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Bruin JP, Diederen BMW, Ijzerman EPF, Den Boer JW, Mouton JW. Correlation of MIC value and disk inhibition zone diameters in clinical Legionella pneumophila serogroup 1 isolates. Diagn Microbiol Infect Dis 2013; 76:339-42. [PMID: 23583350 DOI: 10.1016/j.diagmicrobio.2013.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 03/01/2013] [Accepted: 03/01/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Routine use of disk diffusion tests for detecting antibiotic resistance in Legionella pneumophila has not been described. The goal of this study was to determine the correlation of MIC values and inhibition zone diameter (MDcorr) in clinical L. pneumophila isolates. METHODS Inhibition zone diameter of 183 L. pneumophila clinical isolates were determined for ten antimicrobials. Disk diffusion results were correlated with MICs as determined earlier with E-tests. RESULTS Overall the correlation of MIC values and inhibition zone diameters (MDcorr) of the tested antimicrobials is good, and all antimicrobials showed a WT distribution. Of the tested fluoroquinolones levofloxacin showed the best MDcorr. All macrolides showed a wide MIC distribution and good MDcorr. The MDcorr for cefotaxim, doxycycline and tigecycline was good, while for rifampicin and moxifloxacin, they were not. CONCLUSION Overall good correlation between MIC value and disk inhibition zone were found for the fluoroquinolones, macrolides and cefotaxim.
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Affiliation(s)
- Jacob P Bruin
- Regional Laboratory of Public Health, Haarlem, The Netherlands.
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Viasus D, Di Yacovo S, Garcia-Vidal C, Verdaguer R, Manresa F, Dorca J, Gudiol F, Carratalà J. Community-acquired Legionella pneumophila pneumonia: a single-center experience with 214 hospitalized sporadic cases over 15 years. Medicine (Baltimore) 2013; 92:51-60. [PMID: 23266795 PMCID: PMC5348137 DOI: 10.1097/md.0b013e31827f6104] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Legionella pneumophila has been increasingly recognized as a cause of community-acquired pneumonia (CAP) and an important public health problem worldwide. We conducted the present study to assess trends in epidemiology, diagnosis, clinical features, treatment, and outcomes of sporadic community-acquired L. pneumophila pneumonia requiring hospitalization at a university hospital over a 15-year period (1995-2010). Among 3934 nonimmunosuppressed hospitalized patients with CAP, 214 (5.4%) had L. pneumophila pneumonia (16 cases were categorized as travel-associated pneumonia, and 21 were part of small clusters). Since the introduction of the urinary antigen test, the diagnosis of L. pneumophila using this method remained stable over the years (p = 0.42); however, diagnosis by means of seroconversion and culture decreased (p < 0.001 and p = 0.001, respectively). The median age of patients with L. pneumophila pneumonia was 58.2 years (SD 13.8), and 76.4% were male. At least 1 comorbid condition was present in 119 (55.6%) patients with L. pneumophila pneumonia, mainly chronic heart disease, diabetes mellitus, and chronic pulmonary disease. The frequency of older patients (aged >65 yr) and comorbidities among patients with L. pneumophila pneumonia increased over the years (p = 0.06 and p = 0.02, respectively). In addition, 100 (46.9%) patients were classified into high-risk classes according to the Pneumonia Severity Index (groups IV-V). Twenty-four (11.2%) patients with L. pneumophila pneumonia received inappropriate empirical antibiotic therapy at hospital admission. Compared with patients who received appropriate empirical antibiotic, patients who received inappropriate therapy more frequently had acute onset of illness (p = 0.004), pleuritic chest pain (p = 0.03), and pleural effusion (p = 0.05). The number of patients who received macrolides decreased over the study period (p < 0.001), whereas the number of patients who received levofloxacin increased (p < 0.001). No significant difference was found in the outcomes between patients who received erythromycin and clarithromycin. However, compared with macrolide use during hospital admission, levofloxacin therapy was associated with a trend toward a shorter time to reach clinical stability (median, 3 vs. 5 d; p = 0.09) and a shorter length of hospital stay (median, 7 vs. 10 d; p < 0.001). Regarding outcomes, 38 (17.8%) patients required intensive care unit (ICU) admission, and the inhospital case-fatality rate was 6.1% (13 of 214 patients). The frequency of ICU admission (p = 0.34) and the need for mechanical ventilation (p = 0.57) remained stable over the study period, but the inhospital case-fatality rate decreased (p = 0.04). In the logistic regression analysis, independent factors associated with severe disease (ICU admission and death) were current/former smoker (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.01-8.62), macrolide use (OR, 2.40; 95% CI, 1.03-5.56), initial inappropriate therapy (OR, 2.97; 95% CI, 1.01-8.74), and high-risk Pneumonia Severity Index classes (OR, 9.1; 95% CI, 3.52-23.4). In conclusion, L. pneumophila is a relatively frequent causative pathogen among hospitalized patients with CAP and is associated with high morbidity. The annual number of L. pneumophila cases remained stable over the study period. In recent years, there have been significant changes in diagnosis and treatment, and the inhospital case-fatality rate of L. pneumophila pneumonia has decreased.
