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Studi epidemiologici (2020 - 2017)
[ultimo aggiornamento 25/11/2020]
caused by water-born Legionella
pneumophila in a pediatric hematopoietic stem cell transplantation recipient
for thalassemia major
Özdemir H, Yahşi A, Kara TT, İnce EÜ, Memikoğlu KO, Çiftçi E,
Departments of Pediatric
Infectious Diseases, Ankara University Faculty of Medicine, Ankara, Turkey. email@example.com
Turk J Pediatr
Abstract: Background: Nosocomial pneumonia
caused by Legionella pneumophila
serogroup 2-14 occurred in a 7-year-old patient following allogeneic
hematopoietic stem cell transplantation for thalassemia major. Case: The
patient was diagnosed with nosocomial Legionella
pneumophila by polymerase chain reaction (PCR) examination of the
bronchoalveolar lavage and culturing Legionella
pneumophila serogroup 2-14 from the patient`s room faucet water. Legionella
pneumophila was eradicated from our hospital`s water distribution system by
superheating and chemical eradication methods (hyper-chlorination and hydrogen
peroxide). We did not detect any other case after this event. Conclusion: Early
recognition of contamination of the hospital water system with Legionella proves
the importance of prevention in new cases.
Legionnaires' Disease, Europe, 2008-2017
Plachouras D, Sandin S, Giesecke J, Sparén P.
European Centre for
Disease Prevention and Control, Stockholm, Sweden. firstname.lastname@example.org
Emerg Infect Dis 2020
Legionnaires' disease (HCA LD) can cause nosocomial outbreaks with high death
rates. We compared community-acquired LD cases with HCA LD cases in Europe
during 2008-2017 using data from The European Surveillance System. A total of 29
countries reported 40,411 community-acquired and 4,315 HCA LD cases. Of the HCA
LD cases, 2,937 (68.1%) were hospital-acquired and 1,378 (31.9%) were linked to
other healthcare facilities. The odds of having HCA LD were higher for women,
children and persons <20 years of age, and persons >60 years of age. Out
of the cases caused by Legionella pneumophila with a known serotype,
community-acquired LD was more likely to be caused by L. pneumophila serogroup 1
(92.3%) than was HCA LD (85.1%). HCA LD patients were more likely to die. HCA LD
is associated with specific patient demographics, causative strains, and
outcomes. Healthcare facilities should consider these characteristics when
designing HCA LD prevention strategies.
The burden of
legionnaires' disease in Belgium, 2013 to 2017
Devleesschauwer B, van Cauteren D, Lajot A, Leroy M, Laisnez V, Schirvel C,
Mahieu R, Pierard D, Michel C, Jacquinet S.
Epidemiology and Public Health, Sciensano, Brussels, Belgium. email@example.com
Arch Public Health 2020
Abstract: Background: Legionnaires' disease (LD)
is a severe bacterial infection causing pneumonia. Surveillance commonly
underestimates the true incidence as not all cases are laboratory confirmed and
reported to public health authorities. The aim of this study was to present
indicators for the impact of LD in Belgium between 2013 and 2017 and to estimate
its true burden in the Belgian population in 2017, the most recent year for
which the necessary data were available. Methods: Belgian
hospital discharge data, data from three infectious disease surveillance systems
(mandatory notification, sentinel laboratories and the national reference
center), information on reimbursed diagnostic tests from the Belgian National
Institute for Health and Disability Insurance and mortality data from the
Belgian statistical office were used. To arrive at an estimate of the total
number of symptomatic cases in Belgium, we defined a surveillance pyramid and
estimated a multiplication factor to account for LD cases not captured by
surveillance. The multiplication factor was then applied to the pooled number of
LD cases reported by the three surveillance systems. This estimate was the basis
for our hazard- and incidence-based Disability-Adjusted Life Years (DALYs)
calculation. To account for uncertainty in the estimations of the DALYs and the
true incidence, we used Monte Carlo simulations with 10,000 iterations. Results: We
found an average of 184 LD cases reported by Belgian hospitals annually
(2013-2017), the majority of which were male (72%). The surveillance databases
reported 215 LD cases per year on average, 11% of which were fatal within 90
days after diagnosis. The estimation of the true incidence in the community
yielded 2674 (95% Uncertainty Interval [UI]: 2425-2965) cases in 2017. LD caused
3.05 DALYs per case (95%UI: 1.67-4.65) and 8147 (95%UI: 4453-12,426) total DALYs
in Belgium in 2017, which corresponds to 71.96 (95%UI: 39.33-109.75) DALYs per
100,000 persons. Conclusions: This
analysis revealed a considerable burden of LD in Belgium that is vastly
underestimated by surveillance data. Comparison with other European DALY
estimates underlines the impact of the used data sources and methodological
approaches on burden estimates, illustrating that national burden of disease
studies remain essential.
Legionnaires' Disease on
the Rise in Switzerland: A Denominator-Based Analysis of National Diagnostic
Fischer FB, Schmutz C,
Gaia V, Mäusezahl D.
Faculty of Science,
University of Basel, Basel, Switzerland. firstname.lastname@example.org
Int J Environ Res Public
Health 2020 Oct 8;17(19):7343.
risk of falling ill with Legionnaires' disease (LD) is suggested to increase,
but the global burden of disease is unknown due to a lack of appropriate
diagnosis and surveillance systems. In Switzerland, the number of LD cases,
captured by the National Notification System for Infectious Diseases, has more
than doubled since 2008. This study aims to investigate this increase,
contextualizing disease surveillance data with denominator data, which is not
routinely available, i.e., the number of tests performed for Legionella spp.
We collected the testing data for Legionella spp. of 14 Swiss
diagnostic laboratories and calculated the positivity, defined as the proportion
of the number of positive tests to the number of tests performed. The number of
positive tests increased proportionally to the number of tests performed; hence,
the positivity remained stable. However, the cause of the increase in test
volume is unclear and has a large impact on the interpretation of the positivity
curve. Further, the test outcome was found to be dependent on regional
determinants, and the diagnostic method applied. The lack of understanding if
and at which stage LD is considered in current case management of pneumonia
patients limits the interpretation of observed heterogeneities in incidence or
underestimation of LD in Switzerland. The absence of (or non-adherence to)
existing guidelines and the heterogeneity in diagnostic testing hampers the
comparison of data in the Swiss public health context. Therefore, diagnostic
procedures should be harmonised across Switzerland and adherence to national LD
management guidelines supported.
Frequency of Mycoplasma
pneumoniae, Legionella pneumophila and Chlamydia spp.
among patients with atypical pneumonia in Tehran
Noori Goodarzi N, Pourmand
MR, Rajabpour M, Arfaatabar M, Mosadegh M, Syed Mohamad SA.
Pathobiology, School of Public Health, Tehran University of Medical Sciences,
Tehran, Iran. email@example.com
New Microbes New Infect
2020 Aug 14;37:100744.
pneumophila and Chlamydia pneumoniae are the most
common bacterial agents, which account for 15-40%, 2-15% and 5-10% of atypical
community-acquired pneumonia (CAP) respectively. These agents are mostly
associated with infection in the outpatient setting. The aim of this study was
to evaluate the frequency of these pathogens among patients with CAP attending
outpatient clinics in Tehran. A cross-sectional study was carried out of 150
patients attending to educational hospitals in Tehran with CAP. M.
pneumoniae, L. pneumophila and Chlamydia spp.
were detected by PCR assay, targeting the P1 adhesion gene,
macrophage infectivity potentiator (mip) gene and 16S rRNA gene
respectively from throat swabs obtained from each patient. A total of 86 (57.3%)
of 150 patients were women; median age was 50 years (interquartile range, 35-65
years). M. pneumoniae, L. pneumophila and Chlamydia spp.
were detected in 37 (24.7%), 25 (16.7%) and 11 (7.3%) patients respectively; of
these, 66 patients (44%) were infected at least by one of these three pathogens.
The frequency of L. pneumophila was significantly higher among
patients over 60 years old (p 0.03). Coinfection was detected in seven patients
(4.7%); six were infected by M. pneumoniae and L.
pneumophila, and only one was infected by L. pneumophila and Chlamydia spp. M.
pneumoniae was the most prevalent agent of atypical CAP, and L.
pneumophila was more likely to infect elderly rather than younger
people. Further studies on the prevalence of CAP and its aetiologic agents are
needed to improve the diagnosis and treatment of CAP patients.
Legionnaires' Disease, Hong Kong, China, 2005-2015
Lam CK, Cheung YY, Chan CW, Chuang SK.
Hong Kong Department of
Health, Hong Kong, China. firstname.lastname@example.org
Emerg Infect Dis 2020
reviewed findings of clinical, epidemiologic, and environmental investigations
for 288 confirmed case-patients with Legionnaires' disease reported in Hong
Kong, China, during January 2005-December 2015. We found that chronic renal
failure/impairment (adjusted odds ratio [aOR] 4.09), chronic pulmonary diseases
(aOR 3.22), malignancy (aOR 3.04), and heart diseases (aOR 2.15) were
independently associated with a higher risk for severe Legionnaires' disease.
However, patients with hyperlipidemia had a lower risk for severe outcome (aOR
0.17). Legionella positivity rate was 22% for 1,904 water samples collected. We
found a higher positivity rate in summer months (28%-30%), which corroborated
with months of highest rainfalls. Our novel finding that Legionnaires' disease
patients with hyperlipidemia had a lower risk for severe outcome deserves
further study to confirm the observation and ascertain the underlying reason.
increased risk after COVID-19 lockdown? Italy,
May to June 2020
Palazzolo C, Maffongelli G, D'Abramo A, Lepore L,
Mariano A, Vulcano A, Bartoli TA, Bevilacqua N, Giancola ML, Di Rosa E, Nicastri
Institute for Infectious Diseases ‘Lazzaro Spallanzani’ IRCCS, Rome, Italy. email@example.com
report a case of Legionella pneumonia in a dishwasher of a
restaurant in Rome, Italy, just after the end of the lockdown that was in place
to control the SARS-CoV-2 epidemic. The case highlights the importance of strict
monitoring of water and air systems immediately before reopening business or
public sector buildings, and the need to consider Legionella infections
among the differential diagnosis of respiratory infections after lockdown due to
the ongoing COVID-19 pandemic.
Exposure to potting
soils and compost material as potential sources of Legionella
pneumophilia in Australia
Respiratory Medicine, Gosford Hospital, Gosford, New South Wales, Australia. firstname.lastname@example.org
Respir Med Case Rep 2020
disease is a form of atypical community-acquired pneumonia usually caused by Legionella
pneumophilia, which is typically associated with exposure to tower
cooling or water systems. In Australia, Legionnaires' disease is more commonly
caused by Legionella longbaechae, which is typically associated
with exposure to soil or compost materials, and the presence of Legionella pneumophilia is
less recognized. We report a sporadic case of Legionnaires' disease caused by Legionella pneumophilia serogroup
1 that was contracted following exposure to potting mix and topsoil.
Trends in Legionnaires'
Disease-Associated Hospitalizations, United States, 2006-2010
Mudali G, Kilgore PE, Salim A, McElmurry SP, Zervos
of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences,
Wayne State University, Detroit, Michigan, USA. email@example.com
Open Forum Infect Dis
2020 Jul 17;7(8):ofaa296.
Abstract: Background: Legionella pneumophila is
a waterborne cause of both healthcare-associated and community-acquired
pneumonia. Legionella pneumophila serogroup 1 is responsible
for 80% of infections. There is currently limited published disease burden data
on Legionnaires' disease-associated hospitalization in the United States. Methods: In
this study, we estimated the annual incidence of Legionnaires'
disease-associated hospitalizations in United States and identified demographic,
temporal, and regional characteristics of individuals hospitalized for
Legionnaires' disease. A retrospective study was conducted using the National
Hospital Discharge Survey (NHDS) data from 2006 to 2010. The NHDS is a
nationally representative US survey, which includes estimates of inpatient stays
in short-stay hospitals in the United States, excluding federal, military, and
Veterans Administration hospitals. All discharges assigned with the
Legionnaires' disease International Classification of Diseases 9th
Clinical Modification discharge diagnostic code (482.84) were included
in this study. Results: We observed the annual incidence and number of
Legionnaires' disease-associated hospitalizations (per 100 000 population) in
the United States by year, age, sex, race, and region. Over a 5-year period, 14
574 individuals experienced Legionnaires' disease-associated hospitalizations in
the United States The annual population-adjusted incidence (per 100 000
population) of Legionnaires' disease-associated hospitalizations was 5.37 (95%
confidence interval [CI], 5.12-5.64) in 2006, 7.06 (95% CI, 6.80-7.40) in 2007,
8.77 (95% CI, 8.44-9.11) in 2008, 17.07 (95% CI, 16.62-17.54) in 2009, and 9.66
(95% CI, 9.32-10.01) in 2010. A summer peak of Legionnaires' disease-associated
hospitalizations occurred from June through September in 2006, 2007, 2008, and
2010. Conclusions: Legionnaires'
disease-associated hospitalizations significantly increased over the 5-year
study period. The increasing disease burden of Legionnaires' disease suggests
that large segments of the US population are at risk for exposure to this
Legionnaires' Disease through Toilet Flushing
Ginevra C, Nesa D, Adam M, Gouot C, Descours G, Campèse C, Battipaglia G,
Brissot E, Beraud L, Ranc AG, Jarraud S, Barbut F.
Paris, France. firstname.lastname@example.org
Emerg Infect Dis 2020
describe 2 cases of healthcare-associated Legionnaires' disease in patients in
France hospitalized 5 months apart in the same room. Whole-genome sequencing
analyses showed that clinical isolates from the patients and isolates from the
room's toilet clustered together. Toilet contamination by Legionella pneumophila could lead to a risk for exposure through
Legionnaires' disease outbreak caused by Legionella pneumophila serogroup
1, Italy, July to August 2018
Russo AG, Bonini M, Tunesi S, Murtas R, Sandrini M, Senatore S, Lamberti A,
Ciconali G, Cammarata S, Barrese E, Ceriotti V, Vitaliti S, Foti M, Gentili G,
Graziano E, Panciroli E, Bosio M, Gramegna M, Cereda D, Perno CF, Mazzola E,
Campisi D, Aulicino G, Castaldi S, Girolamo A, Caporali MG, Scaturro M, Rota MC,
for Health Protection of Metropolitan Area of Milan (ATS), Milan, Italy. email@example.com
Surveill 2020 May;25(20):1900523.
In July 2018, a large outbreak of Legionnaires' disease
(LD) caused by Legionella pneumophila serogroup 1 (Lp1)
occurred in Bresso, Italy. Fifty-two cases were diagnosed, including five deaths.
We performed an epidemiological investigation and prepared a map of the places cases
visited during the incubation period. All sites identified as potential sources
were investigated and sampled. Association between heavy rainfall and LD cases
was evaluated in a case-crossover study. We also performed a case-control study
and an aerosol dispersion investigation model. Lp1 was isolated from 22 of 598
analysed water samples; four clinical isolates were typed using monoclonal
antibodies and sequence-based typing. Four Lp1 human strains were ST23, of which
two were Philadelphia and two were France-Allentown subgroup. Lp1 ST23
France-Allentown was isolated only from a public fountain. In the case-crossover
study, extreme precipitation 5-6 days before symptom onset was associated with
increased LD risk. The aerosol dispersion model showed that the fountain matched
the case distribution best. The case-control study demonstrated a significant
eightfold increase in risk for cases residing near the public fountain. The
three studies and the matching of clinical and environmental Lp1 strains
identified the fountain as the source responsible for the epidemic.
A Snapshot of the
Prevalence and Molecular Diversity of Legionella pneumophila in
the Water Systems of Israeli Hotels
Yakunin E, Kostyal E, Agmon V, Grotto I, Valinsky L, Moran-Gilad
Central Laboratories and
Public Health Services, Ministry of Health, Jerusalem 9134302, Israel. firstname.lastname@example.org
Pathogens 2020 May
to Legionella spp. contaminated aerosols in hotel settings
confers risk for travel-associated Legionnaire's disease (TALD). In this study,
we investigated the prevalence of Legionella contamination and
its molecular diversity in hotels and resorts across Israel. The study was
comprised of a convenience sample of water systems from 168 hotels and resorts
countrywide, routinely inspected between March 2015 and February 2017. Isolation
and quantitation of Legionella were performed in a water
laboratory using the ISO 11731 method. The distribution of Legionella isolates
was analyzed according to geography and source. The genetic diversity of a
subset of isolates was analyzed by sequence-based typing (SBT) at the National
Reference Laboratory for Legionella and compared to the
national database. Out of 2830 samples tested, 470 (17%) obtained from 102
different premises (60% of hotels) were positive for Legionella spp.
In 230 samples (49% of all positive, 8% of total samples), accounting for 37% of
hotels, Legionella spp. counts exceeded the regulatory
threshold of 1000 CFU/L. The most frequently contaminated water sources were
cooling towers (38%), followed by faucets, hot tubs, water lines, and storage
tanks (14%-17% each). Furthermore, 32% and 17% of samples obtained from cooling
towers and hot tubs, respectively, exceeded the regulatory thresholds. SBT was
performed on 78 strains and revealed 27 different sequence types (STs),
including two novel STs. The most prevalent STs found were ST1 (26%), ST87
(10%), ST93 (6%), and ST461 and ST1516 (5% each). Several L. pneumophila STs
were found to be limited to certain geographical regions. This is the first
study to investigate the prevalence and diversity of Legionella in
hotels and resorts in Israel during non-outbreak environmental inspections.
These findings will inform risk assessment, surveillance, and control measures
Epidemiologic Survey of
Legionella Urine Antigen Testing Within a Large Wisconsin-Based Health Care
Toberna CP, William HM,
Kram JJF, Heslin K, Baumgardner DJ.
Aurora Sinai Medical Center, Milwaukee, WI, USA. email@example.com
J Patient Cent Res Rev
2020 Apr 27;7(2):165-175.
Abstract: Purpose: Legionella
pneumophila pneumonia is a life-threatening,
environmentally acquired infection identifiable via Legionella urine antigen
tests (LUAT). We aimed to identify cumulative incidence, demographic
distribution, and undetected disease outbreaks of Legionella pneumonia via
positive LUAT in a single eastern Wisconsin health system, with a focus on urban
Milwaukee County. Methods: A
multilevel descriptive ecologic study was conducted utilizing electronic medical
record data from a large integrated health care system of patients who underwent
LUAT from 2013 to 2017. A random sample inclusive of all positive tests was
reviewed to investigate geodemographic differences among patients testing
positive versus negative. Statistical comparisons used chi-squared or 2-sample
t-tests; stepwise regression followed by binary logistic regression was used for
multivariable analysis. Positive cases identified by LUAT were mapped to locate
hotspots; positive cases versus total tests performed also were mapped by zip
code. Results: Of all LUAT
performed (n=21,599), 0.68% were positive. Among those in the random sample
(n=11,652), positive cases by LUAT were more prevalent in the June-November time
period (86.2%) and younger patients (59.4 vs 67.7 years) and were
disproportionately male (70.3% vs 29.7%) (P<0.0001 for each). Cumulative
incidence was higher among nonwhite race/ethnicity (1.91% vs 1.01%, P<0.0001)
but did not remain significant on multivariable analysis. Overall, 5507 tests
were performed in Milwaukee County zip codes, yielding 82 positive cases by LUAT
(60.7% of all positive cases in the random sample). A potential small 2016
outbreak was identified. Conclusions: Cumulative
incidence of a positive LUAT was less than 1%. LUAT testing, if done in real
time by cooperative health systems, may complement public health detection of
Legionella pneumonia outbreaks.
Review Global seroprevalence of legionellosis - a
systematic review and meta-analysis
Graham FF, Hales S, White PS, Baker MG.
Department of Public Health, University of Otago, Wellington,
New Zealand. firstname.lastname@example.org
Sci Rep 2020 Apr 30;10(1):7337.
Abstract: Legionella is a ubiquitous pathogen yet the global
occurrence of legionellosis is poorly understood. To address this deficit, this
paper summarises the available evidence on the seroprevalence of Legionella
antibodies and explores factors that may influence seroprevalence estimates.
Through a systematic review, a total of 3979 studies were identified with
seroprevalence results published after 1 January 1990. We tabulated findings by
World Health Organization (WHO) region, location, study period and design,
composition of study population(s) for all ages in terms of exposure, sex,
detection methods, IFA titre, Legionella species measured, and present
seroprevalence point estimates and 95% confidence intervals. Sampled populations
were classified according to income, WHO region, gender, age, occupation and
publication date. We conducted a meta-analysis on these subgroups using
Comprehensive Meta-Analysis 3.0 software. Heterogeneity across studies was
evaluated by the Q test in conjunction with I2 statistics.
Publication bias was evaluated via funnel plot and Egger's test. Fifty-seven
studies met our inclusion criteria, giving an overall estimate of seroprevalence
for Legionella of 13.7% (95% CI 11.3-16.5), but with substantial heterogeneity
probability-weighted incubation period distributions to traditional wind rose
methodology to improve public health investigations of Legionnaires' disease
Bennett E, Finnie T.
Public Health England,
Manor Farm Road, Porton Down, Salisbury, UK. email@example.com
Epidemiol Infect 2020
the event of a Legionnaires' disease outbreak, rapid location and control of the
source of bacteria are crucial for outbreak management and regulation. In this
paper, we describe an enhancement of the traditional wind rose for
epidemiological use; shifting the focus of measurement from relative frequency
of the winds speeds and directions to the relative volume of air carried, whilst
also incorporating probability distributions of disease incubation periods to
refine identification of the important wind directions during a cases window of
exposure, i.e. from which direction contaminated aerosols most likely originated.
The probability-weighted wind rose offers a potential improvement over the
traditional wind rose by weighting the importance of wind measurements through
incorporation of probability of exposure given an individual's time of symptom
onset (obtained through knowledge of the incubation period), and by instead
focusing on the volume of carrying air which offers better insight into the most
probable direction of the source. This then provides a probabilistic
distribution of which direction the wind was blowing around the time of
infection. We discuss how the probability-weighted wind rose can be implemented
during a Legionnaires' disease outbreak, and how outbreak control teams might
use it as supportive evidence to identify the most likely direction of the
contaminated source from the presumed site of exposure. In addition, this paper
discusses how minor adjustments can be made to the method allowing the
probability-weighted wind rose to be applied to other non-communicable airborne
diseases, providing the disease's probability distribution for the incubation
period distribution is well known.
Fatal Case of
Legionnaires' Disease After Home Exposure to Legionella
pneumophila Serogroup 3 - Wisconsin, 2018
Schumacher A, Kocharian
A, Koch A, Marx J.
Bureau of Communicable
Diseases, Division of Public Health, Wisconsin Department of Health Services. firstname.lastname@example.org
MMWR Morb Mortal Wkly
Rep 2020 Feb 28;69(8):207-211.
January 2018, the Wisconsin Department of Health Services, Division of Public
Health (DPH), received a report of a culture-confirmed case of Legionnaires'
disease. The patient, who was immunocompromised, had died at a local hospital 10
days after being admitted. DPH and an infection preventionist from the hospital
investigated to determine the source of the infection and prevent additional
cases. Because the case was suspected to be nosocomial, health care facility
water samples were tested for Legionella. When these samples were negative,
water sources in the patient's home were tested. These tested positive for Legionella
pneumophila, and the bacteria remained after an attempt to remediate. The
patient and home isolates were identified as L.
pneumophila serogroup 3, sequence type 93, by whole-genome multilocus
sequence typing. A second resident of the home did not become ill. This case
highlights the potential for immunocompromised persons and others at risk for
Legionnaires' disease to be exposed to Legionella through home water systems
containing the bacteria and demonstrates the difficulty of home remediation.
This case also illustrates the role of lower respiratory tract specimens in the
identification of less common Legionella infections (e.g., L.
pneumophila serogroup 3) and confirmation of the infection source.
