did not shows neither detectable antigenuria nor isolation of Legionella from the respiratory sample and was diagnosed as a confirmed case of LD by the detection of DNA of Legionella spp. by PCR directly from the respiratory secretion and the epidemiological link with another case of confirmed LD by culture. Urinary antigen detection is the first-line diagnostic test. However, the incorporation of complementary molecular methods has proved to avoid false negatives and contributed to a better understanding of the true incidence of the disease.
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Affiliation(s)
- Lucía Cipolla
- Instituto Nacional de Enfermedades Infecciosas, ANLIS Dr. Carlos Malbrán, Ciudad Autónoma de Buenos Aires, Argentina
| | - Florencia Rocca
- Instituto Nacional de Enfermedades Infecciosas, ANLIS Dr. Carlos Malbrán, Ciudad Autónoma de Buenos Aires, Argentina
| | - Rita Armitano
- Instituto Nacional de Enfermedades Infecciosas, ANLIS Dr. Carlos Malbrán, Ciudad Autónoma de Buenos Aires, Argentina
| | - Beatriz López
- Instituto Nacional de Enfermedades Infecciosas, ANLIS Dr. Carlos Malbrán, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mónica Prieto
- Instituto Nacional de Enfermedades Infecciosas, ANLIS Dr. Carlos Malbrán, Ciudad Autónoma de Buenos Aires, Argentina.
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Czerwiński M, Księżak E, Piekarska K. Legionellosis in Poland in 2018-2021. Przegl Epidemiol 2023; 77:241-250. [PMID: 37861069 DOI: 10.32394/pe.77.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Objectives The aim of this study is to compare the epidemiological situation of legionellosis in Poland in 2018-2021 to prior years, taking into account the impact of the COVID-19 pandemic in 2020-2021. Material and methods The assessment is based on national surveillance data published in the annual bulletin "Infectious Diseases and Poisons in Poland" from 2013 to 2021, as well as data from Legionnaires' disease case reports collected and sent to the Department of Epidemiology of Infectious Diseases and Surveillance NIPH NIH - NRI by sanitary and epidemiological stations or submitted to EpiBase. Results In Poland, both Legionnaires' disease (an acute infection that progresses to pneumonia) and Pontiac fever (a mild, flu-like sickness) are reported. In 2018-2021, a total of 255 cases of legionellosis were registered, including 236 cases of Legionnaires' disease and 19 cases of Pontiac fever. Each year, there was an increase in the number of notifications compared to the annual median number of cases from 2013-2017. The annual incidence rate in 2019 (0.23 per 100,000 population) was the highest since the start of legionellosis case registration in Poland. It declined again during the years of the COVID-19 pandemic. The notifications occurred throughout the country, but the highest notification rate was observed in the western belt of voivodeships. Pomorskie reported the highest incidence, accounting for more than 20% of all registered cases. The median incidence of Legionnaires' disease in men (0.23 per 100,000) was more than twice that of women (0.10), with the highest incidence (0.58) recorded in men 65 years of age or older. All indigenous cases of Legionnaires' disease were sporadic; all but three patients were hospitalized. State Sanitary Inspection reported 26 fatal cases of Legionnaires' disease (mortality = 11%). Twenty-four cases were linked to contaminated water systems in health-care settings, and 21 cases were likely associated with travel abroad. Summary and conclusions Although the number of notifications has increased in recent years, Legionnaires' disease is still an infrequently diagnosed respiratory infection in Poland, and the reported incidence remains one of the lowest in the entire EU. The most affected demographic group is men aged 65 and older. Improving the early diagnosis of Legionnaires' disease in healthcare settings remains a priority.
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Affiliation(s)
- Michał Czerwiński
- National Institute of Public Health NIH - National Research Institute, Department of Epidemiology of Infectious Diseases and Surveillance
| | - Ewelina Księżak
- National Institute of Public Health NIH - National Research Institute, Department of Epidemiology of Infectious Diseases and Surveillance
| | - Katarzyna Piekarska
- National Institute of Public Health NIH - National Research Institute, Department of Bacteriology and Biocontamination Control
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Nakanishi N, Komatsu S, Tanaka S, Mukai K, Nomoto R. Investigation of a Legionella pneumophila Outbreak at a Bath Facility in Japan Using Whole-Genome Sequencing of Isolates from Clinical and Environmental Samples. Microorganisms 2022; 11:28. [PMID: 36677320 DOI: 10.3390/microorganisms11010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/14/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Exposure to aerosols containing Legionella from artificially made water systems has been established as a primary cause of Legionnaires' disease. In this study, we investigated an outbreak of L. pneumophila serogroup 1 sequence type 138 which occurred at a bath facility in 2022. The whole-genome sequencing of isolates revealed that the colonization of L. pneumophila at the bath facility had occurred before 2013, and the patients had been exposed to multiple genetic lineages of the strain. Our study demonstrates the importance of performing a careful comparative genetic analysis of clinical and environmental isolates from LD outbreaks in order to effectively investigate and prevent future LD outbreaks.
