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Clinica e terapia (2020 - 2017)
[ultimo aggiornamento 25/11/2020]
Epileptic Seizure after
Use of Moxifloxacin in Man with Legionella
Wang JY, Li X, Chen JY, Tong
Department of Internal
Medicine, Jiangxi Provincial People’s Hospital Affiliated to Nanchang
University, Jiangxi, China; email@example.com
Emerg Infect Dis 2020
caused by Legionella longbeachae is
diagnosed mainly by PCR. We report a case of L. longbeachae infection in mainland China, which was diagnosed by
metagenomic next-generation sequencing, in a man who developed an epileptic
seizure after using moxifloxacin. Metagenomic next-generation sequencing may be
a useful tool to detect Legionella spp.
Antibiotic Resistance of Legionella
pneumophila in Clinical and Water Isolates-A Systematic Review
Chochlakis D, Sandalakis V, Dioli C, Psaroulaki A, Mavridou A.
Department of Biomedical Sciences, University of West Attica,
12243 Egaleo, Greece. firstname.lastname@example.org
Environ Res Public Health 2020 Aug 11;17(16):5809.
current systematic review investigates the antibiotic susceptibility pattern of Legionella
pneumophila isolates from the 1980s to the present day, deriving data
from clinical and/or water samples from studies carried out all over the world.
Eighty-nine papers meeting the inclusion criteria, i.e., "Legionella
pneumophila" and "resistance to antibiotics", were evaluated
according to pre-defined validity criteria. Sixty articles referred to clinical
isolates, and 18 articles reported water-related L. pneumophila isolates,
while 11 articles included both clinical and water isolates. Several methods
have been proposed as suitable for the determination of MICs, such as the E-test,
broth and agar dilution, and disk diffusion methods, in vivo and in vitro, using
various media. The E-test method proposed by the European Society of Clinical
Microbiology and Infectious Diseases (EUCAST) seems to be the second most
frequently used method overall, but it is the preferred method in the most
recent publications (2000-2019) for the interpretation criteria. Erythromycin
has been proved to be the preference for resistance testing over the years.
However, in the last 19 years, the antibiotics ciprofloxacin (CIP), erythromycin
(ERM), levofloxacin (LEV) and azithromycin (AZM) were the ones that saw an
increase in their use. A decrease in the sensitivity to antibiotics was
identified in approximately half of the reviewed articles.
Efficacy of delafloxacin
versus moxifloxacin against atypical bacterial respiratory pathogens in adults
with community-acquired bacterial pneumonia (CABP): Data from the Delafloxacin
Phase 3 CABP Trial
Nenninger A, Sheets A, Keedy K, Lawrence L, Quintas M, Cammarata S.
Melinta Therapeutics, Morristown, NJ, USA. email@example.com
Int J Infect Dis 2020
Abstract: Objectives: To report atypical
pathogens from clinical trial data comparing delafloxacin to moxifloxacin in the
treatment of adults with community-acquired bacterial pneumonia (CABP). Methods: Multiple diagnostic methods were employed to
diagnose atypical infections including culture, serology, and urinary antigen. Results: The
microbiological intent-to-treat (MITT) population included 520 patients; 30% had
an atypical bacterial pathogen identified (156/520). Overall, 13.1% (68/520) had
a monomicrobial atypical infection and 2.3% (12/520) had polymicrobial
all-atypical infections. Among patients with polymicrobial infections,
Streptococcus pneumoniae was the most frequently occurring co-infecting organism
and Chlamydia pneumoniae was the most frequently occurring co-infecting atypical
organism. For Mycoplasma pneumoniae and Legionella pneumophila, serology yielded
the highest number of diagnoses. Delafloxacin and moxifloxacin had similar in
vitro activity against M. pneumoniae and delafloxacin had greater activity
against L. pneumophila. Two macrolide-resistant M. pneumoniae isolates were
recovered. No fluoroquinolone-resistant M. pneumoniae were isolated. The rates
of microbiological success (documented or presumed eradication) at test-of-cure
were similar between the delafloxacin and moxifloxacin groups. There was no
evidence of a correlation between minimum inhibitory concentration (MIC) and
outcome; a high proportion of favorable outcomes was observed across all
delafloxacin baseline MICs. Conclusions: Delafloxacin
may be considered a treatment option as monotherapy for CABP in adults, where
broad-spectrum coverage including atypical activity is desirable.
Legionnaires' Disease in a Patient on Maintenance Hemodialysis
Kawashima A, Katagiri D, Kondo I, Sakamoto E,
Suzuki M, Arai Y, Sato F, Tada M, Hinoshita F.
Department of Nephrology, National Center for Global Health
and Medicine, Japan. firstname.lastname@example.org
Intern Med 2020 Aug
herein report a case of fulminant Legionnaires' disease with autopsy findings in
a patient on maintenance hemodialysis (HD). Chronic kidney disease is a strong
risk factor for Legionnaires' disease, although there have been only a few
reports in HD patients. Because most patients on HD are anuric, the use of rapid
assay kits to detect antigens in urine samples for the diagnosis of
Legionnaires' disease is not always feasible. We suggest the use of clinical
predictive tools or the loop-mediated isothermal amplification (LAMP) method,
which can be applied for anuric patients, such as those on HD, with pneumonia.
Legionella infections in allogeneic
hematopoietic cell transplantation recipients
Vaidya T, Schmidt E, Papanicolaou G, Hauser J, Lezcano C,
Tang YW, Markova A.
Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
Department of Dermatology, Weill Cornell Medical College, New York, NY. email@example.com
Dermatol Online J 2020
date, only twenty cases of cutaneous legionellosis have been reported. Cutaneous
legionellosis has heterogeneous manifestations including abscesses, nodules, and
cellulitis. The detection of most cutaneous Legionella species requires specific
diagnostic cultures and assays. Herein, we report a case of cutaneous legionella
in a hematopoietic cell transplantation recipient with culture-negative nodules
unresponsive to empiric antibiotics. We also discuss the varied morphology of
cutaneous legionellosis and important diagnostic considerations.
hemorrhage due to Legionella pneumophila serogroup 3
Khan SA, Haugh S.
Department of Hospital Medicine, Mayo Clinic Health System,
Mankato, MN, USA. Chowdhury.firstname.lastname@example.org
J Community Hosp Intern
Med Perspect 2020 Jun 14;10(3):262-264.
pneumophilia remains an important cause of
pneumonia that can cause substantial clinical morbidity and mortality. We
describe a case involving a 67-year-old woman with legionella pneumonia who
developed diffuse alveolar haemorrhage. We also highlight the pitfalls of
commonly used legionella urine antigen testing. Furthermore, we explore the role
of high-dose steroid therapy as a treatment option for patients with diffuse
alveolar haemorrhage secondary to legionella pneumonia who continue to
deteriorate in spite of adequate antimicrobial therapy.
Disease and Associated Antibiotic Treatment Engender a Highly Disturbed
Pulmonary Microbiome Enriched in Opportunistic Microorganisms
Pérez-Cobas AE, Ginevra
C, Rusniok C, Jarraud S, Buchrieser C.
Biologie des Bactéries Intracellulaires, Paris, France. email@example.com
mBio 2020 May
the importance of pneumonia to public health, little is known about the
composition of the lung microbiome during infectious diseases, such as pneumonia,
and how it evolves during antibiotic therapy. To study the possible relation of
the pulmonary microbiome to the severity and outcome of this respiratory disease,
we analyzed the dynamics of the pathogen and the human lung microbiome during
persistent infections caused by the bacterium Legionella pneumophila and
their evolution during antimicrobial treatment. We collected 10 bronchoalveolar
lavage fluid samples from three patients during long-term hospitalization due to
pneumonia and performed a unique longitudinal study of the interkingdom
microbiome, analyzing the samples for presence of bacteria, archaea, fungi, and
protozoa by high-throughput Illumina sequencing of marker genes. The lung
microbiome of the patients was characterized by a strong predominance of the
pathogen, a low diversity of the bacterial fraction, and an increased presence
of opportunistic microorganisms. The fungal fraction was more stable than the
bacterial fraction. During long-term treatment, no genomic changes or antibiotic
resistance-associated mutations that could explain the persistent infection
occurred, according to whole-genome sequencing analyses of the pathogen. After
antibiotic treatment, the microbiome did not recover rapidly but was mainly
constituted of antibiotic-resistant species and enriched in bacteria, archaea,
fungi, or protozoa associated with pathogenicity. The lung microbiome seems to
contribute to nonresolving Legionella pneumonia, as it is
strongly disturbed during infection and enriched in opportunistic and/or
antibiotic-resistant bacteria and microorganisms, including fungi, archaea, and
protozoa that are often associated with infections. IMPORTANCE: The composition and dynamics of the lung microbiome
during pneumonia are not known, although the lung microbiome might influence the
severity and outcome of this infectious disease, similar to what was shown for
the microbiome at other body sites. Here we report the findings of a
comprehensive analysis of the lung microbiome composition of three patients with
long-term pneumonia due to L. pneumophila and its evolution
during antibiotic treatment. This work adds to our understanding of how the
microbiome changes during disease and antibiotic treatment and points to
microorganisms and their interactions that might be beneficial. In addition to
bacteria and fungi, our analyses included archaea and eukaryotes (protozoa),
showing that both are present in the pulmonary microbiota and that they might
also play a role in the response to the microbiome disturbance.