The relevance of molecular genotyping to allocate
cases in a suspected outbreak of Legionella
pneumonia in patients with prolonged immunosuppressive therapy
Borella P, Vecchi E, Incerti F,
Marchesi I, Meacci M, Frezza G, Fregni Serpini G, Mansi A, Paduano S, Bargellini
Department of Biomedical,
Metabolic and Neural Sciences, Section of Public Health, University of Modena
and Reggio Emilia, Modena, Italy. email@example.com
Int J Infect Dis 2020 Feb;91:174-176.
Abstract: Three cases of pneumonia caused by Legionella pneumophila serogroup 1 (Lp1) in immunosuppressed
patients with repeated hospitalization were suspected as a healthcare-associated
cluster. The environmental investigation did not reveal the presence of
legionellae in the hospital patient rooms. Water samples collected from the
homes of two patients were also negative for Legionella
spp. In the absence of environmental strains potentially involved in the
infections, we proceeded to genotype environmental Lp1 strains isolated in the
hospital during routine water sampling during the decade 2009-2019 and recovered
after long-term storage at -20°C. These 'historical' strains exhibited a high
grade of similarity and stability over time, regardless of the disinfection
systems. The different molecular profiles shown among the clinical and
environmental strains excluded a nosocomial outbreak. The study suggests that
the application of molecular typing may be a useful tool to discriminate
hospital vs community-acquired cases, mostly for severely immunosuppressed
patients in whom the symptomatology could be insidious and the incubation period
could be prolonged. Moreover, the genotyping allowed us to exclude any link
between the cases.
Cases at a Large Community Hospital-Common and Underdiagnosed
Pedutem T, Francisco MJ.
Humber River Hospital,
Toronto, ON, Canada. firstname.lastname@example.org
Int J Environ Res Public
Health 2020 Jan 3;17(1):332.
disease (LD) is a severe pneumonia with a mortality rate of about 10%. The
illness remains largely underdiagnosed with outbreaks occurring with alarming
incidence. In this study, we assessed the frequency of Legionnaires' disease
among pneumonia cases treated at a large community hospital over a summer
season. We invited all admitted patients diagnosed with pneumonia, able to
provide a urine sample for an antigen test, presenting from May to October 2018,
to enroll in our study; 35 patients were tested for the presence of Legionella.
Out of 33 patients tested, 9 (28%) were positive for Legionella.
Three sets of the 9 Legionella cases exhibited spatiotemporal clustering
indicative of LD outbreaks. Only one of the 9 Legionella UAT-positive
patients presented a sporadic case of LD. The number of pneumonia cases in our
community confirmed to be LD was strikingly high (28%), compared to other survey
studies that report between 3.7% and 14%. These results are consistent with
previous knowledge that LD is underdiagnosed and support that routine testing
should be considered for all possible LD cases, particularly in the summer
months. Such testing is likely to prevent further cases of community acquired
Residential water heater cleaning and occurrence of Legionella in
Rhoads WJ, Bradley TN, Mantha
A, Buttling L, Keane T, Pruden A, Edwards MA.
Civil and Environmental Engineering, Blacksburg, VA, USA. email@example.com
Water Res 2020
Abstract: After the Federal emergency in Flint, MI was declared in early 2016 in response to elevated lead-in-water and incidence of Legionnaires' disease, concerns arose that contaminants in residential water heaters could continue to contribute to poor quality tap water. Here, a comprehensive field survey of residential water heaters (n = 30) and associated water quality was conducted and the subsequent effects of an aggressive manual water heater clean-out was determined, including draining the tank and removing sediments via brushing and flushing. Before cleaning, inorganics accumulated in the tank sediments did not serve as a source of metals measured at hot water outlets. After cleaning, hardness- (calcium, magnesium, silica) and corrosion-associated inorganics (lead, iron, copper, aluminum, zinc) decreased by 64% in samples from sediment cleanout drain valves. Culturable L. pneumophila was only detected in 1 home (3.3%) prior to cleaning and 2 homes (6.7%) after cleaning, thus quantitative polymerase chain reaction was used to quantify potential effects on unculturable strains despite the limitation of differentiating live and dead cells. After the cleaning protocol, Legionella spp. and L. pneumophila gene numbers decreased or remained non-detectable in 83% and 98% of samples, respectively. Homes with less than 0.4 mg/L influent free chlorine tended to have quantifiable Legionella spp. gene numbers in water entering the home and had elevated L. pneumophila and Legionella spp. gene numbers throughout the home plumbing. Also, Legionella spp. and L. pneumophila gene numbers were highest for water heaters set at or below 42 °C and significantly decreased >51°C, consistent with Legionella's preferred temperature range. Examination of the only home that had culturable L. pneumophila both before and after the cleaning protocol revealed that the organism was culturable from several sample locations throughout the home, including in water representative of the water main. Notably, the home was located in close proximity to McLaren Hospital, where an outbreak of Legionnaires disease was reported, and the water heater had a setpoint within the Legionella growth range of 44.2 °C. Considering that other factors were more strongly associated with Legionella occurrence and water heater sediment was not detectably mobilizing to tap water, it was concluded that water heater cleaning had some benefits, but was not an overarching factor contributing to possible human health risks.
Clinical Presentation of Community-Acquired Legionella Pneumonia
Identified by Universal Testing in an Endemic Area
Puri S, Boudreaux-Kelly M, Walker JD, Clancy CJ, Decker
Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; Division of Infectious
Diseases, University of Pittsburgh, Pittsburgh, PA 15261, USA. firstname.lastname@example.org
Int J Environ Res Public Health 2020 Jan;17(2):E533.
Abstract: The rapid identification of Legionella pneumonia
is essential to optimize patient treatment and outcomes, and to identify
potential public health risks. Previous studies have identified clinical factors
which are more common in Legionella than non-Legionella pneumonia,
and scores have been developed to assist in diagnosing cases. Since a Legionella pneumonia
outbreak at VA Pittsburgh in 2012, nearly all patients with pneumonia have been
tested for Legionella. The purpose of this study was to evaluate
distinguishing characteristics between Legionella and non-Legionella pneumonia
with the application of universal testing for Legionella in all
cases of community-acquired pneumonia. We performed a retrospective case-control
study matching Legionella and non-Legionella pneumonia
cases occurring in the same month. Between January 2013 and February 2016, 17 Legionella and
54 non-Legionella cases were identified and reviewed. No tested
characteristics were significantly associated with Legionella cases
after Bonferroni correction. Outcomes of Legionella and non-Legionella pneumonia
were comparable. Therefore, in veterans who underwent routine Legionella testing
in an endemic area, factors typically associated with Legionella pneumonia
Legionnaires' Disease Cases at a Large Community
Hospital-Common and Underdiagnosed
Spiegelman J, Pedutem T, Francisco
Humber River Hospital, Toronto, ON M3M 0B2, Canada. email@example.com
Int J Environ Res Public Health 2020 Jan;17(1):332.
Abstract: Legionnaires' disease (LD) is a
severe pneumonia with a mortality rate of about 10%. The illness remains largely
underdiagnosed with outbreaks occurring with alarming incidence. In this study,
we assessed the frequency of Legionnaires' disease among pneumonia cases treated
at a large community hospital over a summer season. We invited all admitted
patients diagnosed with pneumonia, able to provide a urine sample for an antigen
test, presenting from May to October 2018, to enroll in our study; 35 patients
were tested for the presence of Legionella. Out of 33 patients
tested, 9 (28%) were positive for Legionella. Three sets of the 9 Legionella cases
exhibited spatiotemporal clustering indicative of LD outbreaks. Only one of the
9 Legionella UAT-positive patients presented a sporadic case of
LD. The number of pneumonia cases in our community confirmed to be LD was
strikingly high (28%), compared to other survey studies that report between 3.7%
and 14%. These results are consistent with previous knowledge that LD is
underdiagnosed and support that routine testing should be considered for all
possible LD cases, particularly in the summer months. Such testing is likely to
prevent further cases of community acquired LD.
Pieper KJ, Dai D, Pruden A,
Edwards MA, Tang M, Rhoads
Virginia Tech, Civil
and Environmental Engineering, Blacksburg, VA, USA.
Appl Microbiol 2020;70(4):232-240.
Abstract: Unregulated private wells are understudied potential sources of
community-acquired Legionnaires' disease. Here we conducted a comprehensive
survey of 44 homes supplied by private wells in Wake County, North Carolina,
quantifying Legionella spp. DNA, Legionella pneumophila DNA, and
total bacterial 16S rRNA genes via real-time polymerase chain reaction in hot
and cold drinking water samples, along with culturable L. pneumophila via
IDEXX Legiolert in cold drinking water samples. Legionella spp. DNA, L.
pneumophila DNA and culturable L. pneumophila were detected in 100,
65.5 and 15.9% of the 44 homes, respectively, and culturable levels were
comparable to some municipal surveys applying the same methods. Total coliforms
and Escherichia coli were monitored as representative faecal indicators
and were found in 20.4 and 0.0% of homes. Within certain sample types, Legionella
spp. and L. pneumophila gene copy numbers were positively associated with
total bacteria (i.e. total 16S rRNA genes) and water softener use, but were not
associated with faecal indicator bacteria, inorganic water parameters or other
well characteristics. These findings confirm that occurrence of Legionella
and L. pneumophila is highly variable in private wells. SIGNIFICANCE AND
IMPACT OF THE STUDY: Legionella is the leading identified cause of
waterborne disease outbreaks associated with US municipal water systems. While Legionella
is known to occur naturally in groundwater, prior efforts to characterize its
occurrence in unregulated private wells are limited to sampling at the wellhead
and not in the home plumbing where Legionella can thrive. This work
documents much higher levels of Legionella in home plumbing versus water
directly from private wells and examines factors associated with higher Legionella
Yi H,,, Liu B,, Zhou M.
Shanghai, China. firstname.lastname@example.org
Infect Dis Jan 2020;26(1):160-162.
Abstract: We report a case of community-acquired pneumonia
in a patient in China. We verified Legionella pneumophila infection
through next-generation sequencing of blood, sputum, and pleural effusion
samples. Our results show the usefulness of next-generation sequencing and of
testing different samples early in the course of illness to identify this
Hammami N, Laisnez V,
Wybo I, Uvijn D,
Broucke C, Van Damme
A, Van Zandweghe L,
Bultynck W, Temmerman W, Van
De Ginste L, Moens T, Robesyn
European Centre for Disease Prevention and Control,
Surveillance and Response Support Unit, Stockholm, Sweden; Department of Global
Public Health, Karolinska Institutet, Stockholm, Sweden. Emmanuel.Robesyn@ecdc.europa.eu
Epidemiol Infect 2019 Dec;147:e326.
A cluster of Legionnaires' disease (LD) with 10 confirmed, three probable and
four possible cases occurred in August and September 2016 in Dendermonde,
Belgium. The incidence in the district was 7 cases/100 000 population, exceeding
the maximum annual incidence in the previous 5 years of 1.5/100 000.
Epidemiological, environmental and geographical investigations identified a
cooling tower (CT) as the most likely source. The case risk around the tower
decreased with increasing distance and was highest within 5 km. Legionella
pneumophila serogroup 1, ST48, was identified in a human respiratory sample
but could not be matched with the environmental results. Public health
authorities imposed measures to control the contamination of the CT and
organised follow-up sampling. We identified obstacles encountered during the
cluster investigation and formulated recommendations for improved LD cluster
management, including faster coordination of teams through the outbreak control
team, improved communication about clinical and environmental sample analysis,
more detailed documentation of potential exposures obtained through the case
questionnaire and earlier use of a geographical information tool to compare
potential sources and for hypothesis generation.
Smith AF,, Dorevitch S,
Heijnen L, Arntzen VH,
Davies M, Robert-Du Ry van Beest Holle M,
Fujita Y, , Raterman B,
Oesterholt F, Heederik D,
KWR Water Research Institute, Nieuwegein,
Environ Health Perspect
Abstract: Background: A
community-wide outbreak of Legionnaires' disease (LD) occurred in Genesee County,
Michigan, in 2014 and 2015. Previous reports about the outbreak are conflicting
and have associated the outbreak with a change of water source in the city of
Flint and, alternatively, to a Flint hospital. Objective: The
objective of this investigation was to independently identify relevant sources
of Legionella pneumophila that likely resulted in the outbreak.
independent, retrospective investigation of the outbreak was conducted, making
use of public health, health care, and environmental data and whole-genome
multilocus sequence typing (wgMLST) of clinical and environmental isolates. Results: Strong
evidence was found for a hospital-associated outbreak in both 2014 and 2015: a)
49% of cases had prior exposure to Flint hospital A, significantly higher than
expected from Medicare admissions; b) hospital plumbing contained
high levels of L. pneumophila; c) Legionella control
measures in hospital plumbing aligned with subsidence of hospital A-associated
cases; and d) wgMLST showed Legionella isolates
from cases exposed to hospital A and from hospital plumbing to be highly similar.
Multivariate analysis showed an increased risk of LD in 2014 for people residing
in a home that received Flint water or was located in proximity to several Flint
cooling towers. Discussion: This
is the first LD outbreak in the United States with evidence for three sources
(in 2014): a) exposure to hospital A, b) receiving Flint
water at home, and c) residential proximity to cooling towers;
however, for 2015, evidence points to hospital A only. Each source could be
associated with only a proportion of cases. A focus on a single source may have
delayed recognition and remediation of other significant sources of L.
Wolff C, Lange H, Feruglio S, Vold L, MacDonald E
Division for Environmental Health and Infectious Disease Control,
Norwegian Institute of Public Health, Oslo, Norway. email@example.com
Health 2019 Dec;19(1):1624.
Abstract: Background: In
Norway, Legionnaires' disease is reportable upon clinical suspicion to public
health authorities and mandatorily notifiable through the Norwegian surveillance
system for communicable diseases (MSIS) for both clinicians and laboratories. In
the summer of 2017, several European countries reported high notification rates
for Legionnaires' disease, which was not observed in Norway. We evaluated MSIS
to assess if it meets its objectives of detecting cases and trends in incidence
of Legionnaires' disease. Methods: We
retrieved MSIS data from 2008 to 2017 and calculated timeliness as days from
sampling to notification, and internal completeness for key variables as the
proportion of observations with a value. Where possible, we assessed internal
validity on the presence of a plausible value. To estimate external completeness
and validity we linked MSIS with hospital reimbursement claims in the Norwegian
Patient Registry. To assess acceptability and representativeness, we surveyed
doctors in 39 hospitals on their units' diagnostic and notification procedures,
and their use of MSIS. Results: There
were 438 notified cases. Internal completeness and internal validity were high
for key variables (≥95%). The median delay from sampling to notification
was 4 days. There were 73 patients in MSIS only, 70 in the Norwegian Patient
Registry only, and 351 in both registers. The external completeness of MSIS was
83% (95% CI 80-86%). For external validity, the positive predictive value of
MSIS was 83% (95% CI 79-86%). Forty-seven respondents from 28 hospitals
described testing procedures. These were inconsistent: 29 (62%) reported no
systematic application of criteria for requesting legionella testing.
Eighteen (38%) reported testing all patients with suspected pneumonia and a
travel history. Thirty-one (66%) found the notification criteria clear. Conclusions: Our results suggest that
the surveillance in MSIS can detect incidence changes for Legionnaires' disease
over time, by place and person, but likely does not detect every case diagnosed
in Norway. We recommend wider investigation of diagnostic procedures in order to
improve representativeness and awareness of MSIS notification criteria among
clinicians in order to improve acceptability of the surveillance. We also
recommend a more comprehensive assessment of whether patients only registered in
the Norwegian Patient Registry were true Legionnaires' disease cases.
Legionella and Legionellosis in
Touristic-Recreational Facilities: Influence of Climate Factors and
Geostatistical Analysis in Southern Italy (2001-2017)
De Giglio O,
Fasano F, Diella G, Lopuzzo M, Napoli C, Apollonio F, Brigida S, Calia C,
Campanale C, Marzella A, Pousis C, Rutigliano S, Triggiano F, Caggiano G, Montagna
Department of Biomedical Science and Human Oncology,
University of Bari "Aldo Moro", Piazza G. Cesare 11, 70124, Bari,
Environ Res 2019
Abstract: Legionella is the
causative agent of Legionnaires' disease, a flu-like
illness normally acquired following inhalation or aspiration of contaminated
water aerosols. Our recent studies revealed that climatic parameters can
increase the number of reported cases of community-acquired Legionnaires'
disease. Here, we evaluated the presence of Legionella in water networks
and the distribution of Legionnaires' disease cases associated with
touristic-recreational facilities in the Apulia region (southern Italy) during
the period 2001-2017 using geostatistical and climatic analyses. Geostatistical
analysis data revealed that the area with the highest concentration of Legionella
in water systems also had the greatest number of cases of Legionnaires' disease
associated with touristic-recreational facilities. Climatic analysis showed that
higher daily temperature excursion (difference between maximum and minimum
temperature) on the day of sampling was more often associated with Legionella-positive
samples than Legionella-negative samples. In addition, our data
highlighted an increased risk of Legionnaires' disease with increases in
precipitation and average temperature and with decreases in daily temperature
excursion (difference between maximum and minimum temperature over the course of
24 h in the days of incubation period of disease) and minimum temperature.
Healthcare professionals should be aware of this phenomenon and be particularly
vigilant for cases of community-acquired pneumonia during such climatic
conditions and among the tourist population. The innovative geo-statistical
approach used in this study could be applied in other contexts when evaluating
the effects of climatic conditions on the incidence of Legionella infections.
Solar and Climate Effects
Explain the Wide Variation in Legionellosis Incidence Rates in the United States
Department of Laboratory Medicine, The University of
Texas M. D. Anderson Cancer Center, Houston, Texas, USA. firstname.lastname@example.org
Microbiol 2019 Oct;85(22):e01776-19.
an infection caused by the environmental bacteria Legionella spp.,
has become a significant public health problem in the United States in recent
years; however, among the states, the incidence rates vary widely without a
clear explanation. This study examined environmental effects on the 2014-to-2016
average annual legionellosis incidence rates in the U.S. states through
correlative analyses with long-term precipitation, temperature, solar UV
radiation, and sunshine hours. The continental states west of ∼95°W
showed low incidence rates of 0.51 to 1.20 cases per 100,000 population, which
corresponded to low precipitation, below 750 mm annually. For the eastern states,
where precipitation was higher, solar effects were prominent and mixed, leading
to wide incidence variation. Robust regressions suggested a dividing line at 40°N:
north of this line, rising temperature, mainly from solar heat, raised
legionellosis incidence to a peak of 4.25/100,000 in Ohio; south of the line,
intensifying sunlight in terms of high UV indices and long sunshine hours
prevailed to limit incidence gradually to 0.99/100,000 in Louisiana. On or near
the 40°N line were 15 eastern states that had leading legionellosis incidence
rates of >2.0/100,000. These states all showed modest environmental
parameters. In contrast, the frigid climate in Alaska and the strong year-round
solar UV in Hawaii explained the lowest U.S. incidences, 0.14/100,000 and
0.47/100,000, respectively, in these states. The findings of solar and climate
effects explain the wide variation of legionellosis incidence rates in the
United States and may offer insights into the potential exposure to and
prevention of infection. IMPORTANCE: Legionellosis, caused by the
environmental bacteria Legionella spp., has become a
significant public health problem in the United States in recent years, with ∼6,000
cases annually. The present study showed, through a series of correlative
analyses with long-term precipitation, temperature, solar UV radiation, and
sunshine hours, that these environmental conditions strongly influence the
legionellosis incidence rates across the United States in mixed and dynamic
fashions. The incidence rates varied remarkably by region, with the highest in
Ohio and New York and the lowest in Alaska. A precipitation threshold above 750
mm was required for elevated legionellosis activity. Regression models and
dividing lines between regions were established to show the promotive effect of
temperature, as well as the inhibitive effects of solar UV and sunshine hours.
These findings explain the wide variation of legionellosis incidence rates in
the United States. They may also offer insights into potential exposure to and
prevention of infection.
Villanueva D, Schepanski K.
Leibniz Institute for Tropospheric
Research, Leipzig, Germany. email@example.com
Int J Biometeorol 2019
Legionnaires' disease (LD) is a severe lung infection caused by the bacteria Legionella
pneumophila which is usually associated with water managing installations
like cooling towers. Several outbreaks of LD have been linked to individual
sources of bioaerosol in the past. However, the transmission pathways as well as
the influence of meteorological factors in the spreading of such bioaerosols
remain unclear. Using the meteorological data near 12 LD outbreaks in Europe for
the period 2000-2016, the correlation between key meteorological factors and the
occurrence of LD was assessed. Temperature, humidity, atmospheric pressure, wind
speed, precipitation, cloud cover and, for the first time, fog occurrence were
included as potential risk factors. It was found that the occurrence of fog was
related to four of the LD outbreaks, suggesting that the presence of fog
droplets and/or the thermal inversions associated with fog may play a role in
the disease spreading. This finding can contribute to outbreak investigations
and to the prevention of future outbreaks.
Oda N, Hirahara T, Fujioka Y,
Mitani R, Takata I.
Department of Internal Medicine, Fukuyama
City Hospital, Japan. firstname.lastname@example.org
Intern Med 2019
Abstract: We herein report the case of a
62-year-old man diagnosed with Legionella pneumonia while engaged in
recovery work in a flooded area after the Heavy Rain Event of July 2018 in Japan.
The patient was intubated and maintained on mechanical ventilation and
continuous hemodiafiltration. He was also administered antimicrobial therapy
with ciprofloxacin and azithromycin. After 53 days in the hospital, he was
discharged. It is important to recognize the risk of Legionella infection
and to take measures to prevent it during recovery work that involves exposure
to water and soil after a flood disaster.
GA,, López I,, , , Orduña A, Bratos
Service of Microbiology and
Immunology, Hospital Clínico Universitario, Valladolid, Spain. email@example.com
Enferm Infecc Microbiol Clin 2019
Abstract: Purpose: To
perform epidemiological surveillance of Legionella pneumophila in
recreational swimming pools in the city of Valladolid (Spain), an area with a
continental climate and low incidence of legionella-associated infections.
Additionally, wild-type minimum inhibitory concentration (MIC) distributions for
eight antibiotics commonly used for the treatment of legionellosis were
calculated from the isolates obtained. Methods: Twelve
recreational pools were enrolled between June 2003 and December 2016 and 7221
water samples were taken from three different points of the water network (tank,
tap and shower). Legionella culture was performed according to ISO 11731
and 11731-2 standards. MICs of antibiotics were obtained by a gradient test. Results: 1.44%
of the water samples were positive for L. pneumophila. 60 strains
(57.69%) were isolated from showers, 26 (25.00%) from tanks and 18 (17.31%) from
taps. L. pneumophila counts were <100CFU/L in 75 samples (72.12%),
100-1000CFU/L in 17 (16.35%) and >1000CFU/L in 12 (11.54%). The MIC90 values
obtained were for Rifampicin 0.125mg/L; Trimethoprim-Sulfamethoxazole 0.25mg/L;
Azithromycin and Levofloxacin 0.5mg/L; Clarithromycin and Ciprofloxacin 1.0mg/L;
Doxycycline and Tigecycline 4.0mg/L.
Conclusions: The use of showers in
recreational pools can become a potential pathway for exposure to L.
pneumophila, even in cold climates. The wild-type MIC distributions
presented in this article may be useful for a better detection of antibiotic
resistance and can contribute to improvements in the choice of the antibiotic
treatment of legionellosis.
Cassell K, Gacek P, Rabatsky-Her
T, Petit S, Cartter
M, Weinberger DM
Department of Epidemiology of Microbial
Diseases, School of Public Health, Yale University, New Haven, Connecticut.
Am J Epidemiol 2019 Sep;188(9):1686-1694.