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Ortí-Lucas RM, Luciano E. New immunomagnetic separation method to analyze risk factors for Legionella colonization in health care centres. J Expo Sci Environ Epidemiol 2022; 32:744-750. [PMID: 35264765 PMCID: PMC8906530 DOI: 10.1038/s41370-022-00421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND It's pivotal to control the presence of legionella in sanitary structures. So, it's important to determine the risk factors associated with Legionella colonization in health care centres. In recent years that is why new diagnostic techniques have been developed. OBJECTIVE To evaluate risks factors for Legionella colonization using a novel and more sensitive Legionella positivity index. METHODS A total of 204 one-litre water samples (102 cold water samples and 102 hot water samples), were collected from 68 different sampling sites of the hospital water system and tested for Legionella spp. by two laboratories using culture, polymerase chain reaction and a method based on immunomagnetic separation (IMS). A Legionella positivity index was defined to evaluate Legionella colonization and associated risk factors in the 68 water samples sites. We performed bivariate analyses and then logistic regression analysis with adjustment of potentially confounding variables. We compared the performance of culture and IMS methods using this index as a new gold standard to determine if rapid IMS method is an acceptable alternative to the use of slower culture method. RESULTS Based on the new Legionella positivity index, no statistically significant differences were found neither between laboratories nor between methods (culture, IMS). Positivity was significantly correlated with ambulatory health assistance (p = 0.05) and frequency of use of the terminal points. The logistic regression model revealed that chlorine (p = 0.009) and the frequency of use of the terminal points (p = 0.001) are predictors of Legionella colonization. Regarding this index, the IMS method proved more sensitive (69%) than culture method (65.4%) in hot water samples. SIGNIFICANCE We showed that the frequency of use of terminal points should be considered when examining environmental Legionella colonization, which can be better evaluated using the provided Legionella positivity index. This study has implications for the prevention of Legionnaires' disease in hospital settings.
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Affiliation(s)
- Rafael Manuel Ortí-Lucas
- Research group on Public Health and Patient Safety, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain.
- Department of Preventive Medicine, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - Eugenio Luciano
- Department of Preventive Medicine, Hospital Clínico Universitario de Valencia, Valencia, Spain.
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain.
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Gamage SD, Jinadatha C, Coppin JD, Kralovic SM, Bender A, Ambrose M, Decker BK, DeVries AS, Goto M, Kowalskyj O, Maistros AL, Rizzo V, Simbartl LA, Watson RJ, Roselle GA. Factors That Affect Legionella Positivity in Healthcare Building Water Systems from a Large, National Environmental Surveillance Initiative. Environ Sci Technol 2022; 56:11363-11373. [PMID: 35929739 DOI: 10.1021/acs.est.2c02194] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Legionella growth in healthcare building water systems can result in legionellosis, making water management programs (WMPs) important for patient safety. However, knowledge is limited on Legionella prevalence in healthcare buildings. A dataset of quarterly water testing in Veterans Health Administration (VHA) healthcare buildings was used to examine national environmental Legionella prevalence from 2015 to 2018. Bayesian hierarchical logistic regression modeling assessed factors influencing Legionella positivity. The master dataset included 201,146 water samples from 814 buildings at 168 VHA campuses. Overall Legionella positivity over the 4 years decreased from 7.2 to 5.1%, with the odds of a Legionella-positive sample being 0.94 (0.90-0.97) times the odds of a positive sample in the previous quarter for the 16 quarters of the 4 year period. Positivity varied considerably more at the medical center campus level compared to regional levels or to the building level where controls are typically applied. We found higher odds of Legionella detection in older buildings (OR 0.92 [0.86-0.98] for each more recent decade of construction), in taller buildings (OR 1.20 [1.13-1.27] for each additional floor), in hot water samples (O.R. 1.21 [1.16-1.27]), and in samples with lower residual biocide concentrations. This comprehensive healthcare building review showed reduced Legionella detection in the VHA healthcare system over time. Insights into factors associated with Legionella positivity provide information for healthcare systems implementing WMPs and for organizations setting standards and regulations.
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Affiliation(s)
- Shantini D Gamage
- National Infectious Diseases Service, Specialty Care Program Office, Veterans Health Administration, Department of Veterans Affairs (VA), Washington, D.C. 20571, United States
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, United States
| | - Chetan Jinadatha
- Department of Medicine, Central Texas Veterans Health Care System, Temple, Texas 76504, United States
- College of Medicine, Texas A&M University, Bryan, Texas 77807, United States
| | - John D Coppin
- Department of Research, Central Texas Veterans Health Care System, Temple, Texas 76504, United States
| | - Stephen M Kralovic
- National Infectious Diseases Service, Specialty Care Program Office, Veterans Health Administration, Department of Veterans Affairs (VA), Washington, D.C. 20571, United States
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, United States
- Cincinnati VA Medical Center, Cincinnati, Ohio 45220, United States
| | - Alan Bender
- Booz Allen Hamilton, McLean, Virginia 22102, United States
| | - Meredith Ambrose
- National Infectious Diseases Service, Specialty Care Program Office, Veterans Health Administration, Department of Veterans Affairs (VA), Washington, D.C. 20571, United States
| | - Brooke K Decker
- Division of Infectious Diseases, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15240, United States
| | - Aaron S DeVries
- Minneapolis VA Healthcare System, Minneapolis, Minnesota 55417, United States
| | - Michihiko Goto
- Iowa City VA Health Care System, Iowa City, Iowa 52246, United States
- University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, United States
| | - Oleh Kowalskyj
- Office of Healthcare Engineering, Healthcare Environment and Facilities Program, Veterans Health Administration, VA, Washington, D.C. 20571, United States
| | - Angela L Maistros
- VA Capitol Health Care Network, Veterans Integrated Service Network (VISN) 5, Linthicum, Maryland 21090, United States
| | - Vincent Rizzo
- Office of Healthcare Engineering, Healthcare Environment and Facilities Program, Veterans Health Administration, VA, Washington, D.C. 20571, United States
| | - Loretta A Simbartl
- National Infectious Diseases Service, Specialty Care Program Office, Veterans Health Administration, Department of Veterans Affairs (VA), Washington, D.C. 20571, United States
| | - Richard J Watson
- Occupational Health and Safety Program Office, Veterans Health Administration, VA, Washington, D.C. 20571, United States
| | - Gary A Roselle