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Affiliation(s)
- Diego Viasus
- From the Departments of Infectious Diseases (DV, SDY, CGV, FG, JC), Microbiology (RV), and Respiratory Medicine (FM, JD), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona; and Department of Clinical Science (FM, JD, FG, JC), University of Barcelona, Barcelona, Spain
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Grottola A, Forghieri F, Meacci M, Fabio A, Pozzi L, Marchegiano P, Codeluppi M, Morselli M, Potenza L, Paolini A, Coluccio V, Luppi M, Rumpianesi F, Pecorari M. Severe pneumonia caused by Legionella pneumophila serogroup 11, Italy. Emerg Infect Dis 2012; 18:1911-3. [PMID: 23092583 PMCID: PMC3559165 DOI: 10.3201/eid1811.120216] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Rello J, Gattarello S, Souto J, Sole-Violan J, Valles J, Peredo R, Zaragoza R, Vidaur L, Parra A, Roig J. Community-acquired Legionella Pneumonia in the intensive care unit: Impact on survival of combined antibiotic therapy. Med Intensiva 2012; 37:320-6. [PMID: 22854618 DOI: 10.1016/j.medin.2012.05.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Revised: 05/26/2012] [Accepted: 05/29/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To compare intensive care unit (ICU) mortality in patients with severe community-acquired pneumonia (SCAP) caused by Legionella pneumophila receiving combined therapy or monotherapy. METHODS A prospective multicenter study was made, including all patients with sporadic, community-acquired Legionnaires' disease (LD) admitted to the ICU. Admission data and information on the course of the disease were recorded. Antibiotic prescriptions were left to the discretion of the attending physician and were not standardized. RESULTS Twenty-five cases of SCAP due to L. pneumophila were included, and 7 patients (28%) out of 25 died after a median of 7 days of mechanical ventilation. Fifteen patients (60%) presented shock. Levofloxacin and clarithromycin were the antibiotics most commonly used in monotherapy, while the most frequent combination was rifampicin plus clarithromycin. Patients subjected to combination therapy presented a lower mortality rate versus patients subjected to monotherapy (odds ratio for death [OR] 0.15; 95%CI 0.02-1.04; p=0.08). In patients with shock, this association was stronger and proved statistically significant (OR for death 0.06; 95%CI 0.004-0.86; p=0.04). CONCLUSIONS Combined antibiotic therapy decreases mortality in patients with SCAP and shock caused by L. pneumophila.
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Affiliation(s)
- J Rello
- Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Pereira JM, Paiva JA, Rello J. Severe sepsis in community-acquired pneumonia--early recognition and treatment. Eur J Intern Med 2012; 23:412-9. [PMID: 22726369 DOI: 10.1016/j.ejim.2012.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 04/29/2012] [Accepted: 04/30/2012] [Indexed: 01/17/2023]
Abstract
Despite remarkable advances in its management, community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality leading to significant consumption of health, social and economic resources. The assessment of CAP severity is a cornerstone in its management, facilitating selection of the most appropriate site of care and empirical antibiotic therapy. Several clinical scoring systems based on 30-day mortality have been developed to identify those patients with the highest risk of death. Although well validated in appropriate patient groups, each system has its own limitations and each exhibits different sensitivity and specificity values. These problems have increased interest in the use of biomarkers to predict CAP severity. Although so far no ideal solution has been identified, recent advances in bacterial genomic load quantification have made this tool very attractive. Early antibiotic therapy is essential to the reduction of CAP mortality and the selection of antibiotic treatment according to clinical guidelines is also associated with an improved outcome. In addition, the addition of a macrolide to standard empirical therapy seems to improve outcome in severe CAP although the mechanism of this is unclear. Finally, the role of adjuvant therapy has not yet been satisfactorily established. In this review we will present our opinion on current best practice in the assessment of severity and treatment of severe CAP.