Abstract: Over the past decade, the reported
incidence of Legionnaires' disease (LD) in the northeastern United States has
increased, reaching 1-3 cases per 100,000 population. There is reason to suspect
that this is an underestimate of the true burden, since LD cases may be
underdiagnosed. In this analysis of pneumonia and influenza (P&I)
hospitalizations, we estimated the percentages of cases due to Legionella,
influenza, and respiratory syncytial virus (RSV) by age group. We fitted
mixed-effects models to estimate attributable percents using weekly time series
data on P&I hospitalizations in Connecticut from 2000 to 2014. Model-fitted
values were used to calculate estimates of numbers of P&I hospitalizations
attributable to Legionella (and influenza and RSV) by age group, season,
and year. Our models estimated that 1.9%, 8.8%, and 5.1% of total (all-ages)
inpatient P&I hospitalizations could be attributed to Legionella,
influenza, and RSV, respectively. Only 10.6% of total predicted LD cases had
been clinically diagnosed as LD during the study period. The observed incidence
rate of 1.2 cases per 100,000 population was substantially lower than our
estimated rate of 11.6 cases per 100,000 population. Our estimates of numbers of
P&I hospitalizations attributable to Legionella are comparable to
those provided by etiological studies of community-acquired pneumonia and
emphasize the potential for underdiagnosis of LD in clinical settings.
Felice A, Franchi M, De Martin S, Vitacolonna N, Iacumin L, Civilini M
Department of Agriculture, Food,
Environmental and Animal Sciences, University
of Udine, Udine, Italy. firstname.lastname@example.org
PLoS One 2019 Jul;14(7):e0218687.
Legionella spp. are considered an important cause of potentially
preventable morbidity and mortality, making environmental surveillance a crucial
component of risk assessment plans. In this work, 20,319 water samples were
collected in 3,983 environmental surveys during a 16-year period by ARPA, the
Regional Agency for Environmental Protection, Friuli Venezia Giulia, and the
results were studied to better understand the diffusion mechanisms of Legionella.
The data showed a strong seasonal signal, a prevalence of L. pneumophila
serogroup 2-15 in most environments (63% of positive samples), a prevalence of L.
pneumophila serogroup 1 in swimming pool-associated environments (82% of
positive samples), a persistent presence of Legionella in hospitals and a
recurrent presence of Legionella in other facilities such as hotels,
possibly years after interventions, highlighting the difficulty of eradicating
the bacteria. Retrospective spatio-temporal analyses on geocoded historical data
were carried out with SaTScan using an ordinal model with risk as a covariate to
identify potential clusters with an excess of cases in the higher-risk
categories. Although no outbreaks occurred during the period of study, such
analyses identified spatially restricted zones with unusual contamination, which
sometimes were also areas in which several surveys triggered by notifications of
clinical cases were performed. Simulations of periodic prospective analyses
permitted the assessment of the efficacy of the method in early detection of
such clusters. The proposed method may be a useful tool in environmental
surveillance, prevention and control of Legionella.
Mascarella C, Distefano SA, Calà C,
Capra G, Rampulla A, Di
Carlo P, Palermo M,
Department of Health Promotion,
Mother and Child Care, Internal Medicine and Medical Specialties, University of
Palermo, 90133 Palermo, Italy. email@example.com.
J Environ Res Public Health 2019 Jun;16(11): 2062.
Abstract: Background: Legionella
pneumophila (Lp) is the most common etiologic agent causing
Legionnaires' Disease (LD). Water systems offer the best growth conditions for
Lp and support its spread by producing aerosols. From 2015 to 2017, the Regional
Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis
of Palermo monitored the presence of Lp in nine prisons in Western Sicily.
During this investigation, we compared Lp isolates from environmental samples in
a prison located in Palermo with isolates from two prisoners in the same prison.
collected 93 water samples from nine Sicilian prisons and the bronchoalveolar
lavages (BALs) of two prisoners considered cases of LD. These samples were
processed following the procedures described in the Italian Guidelines for the
Prevention and Control of Legionellosis of 2015. Then, genotyping was performed
on 19 Lp colonies (17 from water samples and 2 from clinical samples) using the
Sequence-Based Typing (SBT) method, according to European Study Group for
Legionella Infections (ESGLI) protocols. Results: Lp
serogroup (sg) 6 was the most prevalent serogroup isolated from the prisons
analyzed (40%), followed by Lp sg 1 (16%). Most of all, in four penitentiary
institutions, we detected a high concentration of Lp >104 Colony
Forming Unit/Liter (CFU/L). The environmental molecular investigation found the
following Sequence Types (STs) in Lp sg 6: ST 93, ST 292, ST 461, ST 728, ST
1317 and ST 1362, while most of the isolates in sg 1 belonged to ST 1. We also
found a new ST that has since been assigned the number 2451 in the ESGLI-SBT
database. From the several Lp sg 1 colonies isolated from the two BALs, we
identified ST 2451. Conclusions: In
this article, we described the results obtained from environmental and
epidemiological investigations of Lp isolated from prisons in Western Sicily.
Furthermore, we reported the first cluster of Legionnaires' in an Italian prison
and the molecular typing of Lp sg 1 from one prison's water system and two BALs,
identified the source of the contamination, and discovered a new ST.
Wang J, Sheng
Department of Internal Medicine,
National Taiwan University Hospital, Taipei, Taiwan; Center for Infection
Control, National Taiwan University Hospital, Taipei, Taiwan. firstname.lastname@example.org
J Microbiol Immunol Infect 2019 Jun;52(3):465-470.
Abstract: Background/purpose: Legionella
pneumophila had been recognized as an important pathogen for
community-acquired pneumonia. We aimed to investigate clinical features and
outcomes of patients with Legionnaires' disease at a tertiary medical center in
northern Taiwan. Methods: From
June 2012 to February 2017, a retrospective review of adult community acquired.
Legionnaires' disease at a medical center was conducted. All Legionella
infections were confirmed by positive urinary Legionella antigen assay,
sera indirect immunofluorescence assay, or sputum culture for Legionella.
Literature review of Legionnaires' disease from Medline and PubMed websites was
performed. Results: A
total of 32 cases of Legionnaires' disease were identified. Their mean age was
64.3 years, with male predominance (27 cases, 84.3%). The underlying diseases
were varied and most were attributed to chronic disorders, such as diabetes
mellitus (31%) and cigarette smoking (40.6%). The most common symptoms were
cough (68%) and fever (59.3%). More than half of patients (18, 56.2%) with
Legionnaires' disease could initially present with extrapulmonary manifestations.
Sixteen (50%) patients had delay in initiation of appropriate antibiotic therapy.
Patients without adequately initiation of appropriate antibiotic therapy had
higher proportion (11 of 16, 68.7%) of intensive care unit admission than
patients with adequate initiation (5 of 16, 31.2%). Our results inferred that a
delay in treatment might result in worsening of disease severity and the need
for more intensive management. Overall mortality rate was 21.8%. Development of
vasopressor requirement is an independent risk factor associated with mortality.
disease in Taiwan frequently present with extrapulmonary manifestations.
Patients with hemodynamic instability that need vasopressor therapy associated
Ginevra C, Descours G, Ranc AG, Beraud L, Boisset S, Magand N, Conrad A,
Bergeron-Lafaurie A, Jarraud S, Ader F.
Département des Maladies infectieuses et
tropicales, Hospices Civils de Lyon, Lyon, France.
Clin Infect Dis 2019 Jun:ciz538.
Abstract: Background: Rarely,
Legionnaires' disease (LD) can progress into a slowly or non-resolving form. Methods: A
nation-wide retrospective study was conducted by the French National Reference
Center for Legionella (2013-2017) including cases of slowly or
non-resolving LD defined as persistent clinical symptoms, CT-scan abnormalities,
and Legionella detection in lower respiratory tract (LRT) specimens by
culture and/or real-time (RT) PCR beyond 30 days after the onset of symptoms. Results: Twelve
cases of community-acquired slowly or non-resolving LD were identified among
1686 cases of culture-positive LD. Median age was 63 years (interquartile range,
IQR [29-82]). Ten (83.3%) patients had ≥1 immunosuppressive factor.
Clinically, nine patients transiently recovered before further deterioration (median
symptom-free interval of 30 days, IQR [18-55]), three patients had uniformly
persistent symptoms (median time of 48 days, IQR [41.5-54]). Two patients had
>2 recurrences. CT-scan imagery found lung abscess in five (41.6%) cases.
Slowly or non-resolving LD were diagnosed on positive LRT Legionella
cultures (n=10, 83.3%) at 49.5 days (IQR [33.7-79]). Two cases were documented
through positive Legionella RT PCR at 52 and 53 days (cycle threshold
detection of 21.5 and 33.7, respectively). No genomic microevolution and no Legionella
resistance to antibiotics were detected. The median duration of treatment of
slowly or non-resolving LD was 46.5 days (IQR [21-92.5]). Two empyema cases
required thoracic surgery. At a median follow-up of 26 months (IQR [14-41.5]),
LD-attributable mortality was 16.6% (n=2). Conclusions: Slowly
or non-resolving LD may occur in immunocompromised patients, possibly leading to
lung abscess and empyema.
Edens C, Alden NB, Danila RN, Fill MA, Gacek P, Muse A, Parker E, Poissant T,
Ryan PA, Smelser C, Tobin-D'Angelo M, Schrag SJ.
Atlanta, Georgia, USA. email@example.com
One 2019 May;14(5):e0217632.
Abstract: Detection of clusters of Legionnaires'
disease, a leading waterborne cause of pneumonia, is challenging. Clusters vary
in size and scope, are associated with a diverse range of aerosol-producing
devices, including exposures such as whirlpool spas and hotel water systems
typically associated with travel, and can occur without an easily identified
exposure source. Recently, jurisdictions have begun to use SaTScan
spatio-temporal analysis software prospectively as part of routine cluster
surveillance. We used data collected by the Active Bacterial Core surveillance
platform to assess the ability of SaTScan to detect Legionnaires' disease
clusters. We found that SaTScan analysis using traditional surveillance data and
geocoded residential addresses was unable to detect many common Legionnaires'
disease cluster types, such as those associated with travel or a prolonged time
between cases. Additionally, signals from an analysis designed to simulate a
real-time search for clusters did not align with clusters identified by
traditional surveillance methods or a retrospective SaTScan analysis. A
geospatial analysis platform better tailored to the unique characteristics of
Legionnaires' disease epidemiology would improve cluster detection and decrease
time to public health action.
Bradley BT, Bryan A.
University of Washington, Department of Laboratory
Medicine, Box 357110, 1959 NE Pacific Street, NW120, Seattle, WA 98195-7110,
Pathol 2019 May;36(3):152-159.
Abstract: 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.
J, Sandin S, , Payne Hallström L,
Robesyn E, Giesecke J,, On Behalf of The
European Legionnaires' Disease Surveillance Network
Department of Medical
Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; ECDC,
Stockholm, Sweden. firstname.lastname@example.org
Euro Surveill 2019 May;24(20):pii=1800295.
Abstract: Background: The detection of a cluster of travel-associated
Legionnaires' disease (TALD) cases in any European Union/European Economic Area
(EU/EEA) country prompts action at the accommodation, follow-up by health
authorities and reporting of measures taken. Some accommodations incur further
cases despite presumed implementation of adequate control measures. Aim: To
identify factors associated with the occurrence of a further TALD case after the
implementation of control measures. Methods: We conducted a retrospective cohort
study of hotel and holiday rental accommodations in the EU/EEA associated with
two or more TALD cases with onset dates less than 2 years apart (a 'cluster')
and notification between 1 June 2011-31 December 2016. We fitted Cox regression
models to estimate the association between accommodation characteristics and the
occurrence of a further case, defined as any case with onset date after the
report on measures taken. Results: Of the 357 accommodations in the analysis, 90
(25%) were associated with at least one further case after the report on
measures taken (12.4/100 accommodation-years). Accommodations associated with
two or more cases before the cluster notification were more likely to be
associated with a further case, compared with those not previously associated
with any case (adjusted hazard ratio 1.85; 95% confidence interval: 1.14-3.02).
Neither the detection of Legionella in the water system nor the
type of disinfection were found to be associated with the risk of a further
case. Conclusion: Accommodation size and previous TALD cases were predictive of
further Legionnaires' disease cases after implementation of control measures.
Bellew S, Grijalva CG,
Medical Center, Nashville, Tennessee. email@example.com
Clin Infect Dis 2019 May;68(12):2026-2033.
Abstract: Background: Adult,
community-acquired pneumonia (CAP) guidelines from the Infectious Diseases
Society of America (IDSA) and American Thoracic Society (ATS) include
indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP)
and Legionella pneumophila (LP). These recommendations were based on
expert opinions and have not been rigorously evaluated. Methods: We
used data from a multicenter, prospective, surveillance study of adults
hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS
UAT indications for identifying patients who test positive. SP and LP UATs were
completed on all included patients. Separate analyses were completed for SP and
LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT
recommended vs not recommended) and UAT results (positive vs negative).
Additionally, logistic regression was used to evaluate the association of each
individual criterion in the IDSA/ATS indications with positive UAT results. Results: Among
1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%).
IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49-71%)
and 39% specificity (95% CI 37-41%) for SP, and 63% sensitivity (95% CI 44-79%)
and 35% specificity (95% CI 33-37%) for LP. No clinical characteristics were
strongly associated with positive SP UATs, while features associated with
positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. Conclusions: Recommended
indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines
have poor sensitivity and specificity for identifying patients with positive
tests; future CAP guidelines should consider other strategies for determining
which patients should undergo urinary antigen testing.
U Reber F, Lehfeld A,
Brodhun B, Haas W,, Stemmler F,
Otto C, Gagell C, Lück
C, Gamradt R, Heinig M,
Meisel C, Kölsch U,
Robert Koch Institute,
Berlin, Germany. firstname.lastname@example.org
Agency, Bad Elster, Germany. email@example.com
Int J Hyg Environ Health 2019 Mar;222 (2):315-318.
Abstract: In Germany community-acquired Legionnaires'
disease is usually caused by the species Legionella pneumophila.
Recurrent cases of Legionnaires' disease are rarely reported and are due either
to a second infection (reinfection) or a relapse of a previous case. We report a
case of recurrent Legionnaires' disease in an 86-year-old female patient
infected with Legionella pneumophila serogroup 1, monoclonal
antibody-subtype Knoxville, sequence type unknown. Between the two disease
incidents the patient had completely recovered. Legionella pneumophila
was detected with the monoclonal antibody-subtype Knoxville, sequence type 182,
in the drinking water of the patient's apartment. Exposure to contaminated
drinking water was interrupted after the first incident exposure through the
application of point-of-use water filters. The filters were later removed due to
low water pressure, and the second illness occurred thereafter. It is unclear if
immunological predisposition has contributed to this case of probable
reinfection of Legionnaires' disease. Clinical, microbiological and
epidemiological information combined suggest this is a case of reinfection of
Legionnaires' disease. In cases of recurrent Legionnaires' disease complete
collection of patient and water samples is necessary to differentiate relapse
from reinfection cases, to implicate the source of infection and to gain more
evidence for the role of immunological predisposition.
Beg M, Arif H,
Medicine, University of Texas Health Science Center San Antonio, San Antonio,
Cureus 2019 Feb;11(2):e4080.
Abstract: Community-acquired pneumonia (CAP) is a frequent cause of
hospitalization in adults. Streptococcus pneumoniae is the most
commonly identified pathogen in CAP whereas Legionella pneumophilia is
infrequently identified in CAP. Although co-infections have been previously
described, the presence of both pneumococcus and legionella together is rare. We
present a patient with positive urinary antigens for both Streptococcus
pneumoniae and Legionella pneumophilia serogroup 1,
indicating an unusual co-infection.
Fatal Legionella pneumophila Serogroup 1 Pleural
Empyema: A Case Report
Maillet F, Bonnet N,
Billard-Pomares T, El Alaoui Magdoud F, Tandjaoui-Lambiotte Y.
Intensive Care Unit, Avicenne Hospital, Assistance
Publique - Hôpitaux de Paris, Bobigny, France. firstname.lastname@example.org.
World J Crit
Care Med 2019;8(6):99-105.
pneumophila (L. pneumophila) is a gram-negative intracellular
bacillus composed of sixteen different serogroups. It is mostly known to cause
pneumonia in individuals with known risk factors as immunocompromised status,
tobacco use, chronic organ failure or age older than 50 years. Although
parapneumonic pleural effusion is frequent in legionellosis, pleural empyema is
very uncommon. In this study, we report a case of fatal pleural empyema caused
by L. pneumophila serogroup 1 in an 81-year-old man with
multiple risk factors. Case summary: An 81-year-old man presented to
the emergency with a 3 wk dyspnea, fever and left chest pain. His previous
medical conditions were chronic lymphocytic leukemia, diabetes mellitus, chronic
kidney failure, hypertension and hyperlipidemia, without tobacco use. Chest
X-ray and comouted tomography-scan confirmed a large left pleural effusion,
which puncture showed a citrine exudate with negative standard bacterial
cultures. Despite intravenous cefotaxime antibiotherapy, patient's worsening
condition after 10 d led to thoracocentesis and evacuation of 2 liters of pus.
The patient progressively developed severe hypoxemia and multiorgan failure
occurred. The patient was treated by antibiotherapy with cefepime and amikacin
and with adequate symptomatic shock treatment but died of uncontrolled sepsis.
The next day, cultures of the surgical pleural liquid samples yielded L.
pneumophila serogroup 1, consistent with the diagnosis of pleural
legionellosis. Conclusion: L.
pneumophila should be considered in patients with multiple risk factors
and undiagnosed pleural empyema unresponsive to conventional antibiotherapy.
Evaluation and Treatment of
Severe Rhabdomyolysis in a Patient with Legionnaires' Disease
JW, Zuzek Z, Alencherry
BP, Packer CD.
Case Western Reserve University School of
Medicine, Cleveland, USA. email@example.com
53-year-old man with alcoholism and a three-day history of diarrhea and
abdominal pain was hospitalized with mild acute kidney injury (AKI) and
rhabdomyolysis after a fall where he was down for a short duration. Subsequent
testing revealed patchy right lower lobe infiltrates on chest X-ray and a
positive urinary Legionella antigen test. Creatinine phosphokinase (CPK)
peaked at 85,780 U/L (normal 0-250) on hospital day two and remained markedly
elevated for five days despite aggressive intravenous (IV) hydration and
appropriate antibiotic treatment. When the patient defervesced and showed
clinical signs of resolution of pneumonia, the CPK level declined rapidly, and
renal function returned to baseline. Rhabdomyolysis with AKI is a rare but
serious complication of Legionella pneumonia, with most patients
requiring dialysis. Our patient's complete recovery without renal replacement
therapy can probably be attributed to his normal baseline renal function, timely
diagnosis of his Legionella-associated rhabdomyolysis, and prompt
treatment with aggressive IV hydration and appropriate antibiotics. Legionella
infection should be considered in acutely ill patients with rhabdomyolysis of
Fatal Case of Nosocomial Legionella
pneumophila Pneumonia, Spain, 2018
D, Marimón JM, Lanzeta I, Martin T, Cilla G.
Donostia-Instituto Biodonostia, Microbiology, Paseo Dr Begiristain S/N, San
Sebastian 20014, Spain. firstname.lastname@example.org
nosocomial case of Legionella pneumophila pneumonia likely caused by a
serogroup 3 strain was detected by a urinary antigen test in Spain in 2018.
Although Legionella bacteria could not be isolated from respiratory
samples, molecular methods implicated the sink faucet of the patient's room as
the probable infection source.
Khaledi A, , Vazini H,,,
University of Medical of Sciences,
Mashhad, Iran. email@example.com.
Abstract: Background: Legionella
pneumophila is the main cause for community-acquired pneumonia especially in
hospital environments. In this systematic review and meta-analysis, we evaluated
the prevalence of L. pneumophila in clinical samples obtained from
Iranian patients. Methods: The
studies reporting L. pneumophila prevalence in Iranian clinical samples
that were published between January 2000 and July 2016 were recruited.
Comprehensive Meta-Analysis Software (version 3.3.070) was used for quantitative
data analysis. Because of high heterogeneity between the studies according to
the Cochrane Q and I2 statistics, a random-effects model was
used for meta-analysis. Results: Sixteen
studies encompassing 1956 subjects were included in the meta-analysis. The
overall prevalence of L. pneumophila was 9.6% in clinical samples
obtained from the Iranian patients. The age spectrum ranged from 6 months to 80
years old. Dyspnea and cough comprised the most common clinical manifestations.
In the subgroup analysis, the prevalence of L. pneumophila was higher in
studies with sample size ≤100 (12.9%) in comparison with studies with
sample size >100 (8.4%). In addition, the prevalence of L. pneumophila
was higher in the years 2009-2016 (9.2%) compared with 2000-2008 (0.7%). Conclusion: L.
pneumophila is a major cause of community- and hospital-acquired pneumonia.
It is of pivotal importance to implement sensitive and reliable molecular and
culture-based techniques to detect and control this infection in healthcare
H, Czerwiński M.
Department of Epidemiology of Infectious
Diseases and Surveillance, National Institute of Public Health – National
Institute of Hygiene in Warsaw. firstname.lastname@example.org
Przegl Epidemiol 2019;73(2):151-155.
aim of this study is to assess the epidemiological situation of legionellosis in
Poland in 2017 in comparison with previous years. Material and methods: The
analysis is based on national surveillance data published in the annual bulletin:
“Infectious diseases and poisonings in Poland in 2017” and bulletins from
previous years along with data from legionellosis case reports collected and
sent to the Department of Epidemiology of Infectious Diseases and Surveillance
NIPH – NIH by Sanitary and Epidemiological Stations. Results: In
Poland, both cases of Legionnaires’ disease (an acute form of infection with
pneumonia) and Pontiac fever (a mild, influenza-like form of infection) are
routinely reported to the surveillance system. In 2017, a total of 39 cases of
legionellosis were registered, including 38 cases of Legionnaires’ disease and
1 case of Pontiac fever; the annual incidence rate 0.102 (per 100,000 population)
has increased by almost 50 percent since previous year (0.070) and is almost
three times higher than the median incidence (0.036) for 2011-2015. The
infections were reported in fourteen voivodeships; only one voivodeship (Świętokrzyskie)
did not register any case in last years. The incidence in men (0.129 per
100,000) was higher compared to women (0.076); the highest incidence (0.323) was
noted in men aged 50-59. All reported cases were sporadic and were hospitalised.
The Sanitary Inspection reported nine fatal cases – 6 women and 3 men.
Thirty-three cases were autochthonous including four cases linked with
contaminated water systems in health-care settings. Six cases were associated
with travels abroad (to Egypt, Albania, Italy and Crete). Summary and conclusions: Although
in recent years number of reported cases continues to rise, the incidence of
legionellosis in Poland remains one of the lowest in the entire EU. Also draws
attention variation of incidence between provinces and a high mortality among
reported cases. Our data suggest significant under-diagnosis of legionellosis. A
priority remains to improve early diagnosis of Legionnaires’ disease in health
Bella A, Caporali MG,
Nicolau A, Drasar V, Ricci ML, Scaturro M,
Gumá M, Crespi S
di Malattie Infettive, Istituto Superiore di Sanità, Rome, Italy. email@example.com
Epidemiol Infect 2018 Dec;147:1-6.
According to European Guidelines for Legionnaires' Disease prevention and
control, travel-associated Legionnaires' disease (TALD) cases are managed
differently if classified as sporadic or as part of a cluster and more stringent
control measures are deployed after clusters are identified. In this study, we
propose to modify the current cluster definition: 'two or more cases of
Legionnaires' disease (LD) who stayed at, or visited, the same commercial
accommodation site 2-10 days before onset of illness and whose onset is within
the same 2-year period' with a new cluster definition, i.e. accommodation sites
associated with multiple cases regardless of the time elapsed between them. TALD
cases occurred in Italy and in the Balearic Islands between 2005 and 2015 were
analysed applying the current European Legionnaires' Disease Surveillance
Network (ELDSNet) cluster definition. In a sample of selected accommodation
sites with multiple cases, a microbiological study was also conducted. Using the
new definition, 63 additional sites (16.4% increase) and 225 additional linked
cases (19.5% increase) were identified. Legionella pneumophila sg1 was
isolated from 90.7% of the selected accommodation sites. The use of the here
proposed TALD cluster definition would warrant a full investigation for each new
identified case. This approach should therefore increase the number of sites
that will require a risk assessment and, in the presence of an increased risk,
the adoption of LD control measures to hopefully prevent additional cases.