- National Infectious Diseases Service, Specialty Care Program Office, Veterans Health Administration, Department of Veterans Affairs (VA), Washington, D.C. 20571, United States
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, United States
- Cincinnati VA Medical Center, Cincinnati, Ohio 45220, United States
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Lynch VD, Shaman J. The effect of seasonal and extreme floods on hospitalizations for Legionnaires' disease in the United States, 2000-2011. BMC Infect Dis 2022; 22:550. [PMID: 35705915 PMCID: PMC9202215 DOI: 10.1186/s12879-022-07489-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An increasing severity of extreme storms and more intense seasonal flooding are projected consequences of climate change in the United States. In addition to the immediate destruction caused by storm surges and catastrophic flooding, these events may also increase the risk of infectious disease transmission. We aimed to determine the association between extreme and seasonal floods and hospitalizations for Legionnaires' disease in 25 US states during 2000-2011. METHODS We used a nonparametric bootstrap approach to examine the association between Legionnaires' disease hospitalizations and extreme floods, defined by multiple hydrometeorological variables. We also assessed the effect of extreme flooding associated with named cyclonic storms on hospitalizations in a generalized linear mixed model (GLMM) framework. To quantify the effect of seasonal floods, we used multi-model inference to identify the most highly weighted flood-indicator variables and evaluated their effects on hospitalizations in a GLMM. RESULTS We found a 32% increase in monthly hospitalizations at sites that experienced cyclonic storms, compared to sites in months without storms. Hospitalizations in months with extreme precipitation were in the 89th percentile of the bootstrapped distribution of monthly hospitalizations. Soil moisture and precipitation were the most highly weighted variables identified by multi-model inference and were included in the final model. A 1-standard deviation (SD) increase in average monthly soil moisture was associated with a 49% increase in hospitalizations; in the same model, a 1-SD increase in precipitation was associated with a 26% increase in hospitalizations. CONCLUSIONS This analysis is the first to examine the effects of flooding on hospitalizations for Legionnaires' disease in the United States using a range of flood-indicator variables and flood definitions. We found evidence that extreme and seasonal flooding is associated with increased hospitalizations; further research is required to mechanistically establish whether floodwaters contaminated with Legionella bacteria drive transmission.
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Affiliation(s)
- Victoria D Lynch
- Department of Environmental Health Sciences, Columbia Mailman School of Public Health, Columbia University, 722 W. 168th St, New York, NY, 10032, USA.
| | - Jeffrey Shaman
- Department of Environmental Health Sciences, Columbia Mailman School of Public Health, Columbia University, 722 W. 168th St, New York, NY, 10032, USA
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Rakić A, Vukić Lušić D, Jurčev Savičević A. Influence of Metal Concentration and Plumbing Materials on Legionella Contamination. Microorganisms 2022; 10:1051. [PMID: 35630493 PMCID: PMC9147233 DOI: 10.3390/microorganisms10051051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 12/07/2022] Open
Abstract
Legionella colonization of water supply pipes is a significant public health problem. The objective of this work was to evaluate Legionella colonization in hotel hot water systems and to investigate the relationship between metal concentrations, piping materials (galvanized iron pipes and plastic pipes), and Legionella proliferation. Concentrations of calcium and magnesium ions and the presence of Legionella pneumophila were determined in a total of 108 water samples from the hot water systems of four hotels in Split-Dalmatia County over a 12-month period, and additional data on piping materials were collected. L. pneumophila was isolated in 23.1% of all samples-in 28.8% (15/52) of water samples from galvanized iron pipes and in 17.8% (10/56) of samples from plastic pipes. L. pneumophila serogroups 2-14 were isolated from all samples. This study found higher prevalence of L. pneumophila at higher concentrations of Ca and Mg ions (except for Mg and plastic pipes). The metal parts of the water supply may be important factors in Legionella contamination due to the possibility of lime scale or roughness of the pipes. Higher Ca and Mg ion concentrations increased the risk of Legionella colonization.
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Affiliation(s)
- Anita Rakić
- Public Health Institute of Split-Dalmatia County, Vukovarska 46, 21000 Split, Croatia;
| | - Darija Vukić Lušić
- Department of Environmental Health, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
- Department of Environmental Health, Teaching Institute of Public Health of Primorje-Gorski Kotar County, Krešimirova 52a, 51000 Rijeka, Croatia
- Center for Advanced Computing and Modeling, University of Rijeka, Radmile Matejčić 2, 51000 Rijeka, Croatia
| | - Anamarija Jurčev Savičević
- Public Health Institute of Split-Dalmatia County, Vukovarska 46, 21000 Split, Croatia;
- Department of Health Studies, University of Split, 35 P.P. 464, Ruđera Boškovića Street, 21000 Split, Croatia
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Viasus D, Gaia V, Manzur-Barbur C, Carratalà J. Legionnaires' Disease: Update on Diagnosis and Treatment. Infect Dis Ther 2022. [PMID: 35505000 DOI: 10.1007/s40121-022-00635-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Legionellosis is the infection caused by bacteria of the genus Legionella, including a non-pneumonic influenza-like syndrome, and Legionnaires’ disease is a more serious illness characterized by pneumonia. Legionellosis is becoming increasingly important as a public health problem throughout the world; although it is an underreported disease, studies have consistently documented a high incidence. In addition, health costs associated with the disease are high. Diagnosis of Legionnaires’ disease is based mainly on the detection of Legionella pneumophila serogroup 1 antigen in urine. However, there have been advances in detection tests for patients with legionellosis. New methodologies show greater sensitivity and specificity, detect more species and serogroups of Legionella spp., and have the potential for use in epidemiological studies. Testing for Legionella spp. is recommended at hospital admission for severe community-acquired pneumonia, and antibiotics directed against Legionella spp. should be included early as empirical therapy. Inadequate or delayed antibiotic treatment in Legionella pneumonia has been associated with a worse prognosis. Either a fluoroquinolone (levofloxacin or moxifloxacin) or a macrolide (azithromycin preferred) is the recommended first-line therapy for Legionnaires’ disease; however, little information is available regarding adverse events or complications, or about the duration of antibiotic therapy and its association with clinical outcomes. Most published studies evaluating antibiotic treatment for Legionnaires’ disease are observational and consequently susceptible to bias and confounding. Well-designed studies are needed to assess the usefulness of diagnostic tests regarding clinical outcomes, as well as randomized trials comparing fluoroquinolones and macrolides or combination therapy that evaluate outcomes and adverse events.