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Affiliation(s)
- Jose Manuel Pereira
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Grupo de Infecção e Sepsis, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
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Reclamation of ampicillin sensitivity for the genetic manipulation of Legionella pneumophila. Appl Environ Microbiol 2012; 78:5457-9. [PMID: 22635996 DOI: 10.1128/aem.00669-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Research on Legionella pneumophila, the causative agent of Legionnaires' disease, has been hampered due to the lack of selectable markers for genetic manipulation. We report the construction of a mutant strain of L. pneumophila lacking loxA, a chromosomally encoded β-lactamase, that has enhanced sensitivity to ampicillin. Also described are a method for converting Legionella strains to ampicillin sensitivity and conditions for utilizing bla as a selectable marker.
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Are Fluoroquinolones Superior Antibiotics for the Treatment of Community-Acquired Pneumonia? Curr Infect Dis Rep 2012; 14:317-29. [DOI: 10.1007/s11908-012-0251-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--summary. Clin Microbiol Infect 2012; 17 Suppl 6:1-24. [PMID: 21951384 DOI: 10.1111/j.1469-0691.2011.03602.x] [Citation(s) in RCA: 201] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Bruin JP, Ijzerman EP, den Boer JW, Mouton JW, Diederen BM. Wild-type MIC distribution and epidemiological cut-off values in clinical Legionella pneumophila serogroup 1 isolates. Diagn Microbiol Infect Dis 2012; 72:103-8. [DOI: 10.1016/j.diagmicrobio.2011.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 10/15/2022]
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Birkin C, Biyani CS, Browning AJ. Legionella pneumonia presenting with bilateral flank pain, hyponatraemia and acute renal failure. Can Urol Assoc J 2011; 5:E96-E100. [PMID: 22154178 PMCID: PMC3235190 DOI: 10.5489/cuaj.10128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Legionnaires' disease (LD) is an often overlooked but a possible cause of sporadic community acquired pneumonia. High fever, cough and gastrointestinal symptoms are non-specific symptoms. Hyponatremia is more common in LD than pneumonia linked with other causes. A definitive diagnosis is usually confirmed by culture, urinary antigen testing for Legionella species. Macolide or quinolone antibiotic is the treatment of choice. We describe a case of Legionella pneumonia presenting with high fever, bilateral flank pain and oliguria. It is important for clinicians to be aware of this diagnosis when managing patients with flank pain. The case highlights the problems in differentiating LD from renal colic and the importance of proper history, physical examination with laboratory tests for appropriate management.
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Affiliation(s)
- Celia Birkin
- Department of Urology, Pinderfields General Hospital, Wakefield, UK
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6:E1-59. [PMID: 21951385 PMCID: PMC7128977 DOI: 10.1111/j.1469-0691.2011.03672.x] [Citation(s) in RCA: 620] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Characterization and quantitation of a novel β-lactamase gene found in a wastewater treatment facility and the surrounding coastal ecosystem. Appl Environ Microbiol 2011; 77:8226-33. [PMID: 21965412 DOI: 10.1128/aem.02732-10] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Wastewater treatment plants (WWTPs) are engineered structures that collect, concentrate, and treat human waste, ultimately releasing treated wastewater into local environments. While WWTPs efficiently remove most biosolids, it has been shown that many antibiotics and antibiotic-resistant bacteria can survive the treatment process. To determine how WWTPs influence the concentration and dissemination of antibiotic-resistant genes into the environment, a functional metagenomic approach was used to identify a novel antibiotic resistance gene within a WWTP, and quantitative PCR (qPCR) was used to determine gene copy numbers within the facility and the local coastal ecosystem. From the WWTP metagenomic library, the fosmid insert contained in one highly resistant clone (MIC, ≈ 416 μg ml(-1) ampicillin) was sequenced and annotated, revealing 33 putative genes, including a 927-bp gene that is 42% identical to a functionally characterized β-lactamase from Staphylococcus aureus PC1. Isolation and subcloning of this gene, referred to as bla(M-1), conferred ampicillin resistance to its Escherichia coli host. When normalized to volume, qPCR showed increased concentrations of bla(M-1) during initial treatment stages but 2-fold-decreased concentrations during the final treatment stage. The concentration ng(-1) DNA increased throughout the WWTP process from influent to effluent, suggesting that bla(M-1) makes up a significant proportion of the overall genetic material being released into the coastal ecosystem. Average discharge was estimated to be 3.9 × 10(14) copies of the bla(M-1) gene released daily into this coastal ecosystem. Furthermore, the gene was observed in all sampled coastal water and sediment samples surrounding the facility. Our results suggest that WWTPs may be a pathway for the dissemination of novel antibiotic resistance genes into the environment.