Gramegna A, Sotgiu
G, Di Pasquale M, ,
Terraneo S, Reyes LF,
Vendrell E, Neves J, Menzella F, Blasi
F Aliberti S, Restrepo MI, GLIMP
Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. firstname.lastname@example.org
BMC Infect Dis 2018 Dec;18(1):677.
Abstract: Background: Empirical
antibiotic coverage for atypical pathogens in community-acquired pneumonia (CAP)
has long been debated, mainly because of a lack of epidemiological data. We
aimed to assess both testing for atypical pathogens and their prevalence in
hospitalized patients with CAP worldwide, especially in relation with disease
severity. Methods: A
secondary analysis of the GLIMP database, an international, multicenter,
point-prevalence study of adult patients admitted for CAP in 222 hospitals
across 6 continents in 2015, was performed. The study evaluated frequency of
testing for atypical pathogens, including L. pneumophila, M.
pneumoniae, C. pneumoniae, and their prevalence. Risk factors for
testing and prevalence for atypical pathogens were assessed through univariate
analysis. Results: Among
3702 CAP patients 1250 (33.8%) underwent at least one test for atypical
pathogens. Testing varies greatly among countries and its frequency was higher
in Europe than elsewhere (46.0% vs. 12.7%, respectively, p<0.0001). Detection
of L. pneumophila urinary antigen was the most common test performed
worldwide (32.0%). Patients with severe CAP were less likely to be tested for
both atypical pathogens considered together (30.5% vs. 35.0%, p=0.009) and
specifically for legionellosis (28.3% vs. 33.5%, p=0.003) than the rest of the
population. Similarly, L. pneumophila testing was lower in ICU patients.
At least one atypical pathogen was isolated in 62 patients (4.7%), including M.
pneumoniae (26/251 patients, 10.3%), L. pneumophila (30/1186 patients,
2.5%), and C. pneumoniae (8/228 patients, 3.5%). Patients with CAP due to
atypical pathogens were significantly younger, showed less cardiovascular, renal,
and metabolic comorbidities in comparison to adult patients hospitalized due to
non-atypical pathogen CAP. Conclusions: Testing
for atypical pathogens in patients admitted for CAP in poorly standardized in
real life and does not mirror atypical prevalence in different settings. Further
evidence on the impact of atypical pathogens, especially in the low-income
countries, is needed to guidelines implementation.
Zanella MC, Yerly S,, Renzi G,, Lourenço Cordes L, Delaporte E,, Keiser O, Schrenzel J, Harbarth S, Gaia V, Kaiser L
Laboratory of Virology,
Division of Laboratory Medicine and Division of Infectious Diseases, University
of Geneva Hospitals, Switzerland; University of Geneva Medical School,
Med Wkly 2018 Dec;148:w14687.
Abstract: Purpose: Eight
confirmed cases of Legionnaires’ disease were identified at the Geneva
University Hospitals between 28 July 2017 and 02 August 2017, leading to a
detailed outbreak investigation. Methods: Legionnaires’
disease cases were defined according to Swiss and European (ELDSNet) consensus
guidelines. An outbreak investigation task force was put in place. Patients were
interviewed, when feasible, with a standard questionnaire. A Legionella
pneumophila urinary antigen test was performed in all cases. Lower
respiratory tract (LRT) specimens were collected for culture, polymerase
chain-reaction (PCR) assay, monoclonal antibody subtyping and sequenced-based
typing (SBT). Multiple environmental samples were collected. Case geographical
mapping was performed, and local meteorological data were obtained. Results: Thirty-four
confirmed cases of Legionnaires’ disease were identified between 20 June 2017
and 16 September 2017, including 28 patients living in the Canton of Geneva and
6 cases in neighbouring cantons and France. The case fatality rate was 8.8%. The
urinary antigen test was positive in 32/34 (94.1%) cases. Among the 17/34 (50%)
cases with available LRT specimens, 8 (47.1%) were culture/PCR positive, 5
(29.4%) were PCR positive only, and 4 (23.5%) were culture/PCR negative.
Monoclonal antibody subtyping and SBT on 12 samples allowed subtype
identification of 8 samples, with a predominance of L. pneumophila
serogroup-1 subtype-France/Allentown ST23 among clinical isolates. A specific
city area was identified as a possible outbreak epicentre in 25/34 (73.5%) cases,
although molecular analysis of clinical and environmental specimens revealed
heterogeneous subtypes of L. pneumophila.
De Filippis P,
Mozzetti C, Messina A,
Loreto D'Alò G
Section of Hygiene, Department of Biomedicine and
Prevention, University of Rome "Tor Vergata", Rome, Italy. email@example.com
Total Environ 2018 Dec;643:715-724.
Abstract: Background: Although
historically the focus has been placed above all on hospital infections and
travel-associated outbreaks, most of the cases of Legionella infection
are sporadic and occur in community-dwellers. Objectives: To
evaluate the presence and load of Legionella in hot water systems of
non-healthcare facilities that host closed communities. Furthermore, we tried to
verify the association between Heterotrophic Plate Counts (HPCs) and presence of
Legionella. Methods: We
collected hot water and biofilm samples from the showerheads of retirement homes
and group homes. Samples were tested by culture method for the presence of Legionella.
Confirmation and identification were carried out through Latex test and PCR. We
determined the HPCs at 22 and 37 °C by the pour plate method. Statistics
performed through STATA. Results: We
collected 140 hot water and biofilm samples, 95 from 26 retirement homes and 35
from 9 group homes. Legionella was found in 36.8% samples collected from
retirement homes and only in 10.3% group homes' samples (p=0.01). Legionella was
identified more frequently in water than in biofilm (29.8% vs 16.9%); just in
one case the pathogen was found in the biofilm only. L. pneumophila sg 1
was the pathogen more frequently isolated (65.8%), with an average load of 2720
CFU/L (SD=8393 CFU/L). We have often noticed a high microbial contamination (67%
of HPCs >200 CFU/mL) and identified a higher prevalence of Legionella
for intermediate values of HPC 22 °C (p=0.011). 32% of people hosted in
retirement homes were exposed to Legionella. Conclusions: Colonization
of water-systems of retirement homes and group homes is anything but occasional,
and in our survey it mainly affects the former, moreover often due to L.
pneumophila sg 1. The search for the pathogen in the biofilm has proved to
be of little use. The relationship between HPC and Legionella deserves
Robert S, Lhommet C,
Le Brun C,
Service de Bactériologie
et Virologie, CHRU de Tours, Tours, France; Faculté de Médecine, Université
de Tours, France. firstname.lastname@example.org
J Clin Virol 2018 Nov;108:1-5.
Abstract: Background: PCR-based
techniques for the diagnosis of community- acquired severe lower respiratory
tract infections are becoming the standard of care. However, their relative
ability to identify either atypical bacteria or viruses that cause LRTI from
clinical samples from various sources is yet to be determined. Objectives and study design: The
aim of our study was to compare the diagnostic yield of nasopharyngeal aspirates
with that of pulmonary samples for the etiological diagnosis of severe acute
lower respiratory tract infections by multiplex PCR. Patients were adults with
community-acquired pneumonia or acute exacerbation of chronic obstructive
pulmonary disease. Results: We
obtained concordant results for 81 (79%) of the 103 pairs of samples. In 14 of
the 22 discordant results, more pathogens were evidenced in the lower
respiratory tract samples. Conclusions: Pulmonary
samples had a similar diagnostic sensitivity for virus detection by multiplex
PCR as nasopharyngeal aspirates. In contrast, in our study, the diagnostic
efficacy of pulmonary samples for Legionella pneumophila over simple
aspirates was clearly superior.
Saladi L,,,, Adrish M.
of Pulmonary and Critical Care Medicine, Department of Medicine, BronxCare
Health System, Bronx, NY, USA. email@example.com
Abstract: Rationale: Concurrent
or sequential coinfections of Legionella pneumophila and Mycoplasma
pneumoniae have been reported in the past though infrequently.
Distinguishing a true co-infection from cross reactivity is often challenging as
the diagnosis is mostly dependent on serological testing. Patient concerns: A
77-year-old male presented with worsening dyspnea, cough with yellow sputum,
diarrhea and fever of 2-days duration. Patient had history of chronic
obstructive pulmonary disease (COPD) on home oxygen, bronchiectasis, rheumatoid
arthritis (on methotrexate and leflunomide), treated pulmonary tuberculosis and
30-pack-year smoking. Chest X-ray showed bilateral interstitial changes with
left lower lobe infiltrate. On day 5, his urine antigen for L pneumophila
serogroup 1 was reported positive. The following day his serum M pneumoniae
IgM antibody titers were reported elevated at 6647 U/mL. Patient was started on
antibiotics and placed on non-invasive positive pressure ventilation. Diagnosis: The
patient was diagnosed with possible Legionella and Mycoplasma
co-infection. Outcomes: Sputum
Mycoplasma polymerase chain reaction (PCR) and serum cold agglutinins were
obtained on day 6 and later reported negative. He was treated with azithromycin
for 10 days with clinical improvement. Lessons: Serological
testing alone is an indirect measure with poor sensitivity and specificity and
has its own limitations. Urine antigen detection confirms L pneumophila
serogroup 1 infection in a patient with suggestive symptoms. However, diagnosis
of M pneumonia should be based on combination of tests including serology and
PCR to confirm true co-infection.
Loenenbach AD, Beulens C, Euser SM, van Leuken JPG, Bom B, van der Hoek W, Husman AMR, Ruijs WLM, Bartels AA, Rietveld A, den Boer JW, Brandsema PS.
Stockholm, Sweden. firstname.lastname@example.org
Emerg Infect Dis 2018 Oct;24(10):1914-1918.
Abstract: A biologic wastewater treatment plant was
identified as a common source for 2 consecutive Legionnaires' disease clusters
in the Netherlands in 2016 and 2017. Sequence typing and transmission modeling
indicated direct and long-distance transmission of Legionella, indicating
this source type should also be investigated in sporadic Legionnaires' disease
Romay-Lema E, Corredoira-Sánchez J,
Iñiguez-Vázquez I, García Pais M, García-Garrote F,
Rabuñal Rey R.
Servicio de Medicina Interna, Hospital
Universitario Lucus Augusti, Lugo, España. email@example.com
Clin (Barc) 2018 Oct;151(7):265-269.
Abstract: Objective: Most
of the data on Legionella pneumonia in our country come from the
Mediterranean area, and there are few studies from the Northwest area. This
study tries to assess the situation of this infection in this area. Method: Retrospective
study of all patients with positive Legionella antigenuria treated at the
University Hospital Lucus Augusti in Lugo (Spain) from 2001, the year in which
this test was introduced in our centre, until 2015. We analysed epidemiological
data, risk factors, clinical, radiological and biochemical findings, and
clinical outcome. Results: The
sampled included 136 patients. When comparing the first five years of the study
with the last five, the incidence increased from 10.9 to 64.5 cases/1,000,000;
the number of antigenuria requests increased 3.4 times and compared to other
pneumonia aetiologies Legionella increased from 0.9% to 15%. The mean age
was 64.1years and 84.6% were males; 74.3% had comorbidities. Males were
significantly younger (62.7±16.6 vs 71.9±17.3) and consumed more alcohol
(26.1% vs 0%) and tobacco (67.8% vs 14.3%). Diagnosis was established within the
first 72 hours in 88.9% of cases and most received levofloxacin (95.6%).
Hospitalisation was needed in 85% of cases, 11.7% in ICU and 4.4% died. Conclusions: After
the introduction of antigenuria there was an increase in the incidence of Legionella
pneumonia recorded in our health area. Its rate in recent years has been one of
the highest in our country. Despite the fact that the patients had advanced age
and comorbidities, mortality was low.
Aliberti S, Reyes LF,
Sadud RF, Irfan M, Prat C,, Faverio P,
Gori A, Blasi F, Restrepo
Dept of Pathophysiology and Transplantation, Università
degli Studi di Milano, Milan, Italy; Internal Medicine Dept, Respiratory Unit
and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore
Policlinico Milano, Milan, Italy. firstname.lastname@example.org
ERJ Open Res 2018 0ct;4(4):00096.
Abstract: This study aimed to describe real-life microbiological testing of adults
hospitalised with community-acquired pneumonia (CAP) and to assess concordance
with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic
Society (ATS) and 2011 European Respiratory Society (ERS) CAP guidelines. This
was a cohort study based on the Global Initiative for Methicillin-resistant Staphylococcus
aureus Pneumonia (GLIMP) database, which contains point-prevalence data
on adults hospitalised with CAP across 54 countries during 2015. In total, 3702
patients were included. Testing was performed in 3217 patients, and included
blood culture (71.1%), sputum culture (61.8%), Legionella urinary
antigen test (30.1%), pneumococcal urinary antigen test (30.0%), viral testing
(14.9%), acute-phase serology (8.8%), bronchoalveolar lavage culture (8.4%) and
pleural fluid culture (3.2%). A pathogen was detected in 1173 (36.5%) patients.
Testing attitudes varied significantly according to geography and disease
severity. Testing was concordant with IDSA/ATS and ERS guidelines in 16.7% and
23.9% of patients, respectively. IDSA/ATS concordance was higher in Europe than
in North America (21.5% versus 9.8%; p<0.01), while ERS
concordance was higher in North America than in Europe (33.5% versus 19.5%;
p<0.01). Testing practices of adults hospitalised with CAP varied
significantly by geography and disease severity. There was a wide discordance
between real-life testing practices and IDSA/ATS/ERS guideline recommendations.
Tran OC, Lucero DE, Balter S, Fitzhenry R, Huynh M, Varma JK, Vora NM
Division of Disease Control, New York City Department
of Health and Mental Hygiene, Queens, NY, USA. email@example.com
Public Health Rep 2018 Sep/Oct;133(5):578-583.
certificates are an important source of information for understanding life
expectancy and mortality trends; however, misclassification and incompleteness
are common. Although deaths caused by Legionnaires' disease might be identified
through routine surveillance, it is unclear whether Legionnaires' disease is
accurately recorded on death certificates. We evaluated the sensitivity and
positive predictive value of death certificates for identifying deaths from
confirmed or suspected Legionnaires' disease among adults in New York City. Methods: We
deterministically matched death certificate data from January 1, 2008, through
December 31, 2013, on New York City residents aged ≥18 years to
surveillance data on confirmed and suspected cases of Legionnaires' disease from
January 1, 2008, through October 31, 2013. We estimated sensitivity and positive
predictive value by using surveillance data as the reference standard. Results: Of
294 755 deaths, 27 (<0.01%) had an underlying cause of death of Legionnaires'
disease and 33 (0.01%) had any mention of Legionnaires' disease on the death
certificate. Of 1211 confirmed or suspected cases of Legionnaires' disease, 267
(22.0%) matched to a record in the death certificate data set. The sensitivity
of death certificates that listed Legionnaires' disease as the underlying cause
of death was 17.3% and of death certificates with any mention of Legionnaires'
disease was 20.9%. The positive predictive value of death certificates that
listed Legionnaires' disease as the underlying cause of death was 70.4% and of
death certificates with any mention of Legionnaires' disease was 69.7%. Conclusions: Death
certificates had limited ability to identify confirmed or suspected deaths with
Legionnaires' disease. Provider trainings on the diagnosis of Legionnaires'
disease, particularly hospital settings, and proper completion of death
certificates might improve the sensitivity of death certificates for people who
die of Legionnaires' disease.
Public Health England, Porton, Salisbury
SP1 3DX, UK. firstname.lastname@example.org
Public Health 2018 Sep;138(5):282-286.
Abstract: Climate change is predicted to have a
major impact on people's lives with the recent extreme weather events and
varying abnormal temperature profiles across the world raising concerns. The
impacts of global warming are already being observed, from rising sea levels and
melting snow and ice to changing weather patterns. Scientists state
unequivocally that these trends cannot be explained by natural variability in
climate alone. Human activities, especially the burning of fossil fuels, have
warmed the earth by dramatically increasing concentrations of heat-trapping
gases in the atmosphere; as these concentrations increase, the more the earth
will warm. Climate change and related extreme weather events are being
exacerbated sooner than has previously been considered and are already adversely
affecting ecosystems and human health by increasing the burden and type of
disease at a local level. Changes to the marine environment and freshwater
supplies already affect significant parts of the world's population and warmer
temperatures, especially in more temperate regions, may see an increased spread
and transmission of diseases usually associated with warmer climes including,
for example, cholera and malaria; these impacts are likely to become more severe
in a greater number of countries. This review discusses the impacts of climate
change including changes in infectious disease transmission, patterns of
waterborne diseases and the likely consequences of climate change due to warmer
water, drought, higher rainfall, rising sea levels and flooding.
Kura F, Chida K, Kanatani J,
Isobe J,, Nakajima H,
Hiratsuka T Yoshino S,
Sakata M, Murai M, Ohnishi
M, Working Group for Legionella in Japan.
Department of Bacteriology I, National
Institute of Infectious Diseases, Tokyo, Japan. email@example.com
Appl Environ Microbiol 2018 Aug;84(18):e00721-18.
The Legionella Reference Center in Japan collected 427 Legionella clinical
isolates between 2008 and 2016, including 7 representative isolates from
corresponding outbreaks. The collection included 419 Legionella
pneumophila isolates, of which 372 belonged to serogroup 1 (SG1) (87%)
and the others belonged to SG2 to SG15 except for SG7 and SG11, and 8 isolates
of other Legionella species (Legionella bozemanae, Legionella
dumoffii, Legionella feeleii, Legionella longbeachae, Legionella
londiniensis, and Legionella rubrilucens).
L. pneumophila isolates
were genotyped by sequence-based typing (SBT) and represented 187 sequence types
(STs), of which 126 occurred in a single isolate (index of discrimination of
0.984). These STs were analyzed using minimum spanning tree analysis, resulting
in the formation of 18 groups. The pattern of overall ST distribution among L.
pneumophila isolates was diverse. In particular, some STs were
frequently isolated and were suggested to be related to the infection sources.
The major STs were ST23 (35 isolates), ST120 (20 isolates), and ST138 (16
isolates). ST23 was the most prevalent and most causative ST for outbreaks in
Japan and Europe. ST138 has been observed only in Japan, where it has caused
small-scale outbreaks; 81% of those strains (13 isolates) were suspected or
confirmed to infect humans through bath water sources. On the other hand, 11
ST23 strains (31%) and 5 ST120 strains (25%) were suspected or confirmed to
infect humans through bath water. These findings suggest that some ST strains
frequently cause legionellosis in Japan and are found under different
environmental conditions. IMPORTANCE: Legionella pneumophila serogroup
1 (SG1) is the most frequent cause of legionellosis. Our previous genetic
analysis indicated that SG1 environmental isolates represented 8 major clonal
complexes, consisting of 3 B groups, 2 C groups, and 3 S groups, which included
major environmental isolates derived from bath water, cooling towers, and soil
and puddles, respectively. Here, we surveyed clinical isolates collected from
patients with legionellosis in Japan between 2008 and 2016. Most strains
belonging to the B group were isolated from patients for whom bath water was the
suspected or confirmed source of infection. Among the isolates derived from
patients whose suspected infection source was soil or dust, most belonged to the
S1 group and none belonged to the B or C groups. Additionally, the U group was
discovered as a new group, which mainly included clinical isolates with unknown
Lopez Y, García-Vidal
A, Moreno A,
Torres A, Miró
Department of Pulmonary Medicine, Institut Clinic del Tórax,
Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona.
Clin Infect Dis 2018
Abstract: We investigate whether the clinical
presentations and outcomes of Legionella pneumonia in human
immunodeficiency virus (HIV)-infected patients were comparable to those seen in
non-HIV-infected patients (case-control design). HIV-infected individuals
presented neither a more severe disease nor a worse clinical outcome than
matched HIV-negative control patients.
Johnstone T, , Cains T,
Tan G,, Nilsson S,
Burgess S, Dunn M,
Sydney Local Health District, Public
Health Unit, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales,
Public Health Prep 2018 Aug;12(4):539-542.
The incident command system (ICS) provides a common structure to control and
coordinate an emergency response, regardless of scale or predicted impact. The
lessons learned from the application of an ICS for large infectious disease
outbreaks are documented. However, there is scant evidence on the application of
an ICS to manage a local multiagency response to a disease cluster with
environmental health risks. The Sydney Local Health District Public Health Unit
(PHU) in New South Wales, Australia, was notified of 5 cases of Legionnaires'
disease during 2 weeks in May 2016. This unusual incident triggered a
multiagency investigation involving an ICS with staff from the PHU, 3 local
councils, and the state health department to help prevent any further public
health risk. The early and judicious use of ICS enabled a timely and effective
response by supporting clear communication lines between the incident controller
and field staff. The field team was key in preventing any ongoing public health
risk through inspection, sampling, testing, and management of water systems
identified to be at-risk for transmission of legionella. Good working
relationships between partner agencies and trust in the technical proficiency of
environmental health staff aided in the effective management of the response.
Herwaldt LA, Marra AR.
Division of Infectious Diseases,
Department of Internal Medicine, University of Iowa Carver College of Medicine,
Infect Dis 2018 Aug;31(4):325-333.
Abstract: Purpose of review: The
present review summarizes new knowledge about Legionella epidemiology,
clinical characteristics, community-associated and hospital-based outbreaks,
molecular typing and molecular epidemiology, prevention, and detection in
environmental and clinical specimens. Recent
findings: The incidence of Legionnaire's disease is rising, and
the mortality rate remains high, particularly for immunocompromised patients.
Extracorporeal membrane oxygenation may help support patients with severe
respiratory failure. Fluoroquinolones and macrolides appear to be equally
efficacious for treating Legionnaires' disease. Whole genome sequencing is an
important tool for determining the source for Legionella infections and for
understanding routes of transmission and mechanisms by which new pathogenic
clones emerge. Real-time quantitative polymerase chain reaction testing of
respiratory specimens may improve our ability to diagnose Legionnaire's disease.
The frequency of viable but nonculturable organisms is quite high in some water
systems but their role in causing clinical disease has not been defined. Summary: Legionellosis
remains an important public health threat. To prevent these infections, staff of
municipalities and large buildings must implement effective water system
management programs that reduce Legionella growth and transmission and
all Medicare-certified healthcare facilities must have water management policies.
In addition, we need better methods for detecting Legionella in water
systems and in clinical specimens to improve prevention strategies and clinical
Unit of Hygiene,
Public Health and Medical Statistics, Department of Biomedical and Neuromotor
Sciences, University of Bologna, via S. Giacomo 12, 40126 Bologna, Italy. firstname.lastname@example.org
Int J Environ Res Public Health 2018 Jul;15(8):pii:E1612.
Abstract: Legionella spp. is widespread in many natural and artificial
water systems, such as hot water distribution networks, cooling towers, and spas.
A particular risk factor has been identified in the use of whirlpools and hot
tubs in spa facilities and public baths. However, there has been no systematic
synthesis of the published literature reporting legionellosis cases or outbreaks
related to swimming/spa pools or similar environments used for recreational
purposes (hot springs, hot tubs, whirlpools, natural spas). This study presents
the results of a systematic review of the literature on cases and outbreaks
associated with these environments. Data were extracted from 47 articles,
including 42 events (17 sporadic cases and 25 outbreaks) and 1079 cases, 57.5%
of which were diagnosed as Pontiac fever, without any deaths, and 42.5% were of
Legionnaires' disease, with a fatality rate of 6.3%. The results are presented
in relation to the distribution of Legionella species involved
in the events, clinical manifestations and diagnosis, predisposing conditions in
the patients, favourable environmental factors, and quality of the
epidemiological investigation, as well as in relation to the different types of
recreational water sources involved. Based on the epidemiological and
microbiological criteria, the strength of evidence linking a case/outbreak of
legionellosis with a recreational water system was classified as strong,
probable, and possible; in more than half of the events the resulting
association was strong.
Disease Outbreak on a Merchant Vessel, Indian Ocean, Australia, 2015
Inglis TJJ, Spittle C, Carmichael H,, Chiari M, McQueen-Mason A, Merritt AJ, Hodge M, Murray RJ, Dowse GK.
PathWest Laboratory Medicine WA, Nedlands, Western Australia; University of Western Australia, Crawley, Western Australia, Australia. email@example.com
Emerg Infect Dis 2018 Jul;24(7):1345-1348.