In Vitro and
Intracellular Activities of Omadacycline against Legionella pneumophila
Dubois J, Dubois M,
M360 Inc., Sherbrooke, Québec, Canada. firstname.lastname@example.org
Chemother 2020 Apr 21;64(5):e01972-19.
is an aminomethylcycline antibiotic with in vitro activity
against pathogens causing community-acquired bacterial pneumonia (CABP). This
study investigated the activity of omadacycline against Legionella
pneumophila strains isolated between 1995 and 2014 from nosocomial or
community-acquired respiratory infections. Omadacycline exhibited extracellular
activity similar to comparator antibiotics; intracellular penetrance was found
by day 3 of omadacycline exposure. These results support the utility of
omadacycline as an effective antibiotic for the treatment of CABP caused by L.
culture of antimicrobial-susceptible Legionella pneumophila despite
Shaw B, Dendle C, Opat S, Williamson D, Graham M.
Monash Infectious Diseases, Monash Health, Clayton, Victoria,
Microbiol. 2020 Mar 2;2(5):acmi000113.
Abstract: Legionella pneumophila is a well-known cause of pneumonia that is infrequently cultured in clinical practice. We report a case of an immunocompromised patient with persistently positive L. pneumophila cultures from invasive respiratory samples despite prolonged treatment with appropriate antibiotics. In vitro testing showed that the isolate remained susceptible to ciprofloxacin and azithromycin.
Honsberger S, Husnain MG.
Medical Center, Department of Medicine, Case Western Reserve University School
of Medicine, Cleveland, Ohio, USA email@example.com
Rep 2020 Jan;13(1):e233152.
A 44-year-old right-handed man with a 5-day history of non-productive cough
associated with subjective fevers/chills and night sweats presented to the
emergency department with slurred speech. Radiography and urine antigen testing
confirmed the diagnosis of Legionella pneumonia. The hospital course
was complicated by acute hypoxic respiratory failure that required 7 days of
invasive mechanical ventilation. Following extubation, the patient had
dysarthria and developed new parkinsonism features. Brain imaging revealed a
non-specific focal lesion in the left frontal lobe of unclear significance.
Ciprofloxacin was decided as the final antibiotic of choice for its favourable
central nervous system profile. Levodopa-carbidopa was initiated to help
activate the basal ganglia. The patient had complete resolution of pneumonia and
transient parkinsonism. He was able to regain most of his baseline functional
status with intensive rehabilitation.
Legionella Pneumonia in Late Pregnancy
Mosaad-Boktor HK, Lee SA.
Department, Arnot Ogden Medical Center, Elmira, NY, USA. firstname.lastname@example.org
Am J Case Rep 2019 Dec;20:1956-1960.
Abstract: BACKGROUND Legionella
pneumonia can be an aggressive form of pneumonia. However, it is rare in
pregnant women, particularly in the peripartum period. To the best of our
knowledge this is the only case of Legionella pneumonia with endometrial
sepsis. We are reporting a patient with this rare condition. CASE REPORT The
patient was an 18-year-old female, pregnant with her first baby, who developed
symptoms of the common cold near term. The patient was seen at another major
facility initially and was discharged home with a diagnosis of "cold".
She was still uncomfortable and came to our facility Aront Ogden Medical Center
Elmira, NY, USA, where she had rupture of membranes and underwent C-section. She
was suspected clinically of having pneumonia. Initial chest x-ray was negative,
but computed tomography (CT)-scan did show bilateral pneumonia. Further workup
confirmed the diagnosis of Legionella pneumonia and was treated for that
as well as for endometritis. She did require Intensive Care Unit (ICU) care
during her hospital stay. The patient was seen and evaluated by multiple
subspecialties, including Critical Care, Infectious Disease, and
Gastroenterology subspecialties. The patient improved steadily and was later
discharged home in the care of her family with a healthy baby and was advised to
follow up with her Primary Medical Provider as outpatient. CONCLUSIONS Legionella
pneumonia in pregnancy may be more common than we think, and could be easily
overlooked in that patient population, have to be in the back mind of medical
provider. Overlooking diagnosis could lead to serious adverse consequences for
Farber BF, Pupovac SS, Graver LM.
of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine,
Manhasset, New York. email@example.com
Ann Thorac Surg 2019 Oct;108(4):e271-e272.
This report describes the case of an 80-year-old man with culture-negative
prosthetic valve endocarditis who ultimately was given a diagnosis of Legionella
Jia X, Ren
H, Nie X, Li Y, Li J, Qin T.
Key Laboratory of Infectious Disease Prevention and Control, National Institute
for Communicable Disease Control and Prevention, Collaborative Innovation Center
for Diagnosis and Treatment of Infectious Diseases, Chinese Center for Disease
Control and Prevention, Beijing, China. firstname.lastname@example.org
Antimicrob Agents Chemother 2019
Legionnaires' disease, caused by Legionella pneumophila, has been
treated primarily with antibiotics. However, few reports have been published on
antibiotic-resistant Legionella in China. Our aim was to
determine the azithromycin resistance mechanism of L. pneumophila serogroup
1 in China. The sensitivities of 149 L. pneumophila serogroup 1
strains, isolated from clinical cases or environmental water in China from 2002
to 2016, to five antibiotics, including erythromycin, azithromycin, levofloxacin,
moxifloxacin, and rifampin, were evaluated. The mechanisms of the resistance of L.
pneumophila serogroup 1 to azithromycin were studied. The expression
levels of efflux pump gene lpeAB and the MIC of
azithromycin-resistant strains in the presence and absence of the efflux pump
inhibitor carbonyl cyanide-chlorophenylhydrazone (CCCP) were determined. All 149
strains were sensitive to erythromycin, levofloxacin, moxifloxacin, and rifampin,
among which 25 of the strains exhibited azithromycin resistance. These 25
strains, including strains of sequence type 1 (ST1), ST144, ST150, ST154, and
ST629, were screened. Expression of lpeAB was responsible for
the reduced azithromycin susceptibility in all 25 of these strains. The
phenotypes of 25 strains with virulence were linked by evaluating the
intracellular growth ability in mouse macrophage J774 cells. Among the 25
strains, 60% were more virulent than the ATCC 33152 reference strain. The
results determined in our study represent data supporting the further study of
the antibiotic sensitivity of L. pneumophila strains in China.
Trajtman A, Bernard K, Burdz T, Vélez L, Herrera M, Rueda ZV, Keynan Y.
of Medical Microbiology and Infectious Diseases, University of Manitoba,
Winnipeg, Manitoba, Canada; Yoav.Keynan@umanitoba.ca
Diagn Microbiol Infect Dis 2019 Sep;95(1):71-76.
Due to poor diagnostics and increased co-infections, HIV-associated Legionella
infections are underreported. We aimed to retrospectively determine the
frequency of Legionella infections in bronchoalveolar lavage (BAL) from
HIV-associated pneumonia patients hospitalized in Medellin, Colombia, between
February 2007 and April 2014. Although culture was negative, 17 BAL (36%) were
positive for Legionella by quantitative polymerase chain reaction, most
of which were in the Mycobacterium tuberculosis or Pneumocystis
jirovecii co-infected patients, and included L. anisa (n=6), L.
bozemanae (n=4), L. pneumophila (n=3), and L. micdadei (n=2).
All L. bozemanae and L. micdadei associated with Pneumocystis,
while all L. pneumophila associated with M. tuberculosis. Legionella
probable cases had more complications and higher mortality rates (P=0.02) and
were rarely administered empirical anti-Legionella therapy while in
hospital. Clinicians should be aware of the possible presence of Legionella
in HIV and M. tuberculosis or P. jirovecii co-infected patients.
Shorten RJ, Norman J, Sweeney LC.
Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
Case Rep 2019 Aug;12(8):e230130.
A male patient in his mid-60s presented with a severe pneumonia following return
to the UK after travel to Crete. He was diagnosed with Legionnaire's disease (caused
by an uncommon serogroup of Legionella pneumophila). He was
pancytopenic on admission, and during a long stay on critical care he was
diagnosed with a disseminated Aspergillus infection. Bone
marrow aspiration revealed an underlying hairy cell leukaemia that undoubtedly
contributed to his acute presentation and subsequent invasive fungal infection.
Elikowski W, Małek-Elikowska M, Greberska W, Fertała
N, Zawodna M, Marchlewska J, Dudziak J.