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Varner TR, Bookstaver PB, Rudisill CN, Albrecht H. Role of Rifampin-Based Combination Therapy for Severe Community-Acquired Legionella pneumophila Pneumonia. Ann Pharmacother 2011; 45:967-76. [DOI: 10.1345/aph.1q074] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To review the literature concerning the role of rifampin in the combination treatment of Legionella pneumophila pneumonia. Data Sources: A search of MEDLINE and Ovid databases was conducted (January 1970-May 2011) using the search terms Legionella pneumophila, pneumonia, Legionnaires' disease, rifampin or rifampicin, macrolide, fluoroquinolone, erythromycin, clarithromycin, levofloxacin, ciprofloxacin, and moxifloxacin Study Selection and Data Extraction: In vivo studies published in English that compared antimicrobial therapies including rifampin for the treatment of Legionella pneumonia, as well as in vitro studies including an assessment of rifampin bioactivity, were included. Data Synthesis: Macrolides and fluoroquinolones have been effective as monotherapy in the treatment of L. pneumophila pneumonia. This review includes evidence summaries from 4 bioactivity evaluations. 6 clinical studies, and 6 reported cases of combination rifampin use. Combined with supporting evidence, the role of combination rifampin therapy is further delineated. Conclusions: Interpretation of the data is limited by the potential for selection bias and lack of consistent comparators. Rifampin therapy should be considered only for patients with severe disease or significant comorbid conditions (eg. uncontrolled diabetes, smoking, or obstructive lung disease) including immunocompromised hosts and those refractory to conventional monotherapy regimens. Caution for significant adverse drug events and drug-drug interactions should be taken with the addition of rifampin.
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Affiliation(s)
- Terra R Varner
- Pediatrics, Department of Pharmacy, Palmetto Health Richland, Columbia, SC
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia
| | - Celeste N Rudisill
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina
| | - Helmut Albrecht
- School of Medicine, University of South Carolina; Director, Division of Infectious Diseases, Department of Internal Medicine, University Specialty Clinics
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Guyard C, Low DE. Legionella infections and travel associated legionellosis. Travel Med Infect Dis 2011; 9:176-86. [DOI: 10.1016/j.tmaid.2010.05.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 05/17/2010] [Indexed: 01/17/2023]
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Zarogoulidis P, Alexandropoulou I, Romanidou G, Konstasntinidis TG, Terzi E, Saridou S, Stefanis A, Zarogoulidis K, Constantinidis TC. Community-acquired pneumonia due to Legionella pneumophila, the utility of PCR, and a review of the antibiotics used. Int J Gen Med 2011; 4:15-9. [PMID: 21403787 PMCID: PMC3056326 DOI: 10.2147/ijgm.s15654] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction There are at least 40 types of Legionella bacteria, half of which are capable of producing disease in humans. The Legionella pneumophila bacterium, the root cause of Legionnaires’ disease, causes 90% of legionellosis cases. Case presentation We describe the case of a 60-year-old woman with a history of diabetes mellitus and arterial hypertension who was admitted to our hospital with fever and symptoms of respiratory infection, diarrhea, and acute renal failure. We used real-time polymerase chain reaction (PCR) to detect L. pneumophila DNA in peripheral blood and serum samples and urine antigen from a patient with pneumonia. Legionella DNA was detected in all two sample species when first collected. Conclusion Since Legionella is a cause of 2% to 15% of all community-acquired pneumonias that require hospitalization, legionellosis should be taken into account in an atypical pulmonary infection and not be forgotten. Moreover, real-time PCR should be considered a useful diagnostic method.