Two cases of Legionnaires' disease and 1 of Pontiac fever occurred among the
crew of a merchant ship operating off the shores of Australia. PCR assays
identified potential sources in the ship's cabins. Modification of maritime
regulations for Legionnaires' disease prevention in commercial vessels is needed
for nonpassenger merchant ships.
Alfano R, Borriello T,
De Giglio O, Iervolino C
Montagna MT, Scamardo MS,
Department of Public Health, University of Napoli "Federico
II", Via S. Pansini 5, 80131 Naples, Italy. firstname.lastname@example.org
Environ Res 2018 Jul;164:574-579.
Abstract: Background: Legionellosis'
treatment failures have been recently reported showing the possibility of
resistance development to traditional therapy, especially in healthcare related
disease cases. Environmental impact of antibiotic residues, especially in
hospital waters, may act on the resistome of Legionella resulting in
developing resistance mechanisms. Objectives: In
this study we investigate the antibiotic susceptibility of environmental Legionella
pneumophila (Lpn) strains isolated from hospital water systems in Campania,
a region located in Southwest Italy. Methods: 5321
hospital water samples were investigated for the presence of Lpn. Among
positive samples, antibiotic susceptibility was tested for a random subset of
125 Lpn strains (25 Lpn isolates from each of the following
serogroups: 1, 3, 5, 6, 8). Susceptibility testing was performed, using the
E-test on buffered charcoal yeast extract agar supplemented with α-ketoglutarate, for 10 antimicrobial drugs:
azithromycin, cefotaxime, clarithromycin, doxycycline, erythromycin, rifampicin,
tigecycline, ciprofloxacin, levofloxacin and moxifloxacin. Non parametric tests
were used to determine and assess the significant differences in susceptibility
to the different antimicrobics between the serogroups. Results: Among
the isolated strains, none showed resistance to the antibiotics tested.
Rifampicin was the most active antibiotic against overall Legionella
strains, followed by levofloxacin. Between the macrolides the clarithromycin was
overall the most active drug, instead the azithromycin was the less active.
Analyzing the different serogroups, a significant difference was found between
serogroup 1 and non-1 serogroup isolates for doxycycline and tigecycline. Conclusions: Antibiotic
susceptibility of environmental isolates of Legionella spp. might be
useful for the early detection of resistance to antibiotics that directly
impacts on mortality and length of hospital stay.
Russo A,, Soares PM, Cardoso RM,
Mendes MT, Trigo RM
Instituto Dom Luiz, Faculdade de Ciências da Universidade de
Lisboa, Lisbon, Portugal. email@example.com
Int J Biometeorol 2018 Jul,62(7):1167-1179.
A large outbreak of Legionnaires' disease occurred
in November 2014 nearby Lisbon, Portugal. This epidemic infected 377 individuals
by the Legionella pneumophila bacteria, resulting in 14 deaths. The
primary source of transmission was contaminated aerosolized water which, when
inhaled, lead to atypical pneumonia. The unseasonably warm temperatures during
October 2014 may have played a role in the proliferation of Legionella
species in cooling tower systems. The episode was further exacerbated by high
relative humidity and a thermal inversion which limited the bacterial dispersion.
Here, we analyze if the Legionella outbreak event occurred during a
situation of extreme potential recirculation and/or stagnation characteristics.
In order to achieve this goal, the Allwine and Whiteman approach was applied for
a hindcast simulation covering the affected area during a near 20-year long
period (1989-2007) and then for an independent period covering the 2014 event
(15 October to 13 November 2014). The results regarding the average daily
critical transport indices for the 1989-2007 period clearly indicate that the
airshed is prone to stagnation as these events have a dominant presence through
most of the study period (42%), relatively to the occurrence of recirculation
(18%) and ventilation (17%) events. However, the year of 2014 represents an
exceptional year when compared to the 1989-2007 period, with 53 and 33% of the
days being classified as under stagnation and recirculation conditions,
Hamilton KA, Prussin AJ 2nd, Ahmed W,
Drexel University, 3141 Chestnut Street, Philadelphia,
PA, 19104, USA. firstname.lastname@example.org
Health Rep 2018 Jun;5(2):263-271.
Abstract: Purpose of review: The
global importance of Legionnaires' disease (LD) and Pontiac fever (PF) has grown
in recent years. While sporadic cases of LD and PF do not always provide
contextual information for evaluating causes and drivers of Legionella
risks, analysis of outbreaks provides an opportunity to assess these factors. Recent findings: A
review was performed and provides a summary of LD and PF outbreaks between 2006
and 2017. Of the 136 outbreaks, 115 were LD outbreaks, 4 were PF outbreaks, and
17 were mixed outbreaks of LD and PF. Cooling towers were implicated or
suspected in the a large portion of LD or PF outbreaks (30% total outbreaks, 50%
confirmed outbreak-associated cases, and 60% outbreak-associated deaths) over
this period of time, while building water systems and pools/spas were also
important contributors. Potable water/building water system outbreaks seldom
identify specific building water system or fixture deficiencies. The outbreak
data summarized here provides information for prioritizing and targeting risk
analysis and mitigation strategies.
Orkis LT, Harrison LH, Mertz KJ,
Epidemiology, University of Pittsburgh Graduate School of Public Health, 130
DeSoto Street, Pittsburgh, PA, 15261, USA; Bureau of Assessment, Statistics, and
Epidemiology, Allegheny County Health Department, 542 Fourth Ave. Pittsburgh,
PA, 15219, USA. Lmt61@pitt.edu
Int J Hyg Environ Health 2018 Jun;221(5):764-774.
Abstract: Background: Most
Legionnaires' disease in the US and abroad is community-acquired and believed to
be sporadic, or non-outbreak associated. Most patients are exposed to numerous
water sources, thus making it difficult to focus environmental investigations.
Identifying known sources of sporadic community-acquired Legionnaires' disease
will inform future sporadic Legionnaires' disease investigations as well as
highlight directions for research. The objective is to summarize and rank
sporadic Legionnaires' disease sources based on the level of linkage between the
environmental source and cases. Methods: A
PubMed search was conducted using the search terms legion* and (origins or
source or transmission) and (sporadic or community-acquired). Studies of
nosocomial and/or outbreak-associated disease were excluded from this review.
Definite, probable, possible and suspect ranks were assigned to sources based on
evidence of linkage to sporadic Legionnaires' disease. Results: The
search yielded 196 articles and 47 articles were included in the final review
after application of exclusion criteria. A total of 28 sources were identified.
Of these, eight were assigned definite rank including residential potable water
and car air-conditioner water leakage. Probable rank was assigned to five
sources including solar-heated potable water and soil. Possible rank was
assigned to nine sources including residential potable water and cooling towers.
Suspect rank was assigned to 20 sources including large building water systems
and cooling towers. Conclusion: Residential
potable water, large building water systems and car travel appear to contribute
to a substantial proportion of sporadic Legionnaires' disease. Cooling towers
are also a potentially significant source; however, definitive linkage to
sporadic cases proves difficult. The sources of sporadic Legionnaires' disease
cannot be definitively identified for most cases
Legionnaires Disease Surveillance in US Department of Veterans Affairs
Medical Facilities and Assessment of Health Care Facility Association
Gamage SD, Ambrose M,
Kralovic SM, Simbartl LA, Roselle GA.
National Infectious Diseases Service, Specialty Care Services, Veterans
Health Administration, Department of Veterans Affairs, Washington, DC. email@example.com
Open 2018 Jun;1(2):e180230.
Abstract. Importance: Legionnaires
disease (LD) incidence is increasing in the United States. Health care
facilities are a high-risk setting for transmission of Legionella bacteria
from building water systems to occupants. However, the contribution of LD in
health care facilities to national LD rates is not well characterized.
Objectives: To determine the burden of LD in US Department of
Veterans Affairs (VA) patients and to assess the amount of LD with VA exposure.
Design, setting, and participants: Retrospective cohort study
of reported LD data in VA medical facilities in a national VA LD surveillance
system from January 1, 2014, to December 31, 2016. The study population included
total veteran enrollees and enrollees who used the VA health care system. Main
outcomes and measures: The primary outcome was assessment of annual
LD rates, categorized by VA and non-VA exposure. Legionnaires disease rates for
cases with VA exposure were determined on both population and exposure potential
levels. Rates by VA exposure potential were calculated using inpatient bed days
of care, long-term care resident days, or outpatient encounters. In addition,
types and amounts of LD diagnostic testing were calculated. Case and testing
data were analyzed nationally and regionally. Results: There were
491 LD cases in the case report surveillance system from January 1, 2014, to
December 31, 2016. Most cases (447 [91%]) had no VA exposure or only outpatient
VA exposure. The remaining 44 cases had VA exposure from overnight stays. Total
LD rates from January 1, 2014, to December 31, 2016, increased for all VA
enrollees (from 1.5 to 2.0 per 100 000 enrollees; P = .04) and for users of VA
health care (2.3 to 3.0 per 100 000 enrollees; P = .04). The LD rate for the
subset who had no VA exposure also increased (0.90 to 1.47 per 100 000 enrollees;
P < .001). In contrast, the LD rate for patients with VA overnight stay
decreased on a population level (5.0 to 2.3 per 100 000 enrollees; P < .001)
and an exposure level (0.31 to 0.15 per 100 000 enrollees; P < .001).
Regionally, the eastern United States had the highest LD rates. The urine
antigen test was the most used LD diagnostic method; 49 805 tests were performed
in 2015-2016 with 335 positive results (0.67%). Conclusions and relevance: Data
in the VA LD databases showed an increase in overall LD rates over the 3 years,
driven by increases in rates of non-VA LD. Inpatient VA-associated LD rates
decreased, suggesting that the VA's LD prevention efforts have contributed to
improved patient safety.
Ishiguro T, Yoshii Y, Kanauchi T,
Department of Respiratory
Medicine, Saitama Cardiovascular and Respiratory Center, Japan. firstname.lastname@example.org
Infect Chemother 2018 Jun:24(6):463-469.
The aims of this study were to elucidate the frequency and
etiology of community-acquired lobar pneumonia (CALP) and the clinical and
radiological differences between CALP and tuberculous lobar pneumonia (TLP). Patients and methods: We
retrospectively reviewed medical records of patients with community-acquired
pneumonia (CAP) (n = 1032) and tuberculosis (n = 1101) admitted to our hospital.
(6.7%) patients with CAP and 23 (2.1%) with pulmonary tuberculosis developed
CALP. Legionella species were the most common pathogen (27 patients,
39.1%), followed by Streptococcus pneumoniae (19 patients, 27.5%) and Mycoplasma
pneumoniae (18 patients, 26.1%). Symptom duration was longer in the patients
with TLP than in those with CALP. On chest radiographs, cavitation in the area
of lobar pneumonia and nodular shadows were radiological findings predictive of
TLP. High-resolution computed tomography showed cavitation in the area of lobar
pneumonia, well-defined centrilobular nodules, and tree-in-bud sign to be the
radiological findings predictive of TLP by multivariate logistic regression
models. Conclusion: Common
causes of CALP are Legionella species, S. pneumoniae, and M.
pneumoniae. TLP should be considered in patients with lobar pneumonia,
particularly in patients with long symptom duration, cavitation, and nodular
shadows on chest radiographs, and cavitation, well-defined centrilobular nodules,
and tree-in-bud sign on CT.
Hlavsa MC, Cikesh BL, Roberts VA, Kahler AM, Vigar M, Hilborn ED, Wade TJ, Roellig DM, Murphy JL,, Yates KM,, Arduino MJ,, Fullerton KE, Cooley LA, Beach MJ, Hill VR, Yoder JS.
of Foodborne, Waterborne, and Environmental Diseases, National Center for
Emerging and Zoonotic Infectious Diseases, CDC. email@example.com
Morb Mortal Wkly Rep 2018 May;67(19):547-551.
Abstract: Outbreaks associated with exposure to treated
recreational water can be caused by pathogens or chemicals in venues such as
pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds).
During 2000-2014, public health officials from 46 states and Puerto Rico
reported 493 outbreaks associated with treated recreational water. These
outbreaks resulted in at least 27,219 cases and eight deaths.
Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were
caused by Cryptosporidium (which causes predominantly gastrointestinal
illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a
severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms),
and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub
rash"] and otitis externa ["swimmers' ear"]). Investigations of
the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium,
920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six
of the eight reported deaths occurred in persons affected by outbreaks caused by
Legionella. Hotels were the leading setting, associated with 157 (32%) of
the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution:
275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment
of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella,
or Pseudomonas indicate mixed progress in preventing transmission.
Pathogens able to evade chlorine inactivation have become leading outbreak
etiologies. The consequent outbreak and case count and mortality underscore the
utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent
outbreaks associated with treated recreational water.
Sawano T, Tsubokura M, Ozaki A, Leppold C, Kato S,
Department of Surgery, Minamisoma
Municipal General Hospital. firstname.lastname@example.org
J Occup Health 2018 May;60(3):271-274.
Abstract: Objectives: Legionnaires'
disease (LD), which is atypical pneumonia with a broad variety of clinical
symptoms, can lead to death despite its low incidence. There are multiple risk
factors for LD, yet little information is available concerning what kind of
environmental factors are linked to higher risk of LD development. We have
experienced a fatal case of LD, which occurred in a decontamination worker after
the Fukushima nuclear disaster. Case: A
53-year-old Japanese male visited our hospital with symptoms of fever, vomiting,
diarrhea, and altered mental status, but not with respiratory manifestations. He
was engaged in decontamination work, which generally includes operations such as
the removal of topsoil in mountainous areas and cleaning roads and roofs of
residential buildings with high-pressure water. He was required to wear specific
equipment to prevent radiation exposure, and lived in a workers' dormitory or
shared house, thereby sharing spaces with other workers. Normal antibiotic
therapy did not improve his symptoms following his diagnosis with pneumonia. A
urinary antigen detection test was then conducted, leading to a diagnosis of LD.
Despite the change of antibiotic to levofloxacin, multiple organ failure led to
his death. Conclusion: Decontamination
workers may be at a high risk for developing LD and living and working
conditions among them are possible contributors.
Relich RF, Schmitt BH, Raposo H,
Barker L, Blosser SJ, May M.
Department of Pathology and Laboratory
Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA. email@example.com
Int J Infect
Dis 2018 Apr;69:26-28.
Abstract: Background: To
date, at least 50 species of Legionella have been described. These
organisms are ubiquitous in nature and have been isolated from diverse
ecological environments, including man-made structures such as cooling towers
and spas. Legionellae have also been isolated from human and veterinary clinical
specimens, and their roles in disease are well-established. This report
describes the isolation of a novel Legionella species from a respiratory
specimen from a patient with influenza and suspected pulmonary embolus. Case: A
68-year-old male presented to an Indianapolis-area hospital with pulmonary
disease; upon workup, he was found to have influenza A. Bronchoalveolar lavage
fluid was also submitted for conventional bacterial culture and Legionella
culture. The patient was prescribed a broad-spectrum antibiotic and recovered. Results: A
Legionella-like bacterium was isolated on buffered charcoal yeast extract
agar, and mass spectrometry and comparative 16S rRNA gene sequencing
inconclusively identified the isolate as a Legionella sp. Further
analysis of the 16S rRNA gene confirmed the strain to be a new species, related
to Legionella hackeliae. Physiochemical and morphological testing were
used to confirm the discovery of a novel species, Legionella
indianapolisensis sp. nov., type strain SMNF-IS.
Tomari K, Morino S, Horikoshi Y.
Department of General Pediatrics,
and Division of Infectious Diseases, Department of Pediatrics, Tokyo
Metropolitan Children's Medical Center, Tokyo, Japan.
Pediatr Infect Dis J 2018 Apr;37(4):370-372.
Abstract: A 1-month-old girl developed respiratory failure due to bilateral
interstitial pneumonia after bathing in reheated and reused water. A molecular
test for sputum and an environmental culture detected Legionella pneumophila
serotype 1. This is the first report of infantile legionellosis contracted from
a bathtub at home.
Barrabeig I, Sala MR,
Pedro-Botet ML, Monsó E,, Garcia-Núñez M
Germans Trias i Pujol, Badalona, Spain. firstname.lastname@example.org e email@example.com
Sci Rep 2018
Abstract: Legionella is the causative agent
of Legionnaires' disease (LD). In Spain, Catalonia is the region with the
highest incidence of LD cases. The characterisation of clinical and
environmental isolates using molecular epidemiology techniques provides
epidemiological data for a specific geographic region and makes it possible to
carry out phylogenetic and population-based analyses. The aim of this study was
to describe and compare environmental and clinical isolates of Legionella
pneumophila in Catalonia using sequence-based typing and monoclonal antibody
subgrouping. A total of 528 isolates were characterised. For data analysis, the
isolates were filtered to reduce redundancies, and 266 isolates (109 clinical
and 157 environmental) were finally included. Thirty-two per cent of the
clinical isolates were ST23, ST37 and ST1 while 40% of the environmental
isolates were ST284 and ST1. Although the index of diversity was higher in
clinical than in environmental ST isolates, we observed that clinical STs were
similar to those recorded in other regions but that environmental STs were more
confined to particular study areas. This observation supports the idea that only
certain STs trigger cases or outbreaks in humans. Therefore, comparison of the
genomes of clinical and environmental isolates could provide important
information about the traits that favour infection or environmental persistence.
Jan RA, Shah
Department of Internal and
Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar,
Jammu and Kashmir, India. firstname.lastname@example.org
India 2018 Mar-Apr;35(2):108-115.
Abstract: Background: There is a paucity of literature regarding the microbial etiology of
community-acquired pneumonia (CAP) in India. The current study was aimed to
study the microbial etiology of hospitalized adults with CAP. Methods: The
study was conducted in a 700-bedded North Indian hospital. Consecutive adults
admitted with CAP over a period of 2 years from 2013 to 2015 were recruited for
the study, and apart from clinical evaluation underwent various microbiological
studies in the form of blood culture, sputum culture, urinary antigen for pneumococcus
and Legionella, serology for Mycoplasma and Chlamydia and
real-time reverse transcriptase polymerase chain reaction for influenza viruses.
Radiographic studies were performed in all patients and repeated as required.
The patients were treated with standard antibiotic/antiviral therapy and
outcomes were recorded. Results: A
total of 225 patients (median age: 59 years) were enrolled. Streptococcus
pneumoniae was the most common organism found (30.5%), followed by Legionella
pneumophila (17.5%), influenza viruses (15.4%), Mycoplasma pneumoniae
(7.2%), Chlamydia pneumoniae (5.5%), Mycobacterium tuberculosis
(4.8%), Klebsiella pneumoniae (4.8%), methicillin-resistant Staphylococcus
aureus (3.5%), Pseudomonas aeruginosa (3.1%), methicillin-sensitive S.
aureus (1.7%), and Acinetobacter sp. (0.8%) with 4% of patients
having multiple pathogens etiologies. High Pneumonia Severity Index score
correlated with the severity and outcome of the CAP but was not predictive of
any definite etiological pathogen. In-hospital mortality was 8%. Conclusion: Streptococcus
pneumoniae, Legionella, and influenza constitute the most common
etiological agents for north Indian adults with CAP requiring hospitalization.
Appropriate antibiotic therapy and preventive strategies such as influenza and
pneumococcal vaccination need to be considered in appropriate groups.
MacIntyre CR, Dyda A,
Bui CM, Chughtai AA.
School of Public Health and
Community Medicine, Faculty of Medicine, University of New South Wales, Sydney,
NSW, Australia. email@example.com
Emerg Microbes Infect
Abstract: Legionnaires' disease (LD) is reported
from many parts of the world, mostly linked to drinking water sources or cooling
towers. We reviewed two unusual rolling outbreaks in Sydney and New York, each
clustered in time and space. Data on these outbreaks were collected from public
sources and compared to previous outbreaks in Australia and the US. While
recurrent outbreaks of LD over time linked to an identified single source have
been described, multiple unrelated outbreaks clustered in time and geography
have not been previously described. We describe unusual geographic and temporal
clustering of Legionella outbreaks in two cities, each of which
experienced multiple different outbreaks within a small geographic area and
within a short timeframe. The explanation for this temporal and spatial
clustering of LD outbreaks in two cities is not clear, but climate variation and
deteriorating water sanitation are two possible explanations. There is a need to
critically analyse LD outbreaks and better understand changing trends to
effectively prevent disease.
Marchand G, Lord J, Pépin C, Lacombe
Department of Chemical and Biological
Hazard Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité
du travail (IRSST), Montréal, Quebec, Canada.
Ann Work Expo
Health 2018 Mar;62(3):321-327.
Abstract: Legionella has a global
distribution, mainly in aquatic and man-made environments. Under the right
conditions, this bacterium is a notorious human pathogen responsible for severe
pulmonary illnesses. Legionellosis outbreaks are reported around the world, and
exposure to water droplet aerosols containing Legionella pneumophila is
usually the mechanism of its transmission. Even if L. pneumophila causes
most outbreaks, Legionella longbeachae also accounts for some cases.
Unlike most other Legionella strains, L. longbeachae is typically
found in soil. Given the wide diversity and high concentration of microorganisms
found in soil, isolating L. longbeachae by culture can be challenging.
Because the chances of successfully isolating the strain are low, it is often
not even attempted. This study reports the strategies used to successfully
isolate L. longbeachae strain that was responsible of the two
occupational legionellosis in Quebec. Fifteen random samples were collected from
the soil of the metal recycling plant where the diagnosed workers were employed,
covering 1.5% of the accessible surface of the plant. All samples were analyzed
with both the quantitative polymerase chain reaction (qPCR) and culture methods.
Four qPCR detection systems targeting Legionella spp, L. pneumophila,
L. pneumophila serogroup 1, and L. longbeachae were used. Acid,
heat, and acid/heat treatments were used for the culture method. For the qPCR
method, all samples were positives for Legionella spp but only four were
positives for L. longbeachae. For the culture method, only one isolate
could be confirmed to be L. longbeachae. However, that strain proves to
be the same one that caused the occupational legionellosis. Detecting the
presence of L. longbeachae using the qPCR method made it possible to
target the right samples to enable the cultivable strain of L. longbeachae
to be isolated from the soil of the metal recycling plant. The complementarity
of the two methods was established. This paper demonstrated the advantages of
selecting the proper sampling and analytical strategies to achieve the isolation
of the strain responsible for the infections. It also highlights for the first
time in Quebec the potential occupational risks associated with L.
longbeachae from soil and should motivate questioning soil exposures when
all sources of water contamination have been eliminated from the causal analysis
Zahran S, McElmurry SP,
Kilgore PE, Mushinski D, Press J, Love NG, Sadler RC, Swanson MS.
Department of Microbiology and
Immunology, University of Michigan, Ann Arbor, MI USA. firstname.lastname@example.org
Acad Sci USA 2018 Feb;115(8):E1730-E1739.
Abstract: The 2014-2015 Legionnaires' disease (LD)
outbreak in Genesee County, MI, and the outbreak resolution in 2016 coincided
with changes in the source of drinking water to Flint's municipal water system.
Following the switch in water supply from Detroit to Flint River water, the odds
of a Flint resident presenting with LD increased 6.3-fold (95% CI: 2.5, 14.0).
This risk subsided following boil water advisories, likely due to residents
avoiding water, and returned to historically normal levels with the switch back
in water supply. During the crisis, as the concentration of free chlorine in
water delivered to Flint residents decreased, their risk of acquiring LD
increased. When the average weekly chlorine level in a census tract was <0.5
mg/L or <0.2 mg/L, the odds of an LD case presenting from a Flint
neighborhood increased by a factor of 2.9 (95% CI: 1.4, 6.3) or 3.9 (95% CI:
1.8, 8.7), respectively. During the switch, the risk of a Flint neighborhood
having a case of LD increased by 80% per 1 mg/L decrease in free chlorine, as
calculated from the extensive variation in chlorine observed. In communities
adjacent to Flint, the probability of LD occurring increased with the flow of
commuters into Flint. Together, the results support the hypothesis that a
system-wide proliferation of legionellae was responsible for the LD outbreak in
Genesee County, MI.