Józef Struś Hospital, Department of
Internal Medicine, Poznań, Poland. email@example.com
Pol Merkur Lekarski 2019 Jul;47(277):19-24.
Legionella pneumophila infection (legionellosis) usually presents as a
multisystemic disease, predominantly affecting the lungs (Legionnaires' disease
- LD). Immunodeficiency, chemotherapy or chronic steroids use increase the risk
of developing LD. Extrapulmonary manifestations of LD include cardiac
complications: myocarditis, pericarditis or endocarditis. A case report: The authors describe a
case of a 51-year-old female with a history of cryoglobulinemic vasculitis, Sjögren
syndrome and chronic lymphocytic leukemia who was admitted due to a high fever,
fatigue, tachycardia, dyspnea and cough. Chest X-ray and CT showed bilateral
pulmonary infiltrations and pleural effusion. LD was diagnosed on positive L.
pneumophila urinary antigen test. Echocardiography revealed severe left
ventricular (LV) dysfunction with substantially decreased ejection fraction and
global longitudinal strain (GLS), with a pattern resembling reverse takotsubo
syndrome (rTTS). The coronary arteries in non-invasive coronary angiography were
normal. During therapy with levofloxacin and intravenous immunoglobulins as well
as with carvedilol, ramipril and diuretics, gradual clinical improvement with
complete normalization of LV function was observed within 5 weeks. Cardiac
magnetic resonance (CMR) performed on day 35 revealed only small intramural foci
of late gadolinium enhancement (LGE) with localization not corresponding to the
most decreased regional longitudinal strain in the initial echocardiographic
examination. The authors suggest that the mechanism of transient LV dysfunction
in the case presented may have been of complex nature, including LD myocarditis
and stress-induced cardiomyopathy (with the prevalence of the latter) which has
not so far been reported in the literature.
Yu JH, Avaylon J, Kil H,
Kim JK, Gallemore RP.
of Clinical Research, Retina Macula Institute, Torrance, CA, USA.
Int Med Case Rep J 2019
Purpose: To report a case of endophthalmitis associated with Legionella
pneumophila. Case Report: A 46-year-old, highly myopic male with a
complex history of recurrent retinal detachments, macular hole, cataract surgery
and an infected scleral buckle in the left eye, presented with pain, redness,
hypopyon and vision loss in the left eye, 14 days following blunt head trauma.
Empirical treatment for endophthalmitis with intravitreal injections of
Vancomycin and Ceftazidime afforded minimal improvement. He developed recurrent
hypopyon and underwent vitrectomy surgery with intravitreal antibiotic
injections at the time of surgery and had improvement. Intraoperative culture
was positive for Legionella pneumophila. He had continued episodes
of recurrent inflammation which were quelled by intravitreal moxifloxacin
injections performed every 3-10 days. He developed a recurrent RD with
proliferative vitreoretinopathy (PVR) and underwent vitrectomy with silicone
oil. The retina was reattached but had no light perception vision in the
affected eye. Conclusion: When endophthalmitis is contracted in a
work-place setting, a culture for L. pneumophila should be
considered. A combination of intravitreal moxifloxacin and oral azithromycin may
Foissac M, Bergon L, Vidal J, Cauquil P, Mainar A,
MD, Service de Maladies infectieuses, Centre Hospitalier
Castres-Mazamet, Castres, France. firstname.lastname@example.org
Germs 2019 Jun;9(2):89-94.
micdadei are gram-negative bacilli living in soil and aquatic habitats.
They are responsible for less than 10% of legionellosis but have a propensity to
affect people suffering from immunodeficiency. Lung cavitations may also occur
in this population. Isolation of L. micdadei on clinical
samples requires specific culture media that are not routinely used. Moreover,
serologic methods and urinary assays are specific for Legionella
pneumophila serogroup 1 (the most frequent serogroup isolated from
clinical specimens), and lack sensitivity for diagnosing L. micdadei infection.
As a consequence, this diagnosis is difficult to confirm. Case report: We
report here a severe case of community-acquired legionellosis due to L.
micdadei, in a patient under immunosuppressive medications and high-dose
corticosteroids for rheumatoid arthritis. The source of his infection was
hypothesized to be his continuous positive airway pressure device, which was
regularly cleaned with tap water instead of sterile water, thus potentially
resulting in Legionella contamination. Conclusions: L. micdadei must
be considered as a possible cause of community-acquired severe pneumonia in case
of immunodeficiency. For outpatients, advice concerning the cleaning of
aerosols-generating devices at home must be emphasized.
Bolliger R, Neeser O, Merker M, Vukajlovic T, Felder L,
Fiumefreddo R, Haubitz S, Koch D, Hammerer-Lercher A, Ottiger C, Fux CA, Mueller
B, Schuetz P.
of General Internal and Emergency Medicine, University, Aarau, Switzerland. email@example.com
Open Forum Infect Dis 2019 Jun;6(7):ofz268.
We validated a clinical prediction rule for Legionella based on
clinical parameters (dry cough, fever) and laboratory findings (C-reactive
protein, lactate dehydrogenase, sodium, platelet counts) in 713 consecutive
patients with community-acquired pneumonia. The Legionella Score
performed well in estimating the likelihood for Legionella infection
and thus may help to direct diagnostic and therapeutic decisions.
Sutarjono B, Alexis J, Sachidanandam JC.
Internal Medicine, Brookdale University
Hospital Medical Center, Brooklyn, New York, USA. firstname.lastname@example.org
Case Rep. 2019 Jun 20;12(6):e229243.
Legionnaires' disease is a recognised but rare cause of rhabdomyolysis. It can
be further complicated with renal impairment. In this case report, we describe a
previously healthy, semi active 50-year-old man who within days was reduced to
having periods of dyspnea after minutes of walking in addition to near fatal
acute renal failure. He was found to have the rare triad of Legionella pneumonia,
renal failure and rhabdomyolysis, which is associated with high morbidity and
mortality. He was treated according to guidelines with azithromycin monotherapy
and aggressive fluid hydration. 20 days after admission, the patient was walking
independently and discharged home.
Natås OB, Brekken AL, Bernhoff E, Hetland MAK, Löhr IH,
of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway.
Antimicrob Chemother 2019 Jun;74(6):1545-1550.
pneumophila strains resistant to antimicrobial agents are rare. We tested 10
antimicrobial agents against clinical and environmental strains and performed
WGS to screen for the presence of resistance mechanisms. Methods: A
total of 122 clinical and environmental strains of L. pneumophila
collected between 2000 and 2017 and characterized by serogroup and ST were
included. Antimicrobial susceptibility was tested by gradient diffusion tests on
buffered charcoal yeast extract agar medium supplemented with α-ketoglutarate (BCYE-α) and a subgroup of strains were whole-genome sequenced
using Illumina technology and analysed. Results: All
strains showed a WT MIC distribution for ciprofloxacin, levofloxacin,
moxifloxacin, rifampicin, cefotaxime, tetracycline and trimethoprim/sulfamethoxazole.
All strains of L. pneumophila serogroup 1, ST1 (18/122; 14.7%) showed
reduced susceptibility to azithromycin (MIC 0.5-1 mg/L) and harboured the efflux
pump component lpeAB. Two strains of L. pneumophila serogroup 5 (ST1328)
and one strain of serogroup 4 (ST1973) also showed reduced susceptibility to
azithromycin (MIC 0.5 mg/L). They harboured lpeAB gene variants with 91.37% and
92.52% nucleotide identity, respectively, compared with the lpeAB genes of
serogroup 1, ST1 strains. Conclusions: Our
collection of L. pneumophila strains was susceptible to most
antimicrobial agents except azithromycin. Gradient diffusion tests on BCYE-α test medium detected strains with reduced
susceptibility to azithromycin. All L. pneumophila serogroup 1, ST1
strains showed reduced susceptibility to macrolides and contained the efflux
pump component lpeAB. Reduced susceptibility to azithromycin in non-serogroup 1
strains may be due to the presence of an lpeAB efflux pump variant.
Chaudhry R, Vinayaraj EV, Thakur B.
Department of Microbiology, All India
Institute of Medical Sciences, New Delhi, India.
Microbiol 2019 May;14:661-669.
Aim: Data are limited regarding the antibiotic susceptibility of Legionella
pneumophila in India. The aim of this study was to determine the drug
susceptibility of environmental L. pneumophila isolates in
India for antibiotics commonly used in clinical practice for Legionnaires'
disease treatment. Materials & methods: The activities of seven
antibiotics against 46 environmental isolates of L. pneumophila were
evaluated by using E-test on buffered charcoal yeast extract-α agar. Results: Among the L.
pneumophila isolates tested, no tendency toward drug resistance was
observed. Rifampicin was the most potent drug followed by levofloxacin, while
doxycycline and tetracycline were found to be the less active agents. Conclusion: Susceptibility
testing of Legionella environmental isolates could be
beneficial to notify resistance to antibiotics in the environment before it
becomes evident in clinical strains.
of Washington, Department of Laboratory Medicine, Seattle, USA. email@example.com
Semin Diagn Pathol 2019 May;36(3):152-159.