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Affiliation(s)
- Paul Zarogoulidis
- Regional Laboratory of Public Health, East Macedonia-Thrace, Komotini, Greece.
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Legionella pneumophila pneumonia in a pregnant woman treated with anti-TNF-α antibodies for Crohn's disease: a case report. J Crohns Colitis 2010; 4:687-9. [PMID: 21122583 DOI: 10.1016/j.crohns.2010.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 06/30/2010] [Accepted: 08/01/2010] [Indexed: 02/08/2023]
Abstract
Anti-TNF-α antibodies are widely used. The indications for their usage are still increasing. With their emerging use, their infectious complications are seen more often. We describe the first case of a pneumonia with Legionella pneumophila in a pregnant women with Crohn's disease, during treatment with anti-TNF-α antibodies. She was treated with erythromycin and made a full recovery.
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Does radiographic evidence of prior pulmonary tubercular infection influence the choice of empiric antibiotics for community-acquired pneumonia in a tuberculosis-endemic area? JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2010; 43:386-94. [PMID: 21075705 DOI: 10.1016/s1684-1182(10)60061-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 05/06/2009] [Accepted: 08/20/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Recent medical literature suggests that use of fluoroquinolones (FQs) might be associated with the delayed diagnosis of pulmonary tuberculosis (TB). The purpose of this study was to assess the impact of radiographic evidence of prior pulmonary TB infection on empiric antibiotic choice in cases of community-acquired pneumonia (CAP), as well as the effect of antibiotic regimens on clinical outcome. METHODS A total of 280 patients with CAP between 1 May and 31 December 2007 were included in the study and their medical records were retrospectively reviewed. Patients were divided into two groups: those receiving FQs (FQ group) or those receiving β-lactam-based regimens (β-lactam group). Their demographic data, underlying diseases, clinical features, diseases severity and outcomes were compared. RESULTS Radiographic evidence of a previous pulmonary TB infection (odds ratio = 3.507, 95% confidence interval = 1.422-8.645; p = 0.006) was an independent factor associated with β-lactam-based regimens. Patients with a modified pneumonia severity index (mPSI) category V were more likely to receive FQ therapy (odds ratio = 2.53, 95% confidence interval = 1.140-5.615; p = 0.022). Of the patients with mPSI category V, the 14-day mortality rate of those in the β-lactam group was significantly lower than that of those in the FQ group (0%vs. 23%, respectively; p = 0.044). CONCLUSION Radiographic evidence of a previous pulmonary TB infection and a lower mPSI score increases the probability of the selection of a β-lactam-based regimen for the treatment of CAP.
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Scharf S, Vardarova K, Lang F, Schmeck B, Opitz B, Flieger A, Heuner K, Hippenstiel S, Suttorp N, N'Guessan PD. Legionella pneumophila induces human beta defensin-3 in pulmonary cells. Respir Res 2010; 11:93. [PMID: 20615218 PMCID: PMC2910005 DOI: 10.1186/1465-9921-11-93] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 07/08/2010] [Indexed: 01/23/2023] Open
Abstract
Background Legionella pneumophila is an important causative agent of severe pneumonia in humans. Human alveolar epithelium and macrophages are effective barriers for inhaled microorganisms and actively participate in the initiation of innate host defense. The beta defensin-3 (hBD-3), an antimicrobial peptide is an important component of the innate immune response of the human lung. Therefore we hypothesize that hBD-3 might be important for immune defense towards L. pneumophila. Methods We investigated the effects of L. pneumophila and different TLR agonists on pulmonary cells in regard to hBD-3 expression by ELISA. Furthermore, siRNA-mediated inhibition of TLRs as well as chemical inhibition of potential downstream signaling molecules was used for functional analysis. Results L. pneumophila induced release of hBD-3 in pulmonary epithelium and alveolar macrophages. A similar response was observed when epithelial cells were treated with different TLR agonists. Inhibition of TLR2, TLR5, and TLR9 expression led to a decreased hBD-3 expression. Furthermore expression of hBD-3 was mediated through a JNK dependent activation of AP-1 (c-Jun) but appeared to be independent of NF-κB. Additionally, we demonstrate that hBD-3 elicited a strong antimicrobial effect on L. pneumophila replication. Conclusions Taken together, human pulmonary cells produce hBD-3 upon L. pneumophila infection via a TLR-JNK-AP-1-dependent pathway which may contribute to an efficient innate immune defense.