Lucas KD, Wheeler C, McLendon P,
Leistikow BN, Mohle-Boetani JC
California Correctional Health Care
Services, Public Health Branch, Elk Grove, CA, USA.
Epidemiol Infect 2018 Feb;146(3):
A large outbreak of Legionnaires' disease occurred at a California state prison
in August 2015. We conducted environmental and epidemiological investigations to
identify the most likely source of exposure and characterise morbidity.
Sixty-four inmates had probable Legionnaires' disease; 14 had
laboratory-confirmed legionellosis. Thirteen (17%) inmates were hospitalised;
there were no deaths. Ill inmates were more likely to be ⩾65 years old (P<0.01), have the chronic obstructive
pulmonary disease (P<0.01), diabetes mellitus (P=0.02), hepatitis C infection
(P<0.01), or end-stage liver disease (P<0.01). The case-patients were in
ten housing units throughout the prison grounds. All either resided in or were
near the central clinical building (for appointments or yard time) during their
incubation periods. Legionella pneumophila serogroup 1 was cultured from
three cooling towers on top of the central medical clinic (range, 880-1200 cfu/ml).
An inadequate water management program, dense biofilm within the cooling towers,
and high ambient temperatures preceding the outbreak created an ideal
environment for Legionella sp. proliferation. All state prisons were
directed to develop local operating procedures for maintaining their cooling
towers and the state health department added a review of the maintenance plans
to their environmental inspection protocol.
Timms VJ, Rockett R, Bachmann NL, Martinez E, , Chen SC,, Howard PJ, Smith A, Adamson S, Gilmour R, Sheppeard V,
Centre for Infectious Diseases and
Microbiology-Public Health, Westmead Hospital, Sydney, New South Wales,
Microbiol 2018 Feb;84(5):e02020-17.
Abstract: The city of Sydney, Australia,
experienced a persistent outbreak of Legionella pneumophila serogroup
1 (Lp1) pneumonia in 2016. To elucidate the source and guide public health
actions, the genomes of clinical and environmental Lp1 isolates recovered over 7
weeks were examined. A total of 48 isolates from human cases and cooling towers
were sequenced and compared using single-nucleotide polymorphism (SNP)-based
core-genome multilocus sequencing typing (MLST) and pangenome approaches. All
three methods confirmed phylogenetic relatedness between isolates associated
with outbreaks in the Central Business District (CBD) in March and May and those
in suburb 1. These isolates were designated the "main cluster" and
consisted of isolates from two patients from the CBD March outbreak, one patient
and one tower isolate from suburb 1, and isolates from two cooling towers and
three patients from the CBD May outbreak. All main cluster isolates were
sequence type 211 (ST211), which previously has only been reported in Canada.
Significantly, pangenome analysis identified mobile genetic elements containing
a unique type IV A F-type secretion system (T4ASS), which was specific to the
main cluster, and cocirculating clinical strains, suggesting a potential
mechanism for increased fitness and persistence of the outbreak clone. Genome
sequencing enabled linking of the geographically dispersed environmental sources
of infection among the spatially and temporally coinciding cases of
legionellosis in a highly populated urban setting. The discovery of a unique
T4ASS emphasizes the role of genome recombination in the emergence of successful
Lp1 clones. IMPORTANCE: A new emerging clone has been responsible for a
prolonged legionellosis outbreak in Sydney, Australia. The use of whole-genome
sequencing linked two outbreaks thought to be unrelated and confirmed the
outliers. These findings led to the resampling and subsequent identification of
the source, guiding public health actions and bringing the outbreak to a close.
Significantly, the outbreak clone was identified as sequence type 211 (ST211).
Our study reports this ST in the Southern Hemisphere and presents a description
of ST211 genomes from both clinical and environmental isolates. A unique mobile
genetic element containing a type IV secretion system was identified in Lp1
ST211 isolates linked to the main cluster and Lp1 ST42 isolates that were
cocirculating at the time of the outbreak.
Baldovin T, Pierobon
A, Bertoncello C,
Destefani E, Gennari M,
Stano A, Baldo V
Department of Cardiac, Thoracic and Vascular Sciences,
Hygiene and Public Health Unit, University of Padua, Padua, Italy. email@example.com
Ann Ig 2018
Abstract: Background: Legionella
is a ubiquitous Gram-negative bacterium naturally found in aquatic environments.
It can pose a health problem when it grows and spreads in man-made water systems.
Legionella pneumophila is the most common cause of Legionnaires' disease
nowadays, a community-acquired pneumonia with pulmonary symptoms and chest
radiography no different from any other form of infectious pneumonia. Legionella
monitoring is important for public health reasons, including the identification
of unusual environmental sources of Legionella. Methods: We
report two cases of Legionnaires' disease associated with two different car wash
installations in the province of Vicenza, in the Veneto region, northeastern
Italy. Patients were not employees of the car wash installations, but users of
the service. In both cases, Legionella antigen was detected in urine
using the Alere BinaxNOW® Legionella Urinary Antigen, and Legionella
antibodies were detected in serum using SERION ELISA classic Legionella
pneumophila 1-7 IgG and IgM. Water samples were also analyzed as part of the
surveillance program for Legionella prevention and control in compliance
with the Italian guidelines. Results: Both
patients had clinical symptoms and chest radiography compatible with pneumonia,
and only one of them had diabetes as a risk factor. Legionella urinary
antigen and serological test on serum samples were positive for Legionella
in both patients, even if much slighter in the case A due to the retrospective
serological investigation performed a year later the episode and after the
second clinical case occurred in the same district. The environmental
investigations highlighted two different car wash plants as potential source of
infection. A certified company using shock hyperchlorination was asked to
disinfect the two plants and, subsequently, control samples resulted negative
for Legionella pneumophila. Conclusion: Any
water source producing aerosols should be considered at risk for the
transmission of Legionella bacteria, including car wash installations
frequently used by a large number of customers and where poor maintenance
probably creates favorable conditions for Legionella overgrowth and
spreading. Additional research is needed to ascertain optimal strategies for Legionella
monitoring and control, but environmental surveillance, paying careful attention
to possible unconventional sources, should remain an important component of any
Legionnaires' disease prevention program. Additionally, all available diagnostic
methods would be recommended for the confirmation of all cases even in the event
of non-serogroup 1 Legionella pneumophila infection, probably
underestimated at this time.
Cassell K, Gacek P, Warren JL,
Raymond PA, Cartter M, Weinberger DM.
Epidemiology of Microbial Diseases, New Haven, Connecticut. firstname.lastname@example.org
J Infect Dis 2018 Jan;217(2):179-187.
Abstract: Background: There has been a dramatic
increase in the incidence of sporadic legionnaires' disease in Connecticut since
1999, but the exact reasons for this are unknown. Therefore, there is a growing
need to understand the drivers of legionnaires' disease in the community. In
this study, we explored the relationship between the natural environment and the
spatial and temporal distribution of legionellosis cases in Connecticut. Methods: We
used spatial models and time series methods to evaluate factors associated with
the increase and clustering of legionellosis in Connecticut. Stream flow,
proximity to rivers, and residence in regional watersheds were explored as novel
predictors of disease, while controlling for testing intensity and correlates of
urbanization. Results: In
Connecticut, legionellosis incidence exhibited a strong pattern of spatial
clustering. Proximity to several rivers and residence in the corresponding
watersheds were associated with increased incidence of the disease. Elevated
rainfall and stream flow rate were associated with increases in incidence 2
weeks later. Conclusions: We
identified a novel relationship between the natural aquatic environment and the
spatial distribution of sporadic cases of legionellosis. These results suggest
that natural environmental reservoirs may have a greater influence on the
spatial distribution of sporadic legionellosis cases than previously thought.
Kyritsi MA, Mouchtouri VA, Katsiafliaka A,, Plakokefalos E,, Rachiotis G, Hadjichristodoulou C.
Department of Hygiene and Epidemiology, Faculty of
Medicine, University of Thessaly, Larissa, Greece. email@example.com
Case Rep Infect Dis 2018:2570758.
Abstract: Healthcare-associated Legionnaires'
disease often leads to fatal respiratory tract infection among hospitalized
patients. In this report, three cases of Legionnaires' disease among patients in
two different hospitals (Hospital A and Hospital B) were investigated. After
conducting an epidemiologic and environmental investigation, the water
distribution systems (WDSs) were identified as the possible source of infection,
as Legionella pneumophila serogroup 1 (Lp1) was isolated
from both clinical and environmental samples. Patients received aerosol therapy
with nebulizers during their hospitalization. Based on the results of the
investigation, the hospitals' infection control committees reviewed their
policies for Legionnaires' disease prevention and implemented control measures
focusing on using sterile fluids for aerosol treatments.
Hase R,, Matsuura Y,, Nakamura M, Otsuka Y.
Department of Infectious Diseases, Japanese Red Cross
Narita Hospital, 90-1 Iidacho, Narita, Chiba, Japan. firstname.lastname@example.org
J Infect Chemother
Abstract: Legionella pneumophila is
recognized as a common causative organism for community-acquired pneumonia, but
it is rarely a causative organism for hospital-acquired pneumonia, except in
cases of hospital outbreak. Recently, most of the Legionella cases have
been diagnosed using the urine antigen test. However, this test can reliably
detect only L. pneumophila serogroup 1. Here we report a 63-year-old male
patient who was recently diagnosed with acute leukemia and treated with
chemotherapy and who developed pneumonia on hospital day 8 during the nadir
phase. He was later diagnosed with Legionella pneumonia by culture
despite a negative urine antigen test. This case suggests that Legionella
pneumonia is an important differential diagnosis for pneumonia in inpatients
in the early phase of hospitalization and that when Legionella infection
is clinically suspected, culture using selective media or molecular tests should
be performed even if the urine antigen test is negative.
Stypułkowska-Misiurewicz H, Czerwiński M
National Institute of Public Health – National
Institute of Hygiene in Warsaw, Department of Bacteriology. email@example.com
aim of the study was to assess the epidemiological situation of legionellosis in
Poland in 2016 in comparison to the preceding years. Material and methods: The assessment
was based on national surveillance data published in the annual bulletin:
“Infectious diseases and poisonings in Poland in 2016” and its prior
versions along with data from legionellosis case reports sent from
Sanitary-Epidemiological Stations to the Department of Epidemiology of NIPH -
NIH. Results: In
Poland, both two main forms of legionellosis - Legionnaires’ disease and
Pontiac fever are routinely reported to the surveillance system. In 2016, a
total of 27 cases of legionellosis were registered, including 25 cases of
Legionnaires’ disease and 2 cases of Pontiac fever; in 2016, a total of 27
cases of legionellosis have been reported, including 25 cases of Legionnaires’
disease and 2 cases of Pontiac fever; the annual incidence rate 0.070 (per
100,000 population) was comparable to previous year (0.060) but almost twice as
high as the median (incidence) for 2010-2014. The infections were reported in 11
provinces, including two, which in previous years usually did not register any
cases; only two provinces (out of 16 in the country) have reported no cases in
recent years. The incidence in men (0.080 per 100,000) was higher compared to
women (0.055). All reported cases were sporadic and, except for one mild case of
Legionnaires’ disease, required hospitalization. The Sanitary Inspection
reported two fatal cases – both women aged 59 and 69. Twenty cases were
autochthonous including four cases linked with contaminated water systems in
hospitals. Seven cases were associated with travel abroad (to Germany, Russia,
Greece, Australia, USA and Thailand). Summary
and conclusions: Despite the
increase in the number of cases in recent years as well as number of provinces,
which detected cases, the annual incidence of legionellosis in Poland remains
one of the lowest in the EU, which suggests that this infection is likely
under-recognized and underdiagnosed in all provinces of the country.
Nur N, Bonitati A, Carino G.
Pulmonary and Critical Care Medicine, The
Warren Alpert Medical School, Brown University, Providence, RI, USA.
SAGE Open Med
Case Rep 2017 Dec;5:2050313X17744981.
Abstract: A 67-year-old woman with morbid obesity
and severe obstructive sleep apnea presented to the emergency department with 2
days of productive cough, fever, shortness of breath and loose stools. A chest
x-ray showed extensive bilateral infiltrates, and she was quickly intubated for
acute hypoxic respiratory failure. A urine legionella antigen test was positive,
and she was admitted to the intensive care unit with a diagnosis of severe
legionella pneumonia. She improved over the next week with a course of
levofloxacin. Once improved, the state health department visited her home and
interviewed her husband and determined that she had not been cleaning her
continuous positive pressure mask, tubing and humidifier appropriately. They
concluded that the legionella likely came from her continuous positive airway
pressure equipment. Cases of legionella pneumonia have frequently been reported
through infected water supplies and even respiratory equipment. It is crucial
that the mask and tubing used with these devices are cleaned appropriately to
minimize the risk of infection.
Szewc AM, Taylor S,
Cage GD, de Mello D.
Department of Pathology and Laboratory
Medicine, Phoenix Children's Hospital, Phoenix, AZ. firstname.lastname@example.org
Med. 2017 Dec;49(1):e9-e13.
Legionellaceae are composed of a single genus, Legionella, which is
currently comprised of over 52 species. L. pneumophila, L. micdadei,
L. longbeachae, and L. dumoffi are clinically considered the most
important, with L. pneumophila causing >90% 1,7 of cases of
legionnaires disease (LD). Since LD's recognition in 1976 following an outbreak
of pneumonia involving delegates of an American Legion convention in
Philadelphia, there has been increased awareness and importance of the isolation,
detection, and reporting of these cases. Herein we describe the unfortunate case
of a 7 month old boy with undiagnosed LD that lead to respiratory insufficiency,
sepsis, multisystem organ failure and death. Laboratory investigation methods,
and clinical and pathological findings are discussed.
National Institute of Public Health –
National Institute of Hygiene in Warsaw, Department of Bacteriology. email@example.com
Przegl Epidemiol 2017;71(3):333-337.
aim of the study was to assess the epidemiological situation of legionellosis in
Poland in 2015 in comparison to the preceding years. Material and methods: We
reviewed data published in the annual bulletin: “Infectious diseases and
poisonings in Poland in 2015” and its prior versions along with the
legionellosis case reports sent from Sanitary- Epidemiological Stations to the
Department of Epidemiology of NIPH - NIH. Results: In
Poland, both two forms of legionellosis - Legionnaires’ disease (a severe form
of disease accompanied by pneumonia) and Pontiac fever (mild, influenza-like
form of infection) - are notifiable. In 2015, a total of 23 cases of
Legionnaires’ disease have been reported (there were no reports of Pontiac
fever). The annual incidence rate 0.060 (per 100,000 population) slightly
increased when compared to previous year as well as to the median (incidence)
for 2009-2013. The infections were reported in 10 provinces, including five,
which in previous years usually did not register any cases; however, there is a
number of provinces that did not identify any LD cases in recent years. The
incidence in males (0.097 per 100,000) was almost 4-times higher compared to
females (0.025). Except for one cluster of two, all cases were sporadic; All
patients required hospitalization. The Sanitary Inspection reported four fatal
cases – all men 43- 67 years/old. Eighteen cases were likely acquired in the
country, including a cluster of two cases linked with contaminated building
water system. Four cases were associated with travels abroad (to Russia, Croatia,
United Arab Emirates and USA) and in one case the exposure occurred during the
transport of goods (lorry driver). Summary and
study suggests that legionellosis is likely under recognized and under diagnosed
in all provinces of the country. Geographical variations in incidence may
reflect local differences in availability of laboratory tests for LD. Number of
detected cases - without information on the number of laboratory tests performed
- do not appear to be sufficient to fully assess the epidemiological situation.
Avventuroso E, Casale M,
Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University Hospital of Messina, Italy. firstname.lastname@example.org
J Prev Med Hyg 2017;58 (2):E173-E176.
Abstract: Infective Endocarditis (IE) is a disease
with high morbidity and mortality. Nowadays, in addition to classic pathogens
were isolated exigent Gram-negative bacteria as A. baumannii, A.
lwoffii, C. burnetii, Bartonella, Chlamydia and Legionella.
We present our experience of Legionella isolations in environmental sample
(water and air) collected from the Cardiology units belonging to two hospitals
in Messina (Italy). A total of 80 samples were carried out, 30 and 50,
respectively in the first and in the second structure: 55 of water and 25 of
aerosol. The positivity of 30% of the water samples analyzed and 15% of those
aerosol strengthens the conviction of the need for greater environmental
monitoring, especially in the wards at high risk.
Madsen AM, Holm A, Jensen TG,
Knudsen E, Lundgaard H, Skov MN,
Uldum SA, Kemp M.
Department of Clinical Microbiology,
Odense University Hospital, Odense, Denmark. Anne.Rosendahl@rsyd.dk
J Hosp Infect
of Legionnaires' disease is a serious complication of hospitalization. Rapid
determination of whether or not the infection is caused by strains of Legionella
pneumophila in the hospital environment is crucial to avoid further cases.
This study investigated the use of whole-genome sequencing to identify the
source of infection in hospital-acquired Legionnaires' disease. Phylogenetic
analyses showed close relatedness between one patient isolate and a strain found
in hospital water, confirming suspicion of nosocomial infection. It was found
that whole-genome sequencing can be a useful tool in the investigation of
hospital-acquired Legionnaires' disease.
Chaudhry R, Valavane A, Sreenath K,
Department of Microbiology, All India Institute of
Medical Sciences, New Delhi, India. email@example.com
Am J Trop Med Hyg 2017
Abstract: Atypical pathogens including Mycoplasma pneumoniae and Legionella
pneumophila are increasingly recognized as important causes of
community-acquired pneumonia (CAP). Mycoplasma pneumoniae accounts
for 20-40% of all CAP and L. pneumophila is responsible for
3-15% of cases. The paucity of data from India in this regard prompted us to
conduct this prospective multicentric analysis to detect the prevalence of M.
pneumoniae and L. pneumophila in our geographical
region. A total of 453 patients with symptoms of pneumonia and 90 controls with
no history of lower respiratory tract infections were included in the study. A
duplex polymerase chain reaction (PCR) targeting 543 bp region of P1
adhesin gene of M. pneumoniae and 375 bp region of macrophage
infectivity potentiator (mip) gene of L. pneumophila was
standardized for simultaneous detection of these atypical pathogens. Respiratory
secretions, blood, and urine samples were collected from each patient and
control and were subjected to duplex PCR, culture and serology for M.
pneumoniae and L. pneumophila. Urine samples were subjected
for detecting L. pneumophila antigen. Among the 453 patients
investigated for M. pneumoniae, 52 (11.4%) were positive for IgM
antibodies, 17 were positive by culture, and seven tested positive by PCR (P1 gene).
Similarly for L. pneumophila, 50 cases (11%) were serologically
positive for IgM antibodies, one was positive by PCR (mip gene) and
urine antigen detection. A total of eight samples were positive by duplex PCR
for M. pneumoniae P1 gene (N=7) and L.
pneumophila mip gene (N=1). Of the 90 controls, two samples
(2.2%) showed IgM positivity, and 15 (16.7%) showed IgG positivity for M.
pneumoniae. For L. pneumophila, three samples (3.3%) tested
positive for IgM, and 12 (13.3%) tested positive for IgG antibodies. The study
findings indicate the presence of M. pneumoniae and L.
pneumophila in our geographical region, and a combination of laboratory
approaches including PCR, culture, and serology is required for effective
detection of these agents.
Petzold M, Prior K, Moran-Gilad J, Harmsen D, Lück
Institute of Medical Microbiology and Hygiene,
Dresden University of Technology, Dresden, Germany. firstname.lastname@example.org
Euro Surveill 2017 Nov;22(45):pii=17-00137.
Abstract: Introduction Whole genome sequencing (WGS)
is increasingly used in Legionnaires' disease (LD) outbreak investigations,
owing to its higher resolution than sequence-based typing, the gold standard
typing method for Legionella pneumophila, in the analysis of
endemic strains. Recently, a gene-by-gene typing approach based on 1,521 core
genes called core genome multilocus sequence typing (cgMLST) was described that
enables a robust and standardised typing of L. pneumophila. Methods:
We applied this cgMLST scheme to isolates obtained during the largest outbreak
of LD reported so far in Germany. In this outbreak, the epidemic clone ST345 had
been isolated from patients and four different environmental sources. In total
42 clinical and environmental isolates were retrospectively typed. Results:
Epidemiologically unrelated ST345 isolates were clearly distinguishable from the
epidemic clone. Remarkably, epidemic isolates split up into two distinct
clusters, ST345-A and ST345-B, each respectively containing a mix of clinical
and epidemiologically related environmental samples.
The outbreak was therefore likely caused by both variants of the single sequence
type, which pre-existed in the environmental reservoirs. The two clusters
differed by 40 alleles located in two neighbouring genomic regions of ca 42 and
26 kb. Additional analysis supported horizontal gene transfer of the two regions
as responsible for the difference between the variants. Both regions comprise
virulence genes and have previously been reported to be involved in
recombination events. This corroborates the notion that genomic outbreak
investigations should always take epidemiological information into consideration
when making inferences. Overall, cgMLST proved helpful in disentangling the
complex genomic epidemiology of the outbreak.
McClung RP, Roth DM, Vigar M, Roberts VA, Kahler AM, Cooley LA, Hilborn ED, Wade TJ, Fullerton KE, Yoder JS, Hill VR.
Intelligence Service, CDC. RMcClung@cdc.gov
MMWR Morb Mortal Wkly Rep 2017 Nov;66(44):1222-1225.
Waterborne disease outbreaks in the United States are associated with a wide
variety of water exposures and are reported annually to CDC on a voluntary basis
by state and territorial health departments through the National Outbreak
Reporting System (NORS). A majority of outbreaks arise from exposure to drinking
water (1) or recreational water (2), whereas others are caused by an
environmental exposure to water or an undetermined exposure to water. During
2013-2014, 15 outbreaks associated with an environmental exposure to water and
12 outbreaks with an undetermined exposure to water were reported, resulting in
at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella
was responsible for 63% of the outbreaks, 94% of hospitalizations, and all
deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas,
and Giardia, including six outbreaks of giardiasis caused by ingestion of
water from a river, stream, or spring. Water management programs can effectively
prevent outbreaks caused by environmental exposure to water from human-made
water systems, while proper point-of-use treatment of water can prevent
outbreaks caused by ingestion of water from natural water systems.
Lapierre P, Nazarian E, Zhu Y, Wroblewski D, Saylors A, Passaretti T, Hughes S, Tran A, Lin Y, Kornblum J,, Mercante JW, Fitzhenry R, Weiss D, Raphael BH, Varma JK, Zucker HA, Rakeman JL, Musser KA.
for Medical Science, New York State Department of Health, Wadsworth Center,
Albany, NY 12208, USA. email@example.com
Emerg Infect Dis 2017 Nov;23(11):1784-1791.
Abstract: During the summer of 2015, New York, New
York, USA, had one of the largest and deadliest outbreaks of Legionnaires'
disease in the history of the United States. A total of 138 cases and 16 deaths
were linked to a single cooling tower in the South Bronx. Analysis of
environmental samples and clinical isolates showed that sporadic cases of
legionellosis before, during, and after the outbreak could be traced to a slowly
evolving, single-ancestor strain. Detection of an ostensibly virulent Legionella
strain endemic to the Bronx community suggests potential risk for future cases
of legionellosis in the area. The genetic homogeneity of the Legionella
population in this area might complicate investigations and interpretations of
future outbreaks of Legionnaires' disease.
A Case of Community-Acquired
Pneumonia Due to Legionella pneumophila Serogroup 9 Wherein Initial
Treatment with Single-Dose Oral Azithromycin Appeared Useful
Ito A, Ishida T,
Tachibana H, Ito Y,
Takaiwa T, Fujii H,
Hashimoto T, Nakajima
H, Amemura-Maekawa J.
Department of Respiratory
Medicine, Kurashiki Central Hospital. firstname.lastname@example.org
Jpn J Infect Dis 2017 Nov;70(6):660-662.