Lower respiratory infections remain one of the top global causes of death and
the emergence of new diseases continues to be a concern. In the first two
decades of the 21st century, we have born witness to the emergence of newly
recognized coronaviruses that have rapidly spread around the globe, including
severe acute respiratory syndrome virus (SARS) and Middle Eastern respiratory
syndrome virus (MERS). We have also experienced the emergence of a novel H1N1
pandemic influenza strain in 2009 that caused substantial morbidity and
mortality around the world and has transitioned into a seasonal strain. Although
we perhaps most frequently think of viruses when discussing emerging respiratory
infections, bacteria have not been left out of the mix, as we have witnessed an
increase in the number of infections from Legionella spp. since the organisms'
initial discovery in 1976. Here, we explore the basic epidemiology, clinical
presentation, histopathology, and clinical laboratory diagnosis of these four
pathogens and emphasize themes in humans' evolving relationship with our natural
environment that have contributed to the infectious burden. Histology alone is
rarely diagnostic for these infections but has been crucial to bettering our
understanding of these diseases. Together, we rely on the diagnostic acumen of
pathologists to identify the clinicopathologic features that raise the suspicion
of these diseases and lead to the early control of the spread in our populations.
Kosar J, Suen B, Peermohamed S.
Internal Medicine/Infectious Disease, University of
Saskatchewan College of Medicine, Saskatoon, CAN. firstname.lastname@example.org
Legionella species are Gram-negative bacilli that are relatively rare
causes of community-acquired pneumonia but can be associated with significant
morbidity and mortality if unrecognized or improperly treated. Limited data
exist regarding the use of tigecycline, a third generation glycylcycline, in the
treatment of Legionnaires' disease. We present an immunocompromised patient with
Legionnaires' disease and allergies to both fluoroquinolones and macrolides,
which are first-line treatment options for Legionnaires' disease. He was
successfully treated using tigecycline, a third generation glycylcycline,
indicating that tigecycline may serve as a safe and effective alternative
therapeutic option for treatment of Legionnaires' disease.
Bleuze MO, Hantson P, Devos J.
Department of Intensive Care, Centre
Hospitalier de Mouscron, 7700 Mouscron, Belgium.
Rep Crit Care 2019 Jan;2019:3472627.
53-year-old man developed a Legionella pneumophila pneumonia
complicated by rhabdomyolysis, acute kidney injury, and protracted ileus. Risk
factors were smoking and chronic alcoholism, but the patient had no history of
previous abdominal surgery. Hemodialysis was required for a period of 5 weeks
with a full renal recovery. Pneumonia required respiratory support but for a
limited period of 6 days. The protracted course of the ileus led to explorative
laparotomy despite negative computed tomography findings. No cause of mechanical
obstruction was found at surgery and common etiologies of intestinal obstruction
were excluded. Parenteral nutrition was needed for a total of 4 weeks, before
recovery of intestinal motility. This case illustrates the apparent discrepancy
between the pulmonary symptoms and the extrapulmonary manifestations that could
be seen as a consequence of an exaggerated immune response.
Asaki M, Masuda T, Miki Y.
Department of Emergency Medicine,
Emergency and Critical Care Center, Fujieda Municipal General Hospital, Shizuoka,
Case Rep Crit Care 2018
57-year-old man presented to the emergency department with fever and progressive
altered level of consciousness of 5 days' duration. Three days before admission,
influenza A was diagnosed at a clinic. On admission, his vital signs were
unstable. Pneumonia was diagnosed through chest computed tomography, and urinary Legionella antigen
test was positive. A diagnosis of septic shock due to Legionella and
influenza pneumonia was made, and critical care management was initiated,
including mechanical ventilation and vasopressors. However, tachycardia did not
improve, left ventricular ejection fraction was 20%, and circulatory
insufficiency progressed. Therefore, considering the involvement of septic
cardiomyopathy and cardiogenic shock, veno-arterial extracorporeal membrane
oxygenation (VA-ECMO) was initiated for circulation assistance on day 3 since
admission. Tachycardia and myocardial dysfunction improved by day 8, and VA-ECMO
was withdrawn. Subsequently, nutrition management and rehabilitation were
performed, and the patient was transferred to a recovery hospital on day 108.
VA-ECMO may be beneficial when concomitant with circulatory assistance in
uncontrollable cases of septic cardiomyopathy using catecholamines and β-blockers. It may be necessary to adopt VA-ECMO at an
appropriate time before the patient progresses to cardiopulmonary arrest.
Hill RLR, Chalker VJ, Mentasti M, Ready D.
Public Health England, Colindale, London,
J Antimicrob Chemother 2018
susceptibility of Legionella pneumophila is poorly understood, with
treatment of Legionnaires' disease often based on empirical choice. The aim of
this study was to determine the antibiotic susceptibility of L. pneumophila
strains. Methods: Antibiotic
susceptibility of 92 L. pneumophila strains isolated in England and Wales
between 2007 and 2017 was determined using a microbroth dilution methodology for
each agent tested. MICs and MBCs were determined and compared with published
intracellular concentrations of each agent tested. Results: The
MIC range of erythromycin was 0.06-1 mg/L, the MIC range of rifampicin was
0.0001 mg/L, the MIC range of ciprofloxacin was 0.004-0.25 mg/L and the MIC
range of levofloxacin and moxifloxacin was 0.03-0.25 mg/L. The MBC range of
erythromycin was 1-32 mg/L, but the MBC range of ciprofloxacin was the same as
the MIC range. For levofloxacin and moxifloxacin, the MBC range was elevated by
one dilution and two dilutions, respectively. Typically, intracellular bronchial
secretion concentrations of erythromycin might be expected to reach a suitable
level to exceed the MIC range; however, 91 of 92 (98.9%) isolates had an MBC
below the expected intracellular concentrations, which indicated erythromycin
may have variable efficacy. MIC and MBC values of ciprofloxacin, levofloxacin
and moxifloxacin were below achievable intracellular levels within bronchial
secretions. Comparison of the MIC/MBC correlation showed very little clustering
for erythromycin, but strong clustering for levofloxacin and to a lesser extent
ciprofloxacin. Conclusions: Use
of the MIC/MBC linkage analysis seems an appropriate way forward for
antimicrobial susceptibility testing and supports current guidance recommending
levofloxacin for the treatment of Legionnaires' disease.
Koda R, Itoh R, Tsuchida M, Ohashi K, Iino N, Takada T, Narita I.
Department of Nephrology, Uonuma
Institute of Community Medicine, Niigata University Medical and Dental Hospital,
Intern Med 2018
Legionella pneumonia is occasionally accompanied by renal complications;
however, the cause of this remains unknown. We herein report a 70-year-old
Japanese man with Legionella pneumonia who presented with hyponatremia,
hypophosphatemia, and hypouricemia. The levels of urinary β2-microglobulin
were remarkably high, indicating severe renal tubular damage. The presence of
glycosuria and aminoaciduria as well as increased fractional excretion of uric
acid and decreased tubular reabsorption of phosphate indicated that the
patient's condition was complicated with Fanconi syndrome. After antimicrobial
therapy, the electrolyte abnormalities and renal tubular damage were completely
Nunokawa H, Ohkuma K, Watanabe T, Sada M, Inoue M, Honda K, Oda M, Ogawa Y,
Tamura M, Yokoyama T, Kurai D, Kimura H, Ishii H, Goto H, Takizawa H.
Department of Respiratory Medicine,
Kyorin University School of Medicine, Japan.
Intern Med 2018 Sep;57(17):2479-2487.
Objective We investigated a novel diagnostic scoring system to differentiate Legionella
pneumophila pneumonia from Streptococcus pneumoniae pneumonia.
Methods We retrospectively reviewed the clinical data of 62 patients with L.
pneumophila pneumonia (L-group) and 70 patients with S. pneumoniae
pneumonia (S-group). Results The serum sodium (Na) levels tended to be lower
according to the severity [age, dehydration, respiratory failure, orientation
disturbance, low blood pressure (A-DROP)] score in the L-group. On a
multivariate analysis, we found that four factors were independent predictive
markers for inclusion in the L-group: relative bradycardia [hazard ratio (HR)
5.177, 95% confidence interval (CI): 1.072-24.993, p=0.041], lactate
dehydrogenase (LDH) levels ≥292 IU/L (HR 6.804, 95% CI: 1.629-28.416,
p=0.009), C-reactive protein (CRP) levels ≥21 mg/dL (HR 28.073, 95% CI:
5.654-139.462, p<0.001), and Na levels ≤137 meq/L (HR 5.828, 95% CI:
1.411-24.065, p=0.015). Furthermore, a total score [ranging from 0 to 4, the sum
of the points for each factor (0 or 1)] ≥3 points indicated a higher
probability of inclusion in the L-group than in the S-group. The diagnostic
accuracy of a total score of 3 had a sensitivity of 36.3%, specificity of 100%,
and area under the curve of 0.682 (95% CI: 0.558-0.806, p=0.004), and that of a
total score of 4 had a sensitivity 27.4%, specificity of 98.2%, and area under
the curve (AUC) of 0.627 (95% CI: 0.501-0.754, p=0.045). The diagnostic accuracy
had low sensitivity but high specificity. Conclusions We found four markers that
might be useful for differentiating L-group from S-group and created a novel
diagnostic scoring system.