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Doménech-Sánchez A, Laso E, Berrocal CI, Albertí S. Environmental surveillance of Legionella in tourist facilities of the Balearic Islands, Spain, 2006 to 2010 and 2015 to 2018. Euro Surveill 2022; 27:2100769. [PMID: 35621000 PMCID: PMC9137269 DOI: 10.2807/1560-7917.es.2022.27.21.2100769] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/20/2021] [Indexed: 06/15/2023] Open
Abstract
BackgroundLegionnaires' disease is a respiratory illness often associated with hotels and travel. Spain is a major tourist destination and one of the European countries with most cases of Legionnaires' disease , both community- and travel-associated. However, the prevalence of Legionella in tourist facilities is unknown.AimThe present investigation aimed to survey the tourist facilities in the Balearic Islands, Spain, for Legionella prevalence.MethodsWe visited tourist facilities in the Balearic Islands in two different periods (2006-2010 and 2015-2018) and took water samples following national and international guidelines. Legionella was investigated by culture methods following international standards (ISO 11731:1998).ResultsWe evaluated 13,472 samples from 465 facilities. Bacteria of the Legionella genus were detected in 65.4% of the surveyed facilities. Contamination of the facilities was significantly higher during the second decade (54.5 vs 78.6%). The most frequent colonisers were L. pneumophila serogroup 2-14. We detected the pathogen in 15.9% and 6.9% of hot and cold water distribution systems samples, respectively. The Legionella contamination rate in cold water systems samples was higher when free chlorine levels were < 0.2 mg/L and at > 25 °C temperatures, while in the hot water systems samples, the contamination rate was higher at < 50 °C. Of the samples from hot tubs, 10.9% were contaminated.ConclusionLegionella prevalence in hotels in the Balearic Islands was high but the contamination rates depended on the installations. Corrective measures are still needed to improve Legionella control.
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Affiliation(s)
- Antonio Doménech-Sánchez
- Saniconsult Ibérica SL, Palma de Mallorca, Spain
- Instituto Universitario de Investigación en Ciencias de la Salud (IUNICS), Universidad de las Islas Baleares, Palma de Mallorca, Spain
- Instituto de Investigación Sanitaria de les Illes Balears (IdIsBa), Palma de Mallorca, Spain
| | - Elena Laso
- Saniconsult Ibérica SL, Palma de Mallorca, Spain
| | | | - Sebastián Albertí
- Instituto Universitario de Investigación en Ciencias de la Salud (IUNICS), Universidad de las Islas Baleares, Palma de Mallorca, Spain
- Instituto de Investigación Sanitaria de les Illes Balears (IdIsBa), Palma de Mallorca, Spain
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Djordjevic Z, Folic M, Petrovic I, Zornic S, Stojkovic A, Miljanovic A, Randjelovic S, Jovanovic S, Jovanovic M, Jankovic S. An outbreak of Legionnaires' disease in newborns in Serbia. Paediatr Int Child Health 2022; 42:59-66. [PMID: 35944175 DOI: 10.1080/20469047.2022.2108672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Legionnaires' disease is an atypical pneumonia caused by inhaling small droplets of water containing the bacterium Legionella spp. In newborns, it is a rare event, usually associated with water births and the use of air conditioning systems or air humidifiers. A nosocomial outbreak of Legionnaires' disease in the maternity ward of a secondary-care hospital in Arandjelovac, Serbia is described.Two male newborns were found to be infected with Legionnella pneumophila. On Days 7 and 6 of life, respectively, they were transferred to a tertiary-care hospital with signs of severe pneumonia which was radiologically confirmed. L. pneumophila was detected in tracheal secretions from both infants by RT-PCR, and its antigens were also positive in urine samples. The source of infection in the secondary-care hospital was the internal hot water heating system, and the main contributory factor to the emergence of the infection was the low temperature of the hot water which did not kill the bacteria during the available exposure time.These two cases highlight the importance of being cautious about possible Legionnaires' disease in maternity wards with outdated or irregularly maintained internal water supply systems. The adoption of official guidelines for the control and regular maintenance of water supply systems, including the multidisciplinary cooperation of all relevant parties, forms the basis for direct monitoring for Legionella and the prevention of new outbreaks.Abbreviations: BCYE: buffered charcoal yeast extract agar; GVPC: glycine vancomycin polymyxin cycloheximide agar; LD - Legionnaires' disease; TR-PCR: Reverse transcription polymerase chain reaction.