Abstract: Legionella species are important
causative pathogens for severe community-acquired pneumonia (CAP). Most cases of
Legionella pneumonia are due to Legionella pneumophila serogroup
1, and CAP due to L. pneumophila serogroup 9 is rare. A fourth case of
CAP due to L. pneumophila serogroup 9 has been reported, and initial
treatment using single-dose oral azithromycin appeared useful. Azithromycin or
fluoroquinolone injection is usually recommended for the treatment of Legionella
pneumonia, and no previous reports have shown the effectiveness of single-dose
oral azithromycin. This case report is therefore valuable from the perspective
of possible treatment for mild to moderate Legionella pneumonia using
single-dose oral azithromycin.
R, Weiss D, Cimini D, Balter S, Boyd C,
Alleyne L, Stewart R, McIntosh N, Econome A, Lin Y, Rubinstein I, Passaretti T,
Kidney A, Lapierre P, Kass D, Varma JK.
Department of Health and
Mental Hygiene, Bureau of Communicable Disease, New York, USA. email@example.com
Emerg Infect Dis 2017 Nov;23(11):1769-1776.
Abstract: The incidence of Legionnaires' disease in the
United States has been increasing since 2000. Outbreaks and clusters are
associated with decorative, recreational, domestic, and industrial water systems,
with the largest outbreaks being caused by cooling towers. Since 2006, 6
community-associated Legionnaires' disease outbreaks have occurred in New York
City, resulting in 213 cases and 18 deaths. Three outbreaks occurred in 2015,
including the largest on record (138 cases). Three outbreaks were linked to
cooling towers by molecular comparison of human and environmental Legionella isolates,
and the sources for the other 3 outbreaks were undetermined. The evolution of
investigation methods and lessons learned from these outbreaks prompted
enactment of a new comprehensive law governing the operation and maintenance of
New York City cooling towers. Ongoing surveillance and program evaluation will
determine if enforcement of the new cooling tower law reduces Legionnaires'
disease incidence in New York City.
Polgreen LA, Hornick DB, Sewell DK, Polgreen PM.
Division of Infectious
Diseases, Carver College of Medicine, University of Iowa, Iowa City, USA.
Dis 2017 Nov;23(11):1843-1851.
Abstract: Using the Nationwide Inpatient Sample
and US weather data, we estimated the probability of community-acquired
pneumonia (CAP) being diagnosed as Legionnaires' disease (LD). LD risk increases
when weather is warm and humid. With warm weather, we found a dose-response
relationship between relative humidity and the odds for LD. When the mean
temperature was 60°-80°F with high humidity (>80.0%), the odds for CAP
being diagnosed with LD were 3.1 times higher than with lower levels of humidity
(<50.0%). Thus, in some regions (e.g., the Southwest), LD is rarely the cause
of hospitalizations. In other regions and seasons (e.g., the mid-Atlantic in
summer), LD is much more common. Thus, suspicion for LD should increase when
weather is warm and humid. However, when weather is cold, dry, or extremely hot,
empirically treating all CAP patients for LD might contribute to excessive
antimicrobial drug use at a population level.
P, Costa AL,
Cappello A, Casini B,
Privitera G, BaggianiA.
Translational Research N.T.M.S., University of Pisa, 56126 Pisa, Italy. firstname.lastname@example.org
Int J Environ Res Public Health 2017 Oct;14(11):1296.
Abstract: Although the European reports highlight an increase in
community-acquired Legionnaires' disease cases, the risk of Legionella spp.
in private houses is underestimated. In Pisa (Italy) we performed a three-year
survey on Legionella presence in 121 buildings with an independent hot water
production (IB); 64 buildings with a central hot water production (CB); and 35
buildings with a solar thermal system for hot water production (TB). From all
the 220 buildings Legionella spp. was researched in two hot
water samples collected either at the recirculation point or on the first floor
and on the last floor, while the potable water quality was analysed in three
cold water samples collected at the inlet from the aqueduct network, at the exit
from the autoclave, and at the most remote tap. Legionella pneumophila sg1, Legionella
pneumophila sg2-16, and non-pneumophila Legionella species
were detected in 26% of the hot water networks, mostly in CB and TB. In these
buildings we detected correlations between the presence of Legionella and
the total chlorine concentration decrease and/or the increase of the
temperature. Cold water resulted free from microbiological hazards, with the
exception of Serratia liquefaciens and Enterobacter
cloacae isolated at the exit from two different autoclaves. We observed
an increase in total microbial counts at 22 °C and 37 °C between the samples
collected at the most remote taps compared to the ones collected at the inlet
from the aqueduct. The study highlights a condition of potential risk for
susceptible categories of population and supports the need for measures of risk
assessment and control.
S, Podczervinski S, Butler-Wu SM, Hawkins V,
Stednick Z, Helbert LA, Glover WA, Whimbey E, Duchin J, Cheng GS, Pergam SA.
Vaccine and Infectious Disease Division,
Fred Hutchinson Cancer Research Center, Seattle, WA, USA. email@example.com
Transpl Infect Dis 2017
Abstract: Legionnaires' disease (LD) can be fatal
among high-risk transplant recipients. To understand the epidemiology of LD, we
reviewed 15-year longitudinal data from a center in Seattle, Washington that
cares for both solid organ transplant (SOT) and hematopoietic cell transplant (HCT)
recipients. We identified all laboratory-confirmed LD and extracted data on
species, diagnostic modalities, clinical presentation, management, and outcomes
from medical records. Among 32 patients with LD, transplant recipients made up
the majority of diagnoses (22, 69%; SOT 10, HCT 12). Approximately 0.8% of
transplant recipients who underwent Legionella-specific testing were positive.
Non-pneumophila Legionella species (LNLP), which are not detected by
urinary antigen test, accounted for half the cases, led by Legionella
micdadei (32%). The severity and outcome between Legionella pneumophila
and LNLP infections were similar (attributed mortality, 36% vs 27%); all LNLP
deaths occurred in transplant recipients with L. micdadei. The clinical
and radiological features mimicked other opportunistic pathogens; 32% (n=7) were
not on empiric treatment at the time of diagnosis. These data add to the
emerging literature describing the importance of LD and highlight the need for
both routine Legionella testing on transplant recipients with pulmonary
findings and empiric Legionella-active antibiotic therapy.
Rhoads WJ, Garner E, P Ji,
Zhu N, Parks J,
Schwake DO, Pruden A,
of Civil and Environmental Engineering, Virginia Tech, Blacksburg, Virginia, USA. firstname.lastname@example.org
Technol 2017 Oct;51(20):11986-11995.
Abstract: We hypothesize that the increase in
reported Legionnaires' disease from June 2014 to November 2015 in Genesee County,
MI (where Flint is located) was directly linked to the switch to corrosive Flint
River water from noncorrosive Detroit water from April 2014 to October 2015. To
address the lack of epidemiological data linking the drinking water supplies to
disease incidence, we gathered physiochemical and biological water quality data
from 2010 to 2016 to evaluate characteristics of the Flint River water that were
potentially conducive to Legionella growth. The treated Flint River water
was 8.6 times more corrosive than Detroit water in short-term testing, releasing
more iron, which is a key Legionella nutrient, while also directly
causing disinfectant to decay more rapidly. The Flint River water source was
also 0.8-6.7°C warmer in summer months than Detroit water and exceeded the
minimum Legionella growth temperature of 20°C more frequently (average
number of days per year for Detroit was 63 versus that for the Flint River,
which was 157). The corrosive water also led to 1.3-2.2 times more water main
breaks in 2014-2015 compared to 2010-2013; such disruptions have been associated
with outbreaks in other locales. Importantly, Legionella spp. and Legionella
pneumophila decreased after switching back to Detroit water, in terms of
both gene markers and culturability, when August and October 2015 were compared
to November 2016.
Pebody R, Phin N
Centre for Infectious Disease
Surveillance and Control, National Infection Service, Public Health England,
London, United Kingdom. email@example.com
Euro Surveill 2017 Sep;22(38):30618.
Abstract: Between 1 October 2016 and 31 August 2017, 51 Legionnaires' disease (LD)
cases from the United Kingdom, Sweden and the Netherlands were identified with
associated travel to Dubai. Cases did not all stay in the same accommodation,
indicating that no single accommodation could be the source for all these
infections. While local investigations continue into other potential sources,
clinicians should remain alert to the possibility of LD among travellers
returning from Dubai with respiratory illness.
Chochlakis D, Sandalakis V, Keramarou
M, Tselentis Y, Psaroulaki A.
Regional Laboratory of Public Health of
Crete, Heraklion, Crete, Greece. firstname.lastname@example.org
Cent Eur J Public Health 2017 Sep;25(3):235-239.
Abstract: Objectives: Although
a number of human Legionnaires' disease in tourists are recorded annually in
Europe, there are few cases where a direct link can be made between the infected
person and the source of infection (hotel or other accommodation). We present a
scheme followed in order to track down and identify the source of infection in a
tourist suffering from L. pneumophila sg 5 infection, who was
accommodated in seven different hotels during his holidays in the island of
Crete, and we comment on various difficulties and draw-backs of the process. Method: Water
samples were collected from the seven hotels where the patient had resided and
analyzed at the regional public health laboratory using cultivation and
molecular tests. Results: Of
103 water samples analyzed, 19 (18.4%) were positive for Legionella non-pneumophila
and 8 (7.8%) were positive for L. pneumophila. A successful L.
pneumophila sg 5 match was found between the clinical and environmental
sample, which led us to the final identification of the liable hotel. Conclusion: Timely
notification of the case, within the European Legionnaires' Disease Surveillance
Network (ELDSNet) of the partners involved, is crucial during a course of travel
associated with Legionella case investigation. Moreover, the urinary
antigen test alone cannot provide sufficient information for the source
identification. However, acquiring clinical as well as environmental isolates
for serogroup and SBT identification is highly important for the successful
Soda EA, Barskey AE, Shah PP,
Schrag S, Whitney CG,
Arduino MJ, Reddy SC,
Kunz JM, Hunter CM,
Raphael BH, Cooley LA
Epidemic Intelligence Service, CDC,
Transplant 2017 Aug;17(8):2215-2220.
Abstract: Background: Legionnaires'
disease, a severe pneumonia, is typically acquired through inhalation of
aerosolized water containing Legionella bacteria. Legionella can grow in
the complex water systems of buildings, including health care facilities.
Effective water management programs could prevent the growth of Legionella in
building water systems. Methods: Using
national surveillance data, Legionnaires' disease cases were characterized from
the 21 jurisdictions (20 U.S. states and one large metropolitan area) that
reported exposure information for ≥90% of 2015 Legionella infections.
An assessment of whether cases were health care-associated was completed;
definite health care association was defined as hospitalization or long-term
care facility residence for the entire 10 days preceding symptom onset, and
possible association was defined as any exposure to a health care facility for a
portion of the 10 days preceding symptom onset. All other Legionnaires' disease
cases were considered unrelated to health care. Results: A
total of 2,809 confirmed Legionnaires' disease cases were reported from the 21
jurisdictions, including 85 (3%) definite and 468 (17%) possible health
care-associated cases. Among the 21 jurisdictions, 16 (76%) reported 1-21
definite health care-associated cases per jurisdiction. Among definite health
care-associated cases, the majority (75, 88%) occurred in persons aged ≥60
years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term
care facilities). The case fatality rate was 25% for definite and 10% for
possible health care-associated Legionnaires' disease. Conclusions and implications for public health practice: Exposure
to Legionella from health care facility water systems can result in
Legionnaires' disease. The high case fatality rate of health care-associated
Legionnaires' disease highlights the importance of case prevention and response
activities, including implementation of effective water management programs and
timely case identification.
Thornley CN, Harte DJ,
Weir RP, Allen LJ,
Knightbridge KJ, Wood PRT
MidCentral Public Health Services, MidCentral District
Health Board, Palmerston North, New Zealand. email@example.com
Epidemiol Infect 2017 Aug;145(11):2382-2389.
Abstract: A legionellosis outbreak at an
industrial site was investigated to identify and control the source. Cases were
identified from disease notifications, workplace illness records, and from
clinicians. Cases were interviewed for symptoms and risk factors and tested for
legionellosis. Implicated environmental sources were sampled and tested for
legionella. We identified six cases with Legionnaires' disease and seven with
Pontiac fever; all had been exposed to aerosols from the cooling towers on the
site. Nine cases had evidence of infection with either Legionella pneumophila
serogroup (sg) 1 or Legionella longbeachae sg1; these organisms were also
isolated from the cooling towers. There was 100% DNA sequence homology between
cooling tower and clinical isolates of L. pneumophila sg1 using
sequence-based typing analysis; no clinical L. longbeachae isolates were
available to compare with environmental isolates. Routine monitoring of the
towers prior to the outbreak failed to detect any legionella. Data from
this outbreak indicate that L. pneumophila sg1 transmission occurred from
the cooling towers; in addition, L. longbeachae transmission was
suggested but remains unproven. L. longbeachae detection in cooling
towers has not been previously reported in association with legionellosis
outbreaks. Waterborne transmission should not be discounted in investigations
for the source of L. longbeachae infection.
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 Aug;68(3):328-333.
Abstract: Legionnaires' 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. 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
Kenagy E, Priest PC, Cameron CM, Smith D, Scott P, Cho V, Mitchell P, Murdoch DR.
of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand. email@example.com
Infect Dis 2017 Jul;23(7):1148-1154.
Legionella longbeachae, found in soil and compost-derived products, is a
globally underdiagnosed cause of Legionnaires' disease. We conducted a
case-control study of L. longbeachae Legionnaires' disease in Canterbury,
New Zealand. Case-patients were persons hospitalized with L. longbeachae
pneumonia, and controls were persons randomly sampled from the electoral roll
for the area served by the participating hospital. Among 31 cases and 172
controls, risk factors for Legionnaires' disease were chronic obstructive
pulmonary disease, history of smoking >10 years, and exposure to compost or
potting mix. Gardening behaviors associated with L. longbeachae disease
included having unwashed hands near the face after exposure to or tipping and
troweling compost or potting mix. Mask or glove use was not protective among
persons exposed to compost-derived products. Precautions against inhaling
compost and attention to hand hygiene might effectively prevent L.
longbeachae disease. Long-term smokers and those with chronic obstructive
pulmonary disease should be particularly careful.
Petti S, Vitali M.
Department of Public Health and
Infectious Diseases, Sapienza University of Rome, Rome, Italy.
BMJ Open 2017 Jul;7(7):e015374.
Abstract: Objective: The
occupational risk for Legionella infection among dental
healthcare workers (DHCWs) is conjectured because of the risk of routine
inhalation of potentially contaminated aerosols produced by the dental
instruments. Nevertheless, occupational epidemiology studies are contrasting.
This meta-analysis assessed the level of scientific evidence regarding the
relative occupational risk for Legionella infection among DHCWs.
search was performed without time and language restrictions, using broad data
banks (PubMed, Scopus, Web of Science, GOOGLE Scholar) and generic keywords ('legionella'
AND 'dent*'). Analytical cross-sectional studies comparing prevalence of high
serum Legionella antibody levels in DHCWs and occupationally
unexposed individuals were considered. The relative occupational risk was
assessed through prevalence ratio (PR) with 95% CI. Between-study heterogeneity
was assessed (Cochran's Q test) and was used to choose the meta-analytic method.
Study quality (modified Newcastle-Ottawa Scale) and publication bias (Begg and
Mazumdar's test, Egger and colleagues' test, trim and fill R0 method)
were assessed formally and considered for the sensitivity analysis. Sensitivity
analysis to study inclusion, subgroup analyses (dental staff categories;
publication year, before vs after 1998, ie, 5 years after the release by the
Centers for Disease Control and Prevention of the infection control guidelines
in dental healthcare setting) were performed. Results: Seven
studies were included (2232 DHCWs, 1172 occupationally unexposed individuals).
No evidence of publication bias was detected. The pooled PR estimate was
statistically non-significant at 95% level (1.7; 95% CI 0.8 to 3.2),
study-quality adjustment did not change the PR considerably (PR, 1.5; 95% CI 0.5
to 4.1). PR was statistically significant before 1998 and no longer significant
after 1998. Subgroup analysis according to DHCW categories was inconclusive. Conclusions: There
is no scientific evidence that DHCWs are at high occupational risk. The
differences between former and recent studies could be due to different
characteristics of municipal water systems and the infection control guideline
on behalf of The European Legionnaires' Disease Surveillance Network.
European Centre for
Disease Prevention and Control (ECDC), Stockholm,
Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska
Institutet, Stockholm, Sweden.
Euro Surveill 2017 Jul;22(27):pii=30566.
Abstract: Under the coordination of the European
Centre for Disease Prevention and Control (ECDC), the European Legionnaires'
disease Surveillance Network (ELDSNet) conducts surveillance of Legionnaires'
disease (LD) in Europe. Between 2011 and 2015, 29 countries reported 30,532 LD
cases to ECDC (28,188 (92.3%) confirmed and 2,344 (7.7%) probable). Four
countries (France, Germany, Italy and Spain) accounted for 70.3% of all reported
cases, although their combined populations represented only 49.9% of the study
population. The age-standardised rate of all cases increased from 0.97 cases/100,000
population in 2011 to 1.30 cases/100,000 population in 2015, corresponding to an
annual average increase of 0.09 cases/100,000 population (95%CI 0.02-0.14; p =
0.02). Demographics and infection setting remained unchanged with ca 70% of
cases being community-acquired and 80% occurring in people aged 50 years and
older. Clinical outcome was known for 23,164 cases, of whom 2,161 (9.3%) died.
The overall case fatality ratio decreased steadily from 10.5% in 2011 to 8.1% in
2015, probably reflecting improved reporting completeness. Five countries
(Austria, Czech Republic, Germany, Italy, and Norway) had increasing
age-standardised LD notification rates over the 2011-15 period, but there was no
increase in notification rates in countries where the 2011 rate was below
ME, Delia S.
Department of Biomedical and Dental Sciences and
Morphofunctional Imaging, University of Messina, Italy. firstname.lastname@example.org
Ann Agric Environ Med 2017 Jun;24(2):276-282.
The increasing development of marine traffic has led to a rise in the incidence
of legionellosis among travellers. It occurs in similar environments, especially
closed and crowded, and aboard ships Legionella survives and multiplies
easily in water pipes, spreading into the environment through air conditioning
systems and water distribution points. Although in recent years in the
construction of cruise ships preventive measures aimed at curbing the
proliferation of Legionella (design, materials, focus on the operation
and maintenance of the water system), have been taken account, little or no
attention has been paid to small ships which, in many cases, are old and not
well maintained. Objective: The
aim of the study was to evaluate the frequency and severity of Legionella
contamination in ferries and cruise ships in order to adopt more specific
control measures. Materials and method:
A prevalence study was carried out on 10 ferries and 6 cruise ships docking or
in transit across the port of Messina (Sicily, Italy). Water and air samples
collected from many critical points were tested for qualitative and quantitative
identification of Legionella. Results
and conclusions: Legionella pneumophila sg 1 was isolated from the
samples of shower and tap water in 7 (70%) of the 10 ferries examined, and in 3
(33%) of the 6 cruise ships examined, and L. pneumophila sg 2-14 in 8
(80%) and 1 (16.7%) of these ships, respectively. No Legionella
contamination was found in whirlpool baths, air and ice samples. In conclusion,
the data obtained confirm higher levels of Legionella contamination in
local ferries and cruise ships, underlining the need to adopt corrective actions
more specific for these smaller vessels.
Stegger M, Kjelsø C,
Lilje B,, Petersen RF,
David S, Uldum SA, ESCMID
Study Group for Legionella Infections (ESGLI)
Department of Bacteria, Parasites and
Fungi, Statens Serum Institut, Copenhagen, Denmark; European
Programme for Public Health Microbiology Training (EUPHEM), ECDC, Stockholm,
Euro Surveill 2017 Jun;22(25):pii=30558.
Abstract: Between July and November 2014, 15
community-acquired cases of Legionnaires´ disease (LD), including four with Legionella
pneumophila serogroup 1 sequence type (ST) 82, were diagnosed in Northern
Zealand, Denmark. An outbreak was suspected. No ST82 isolates were found in
environmental samples and no external source was established. Four
putative-outbreak ST82 isolates were retrospectively subjected to whole genome
sequencing (WGS) followed by phylogenetic analyses with epidemiologically
unrelated ST82 sequences. The four putative-outbreak ST82 sequences fell into
two clades, the two clades were separated by ca 1,700 single nt polymorphisms (SNP)s
when recombination regions were included but only by 12 to 21 SNPs when these
were removed. A single putative-outbreak ST82 isolate sequence segregated in the
first clade. The other three clustered in the second clade, where all included
sequences had <5 SNP differences between them. Intriguingly, this clade also
comprised epidemiologically unrelated isolate sequences from the UK and Denmark
dating back as early as 2011. The study confirms that recombination plays a
major role in L. pneumophila evolution. On the other hand, strains
belonging to the same ST can have only few SNP differences despite being sampled
over both large timespans and geographic distances. These are two important
factors to consider in outbreak investigations.
Saladi L, Petersen F,, Diaz-Fuentes G
of Pulmonary and Critical Care Medicine, Bronx-Lebanon Hospital Center, Bronx,
NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA. email@example.com
Clin Med Insights Circ Respir Pulm Med 2017 Jun;11:1179548417711941.
2015, New York City experienced the worst outbreak of Legionnaires' disease in
the history of the city. We compare patients seen during the 2015 outbreak with
sporadic cases of Legionella during the past 5 years. Methods: We
conducted a retrospective chart review of 90 patients with Legionnaires' disease,
including sporadic cases of Legionella infection admitted from
2010 to 2015 (n=55) and cases admitted during the 2015 outbreak (n=35). Results: We
saw no significant differences between the 2 groups regarding demographics,
smoking habits, alcohol intake, underlying medical disease, or residence type.
Univariate and multivariate analyses showed that patients with sporadic case of Legionella had
a longer stay in the hospital and intensive care unit as well as an increased
stay in mechanical ventilation. Short-term mortality, discharge disposition, and
most clinical parameters did not differ significantly between the 2 groups. Conclusions: We
found no specific clinicoradiological characteristics that could differentiate
sporadic from epidemic cases of Legionella. Early recognition and
high suspicion for Legionnaires' disease are critical to provide appropriate
treatment. Cluster of cases should increase suspicion for an outbreak.
Division of Infectious Disease Control, Gyeonggi
Provincial Government, Suwon, Korea. firstname.lastname@example.org
J Prev Med Public
Health 2017 Jun;50(4):274-277.
Abstract: Objectives: Legionnaires'
disease (LD) is a severe type of pneumonia caused by inhalation of aerosols
contaminated with Legionella. On September 22, 2016, a single case
of LD was reported from a newly built apartment building in Gyeonggi province.
This article describes an epidemiologic investigation of LD and identification
of the possible source of infection. Methods: To
identify the source of LD, we interviewed the patient's husband using a
questionnaire based on the Legionella management guidelines
from the Korea Centers for Disease Control and Prevention. Water samples from
the site were collected and analyzed. An epidemiological investigation of the
residents and visitors in the apartment building was conducted for 14 days
before the index patient's symptoms first appeared to 14 days after the
implementation of environmental control measures. Results: Legionella
pneumophila serogroup 1 was isolated from the heated-water samples from
the patient's residence and the basement of the apartment complex. Thirty-two
suspected cases were reported from the apartment building during the
surveillance period, yet all were confirmed negative based on urinary antigen
tests. Conclusions: The
likely source of infection was the building's potable water, particularly heated
water. Further study of effective monitoring systems in heated potable water
should be considered.
Soda EA, Barskey AE,, Schrag S, Whitney CG, Arduino MJ,,,, Raphael BH, Cooley LA.
Service, CDC; Divison of Bacterial Diseases, National Center of Immunization and
Respiratory Diseases, CDC. email@example.com
MMWR Morb Mortal Wkly Rep 2017 Jun;66(22):584-589.
Abstract: Background: Legionnaires'
disease, a severe pneumonia, is typically acquired through inhalation of
aerosolized water containing Legionella bacteria. Legionella can
grow in the complex water systems of buildings, including health care facilities.