Petrelli F, Lizioli A, Pregliasco F, Masia C, Cossellu G, Farronato G, Consonni
M, Sisto F.
Department of Biomedical Surgical and
Dental Sciences, University of Milan, Italy.
Ann Ig 2018 Sep-Oct;30(5):387-390.
Aims: The aim of this
research is to verify the presence of Legionella in human dental plaque. Methods: 65
adult patients not treated with systemic or local antibiotics at least 2 months
before the time of sample collection were enrolled for plaque collection between
September 2015 and December 2016. A brief questionnaire about lifestyle and
health risks was administered. Legionella spp. detection has been
executed by semi- nested PCR. Results: 8
out of 65 plaque samples (12.3%) were positive for Legionella spp. As
regards health risks and lifestyle aspects, no relevant difference was observed
between patients involved in our study, except for two positive patients who
have reported a COPD ongoing and a pneumonia in the past. Conclusions: This
study represents a step forward in the knowledge of reservoirs of the
microorganism and richness of oral microbiota.
Chitasombat MN, Ratchatanawin N, Visessiri Y.
of Infectious Disease, Department of Medicine, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, Bangkok, Thailand. email@example.com
Dis 2018 Sep;18(1):467.
Ochman M, Latos M, Biniszkiewicz P, Karolak W, Woźniak-Grygiel E,
Maruszewski M, Urlik M, Mędrala W, Kułaczkowska Z, Pyrc K, Żegleń
Department of Cardiac, Vascular and
Endovascular Surgery and Transplantology, Medical University of Silesia in
Katowice, Silesian Center for Heart Diseases, Zabrze, Poland. firstname.lastname@example.org
Proc 2018 Sep;50(7):2053-2058.
Wang H, D'Souza
C, Lim XY, Kostenko L, Pediongco TJ, Eckle SBG, Meehan BS, Shi M, Wang
N, Li S, Liu L, Mak JYW, Fairlie DP, Iwakura Y,
Gunnersen JM, Stent AW, Godfrey DI, Rossjohn J, Westall GP, Kjer-Nielsen L,
Strugnell RA, McCluskey J, Corbett AJ, Hinks TSC, Chen Z.
Department of Microbiology and Immunology,
Peter Doherty Institute for Infection and Immunity, University of Melbourne,
Melbourne, VIC, Australia. email@example.com
Nat Commun 2018
Miyashita N, Kobayashi I, Higa F, Aoki Y, Kikuchi T, Seki M,
Tateda K, Maki N, Uchino K, Ogasawara K, Kurachi S, Ishikawa T, Ishimura Y,
Kanesaka I, Kiyota H, Watanabe A.
Department of Internal Medicine 1,
Kawasaki Medical School, Okayama, Japan. firstname.lastname@example.org
Chemother 2018 May;24(5):325-329.
Verykiou S, Goodhead C, Parry G, Meggitt S.
Dermatology Department, Royal Victoria
Infirmary, Newcastle upon Tyne, UK. email@example.com
Dermatol Apr 2018;43(3):300-302.
We report a 23-year-old immunocompromised woman who, following cardiac
transplantation, presented with an unusual cutaneous eruption. She developed a
widespread pustular rash, systemic symptoms and a high temperature with raised
inflammatory markers. The diagnosis was reached when a skin biopsy was cultured
onto Legionella agar (buffered charcoal yeast extract) and Legionella
feeleii was isolated. The patient was treated with 6 weeks of moxifloxacin
and her cutaneous lesions gradually resolved. Cutaneous Legionella
infections are uncommon and usually affect immunocompromised patients.
Lapidot R, Alawdah L, Köhler JR, Paulson
V, Levy O.
of Pediatric Infectious Diseases, Boston Medical Center, Boston, MA, USA. firstname.lastname@example.org
Pediatr Infect Dis J 2018
Cunha BA, Varantsova A, Jimada I.
Disease Division, NYU Winthrop Hospital, Mineola, NY, USA. email@example.com
Eur J Clin Microbiol Infect Dis 2018 Mar;37(3):463-468.
Abstract: An index case of Legionnaires's disease with
mediastinal adenopathy prompted us to review our recent experience with
Legionnaires' disease to determine the incidence of mediastinal adenopathy of
this finding in Legionnaires' disease. We reviewed the radiographic findings of
90 hospitalized adults with Legionnaires' disease from 2015 to 2017. Excluded
were 11 patients with mediastinal adenopathy due to non-Legionnaires' disease
causes, e.g., lymphoma. Thirty-seven of the remaining patients had both chest
films and chest computed tomography (CT) scans. Of the 37 Legionnaires' disease
cases, 13/37 (35%) had mediastinal adenopathy and 8/27 (24%) also had unilateral
hilar adenopathy. These chest CT findings were not seen on chest films. Chest CT
scans are needed to detect mediastinal adenopathy in Legionnaires' disease.
Mediastinal adenopathy may be due to Legionnaires' disease or a malignancy. Some
findings in Legionnaires' disease are also present in mediastinal adenopathy due
to lymphomas, e.g., highly elevated erythrocyte sedimentation rate (ESR),
lactate dehydrogenase (LDH), and ferritin. Hospitalized adults with
Legionnaires' disease and mediastinal adenopathy should have serial chest CT
scans to monitor resolution of the mediastinal adenopathy. In hospitalized
adults with otherwise unexplained persistent mediastinal adenopathy, they should
be considered as being due to another etiology, e.g., lymphoma, until proven
Ito A, Ishida T, Washio Y, Yamazaki A, Tachibana H.
of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central
Hospital, Okayama, Japan. firstname.lastname@example.org
BMC Pulm Med 2017 Dec;17(1):211.
of a limited number of reports, we aimed to investigate the clinical
characteristics of patients with Legionella pneumonia due to non-Legionella
pneumophila serogroup 1 and the diagnostic usefulness of the six-point
scoring system for such patients compared with patients with pneumonia caused by
L. pneumophila serogroup 1. Methods: We
retrospectively analysed patients diagnosed with Legionella pneumonia due
to non-L. pneumophila serogroup 1 between March 2001 and June 2016. We
examined the clinical characteristics, including symptoms, laboratory findings,
radiologic findings, pneumonia severity, initial treatment and prognosis. We
also calculated scores using the six-point scoring system in these patients.
Furthermore, we compared the clinical characteristics and six-point scores
between non-L. pneumophila serogroup 1 patients and L. pneumophila
serogroup 1 patients among hospitalized community-acquired pneumonia patients
enrolled prospectively between October 2010 and July 2016. Results: Eleven
patients had pneumonia due to non-L. pneumophila serogroup 1; their
median age was 66 years and 8 patients (72.7%) were male. The most common
pathogen was L. pneumophila serogroup 3 (6/11), followed by L.
pneumophila serogroup 9 (3/11), L. pneumophila serogroup 6 (1/11) and
L. longbeachae (1/11). Non-specific symptoms, such as fever and cough,
were common. Six patients (54.5%) had liver enzyme elevation, but no patient
developed hyponatremia at <130 mEq/L. Nine patients (81.8%) showed lobar
pneumonia and 7 patients (63.6%) manifested with consolidation and ground-glass
opacity. Patients with mild to moderate severity comprised 10 (90.9%) by CURB-65
and 5 (45.5%) by the Pneumonia Severity Index. Of all patients, 4 were admitted
to the intensive care unit and 3 died despite appropriate empiric therapy. The
clinical characteristics were not significantly different between non-L.
pneumophila serogroup 1 patients and L. pneumophila serogroup 1
patients (n=23). At a cut-off value of ≥2 points, the sensitivity of the
six-point scoring system was 54.5% (6/11) for non-L. pneumophila
serogroup 1 patients and 95.7% (22/23) for L. pneumophila serogroup 1
patients. Conclusions: Cases
of non-L. pneumophila serogroup 1 pneumonia varied in severity from mild
to severe and the clinical characteristics were often non-specific. The
six-point scoring system was not useful in predicting such Legionella
Edouard S, Million M, Casalta JP, Collart F, Amphoux B, Raoult D.