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Affiliation(s)
- Stefanie Scharf
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, Germany
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Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am 2010; 24:73-105. [PMID: 20171547 PMCID: PMC7127122 DOI: 10.1016/j.idc.2009.10.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, 259 First Street, Mineola, Long Island, NY 11501, USA
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Scharf S, Hippenstiel S, Flieger A, Suttorp N, N'Guessan PD. Induction of human β-defensin-2 in pulmonary epithelial cells by Legionella pneumophila: involvement of TLR2 and TLR5, p38 MAPK, JNK, NF-κB, and AP-1. Am J Physiol Lung Cell Mol Physiol 2010; 298:L687-95. [PMID: 20154223 DOI: 10.1152/ajplung.00365.2009] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Legionella pneumophila is an important causative agent of severe pneumonia in humans. Human alveolar epithelium is an effective barrier for inhaled microorganisms and actively participates in the initiation of innate host defense. Induction of antimicrobial peptide human β-defensin-2 (hBD-2) by various stimuli in epithelial cells has been reported. However, the mechanisms by which bacterial infections enhance hBD-2 expression remain poorly understood. In this study, we investigated the effect of the pulmonary pathogen L. pneumophila on induction of hBD-2 in human pulmonary epithelial cells. Infection with L. pneumophila markedly increased hBD-2 production, and the response was attenuated in Toll-like receptor (TLR) 2 and TLR5 transient knockdown cells. Furthermore, pretreatment with SB-202190 (an inhibitor of p38 MAPK) and JNK II (an inhibitor of c-Jun NH(2)-terminal kinase), but not U0126 (an inhibitor of ERK), reduced L. pneumophila-induced hBD-2 release in A549 cells. L. pneumophila-induced hBD-2 liberation was mediated via recruitment of NF-κB and AP-1 to the hBD-2 gene promoter. Additionally, we showed that exo- and endogenous hBD-2 elicited a strong antimicrobial effect towards L. pneumophila. Together, these results suggest that L. pneumophila induces hBD-2 release in A549 cells, and the induction seems to be mediated through TLR2 and TLR5 as well as activation of p38 MAPK, JNK, NF-κB, and AP-1.
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Affiliation(s)
- Stefanie Scharf
- Dept. of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Germany
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72
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Palusińska-Szysz M, Cendrowska-Pinkosz M. Pathogenicity of the family Legionellaceae. Arch Immunol Ther Exp (Warsz) 2009; 57:279-90. [DOI: 10.1007/s00005-009-0035-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 01/30/2009] [Indexed: 10/20/2022]
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73
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Abstract
Given the nonspecific clinical manifestations of Legionnaires' disease and the high mortality of untreated Legionnaires' disease, we recommend routine use of Legionella testing, especially the Legionella urinary antigen test, for all patients with community-acquired pneumonia. This includes patients with ambulatory pneumonia and hospitalized children. Legionella cultures should be more widely available, especially in hospitals where the drinking water is colonized with Legionella. Azithromycin or levofloxacin can be considered as first-line therapy. Other antibiotics including tetracyclines, tigecycline, other fluoroquinolones and other macrolides (especially clarithromycin) are also effective. The clinical response of quinolones may be somewhat more favorable compared to macrolides, but the outcome is similar. If the Legionnaires' disease is hospital-acquired, culturing of the hospital drinking water for Legionella is indicated.