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Affiliation(s)
- Zorana Djordjevic
- Department of Hospital Infection Control, University Clinical Centre Kragujevac, Kragujevac, Serbia
| | - Marko Folic
- Department of Clinical Pharmacology, University Clinical Centre of Kragujevac and Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Ivana Petrovic
- Department of Clinical Microbiology, University of Kragujevac Clinical Centre, Kragujevac, Serbia
| | - Sanja Zornic
- Department of Clinical Microbiology, University of Kragujevac Clinical Centre, Kragujevac, Serbia
| | - Andjelka Stojkovic
- Institute of Public Health Kragujevac, Centre for Disease Control and Prevention, Kragujevac, Serbia
| | - Ana Miljanovic
- Paediatric Clinic, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Sladjana Randjelovic
- Human Ecology and Ecotoxicology Laboratory, City Institute for Public Health Belgrade, Belgrade, Serbia
| | - Snezana Jovanovic
- Department of Medical Microbiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Milica Jovanovic
- Department of Medical Microbiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Slobodan Jankovic
- Department of Clinical Pharmacology, University Clinical Centre of Kragujevac and Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Delaney S, Arcari T, O'Connor O. Legionella water testing and the EU Drinking Water Directive: could potentially harmful Legionella bacteria slip through the gaps? Biotechniques 2022; 72:229-231. [PMID: 35469440 DOI: 10.2144/btn-2022-0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Sarah Delaney
- BioProbe Diagnostics, Room 218, Business Innovation Centre, Newcastle Road, NUI Galway, H91 NV29, Ireland
| | - Talia Arcari
- BioProbe Diagnostics, Room 218, Business Innovation Centre, Newcastle Road, NUI Galway, H91 NV29, Ireland
| | - Orla O'Connor
- BioProbe Diagnostics, Room 218, Business Innovation Centre, Newcastle Road, NUI Galway, H91 NV29, Ireland
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Lancaster EC, Lee J. Potential environmental and health risk when returning to normal amidst COVID-19 vaccination. Curr Opin Environ Sci Health 2022; 26:100328. [PMID: 35155880 PMCID: PMC8817624 DOI: 10.1016/j.coesh.2022.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Due to the SARS-CoV-2 pandemic and restricted occupancy in work and school settings, there is a heightened risk for Legionella infection. An increase of stagnation in water pipe systems with limited water usage stimulates biofilm build-up, further facilitating Legionella proliferation. Individuals can inhale infected water aerosols and develop Legionellosis that can progress into mild flu-like symptoms or severe pneumonia. While SARS-CoV-2 vaccinations have been introduced globally, there is a concern for bacterial coinfections as individuals resume normal activities. Even with new SARS-CoV-2 variants circulating, Legionella persists as a public health threat as vulnerable communities' restrictions fluctuate. Proper water monitoring and management are critical while reopening communities. This article features Legionella characteristics and novel case reports amidst the pandemic. This article encourages greater awareness for building managers to minimize water stagnancy by disinfecting water distribution systems and promotes healthcare professionals to properly diagnose other illnesses during the ongoing pandemic to reduce morbidity and mortality.
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Affiliation(s)
- Emma C Lancaster
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Jiyoung Lee
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, Columbus, OH, USA
- Department of Food Science & Technology, The Ohio State University, Columbus, OH, USA
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Abstract
Reported Legionnaires' disease (LD) cases began increasing in the United States in 2003 after relatively stable numbers for >10 years; reasons for the rise are unclear. We compared epidemiologic patterns associated with cases reported to the Centers for Disease Control and Prevention before and during the rise. The age-standardized average incidence was 0.48 cases/100,000 population during 1992-2002 compared with 2.71 cases/100,000 in 2018. Reported LD incidence increased in nearly every demographic, but increases tended to be larger in demographic groups with higher incidence. During both periods, the largest number of cases occurred among White persons, but the highest incidence was in Black or African American persons. Incidence and increases in incidence were generally largest in the East North Central, Middle Atlantic, and New England divisions. Seasonality was more pronounced during 2003-2018, especially in the Northeast and Midwest. Rising incidence was most notably associated with increasing racial disparities, geographic focus, and seasonality.
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40
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Riccò M, Ferraro P, Peruzzi S, Zaniboni A, Ranzieri S. SARS-CoV-2-Legionella Co-Infections: A Systematic Review and Meta-Analysis (2020-2021). Microorganisms 2022; 10:499. [PMID: 35336074 PMCID: PMC8951730 DOI: 10.3390/microorganisms10030499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
Legionnaires' Disease (LD) is a severe, sometimes fatal interstitial pneumonia due to Legionella pneumophila. Since the inception of the SARS-CoV-2 pandemic, some contradictory reports about the effects of lockdown measures on its epidemiology have been published, but no summary evidence has been collected to date. Therefore, we searched two different databases (PubMed and EMBASE) focusing on studies that reported the occurrence of LD among SARS-CoV-2 cases. Data were extracted using a standardized assessment form, and the results of such analyses were systematically reported, summarized, and compared. We identified a total of 38 articles, including 27 observational studies (either prospective or retrospective ones), 10 case reports, and 1 case series. Overall, data on 10,936 SARS-CoV-2 cases were included in the analyses. Of them, 5035 (46.0%) were tested for Legionella either through urinary antigen test or PCR, with 18 positive cases (0.4%). A pooled prevalence of 0.288% (95% Confidence Interval (95% CI) 0.129-0.641), was eventually calculated. Moreover, detailed data on 19 co-infections LD + SARS-CoV-2 were obtained (males: 84.2%; mean age: 61.9 years, range 35 to 83; 78.9% with 1 or more underlying comorbidities), including 16 (84.2%) admissions to the ICU, with a Case Fatality Ratio of 26.3%. In summary, our analyses suggest that the occurrence of SARS-CoV-2-Legionella infections may represent a relatively rare but not irrelevant event, and incident cases are characterized by a dismal prognosis.
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Affiliation(s)
- Matteo Riccò
- AUSL–IRCCS di Reggio Emilia, Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), Local Health Unit of Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Pietro Ferraro
- Servizio di Medicina del Lavoro, ASL di Foggia, 71121 Foggia, Italy;
| | - Simona Peruzzi
- AUSL–IRCCS di Reggio Emilia, Laboratorio Analisi Chimico Cliniche e Microbiologiche, Ospedale Civile di Guastalla, 42016 Guastalla, Italy;
| | - Alessandro Zaniboni
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.Z.); (S.R.)
| | - Silvia Ranzieri
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.Z.); (S.R.)