Effective water management programs could prevent the growth of Legionella
in building water systems. Methods: Using
national surveillance data, Legionnaires' disease cases were characterized from
the 21 jurisdictions (20 U.S. states and one large metropolitan area) that
reported exposure information for ≥90% of 2015 Legionella
infections. An assessment of whether cases were health care-associated was
completed; definite health care association was defined as hospitalization or
long-term care facility residence for the entire 10 days preceding symptom onset,
and possible association was defined as any exposure to a health care facility
for a portion of the 10 days preceding symptom onset. All other Legionnaires'
disease cases were considered unrelated to health care. Results: A
total of 2,809 confirmed Legionnaires' disease cases were reported from the 21
jurisdictions, including 85 (3%) definite and 468 (17%) possible health
care-associated cases. Among the 21 jurisdictions, 16 (76%) reported 1-21
definite health care-associated cases per jurisdiction. Among definite health
care-associated cases, the majority (75, 88%) occurred in persons aged ≥60
years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term
care facilities). The case fatality rate was 25% for definite and 10% for
possible health care-associated Legionnaires' disease. Conclusions
and implications for public health practice: Exposure
to Legionella from health care facility water systems can result in
Legionnaires' disease. The high case fatality rate of health care-associated
Legionnaires' disease highlights the importance of case prevention and response
activities, including implementation of effective water management programs and
timely case identification.
Dias A, Cysneiros A,
Lopes FT, von Amann B,
Costa C, Dionísio P,
Carvalho J, Durão V,
Carvalho G, Paula F,
Serrado M, Nunes B,
Marques T, Froes F,
Chest Department, Centro Hospitalar Lisboa Norte,
Lisboa, Portugal. firstname.lastname@example.org
Pneumol 2017 May-Jun;23(3):117-123.
Abstract: Background: An
outbreak of Legionella pneumophila serogroup 1, with 403 cases was
identified on the 7th November 2014 in Vila Franca de Xira, Portugal. Outbreak
source was the wet cooling system of a local factory. Hospital Pulido Valente
was one of the hospitals receiving patients with Legionnaires' disease (LD). Methods: We
describe the clinical findings and diagnostic methods used among the 43
confirmed or probable cases admitted to our department. Results: 60.5%
were male, mean age was 56.1±13.5 years and tobacco smoking was the most
frequent risk factor (76.7%). All patients had fever, 62.8% ≥39.5°C,
72.1% had chills and myalgia/arthralgia and 62.8% had dry cough. Extra pulmonary
symptoms were frequent: confusion and headache occurred in 34.9% and
gastrointestinal symptoms in 20.9%. High C-Reactive Protein
(55.8%≥30mg/dL) and hyponatremia (62.8%) were the laboratorial
abnormalities most commonly found. Hypoxemia occurred in 55.8% and hypocapnia in
93%. Urinary Antigen Test (UAT) was positive in 83.7% of the cases. Conclusions: Although
not specific, a combination of risk factors, symptoms and laboratory findings
can be highly suggestive of LD, even in an outbreak. This should prompt
diagnosis confirmation. Routine use of UAT in less severe cases of community
acquired pneumonia might contribute to earlier diagnosis.
Schönning C, Jernberg C, Klingenberg D, Andersson S, Pääjärvi A,
Alm E, Tano E, Lytsy B
Department of Surveillance and
Coordination, Public Health Agency of Sweden, Sweden. email@example.com
J Hosp Infect 2017
In 2012, an elderly immunocompromised man died from legionellosis at a hospital
in Uppsala, Sweden. The patient had visited a dental ward at the hospital during
the incubation period. Legionella spp. at a concentration of 2.000
colony-forming units/L were isolated from the cupfiller outlet providing water
for oral rinsing. Isolates from the patient and the dental unit were Legionella
pneumophila serogroup 1, subgroup Knoxville and ST9. Pulsed-field gel
electrophoresis and whole-genome sequencing strongly suggested that the isolates
were of common origin. This report presents one of few documented cases of
legionellosis acquired through a dental unit.
Sepin Özen N,,
Clinical Microbiology, Public Health Laboratory,
Antalya, Turkey. firstname.lastname@example.org
Pollut Res Int 2017 May;24(13):12238-12242.
Abstract: The genus Legionella is a
fastidious Gram-negative bacteria widely distributed in natural waters and
man-made water supply systems. Legionella pneumophila is the aetiological
agent of approximately 90% of reported Legionellosis cases, and serogroup 1 is
the most frequent cause of infections. Legionnaires' disease is often associated
with travel and continues to be a public health concern at present. The correct
water management quality practices and rapid methods for analyzing Legionella
species in environmental water is a key point for the prevention of
Legionnaires' disease outbreaks. This study aimed to evaluate the positivity
rates and serotyping of Legionella species from water samples in the
region of Antalya, Turkey, which is an important tourism center. During
January-December 2010, a total of 1403 samples of water that were collected from
various hotels (n=56) located in Antalya were investigated for Legionella
pneumophila. All samples were screened for L. pneumophila by culture
method according to "ISO 11731-2" criteria. The culture positive Legionella
strains were serologically identified by latex agglutination test. A total of
142 Legionella pneumophila isolates were recovered from 21 (37.5%) of 56
hotels. The total frequency of L. pneumophila isolation from water
samples was found as 10.1%. Serological typing of 142 Legionella isolates
by latex agglutination test revealed that strains belonging to L. pneumophila
serogroups 2-14 predominated in the examined samples (85%), while strains of L.
pneumophila serogroup 1 were less numerous (15%). According to our knowledge,
our study with the greatest number of water samples from Turkey demonstrates
that L. pneumophila serogroups 2-14 is the most common isolate. Rapid
isolation of L. pneumophila from environmental water samples is essential
for the investigation of travel related outbreaks and the possible resources.
Further studies are needed to have epidemiological data and to determine the
types of L. pneumophila isolates from Turkey.
Watanabe Y, Teranishi H,
Izumiyama S, Amemura-Maekawa J,
Microbiology, Kanagawa Prefectural Institute of Public Health, Chigasaki,
Kanagawa, Japan. email@example.com
Abstract: This study determined the occurrence of
legionellae in private houses for which there were no available data on aquatic
environments other than the water supply system. From June 2013 to November
2014, we collected 138 water and 90 swab samples from aquatic environments in 19
houses. Legionella DNA was detected via a loop-mediated isothermal
amplification assay in 66 (47·8%) water and 17 (18·9%) swab samples. High Legionella
DNA detection rates were observed in water samples from washing machines and
aquariums. Legionella spp. was isolated from 9 (6·5%) water and 3 (3·3%)
swab samples. Legionella pneumophila SG 1 was detected from the outlet
water of a bathtub spout and a bath sponge. Use of amoebic co-culture
effectively increased legionellae and Legionella DNA detection rates from
all sample types. A logistic regression analysis revealed that the heterotrophic
plate count was significantly related to Legionella contamination. Our
findings indicate that there is a risk of legionellosis from exposure to Legionella
spp. in a variety of aquatic environments in residential houses. Control
measures for legionellae in houses should include frequent cleaning and
disinfecting to reduce heterotrophic bacteria in water and, where possible,
preventing aerosolization from aquatic environments.
Patiño-Barbosa AM,, Restrepo-Montoya V, Villamil-Gomez WE, Cardona-Ospina JA, Rodriguez-Morales AJ
Public Health and
Infection Research Group, Faculty of Health Sciences, Universidad Tecnológica De Pereira. firstname.lastname@example.org
Abstract: Infection due to Legionella
pneumophila has been not studied in Colombia, although it is present.
The observational, retrospective study in which the incidence of legionellosis
in Colombia, 2009-2013, was estimated based on data extracted from the personal
health records system (Registro Individual de Prestación de Servicios,
RIPS) using the ICD-10 codes A48.1 (Legionnaires' disease) and A48.2 (Pontiac
Fever). Using official population estimates of the National Administrative
Department of Statistics (DANE), crude and adjusted incidence rates were
estimated (cases/100,000 pop). During the period, 206 cases were reported (mean
of 41.2 per year) for the cumulated national rate of 0.45 cases/100,000 pop. The
clinical form of legionellosis with the highest incidence rates was the
non-pneumonic Legionnaires' disease (0.39 cases/100,000 pop) with women being
the main affected (0.42 cases/100,000 pop). The territory with the highest
incidence rate was Bolivar department (1.94 cases/100,000 pop), followed by La
Guajira (1.7 cases/100,000 pop). Finally, age groups with the highest morbidity
were 0-9.999 years old (1.16 cases/100,000 pop) and system of identification for
social subsidies beneficiaries (SISBEN) category with the highest number of
total cases was level one (88 cases). According to these results, we can show
that legionellosis in Colombia is more common than it could be thought.
Nevertheless, cross-sectional and prospective studies should be conducted in our
country in order to improve the knowledge of incidence, prevalence, and burden
University of Western Australia,
Level 4 MRF Building, Royal Perth Hospital, Wellington Street, Perth 6000,
Australia; Northwestern University, 420 East Superior Street, Chicago, IL 60611,
Clin Chest Med 2017
Abstract: The 'atypical' pathogens causing pneumonia have long been problematic
for physicians because we have had to rely on serologic tests to make a
diagnosis. The introduction of polymerase chain reaction techniques
revolutionized the diagnosis of respiratory infections and now a new wave of
technologies promising faster, cheaper, and more comprehensive testing are
becoming available. This review focuses principally on the diagnosis of Legionella,
Mycoplasma, and influenza infections, but also covers recent publications
on the cutting edge of diagnostic tools likely to transform the field of
infectious diseases over the coming decade.
of Clinical Microbiology and Infectious Diseases, Hospital General Universitario
Gregorio Marañón, Madrid, Spain. email@example.com
Clin North Am 2017 Mar;31(1):7-27.
Abstract: Legionnaire's disease (LD) is the pneumonic form of legionellosis caused
by aerobic gram-negative bacilli of the genus Legionella. Individuals
become infected when they inhale aerosolized water droplets contaminated with Legionella
species. Forty years after the identification of Legionella pneumophila
as the cause of the 1976 pneumonia outbreak in a hotel in Philadelphia, we have
non-culture-based diagnostic tests, effective antibiotics, and preventive
measures to handle LD. With a mortality rate still around 10%, underreporting,
and sporadic outbreaks, there is still much work to be done. In this article,
the authors review the microbiology, laboratory diagnosis, and epidemiology of
Estrich CG, Gruninger SE, Lipman RD.
for Scientific Information, American Dental Association, Chicago, USA. firstname.lastname@example.org
Am Dent Assoc 2017 Mar;148(3):164-171.
Abstract: Background: In
this study, the authors compared the odds of exposure to Legionella
pneumophila among currently active dental practitioners with that of
nonpractitioners and evaluated demographic and clinical practice predictors of
exposure. Methods: The
authors obtained demographic characteristics and dental practice behaviors from
participants in the annual American Dental Association Health Screening Program
survey administered from 2002 through 2012. The authors assayed serum samples
obtained from participants for L. pneumophila antibodies. The authors
used an adjusted logit model to evaluate predictors of positive results. Results: Among
5,431 participants, approximately 10% were positive for L. pneumophila,
with no significant differences between dental practitioners and
nonpractitioners. Geographic location was the only significant predictor of
seropositivity, with no increased risk of being exposed to L. pneumophila
associated with age, race, sex, years in practice, hours of practice per week,
use of barrier protection, or infection control practices. Conclusions: Prevalence
of L. pneumophila antibodies was 10.4% among dental and nondental
personnel. US Census division was the only significant predictor of
seropositivity. The authors conclude that provision of dental care did not
increase the risk of being exposed to Legionella. Practical implications: Dentists
should be aware of the prevalence of Legionella species in their practice
areas to understand their personal risk of developing an infection.
Agarwal S, Abell V,
File TM Jr.
Infectious Disease Division, Summa Health, 1077 Forge
Boulevard, Akron, OH 44310, USA; Internal Medicine, Infectious Disease Section,
Northeast Ohio Medical University, 4029 Street Rt 44, Rootstown, OH 44272, USA. email@example.com.
Clin North Am 2017 Mar;31(1):155-165.
Abstract: Nosocomial Legionnaire's disease is most
frequently associated with presence of the organism in hospital water systems.
Patients are often susceptible as a result of age, underlying comorbidities, or
immunosuppression. Prevention focuses on reducing the reservoir within water
systems and includes super heating, ultraviolent light, chlorination,
silver-copper ionization, and distal filtration. This article reviews the
epidemiology of health care-associated Legionnaire's disease, reviews
characteristics of several health care-associated outbreaks, and discusses
strategies to prevent health care-associated infection.
Watkins LK, Toews KE, Harris AM, Davidson S, Ayers-Millsap S,, Hubbard BC, Kozak-Muiznieks NA, Khan E,
Intelligence Service Program, Atlanta, Georgia.
Infect Control Hosp Epidemiol 2017 Mar;38(3):306-313.
Abstract: OBJECTIVES To define the scope of an
outbreak of Legionnaires' disease (LD), to identify the source, and to stop
transmission. DESIGN AND SETTING Epidemiologic investigation of an LD outbreak
among patients and a visitor exposed to a newly constructed hematology-oncology
unit. METHODS An LD case was defined as radiographically confirmed pneumonia in
a person with positive urinary antigen testing and/or respiratory culture for Legionella
and exposure to the hematology-oncology unit after February 20, 2014. Cases were
classified as definitely or probably healthcare-associated based on whether they
were exposed to the unit for all or part of the incubation period (2-10 days).
We conducted an environmental assessment and collected water samples for
culture. Clinical and environmental isolates were compared by monoclonal
antibody (MAb) and sequence-based typing. RESULTS Over a 12-week period, 10
cases were identified, including 6 definite and 4 probable cases. Environmental
sampling revealed Legionella pneumophila serogroup 1 (Lp1) in the potable
water at 9 of 10 unit sites (90%), including all patient rooms tested. The 3
clinical isolates were identical to environmental isolates from the unit
(MAb2-positive, sequence type ST36). No cases occurred with exposure after the
implementation of water restrictions followed by point-of-use filters.
CONCLUSIONS Contamination of the unit's potable water system with Lp1 strain
ST36 was the likely source of this outbreak. Healthcare providers should
routinely test patients who develop pneumonia at least 2 days after hospital
admission for LD. A single case of LD that is definitely healthcare associated
should prompt a full investigation.
Division of Infectious Disease, Rhode Island Hospital,
Miriam Hospital, Brown University Alpert School of Medicine, Providence, USA. firstname.lastname@example.org
Clin North Am 2017 Mar;31(1):1-5.
Abstract: Legionnaire's disease has been
recognized as a cause of severe community-acquired pneumonia (CAP).
Legionnaire's disease has characteristic extrapulmonary findings that are the
basis for a presumptive clinical diagnosis. The widespread use of Legionella
culture, sputum DFA, serology, urinary antigen testing, and polymerase chain
reaction have allowed earlier diagnosis of Legionnaire's disease. Excluding
common source outbreaks, CAP caused by Legionnaire's disease is manifested as
sporadic cases. In contrast, nosocomial Legionnaire's disease occurs in clusters
or outbreaks from common Legionella species-contaminated water sources.
Improved diagnostic tests have permitted accurate diagnosis. Bacterial
coinfections with Legionnaire's disease are uncommon, but when present, are most
often associated with bacteremia pneumococcal pneumonia.
Stevenson D, Mentasti M,
Shaw A, Johnson A,
Crossley L, Willis C
Biosafety, Air and Water Microbiology
Group, National Infection Service, Public Health England, Porton, UK.
Infect 2017 Mar;145(4):647-655.
Abstract: There is a paucity of information on the
risk from potable water in non-passenger merchant vessels (NPMVs) particularly
with regard to Legionella and other bacteria. This retrospective study
examined water samples from 550 NPMVs docked in eight UK ports. A total of 1027
samples from 412 NPMVs were examined for total aerobic colony counts (ACC),
coliforms, Escherichia coli and enterococci; 41% of samples yielded ACC
above the action level (>1×103 c.f.u./ml) and 4.5% contained
actionable levels (>1 c.f.u./100 ml) of faecal indicator bacteria. Eight
hundred and three samples from 360 NPMVs were cultured specifically for Legionella
and 58% of vessels proved positive for these organisms with 27% of samples
showing levels greater than the UK upper action limit of 1×103
c.f.u./l. Cabin showers (49%) and hospital shower (45%) were frequently
positive. A subset of 106 samples was analysed by quantitative polymerase chain
reaction for Legionella and identified a further 11 Legionella-positive
NPMVs, returning a negative predictive value of 100%. There was no correlation
between NPMV age or size and any microbial parameters (P>0.05). Legionella
pneumophila serogroup 1 was isolated from 46% of NPMVs and sequence-based
typing of 17 isolates revealed four sequence types (STs) previously associated
with human disease. These data raise significant concerns regarding the
management of microbial and Legionella risks on board NPMVs and suggest
that better guidance and compliance are required to improve control.
Chua KYL, Baines SL, Kwong J, Gao W, Cutcher Z, Adcock S, Ballard S, Schultz MB,
Tomita T, Subasinghe N, Carter GP, Pidot SJ, Franklin L, Seemann T, Gonçalves
Da Silva A, Howden BP, Stinear TP.
Department of Microbiology and Immunology
at the Peter Doherty Institute for Infection and Immunity, The University of
Melbourne, Parkville, Victoria, Australia. email@example.com
Microbiol 2017 Oct:83(21): e01482-17.
Abstract: Public health agencies are increasingly
relying on genomics during Legionnaires' disease investigations. However, the
causative bacterium (Legionella pneumophila) has an unusual population
structure, with extreme temporal and spatial genome sequence conservation.
Furthermore, Legionnaires' disease outbreaks can be caused by multiple L.
pneumophila genotypes in a single source. These factors can confound
cluster identification using standard phylogenomic methods. Here, we show that a
statistical learning approach based on L. pneumophila core
genome single nucleotide polymorphism (SNP) comparisons eliminates ambiguity for
defining outbreak clusters and accurately predicts exposure sources for clinical
cases. We illustrate the performance of our method by genome comparisons of 234 L.
pneumophila isolates obtained from patients and cooling towers in
Melbourne, Australia, between 1994 and 2014. This collection included one of the
largest reported Legionnaires' disease outbreaks, which involved 125 cases at an
aquarium. Using only sequence data from L. pneumophila cooling
tower isolates and including all core genome variation, we built a multivariate
model using discriminant analysis of principal components (DAPC) to find cooling
tower-specific genomic signatures and then used it to predict the origin of
clinical isolates. Model assignments were 93% congruent with epidemiological
data, including the aquarium Legionnaires' disease outbreak and three other
unrelated outbreak investigations. We applied the same approach to a recently
described investigation of Legionnaires' disease within a UK hospital and
observed a model predictive ability of 86%. We have developed a promising means
to breach L. pneumophila genetic diversity extremes and provide
objective source attribution data for outbreak investigations. IMPORTANCE: Microbial
outbreak investigations are moving to a paradigm where whole-genome sequencing
and phylogenetic trees are used to support epidemiological investigations. It is
critical that outbreak source predictions are accurate, particularly for
pathogens, like Legionella pneumophila, which can spread widely and
rapidly via cooling system aerosols, causing Legionnaires' disease. Here, by
studying hundreds of Legionella pneumophila genomes collected
over 21 years around a major Australian city, we uncovered limitations with the
phylogenetic approach that could lead to a misidentification of outbreak sources.
We implement instead a statistical learning technique that eliminates the
ambiguity of inferring disease transmission from phylogenies. Our approach takes
geolocation information and core genome variation from environmental L.
pneumophila isolates to build statistical models that predict with high
confidence the environmental source of clinical L. pneumophila during
disease outbreaks. We show the versatility of the technique by applying it to
unrelated Legionnaires' disease outbreaks in Australia and the UK.
Kuroki T, Amemura-Maekawa J,, Furukawa I, Suzuki M,,, Hibi K,, Lee KI, Ohnishi M, Kura F.
of Microbiology, Kanagawa Prefectural Institute of Public Health, Chigasaki,
Kanagawa, Japan. firstname.lastname@example.org
Dis 2017 Feb;23(2):349-351.
In Japan, hot springs and public baths are the major sources of legionellosis.
In 2015, an outbreak of Legionnaires' disease occurred among 7 patients who had
visited a spa house. Laboratory investigation indicated that L. pneumophila
serogroup 1 and 13 strains caused the outbreak and that these strains were
Harris AM, Bramley AM, Jain S,
Arnold SR, Ampofo
K, Self WH,
Centers for Disease Control and Prevention, Atlanta,
Open Forum Infect Dis
Abstract: Background: Specimens
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.
Weedmark KA, Conly J,
Ensminger AW, Hosein FS, Drews
SJ, Legionella Outbreak Investigative Team.
Services, Calgary, Alberta, Canada. email@example.com
Epidemiol Infect 2017 Jan;145(2):254-265.
Abstract: An outbreak of Legionnaires' disease
occurred in an inner city district in Calgary, Canada. This outbreak spanned a
3-week period in November-December 2012, and a total of eight cases were
identified. Four of these cases were critically ill requiring intensive care
admission but there was no associated mortality. All cases tested positive for Legionella
pneumophila serogroup 1 (LP1) by urinary antigen testing. Five of the eight
patients were culture positive for LP1 from respiratory specimens. These
isolates were further identified as Knoxville monoclonal subtype and sequence
subtype ST222. Whole-genome sequencing revealed that the isolates differed by no
more than a single vertically acquired single nucleotide variant, supporting a
single point-source outbreak. Hypothesis-based environmental investigation and
sampling was conducted; however, a definitive source was not identified.
Geomapping of case movements within the affected urban sector revealed a 1.0 km
common area of potential exposure, which coincided with multiple active
construction sites that used water spray to minimize transient dust. This
community point-source Legionnaires' disease outbreak is unique due to its ST222
subtype and occurrence in a relatively dry and cold weather setting in Western
Canada. This report suggests community outbreaks of Legionella should not
be overlooked as a possibility during late autumn and winter months in the
Marchello C, Dale AP, Thai TN, Han DS, Ebell MH.
Department of Epidemiology and
Biostatistics, College of Public Health, University of Georgia, Athens, Georgia.
Ann Fam Med 2016 Nov;14(6):552-566.
Abstract: Purpose: Community-acquired pneumonia (CAP), acute cough, bronchitis, and lower
respiratory tract infections (LRTI) are often caused by infections with viruses
or Streptococcus pneumoniae. The prevalence of atypical pathogens Mycoplasma
pneumoniae, Chlamydophila pneumoniae, Legionella
pneumophila, and Bordetella pertussis among patients with
these illnesses in the ambulatory setting has not been previously summarized. We
set out to derive prevalence information from the existing literature. Methods: We
performed a systematic review of MEDLINE for prospective, consecutive-series
studies reporting the prevalence of M pneumoniae, C pneumoniae, L
pneumophila and/or B pertussis in outpatients with
cough, acute bronchitis, LRTI, or CAP. Articles were independently reviewed by 2
authors for inclusion and abstraction of data; discrepancies were resolved by
consensus discussion. A meta-analysis was performed on each pathogen to
calculate the pooled prevalence estimates using a random effects model of raw
proportions. Results: Fifty
studies met our inclusion criteria. While calculated heterogeneity was high,
most studies reported prevalence for each pathogen within a fairly narrow range.
In patients with CAP, the overall prevalence of M pneumoniae and C
pneumoniae were 10.1% (95% CI, 7.1%-13.1%) and 3.5% (95% CI,
2.2%-4.9%), respectively. Consistent with previous reports, M pneumoniae prevalence
peaked in roughly 6-year intervals. Overall prevalence of L pneumophila was
2.7% (95% CI, 2.0%-3.4%), but the organism was rare in children, with only 1
case in 1,765. In patients with prolonged cough in primary care, the prevalence
of B pertussis was 12.4% (95% CI, 4.9%-19.8%), although it was
higher in studies that included only children (17.6%; 95% CI, 3.4%-31.8%). Conclusions: Atypical
bacterial pathogens are relatively common causes of lower respiratory diseases,
including cough, bronchitis, and CAP. Where surveillance data were available, we
found higher prevalence in studies where all patients are tested for these
pathogens. It is likely that these conditions are underreported, underdiagnosed,
and undertreated in current clinical practice.