Aix Marseille Univ, CNRS, Marseille,
burnetii is an intracellular and fastidious bacterium responsible of acute
and persistent Q fever infection. Endocarditis and vascular infections are the
most common serious complications of acute Q fever. Case report: We
report the case of a 63-year-old man that presented a mediastinitis associated
with a prosthetic vascular infection. Serological cross-reaction was observed
between Coxiella burnetii, the agent of Q fever, and Legionella
pneumophila with higher antibodies titer for L. pneumophila (IgG=1:512)
than for C. burnetii (phase I IgG=1:400). We performed western blot with
cross-adsorption that supports the diagnosis of C. burnetii infection.
Two weeks later, a positive qPCR and culture for C. burnetii on swab
taken from the mediastinal cutaneous fistula confirmed the definitive
microbiological diagnosis of Q fever mediastinitis. Conclusion: Cross-reactivity
between C. burnetii and Legionella spp. has long been known and
should be considered in patients with persistent infections. It is important to
establish the definite diagnosis because the antibiotic treatment regimens and
duration are significantly different. To the best of our knowledge, we reported
here the first case of mediastinitis associated to C. burnetii and we
diagnosed this persistent infection despite low anti-C. burnetii phase I
Laganà P, Soraci L, Gambuzza ME, Mancuso G, Delia SA.
Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis,
Department of Biomedical and Dental Sciences and Morphofunctional Imaging,
University of Messina, Messina, Italy. email@example.com
CNS Neurol Disord Drug Targets 2017;16(10):1080-1089.
aim of this review is to bring together the latest findings concerning L.
pneumophila infection and innate immune host cell responses. A deeper
knowledge of these processes could allow the use of immunomodulatory compounds
able to counteract CNS involvement following L. pneumophila infection.
Seegobin K, Maharaj S, Baldeo C, Downes JP, Reddy P.
Department of Internal Medicine,
University of Florida College of Medicine, Jacksonville, FL 32209, USA. firstname.lastname@example.org
Case Rep Infect Dis 2017;2017:8051096.
Miyashita N, Higa F, Aoki Y, Kikuchi T, Seki M, Tateda K,
Maki N, Uchino K, Ogasawara K, Kiyota H, Watanabe A.
Department of Internal Medicine 1,
Kawasaki Medical School, Okayama, Japan. email@example.com
J Infect Chemother 2017 Nov;23(11):727-732.
Sanchez-Rodriguez I, Simonetti AF, Burgos J, Viasus D, Martin MT, Falco V,
Hospital Universitari de Bellvitge,
IDIBELL, Universitat de Barcelona, Barcelona, Spain; REIPI, Instituto de Salud
Carlos III, Madrid, Spain. firstname.lastname@example.org
Clin Microbiol Infect 2017 Sep;23(9):653-658.
have arisen regarding the equivalence of levofloxacin and some macrolides for
treating community-acquired legionella pneumonia (LP). We aimed to compare the
outcomes of current patients with LP treated with levofloxacin, azithromycin and
clarithromycin. Methods: Observational
retrospective multicentre study of consecutive patients with LP requiring
hospitalization (2000-2014) conducted in two hospitals. The primary outcome
assessed was 30-day mortality. To control for confounding, therapy was assessed
by multivariate analysis. Results: We
documented 446 patients with LP, of which 175 were treated with levofloxacin,
177 with azithromycin and 58 with clarithromycin. No significant differences in
time to defervescence (2 (interquartile range (IQR) 1-4) versus 2 (IQR 1-3) days;
p 0.453), time to achieve clinical stability (3 (2-5) versus 3 (2-5) days; p
0.486), length of intravenous therapy (3 (2-5.25) versus 4 (3-6) days; p 0.058)
and length of hospital stay (7 (5-10) versus 6 (5-9) days; p 0.088) were found
between patients treated with levofloxacin and those treated with azithromycin.
Patients treated with clarithromycin had longer intravenous antibiotic treatment
(3 (2-5.25) versus 5 (3-6.25) days; p 0.002) and longer hospital stay (7 (5-10)
versus 9 (7-14) days; p 0.043) compared with those treated with levofloxacin.
The overall mortality was 4.3% (19 patients). Neither univariate nor
multivariate analysis showed a significant association of levofloxacin versus
azithromycin on mortality (4 (2.3%) versus 9 (5.1%) deaths; p 0.164). The
results did not change after incorporation of the propensity score into the
models. Conclusions: In
our study, no significant differences in most outcomes were found between
patients treated with levofloxacin and those treated with azithromycin. Due to
the small number of deaths, results regarding mortality should be interpreted
Blaich A, Soleman E, Gaia V, Osthoff M.
of Infectious Diseases and Hospital Epidemiology, University Hospital Basel,
Basel, Switzerland. email@example.com
Legionella spp. are an important cause of pulmonary and rarely
extrapulmonary infections. L. cincinnatiensis has only been implicated in
five cases to date. We herein report the first case of L. cincinnatiensis
septic arthritis in a 90-year old lady with a past medical history of chronic
kidney disease. She developed septic arthritis of her left wrist after having
received intraarticular corticosteroid injections and oral corticosteroids
administered for presumed chondrocalcinosis. Appropriate antimicrobial treatment
of L. cincinnatiensis septic arthritis was delayed until identification
of this organism in joint biopsies by broad-range bacterial PCR targeting the
16S rRNA gene with subsequent rDNA sequence analysis and by culture on special
media. Reviewing all reported cases of septic arthritis caused by Legionella
spp. other than L. cincinnatiensis it is notable that diagnosis was
established by PCR in the majority of cases and only subsequently confirmed by
special culture. Although most patients were immunosuppressed, outcome was
favourable. Treatment consisted of a fluoroquinolone alone or in combination
with rifampicin or a macrolide. Our case highlights the need for a high index of
suspicion for infections with unusual/fastidious organisms when symptoms are
suggestive of septic arthritis, but conventional methods fail to identify a
Rodrigue J, Villeneuve J, Lacasse Y.
Centre de recherche, Centre de pneumologie, Institut
universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec
City, Québec, Canada. firstname.lastname@example.org
Can Assoc Radiol J 2017
disease (LD) may occur sporadically or in the course of outbreaks, where the
typical radiological manifestations of the disease may better be delineated. We
took advantage of a rare community-based epidemic of LD (181 patients) that
occurred in 2012 in Quebec City, Canada, to describe the radiographic features
of LD and compare the its tomographic presentation with that of
community-acquired pneumonia caused by common bacteria other than Legionella
pneumophila. Methods: From
the 181 individuals affected in the outbreak, we obtained the chest radiographs
of 159 individuals (mean 63±15 years of age) for detailed analysis; 33 patients
had a computed tomography (CT) scan performed during the course of their illness.
In a case-control study, we compared the CT scans of patients with LD with those
of patients who had received a diagnosis of community-acquired pneumonia caused
by a pathogen other than Legionella and confirmed by chest CT scan. Results: Overall,
LD most often presented as an airspace consolidation involving 1 of the lower
lobes. Pleural effusion and mediastinal adenopathies were apparent only in a
minority, whereas no pneumothorax or cavitation was noted. We did not find any
significant difference in chest CT scan findings in patients with LD vs those
with community-acquired pneumonia from other bacterial origin. No radiological
finding was clearly associated with an increased risk of intensive care unit
admission or mortality. Conclusions: The
early radiographic and tomographic manifestations of LD are nonspecific and
similar to those found in community-acquired pneumonia from other bacterial
Eckburg PB, Talbot GH, Llorens L, Friedland HD.
Summa Health System, Akron, OH, USA. email@example.com
J Antimicrob Agents 2017 Aug;50(2):247-251.
Background: Therapy directed against
atypical pathogens in patients with community-acquired pneumonia (CAP) is often
recommended. This post-hoc analysis evaluated the effect of addition of a
macrolide to ceftaroline fosamil or ceftriaxone treatment in atypical CAP. Methods: Two
phase 3, double-blind, comparative safety and efficacy studies of ceftaroline
fosamil vs. ceftriaxone, FOCUS 1 and FOCUS 2, enrolled adults with CAP. Only
FOCUS 1 included 24-h adjunctive clarithromycin therapy for all patients on day
1. Day 4 and test-of-cure (TOC) outcomes were compared for adjunctive vs. no
adjunctive therapy. Results: Of
1240 enrolled patients, 130 patients with CAP due to atypical pathogens alone
were included (FOCUS 1, n=64; FOCUS 2, n=66). Among patients infected with Mycoplasma
pneumoniae and/or Chlamydophila pneumoniae alone, a higher clinical
response rate was observed with clarithromycin plus ceftaroline fosamil or
ceftriaxone compared with treatment without additional clarithromycin at day 4
[38/49 (77.6%; FOCUS 1) vs. 24/43 (55.8%; FOCUS 2)], but not at the TOC
assessment [42/49 (85.7%; FOCUS 1) vs. 41/43 (95.3%; FOCUS 2)]. In patients
infected with Legionella pneumophila alone, a higher clinical response
rate with adjunctive clarithromycin therapy was observed at the TOC assessment
alone [12/12 (100%; FOCUS 1) vs. 14/19 (73.7%; FOCUS 2)]. The unadjusted odds
ratio of a favourable clinical response at day 4 with adjunctive clarithromycin
vs. no adjunctive clarithromycin was 2.4 (95% confidence interval
1.1-5.1;P=0.0299) for all pathogens combined. Conclusions: These
results suggest that empirical antibiotic therapy against atypical pathogens may
improve early clinical response rate. This hypothesis is best evaluated in a
Shachor-Meyouhas Y, Ravid S, Hanna S, Yaacoby-Bianu K, Kassis I.