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Uldum SA, Schjoldager LG, Baig S, Cassell K. A Tale of Four Danish Cities: Legionella pneumophila Diversity in Domestic Hot Water and Spatial Variations in Disease Incidence. Int J Environ Res Public Health 2022; 19:2530. [PMID: 35270223 DOI: 10.3390/ijerph19052530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023]
Abstract
Denmark has one of the highest Legionnaires' disease notification rates within Europe, averaging 4.7 cases per 100,000 population annually (2017 to 2020). The relatively high incidence of disease is not uniform across the country, and approximately 70% of all domestically acquired cases in Denmark are caused by Legionella pneumophila (LP) strains that are considered less virulent. The aim of this study was to investigate if colonization rates, levels of colonization, and/or types of LP present in hot water systems were associated with geographic differences in Legionnaires' disease incidence. Domestic water systems from four cities in Denmark were analyzed via culture and qPCR. Serogrouping and sequence typing was performed on randomly selected isolates. Single nucleotide polymorphism was used to identify clonal relationship among isolates from the four cities. The results revealed a high LP colonization rate from 68% to 87.5% among systems, composed primarily of non-serogroup 1. LP serogroup 1 reacting with the monoclonal antibody (MAb) 3/1 was not identified in any of the systems tested, while MAb 3/1 negative serogroup 1 strains were isolated from 10 systems (9.6%). We hypothesize that a combination of factors influences the incidence rate of LD in each city, including sequence type and serogroup distribution, colonization rate, concentration of Legionella in Pre-flush and Flush samples, and potentially building characteristics such as water temperature measured at the point of use.
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Graham FF, Finn N, White P, Hales S, Baker MG. Global Perspective of Legionella Infection in Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Observational Studies. Int J Environ Res Public Health 2022; 19:1907. [PMID: 35162928 DOI: 10.3390/ijerph19031907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/11/2021] [Accepted: 01/20/2022] [Indexed: 01/27/2023]
Abstract
Legionnaires’ disease (LD) (Legionella) is a common cause of community-acquired pneumonia (CAP) in those requiring hospitalization. Geographical variation in the importance of Legionella species as an aetiologic agent of CAP is poorly understood. We performed a systematic review and meta-analysis of population-based observational studies that reported the proportion of Legionella infection in patients with CAP (1 January 1990 to 31 May 2020). Using five electronic databases, articles were identified, appraised and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality of the included studies was assessed using the Newcastle–Ottawa Scale. Univariate and multivariate meta-regression analyses were conducted using study design, WHO region, study quality and healthcare setting as the explanatory variables. We reviewed 2778 studies, of which 219 were included in the meta-analysis. The mean incidence of CAP was 46.7/100,000 population (95% CI: 46.6–46.8). The mean proportion of Legionella as the causative agent for CAP was 4.6% (95% CI: 4.4 to 4.7). Consequently, the mean Legionella incidence rate was 2.8/100,000 population (95% CI: 2.7–2.9). There was significant heterogeneity across all studies I2 = 99.27% (p < 0.0001). After outliers were removed, there was a decrease in the heterogeneity (I2 = 43.53%). Legionella contribution to CAP has a global distribution. Although the rates appear highest in high income countries in temperate regions, there are insufficient studies from low- and middle-income countries to draw conclusions about the rates in these regions. Nevertheless, this study provides an estimate of the mean incidence of Legionella infection in CAP, which could be used to estimate the regional and global burden of LD to support efforts to reduce the impact of this infection as well as to fill important knowledge gaps.
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James AE, Kesteloot K, Paul JT, McMullen RL, Louie S, Waters C, Dillaha J, Tumlison J, Haselow DT, Smith JC, Lee S, Ritter T, Lucas C, Kunz J, Miller LA, Said M. Potential Association of Legionnaires' Disease with Hot Spring Water, Hot Springs National Park and Hot Springs, Arkansas, USA, 2018-2019. Emerg Infect Dis 2022; 28:44-50. [PMID: 34932451 PMCID: PMC8714197 DOI: 10.3201/eid2801.211090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Legionella pneumophila is the cause of Legionnaires' disease, a life-threatening pneumonia that occurs after inhalation of aerosolized water containing the bacteria. Legionella growth occurs in stagnant, warm-to-hot water (77°F-113°F) that is inadequately disinfected. Piped hot spring water in Hot Springs National Park, Arkansas, USA, has naturally high temperatures (>135°F) that prevent Legionella growth, and Legionnaires' disease has not previously been associated with the park or other hot springs in the United States. During 2018-2019, Legionnaires' disease occurred in 5 persons after they visited the park; 3 of these persons were potentially exposed in spa facilities that used untreated hot spring water. Environmental testing revealed Legionella bacteria in piped spring water, including 134°F stagnant pipe water. These findings underscore the importance of water management programs to reduce Legionella growth in plumbing through control activities such as maintaining hot water temperatures, reducing stored water age, and ensuring adequate water flow.
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Caldas JP, Silva-Pinto A, Faustino AS, Figueiredo P, Sarmento A, Santos L. Septic shock due to co-infection with Legionella pneumophila and Saprochaete clavata. IDCases 2021; 27:e01369. [PMID: 35024339 PMCID: PMC8724953 DOI: 10.1016/j.idcr.2021.e01369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/18/2021] [Accepted: 12/18/2021] [Indexed: 11/23/2022] Open
Abstract
Septic shock is the most dreaded presentation of an infection, carrying a reserved prognosis. Appropriate antimicrobial therapy is therefore the mainstay of treatment, alongside organ support as needed. Legionnaires' disease is mainly due to Legionella pneumophila serogroup 1 but it can be caused by other serogroups and species not detected by the urinary antigen test. Anti-tumour necrosis factor α therapy may increase the risk of invasive fungal infection, which carry a poor prognosis. We present a challenging case of a septic shock due to Legionella pneumophila and Saprochaete clavata infections, with a review of the two infections presented.