Pediatric Infectious Diseases Unit, Ruth
Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel. firstname.lastname@example.org
J Pediatr 2017 Jul;186:186-188.
with infantile spasms, an intractable epileptic disorder, often are treated with
adrenocorticotropic hormone. Legionella pneumophila is a rare cause of
pneumonia in children. We describe 2 infants with Legionella pneumonia
whose infection occurred within 1 month after starting adrenocorticotropic
Roncon-Albuquerque R Jr, Vilares-Morgado R, van der Heijden GJ,
Ferreira-Coimbra J, Mergulhão P, Paiva JA.
Department of Emergency and Intensive
Care Medicine, Centro Hospitalar S. João, Porto, Portugal.
J Intensive Care Med 2019 Apr;34(4):344-350.
analyze the management and outcome of patients with refractory respiratory
failure complicating severe Legionella pneumonia rescued with
extracorporeal membrane oxygenation (ECMO) in our Center. Design and setting: Observational
study of patients with refractory respiratory failure treated with ECMO in
Hospital S. João (Porto, Portugal), between November 2009 and September 2016. Participants: A
total of 112 patients rescued with ECMO, of which 14 had Legionella
pneumonia. Results: Patients
with Legionella pneumonia were slightly older than patients with acute
respiratory failure of other etiologies (51 [48-56] vs 45 [35-54]), but with no
significant differences in acute respiratory failure severity between groups:
Pao2/Fio2 ratio 67 (60-75) versus 69 (55-85) and
Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score 4
(1-5) versus 2 (-1-4), respectively. Legionella pneumonia was associated
with earlier ECMO initiation (days of invasive mechanical ventilation [IMV]
before ECMO: 2.0 [1.0-4.0] vs 5.0 [2.0-9.5]). After IMV adjustment to "lung
rest" settings, this group presented higher respiratory system (RS) static
compliance (28.7 [18.8-37.4] vs 16.0 [10.0-20.8] mL/cmH2O) but
required higher ECMO support (blood flow 5.0 [4.3-5.4] vs 4.2 [3.6-4.8]).
Patients with Legionella pneumonia had shorter IMV (16 [14-23] vs 27
[20-42] days) and lower incidence of intensive care unit nosocomial infections
(35.7% vs 64.3%), with a trend to higher hospital survival (85.7% vs 62.2%; P =
.13). Conclusion: In
Legionella pneumonia complicated by refractory respiratory failure, ECMO
support allowed patient stabilization under lung protective ventilation and high
survival rates. Timely ECMO referral should be considered for Legionella
pneumonia failing conventional treatment.
Kashif M, Patel R, Bajantri B, Diaz-Fuentes G.
Division of Pulmonary and Critical Care
Medicine, Department of Medicine, Bronx Lebanon Hospital Center, Affiliated with
Icahn School of Medicine at Mount Sinai, USA. email@example.com
Respir Med Case Rep, 2017
Legionella pneumophila is a common, usually underreported and
undiagnosed cause of community acquired pneumonia which can lead to significant
morbidity and mortality. Diffuse alveolar hemorrhage rarely has been associated
with legionella infection. We present a 61-year-old man with hypertension,
diabetes mellitus and obesity admitted with severe acute respiratory distress
syndrome. He was found to have Legionella pneumonia with associated
diffuse alveolar hemorrhage diagnosed with bronchoscopic sequential
bronchoalveolar lavage. He was successfully managed with antibiotics, lung
protective strategies and intravenous pulse dose steroids. This patient
highlights the unusual association ofinfection and diffuse alveolar hemorrhage.
Additionally, the case re-enforces the need for early and aggressive evaluation
and management of patients presenting with pneumonia and progressive hypoxia
despite adequate treatment.
Cunha BA, Cunha
Infectious Disease Division,
Winthrop-University Hospital, Mineola, NY, USA. firstname.lastname@example.org
Infect Dis Clin North Am 2017 Mar;31(1):95-109.
Whenever the cardinal manifestations of a disorder occur in similar disorders,
there is potential for a disease mimic. Legionnaire's disease has protean
manifestations and has the potential to mimic or be mimicked by other community
acquired pneumonias (CAPs). In CAPs caused by other than Legionella
species, the more characteristic features in common with legionnaire's disease
the more difficult the diagnostic conundrum. In hospitalized adults with CAP,
legionnaire's disease may mimic influenza or other viral pneumonias. Of the
bacterial causes of CAP, psittacosis and Q fever, but not tularemia, are
frequent mimics of legionnaire's disease.
Cunha BA, Cunha CB.
Infectious Disease Division,
Winthrop-University Hospital, Mineola, NY, USA. email@example.com
Infect Dis Clin North Am 2017 Mar;31(1):81-93.
Legionnaire's disease is a nonzoonotic atypical pneumonia caused by Legionella
sp that occurs sporadically or in outbreaks. Legionnaire's disease pneumonia is
accompanied by several extrapulmonary clinical and laboratory findings. Rather
than testing all pneumonias for Legionnaire's disease, the clinical challenge is
to recognize the diagnostic significance of Legionnaire's disease. The pretest
probability of Legionnaire's disease is increased if several characteristic
extrapulmonary findings are present. Similarly, if certain key findings are
absent, Legionnaire's disease may be eliminated from further diagnostic
consideration. If characteristic clinical findings are present, then specific
tests should be ordered to confirm or rule out Legionnaire's disease.
Department, Cambridge Health Alliance, Cambridge, MA, USA. firstname.lastname@example.org
Clin North Am 2017 Mar;31(1):69-80.
Most cardiac infections with Legionella are secondary to bacteremias
arising from a pulmonary focus. Other possible sites of origin are infected
sternotomy wounds or equipment contaminated by Legionella spp. Legionella
endocarditis is truly a "stealth" infection, with almost no hallmarks
of bacterial endocarditis. The key step in making the diagnosis of Legionella
endocarditis is for the physician to be aware of the clinical causes of
culture-negative infective endocarditis and to include Legionella cardiac
involvement in this differential. Many times the issue of endocarditis arises
only on examination of resected valvular material.
Cunha CB, Cunha
of Infectious Disease, Rhode Island Hospital, The Miriam Hospital, Brown
University Alpert School of Medicine, Providence, RI, USA. email@example.com
Infect Dis Clin North Am 2017 Mar;31(1):179-191.
Legionnaire's disease is a common cause of community-acquired pneumonia (CAP).
Although no single clinical feature is diagnostic, if characteristic
extrapulmonary findings are present a presumptive clinical syndromic diagnosis
is possible. Depending on geographic location, season, and physician awareness,
Legionnaire's disease may be included in the differential diagnosis of CAP. Some
antibiotics effective against Legionella sp are also effective in
treating the typical bacterial causes of CAP. From an antimicrobial stewardship
program (ASP) perspective, monotherapy is preferred to double-drug therapy. From
an ASP and pharmacoeconomic standpoint, monotherapy with doxycycline or a
respiratory quinolone provides optimal cost-effective therapy.
Magira EE, Zakynthinos S.
1st Department of Critical Care Medicine,
Evangelismos General Hospital, National and Kapodistrian University of Athens,
Athens, Greece. firstname.lastname@example.org
Clin North Am 2017 Mar;31(1):137-153.
Legionella pneumophila and influenza types A and B viruses can cause
either community-acquired pneumonia with respiratory failure, or Legionella infection
could attribute to influenza infection with potentially fatal prognosis.
Copathogenesis between pandemic influenza and bacteria is characterized by
complex interactions between coinfecting pathogens and the host. Understanding
the underlying reason of the emersion of the secondary bacterial infection
during an influenza infection is challenging. The dual infection has an impact
on viral control and may delay viral clearance. Effective vaccines and antiviral
therapy are crucial to increase resistance toward influenza, decrease the
prevalence of influenza, and possibly interrupt the potential secondary
Lanternier F, Ader F, Pilmis B, Catherinot E, Jarraud S, Lortholary
Hôpital Necker-Enfants malades, Centre d'Infectiologie Necker-Pasteur, IHU
Imagine, Université Paris Descartes, Paris, France. Fanny.email@example.com e firstname.lastname@example.org
Infect Dis Clin North Am 2017 Mar;31(1):123-135.