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Affiliation(s)
- João Paulo Caldas
- Infectious Diseases Department of Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - André Silva-Pinto
- Infectious Diseases Department of Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - Ana Sofia Faustino
- Infectious Diseases Department of Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - Paulo Figueiredo
- Infectious Diseases Department of Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - António Sarmento
- Infectious Diseases Department of Centro Hospitalar Universitário de São João, Oporto, Portugal
| | - Lurdes Santos
- Infectious Diseases Department of Centro Hospitalar Universitário de São João, Oporto, Portugal
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Gleason JA, Cohn PD. A review of legionnaires' disease and public water systems - Scientific considerations, uncertainties and recommendations. Int J Hyg Environ Health 2021; 240:113906. [PMID: 34923288 DOI: 10.1016/j.ijheh.2021.113906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
Legionella is an opportunistic premise plumbing pathogen and causative agent of a severe pneumonia called Legionnaires' Disease (LD). Cases of LD have been on the rise in the U.S. and globally. Although Legionella was first identified 45 years ago, it remains an 'emerging pathogen." Legionella is part of the normal ecology of a public water system and is frequently detected in regulatory-compliant drinking water. Drinking water utilities, regulators and public health alike are increasingly required to have a productive understanding of the evolving issues and complex discussions of the contribution of the public water utility to Legionella exposure and LD risk. This review provides a brief overview of scientific considerations important for understanding this complex topic, a review of findings from investigations of public water and LD, including data gaps, and recommendations for professionals interested in investigating public water utilities. Although the current literature is inconclusive in identifying a public water utility as a sole source of an LD outbreak, the evidence is clear that minimizing growth of Legionella in public water utilities through proper maintenance and sustained disinfectant residuals, throughout all sections of the water utility, will lead to a less conducive environment for growth of the bacteria in the system and the buildings they serve.
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Affiliation(s)
- Jessie A Gleason
- Environmental and Occupational Health Surveillance Program, New Jersey Department of Health, 135 E. State Street, P.O. Box 369, Trenton, NJ, 08625, USA.
| | - Perry D Cohn
- Retired, Environmental and Occupational Health Surveillance Program, New Jersey Department of Health, PO Box 369, Trenton, NJ, 08625, USA.
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Karer M, Haider T, Kussmann M, Obermüller M, Tiehen C, Burgmann H, Lagler H, Traby L. Treatment of legionellosis including a single intravenous dose of 1.5 g azithromycin: 18-year experience at a tertiary care hospital. Int J Antimicrob Agents 2021; 59:106481. [PMID: 34801678 DOI: 10.1016/j.ijantimicag.2021.106481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 10/11/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Due to recent safety concerns regarding fluoroquinolones and the potential medical and economic benefits, we investigated the efficacy of a single intravenous dose of 1.5 g azithromycin for the treatment of pulmonary legionellosis. METHODS Using a nationwide legionellosis registry for pre-selection, 74 patients admitted from 2000-2018 to a tertiary care hospital owing to pneumonia caused by Legionella pneumophila were retrospectively included in this study. RESULTS Conventional treatment regimens consisting of fluoroquinolones (n = 20), macrolides (n = 30) or combinations of both (n = 24) and a single intravenous dose of azithromycin (n = 12) have been demonstrated to be equally effective. Single-dose azithromycin treatment was well tolerated and resulted in a shorter hospital stay (P = 0.0464) and shorter antibiotic treatment duration (P = 0.0004) allowing earlier discharge. CONCLUSION A single intravenous dose of azithromycin might be a valuable treatment alternative for patients with legionellosis.
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Affiliation(s)
- Matthias Karer
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; Department of Clinical Pharmacology, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Teresa Haider
- Department of Neurophysiology, Center for Brain Research, Medical University Vienna, Spitalgasse 4, 1090 Vienna, Austria
| | - Manuel Kussmann
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Markus Obermüller
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Claas Tiehen
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Heinz Burgmann
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Heimo Lagler
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Ludwig Traby
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Böck D, Hüsler D, Steiner B, Medeiros JM, Welin A, Radomska KA, Hardt WD, Pilhofer M, Hilbi H. The Polar Legionella Icm/Dot T4SS Establishes Distinct Contact Sites with the Pathogen Vacuole Membrane. mBio 2021; 12:e0218021. [PMID: 34634944 DOI: 10.1128/mBio.02180-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Legionella pneumophila, the causative agent of Legionnaires' disease, is a facultative intracellular pathogen that survives inside phagocytic host cells by establishing a protected replication niche, termed the "Legionella-containing vacuole" (LCV). To form an LCV and subvert pivotal host pathways, L. pneumophila employs a type IV secretion system (T4SS), which translocates more than 300 different effector proteins into the host cell. The L. pneumophila T4SS complex has been shown to span the bacterial cell envelope at the bacterial poles. However, the interactions between the T4SS and the LCV membrane are not understood. Using cryo-focused ion beam milling, cryo-electron tomography, and confocal laser scanning fluorescence microscopy, we show that up to half of the intravacuolar L. pneumophila bacteria tether their cell pole to the LCV membrane. Tethering coincides with the presence and function of T4SSs and likely promotes the establishment of distinct contact sites between T4SSs and the LCV membrane. Contact sites are characterized by indentations in the limiting LCV membrane and localize juxtaposed to T4SS machineries. The data are in agreement with the notion that effector translocation occurs by close membrane contact rather than by an extended pilus. Our findings provide novel insights into the interactions of the L. pneumophila T4SS with the LCV membrane in situ. IMPORTANCE Legionnaires' disease is a life-threatening pneumonia, which is characterized by high fever, coughing, shortness of breath, muscle pain, and headache. The disease is caused by the amoeba-resistant bacterium L. pneumophila found in various soil and aquatic environments and is transmitted to humans via the inhalation of small bacteria-containing droplets. An essential virulence factor of L. pneumophila is a so-called "type IV secretion system" (T4SS), which, by injecting a plethora of "effector proteins" into the host cell, determines pathogen-host interactions and the formation of a distinct intracellular compartment, the "Legionella-containing vacuole" (LCV). It is unknown how the T4SS makes contact to the LCV membrane to deliver the effectors. In this study, we identify indentations in the host cell membrane in close proximity to functional T4SSs localizing at the bacterial poles. Our work reveals first insights into the architecture of Legionella-LCV contact sites.