Legionnaire's disease (LD) is mainly reported in apparently immunocompetent
patients. Among them, risk factors include chronic lung disease and smoking.
However, LD is also well reported among immunocompromised patients, particularly
those treated with anti-tumor necrosis factor alpha therapy, patients with
hematological malignancy, and transplant patients. This article discusses the
available data on immunity against Legionella spp, epidemiology, clinical
presentation, diagnosis, and treatment of LD in immunocompromised patients.
Chahin A, Opal SM.
Care Division, Miriam Hospital, Brown University Alpert School of Medicine,
Providence, RI, USA. Abdullah_Chahin@brown.edu
Infect Dis Clin North Am 2017 Mar;31(1):111-121.
Severe legionella pneumonia poses a diagnostic challenge and requires early
intervention. Legionnaire's disease can have several presenting signs, symptoms,
and laboratory abnormalities that suggest that Legionella pneumophila is
the pathogen, but none of these are sufficient to distinguish L. pneumophila
pneumonia from other respiratory pathogens. L. pneumophila is primarily
an intracellular pathogen and needs treatment with antibiotics that efficiently
enter the intracellular space.
Htwe TH, Khardori NM.
Sentara Infectious Diseases Specialists,
Sentara Medical Group, Norfolk, VA, USA. TinHanHtwe@gmail.com
Infect Dis Clin North Am 2017 Mar;31(1):29-42.
Immunosuppressive agents predispose patients to legionnaire's disease. Patients
receiving tumor necrosis factor antagonists are generally not severely
immunocompromised by the underlying disease. In patients with malignancy
receiving immunosuppressive therapies, it is difficult to balance the underlying
disease versus the therapy used. Transplant recipients are often on multiple
drugs, including immunosuppressants. It seems that immunosuppressive drugs add
to the risk for legionella infection. The index of suspicion should be high for
legionella infection early during a compatible clinical syndrome. The control of
Legionella species and prevention of transmission should be the foremost
goal in protecting susceptible populations from Legionnaire's disease.
Sidney Kimmel Medical College of Thomas
Jefferson University, Summit, NJ, USA. John.email@example.com
Clin North Am 2017 Mar;31(1):55-68.
Sikora A, Gładysz
I, Kozioł-Montewka M, Wójtowicz-Bobin M, Stańczak T, Matuszewska R,
Department of Medical Microbiology,
Medical University of Lublin, Poland.
Agric Environ Med 2017 Mar;24(1):66-69.
Introduction and objective: Several
studies have reported therapy failures in patients with Legionnaires’ disease;
however, antimicrobial resistance of clinical and environmental isolates of Legionella
spp. has not yet been documented. Routine susceptibility testing of Legionella
spp. is not recommended because of difficulties in determining standard minimal
inhibitory concentration values. The purpose of this study was to analyze the
antimicrobial susceptibility of Legionella pneumophila strains isolated
from a water supply system. Materials and
isolates of L. pneumophila (16-L. pneumophila SG 1, 12-L.
pneumophila SG 2-14) obtained from water systems in public buildings in
Poland were tested. Susceptibility testing was performed using the E-test method.
The tested antibiotic were azithromycin, ciprofloxacin, and rifampicin. The
medium used for the susceptibility testing was BCYE-, a special medium for Legionella
cultivation. Results: Among
the tested strains, L. pneumophila was the only one resistant to
azithromycin. It was a strain of L. pneumophila SG 2-14 isolated from the
water system in a sanitorium. All isolates were found to be sensitive to
ciprofloxacin and rifampicin. However, the azithromycin-resistant strain
exhibited higher ciprofloxacin and rifampicin MIC (1.5 μg/ml,
and 0.19 μg/ml,
respectively). The MIC50 for azithromycin, ciprofloxacin, and rifampicin were
0.032, 0.125, and 0.003 μg/ml,
respectively. The MIC90 for azithromycin, ciprofloxacin, and rifampicin were
0.032, 0.125, and 0.003 μg/ml,
respectively. Conclusions: Azithromycin
resistance was found in one strain of L. pneumophila SG 2-14, but the
resistance mechanism is unknown and needs further study. It is possible that
therapeutic failures in Legionnaires' disease may be associated with bacterial
resistance which should be taken into account. The antibiotic sensitivity
testing described in this study could be helpful in detecting the resistance of
clinical L. pneumophila isolates. Ciprofloxacin and rifampicin have good
in vitro activity against environmental L. pneumophila SG 1 and SG 2-14
of Pathology and Laboratory Medicine, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, PA, USA. firstname.lastname@example.org
J Infect Chemother 2017 Jan;23(1):59-61.
A fatal case of Legionnaires' disease caused by Legionella jamestowniensis
is reported in a severely immunocompromised patient with metastatic
hepatocellular carcinoma, and liver and kidney transplants. L.
jamestowniensis was cultured from two separate respiratory tract specimens
and a PCR test for Legionella species was also positive from the same
specimens. This is apparently the first reported case of human infection caused
by L. jamestowniensis.
Bramley AM, Jain S, Arnold SR, Ampofo K, Self WH, Williams DJ, Anderson EJ,
Grijalva CG, McCullers JA, Pavia AT, Wunderink RG, Edwards KM, Winchell JM,
for Disease Control and Prevention, Atlanta, Georgia.
Open Forum Infect Dis 2017 Feb;4(1):ofx014.
collected after antibiotic exposure may reduce culture-based bacterial
detections. The impact on culture-independent diagnostic tests is unclear. We
assessed the effect of antibiotic exposure on both of these test results among
patients hospitalized with community-acquired pneumonia (CAP). Methods: Culture-based
bacterial testing included blood cultures and high-quality sputum or
endotracheal tube (ET) aspirates; culture-independent testing included urinary
antigen testing (adults) for Streptococcus pneumoniae and Legionella
pneumophila and polymerase chain reaction (PCR) on nasopharyngeal and
oropharyngeal (NP/OP) swabs for Mycoplasma pneumoniae and Chlamydia
pneumoniae. The proportion of bacterial detections was compared between
specimens collected before and after either any antibiotic exposure (prehospital
and/or inpatient) or only prehospital antibiotics and increasing time after
initiation of inpatient antibiotics. Results: Of
4678 CAP patients, 4383 (94%) received antibiotics: 3712 (85%) only inpatient,
642 (15%) both inpatient and prehospital, and 29 (<1%) only prehospital.
There were more bacterial detections in specimens collected before antibiotics
for blood cultures (5.2% vs 2.6%; P<.01) and sputum/ET cultures
(50.0% vs 26.8%; P<.01) but not urine antigen (7.0% vs 5.7%; P=.53)
or NP/OP PCR (6.7% vs 5.4%; P=.31). For all diagnostic testing,
bacterial detections declined with increasing time between inpatient antibiotic
administration and specimen collection. Conclusions: Bacteria
were less frequently detected in culture-based tests collected after antibiotics
and in culture-independent tests that had longer intervals between antibiotic
exposure and specimen collection. Bacterial yield could improve if specimens
were collected promptly, preferably before antibiotics, providing data for
improved antibiotic selection.
Peretz A, Lesnik R, Aizenberg-Gershtein Y, Rodríguez-Martínez S, Sharaby Y,
Pastukh N, Brettar I, Höfle MG, Halpern M.
of Evolutionary and Environmental Biology, Faculty of Natural Sciences,
University of Haifa, Mount Carmel, Haifa, Israel.
Sci Rep 2017 Jan;7:40114.
Bacteria of the genus Legionella cause water-based infections resulting
in severe pneumonia. Here we analyze and compare the bacterial microbiome of
sputum samples from pneumonia patients in relation to the presence and abundance
of the genus Legionella. The prevalence of Legionella species was
determined by culture, PCR, and Next Generation Sequencing (NGS). Nine sputum
samples out of the 133 analyzed were PCR-positive using Legionella
genus-specific primers. Only one sample was positive by culture. Illumina MiSeq
16S rRNA gene sequencing analyses of Legionella-positive and Legionella-negative
sputum samples, confirmed that indeed, Legionella was present in the
PCR-positive sputum samples. This approach allowed the identification of the
sputum microbiome at the genus level, and for Legionella genus at the
species and sub-species level. 42% of the sputum samples were dominated by Streptococcus.
Legionella was never the dominating genus and was always accompanied by
other respiratory pathogens. Interestingly, sputum samples that were Legionella
positive were inhabited by aquatic bacteria that have been observed in an
association with amoeba, indicating that amoeba might have transferred Legionella
from the drinking water together with its microbiome. This is the first study
that demonstrates the sputum major bacterial commensals and pathogens profiles
with regard to Legionella presence.