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Riccò M, Peruzzi S, Ranzieri S, Giuri PG. Epidemiology of Legionnaires' Disease in Italy, 2004-2019: A Summary of Available Evidence. Microorganisms 2021; 9:microorganisms9112180. [PMID: 34835307 PMCID: PMC8624895 DOI: 10.3390/microorganisms9112180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 01/11/2023] Open
Abstract
Legionnaires’ disease (LD) incidence has been increasing in several European countries since 2011. Currently, Italy is experiencing high notification rates for LD, whose cause still remains scarcely understood. We sought to summarize the available evidence on the epidemiology of LD in Italy (2004–2019), characterizing the risk of LD by region, sex, age group, and settings of the case (i.e., community, healthcare, or travel-associated cases). Environmental factors (e.g., average air temperatures and relative humidity) were also included in a Poisson regression model in order to assess their potential role on the annual incidence of new LD cases. National surveillance data included a total of 23,554 LD cases occurring between 2004 and 2019 (70.4% of them were of male gender, 94.1% were aged 40 years and older), with age-adjusted incidence rates increasing from 1.053 cases per 100,000 in 2004 to 4.559 per 100,000 in 2019. The majority of incident cases came from northern Italy (43.2% from northwestern Italy, 25.6% from northeastern Italy). Of these, 5.9% were healthcare-related, and 21.1% were travel-associated. A case-fatality ratio of 5.2% was calculated for the whole of the assessed timeframe, with a pooled estimate for mortality of 0.122 events per 100,000 population per year. Poisson regression analysis was associated with conflicting results, as any increase in average air temperature resulted in reduced risk for LD cases (Incidence Rate Ratio [IRR] 0.807, 95% Confidence Interval [95% CI] 0.744–0.874), while higher annual income in older individuals was associated with an increased IRR (1.238, 95% CI 1.134–1.351). The relative differences in incidence between Italian regions could not be explained by demographic factors (i.e., age and sex distribution of the population), and also a critical reappraisal of environmental factors failed to substantiate both the varying incidence across the country and the decennial trend we were able to identify.
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Affiliation(s)
- Matteo Riccò
- Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), AUSL—IRCCS di Reggio Emilia, Via Amendola n.2, I-42022 Reggio Emilia, Italy
- Correspondence: or ; Tel.: +39-3392-994-343 or +39-522-837-587
| | - Simona Peruzzi
- Laboratorio Analisi Chimico Cliniche e Microbiologiche, Ospedale Civile di Guastalla, AUSL—IRCCS di Reggio Emilia, I-42016 Guastalla, Italy;
| | - Silvia Ranzieri
- Department of Medicine and Surgery, School of Occupational Medicine, University of Parma, Via Gramsci n.14, I-43123 Parma, Italy;
| | - Pasquale Gianluca Giuri
- Dipartimento Internistico Interaziendale, Struttura Operativa Semplice Dipartimentale “Medicina Infettivologica”, AUSL—IRCCS di Reggio Emilia, Ospedale “Sant’Anna”, I-42035 Castelnovo ne’ Monti, Italy;
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Kamus L, Roquebert B, Allyn J, Allou N, Valance D, Simon C, Jaffar-Bandjee MC, Descours G, Jarraud S, Miltgen G. Severe bilateral pleuropneumonia caused by Legionella sainthelensi: a case report. BMC Infect Dis 2021; 21:966. [PMID: 34535079 DOI: 10.1186/s12879-021-06651-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Legionella spp. are ubiquitous freshwater bacteria responsible for rare but potentially severe cases of Legionnaires' disease (LD). Legionella sainthelensi is a non-pneumophila Legionella species that was first isolated in 1980 from water near Mt. St-Helens (USA). Although rare cases of LD caused by L. sainthelensi have been reported, very little data is available on this pathogen. CASE PRESENTATION We describe the first documented case of severe bilateral pleuropneumonia caused by L. sainthelensi. The patient was a 35-year-old woman with Sharp's syndrome treated with long-term hydroxychloroquine and corticosteroids who was hospitalized for an infectious illness in a university hospital in Reunion Island (France). The patient's clinical presentation was complicated at first (bilateral pneumonia, multiloculated pleural effusion, then bronchopleural fistula) but her clinical condition eventually improved with the reintroduction of macrolides (spiramycin) in intensive care unit. Etiological diagnosis was confirmed by PCR syndromic assay and culture on bronchoalveolar lavage. CONCLUSIONS To date, only 14 documented cases of L. sainthelensi infection have been described worldwide. This pathogen is difficult to identify because it is not or poorly detected by urinary antigen and molecular methods (like PCR syndromic assays that primarily target L. pneumophila and that have only recently been deployed in microbiology laboratories). Pneumonia caused by L. sainthelensi is likely underdiagnosed as a result. Clinicians should consider the possibility of non-pneumophila Legionella infection in patients with a compatible clinical presentation when microbiological diagnostic tools targeted L. pneumophila tested negative.
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