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74
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Gudiol C, Garcia-Vidal C, Fernández-Sabé N, Verdaguer R, Lladó L, Roca J, Gil-Vernet S, Carratalà J. Clinical features and outcomes of Legionnaires' disease in solid organ transplant recipients. Transpl Infect Dis 2009; 11:78-82. [DOI: 10.1111/j.1399-3062.2008.00337.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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75
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Niven DJ, Laupland KB. Severe community-acquired pneumonia in adults: current antimicrobial chemotherapy. Expert Rev Anti Infect Ther 2009; 7:69-81. [DOI: 10.1586/14787210.7.1.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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76
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Lee CH, Wu CL. An Update on the Management Of Hospital-Acquired Pneumonia in the Elderly. INT J GERONTOL 2008. [DOI: 10.1016/s1873-9598(09)70007-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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77
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Falguera M. Pharmacotherapy of pneumonia occurring in older patients. Expert Opin Pharmacother 2008; 9:2867-79. [DOI: 10.1517/14656566.9.16.2867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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78
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Atypical pneumonias: current clinical concepts focusing on Legionnaires' disease. Curr Opin Pulm Med 2008; 14:183-94. [PMID: 18427241 DOI: 10.1097/mcp.0b013e3282f79678] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review provides clinicians with an overview of the clinical features of the atypical pneumonias. Atypical community-acquired pneumonia pathogens cause systemic infections with pneumonia. The key to the clinical diagnosis of atypical pneumonias depends on recognizing the characteristic pattern of extrapulmonary organ involvement different for each pathogen. As Legionella is likely to present as severe pneumonia and does not respond to beta-lactams, it is important to presumptively diagnose Legionnaires' disease clinically so that Legionella coverage is included in empiric therapy. This study reviews the clinical features and nonspecific laboratory markers of atypical pathogens, focusing on Legionnaires' disease. RECENT FINDINGS Case reports/outbreaks increase our understanding of Legionnaires' disease transmission. Both Mycoplasma pneumoniae and Chlamydophilia pneumoniae may cause asthma. Antimicrobial therapy of Chlamydophilia pneumoniae/Mycoplasma pneumoniae is important to decrease person-to-person spread and to decrease potential long-term sequelae. SUMMARY Atypical pulmonary pathogens cause systemic infections accompanied by a variety of characteristic extrapulmonary features. Clinically, it is possible to differentiate Legionnaires' disease from the other typical/atypical pneumonias. Rapid clinical diagnosis of atypical pathogens, particularly Legionnaires' disease, is important in selecting effective empiric therapy and prompting definitive laboratory testing.
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79
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Sandkovsky U, Sandkovsky G, Suh J, Smith B, Sharp V, Polsky B. Legionella pneumonia and HIV: case reports and review of the literature. AIDS Patient Care STDS 2008; 22:473-81. [PMID: 18462074 DOI: 10.1089/apc.2007.0111] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although Legionnaires' disease occurs more commonly in patients with some degree of immunosuppression (diabetes, chronic lung disease, end stage renal disease, cancer, etc.), it has been infrequently described in patients infected with human immunodeficiency virus (HIV) and AIDS. Some studies suggest that pneumonia caused by Legionella tends to present with more severe clinical features and complications in the HIV-infected population. The use of antibiotic prophylaxis or the association of severe pneumonia with other pathogens may account for under diagnosis of the disease. We diagnosed five cases of Legionella pneumonia in patients with HIV infection at our institution during a 1-year period. The cases seen ranged in severity, regardless of the CD4(+) counts of the patients. Based on our observations, it seems impossible to discern whether HIV infection is an additional risk factor for Legionnaires' disease. We describe those five cases and review the available literature.
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Affiliation(s)
- Uriel Sandkovsky
- Department of Internal Medicine, St. Luke's-Roosevelt Hospital Center New York, New York
| | - Gabriel Sandkovsky
- Division of Infectious Diseases, St. Luke's-Roosevelt Hospital Center New York, New York
| | - Jin Suh
- Department of Internal Medicine, St. Luke's-Roosevelt Hospital Center New York, New York
- Division of Infectious Diseases, St. Luke's-Roosevelt Hospital Center New York, New York
- Center for Comprehensive Care, St. Luke's-Roosevelt Hospital Center New York, New York
| | - Barbara Smith
- Department of Infection Control, St. Luke's-Roosevelt Hospital Center New York, New York
| | - Victoria Sharp
- Center for Comprehensive Care, St. Luke's-Roosevelt Hospital Center New York, New York
| | - Bruce Polsky
- Department of Internal Medicine, St. Luke's-Roosevelt Hospital Center New York, New York
- Division of Infectious Diseases, St. Luke's-Roosevelt Hospital Center New York, New York
- Department of Infection Control, St. Luke's-Roosevelt Hospital Center New York, New York
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80
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Abstract
Legionella is an important cause of nosocomial and community-acquired pneumonia in both immunocompetent and immunosuppressed patients worldwide; however, the clinical course and optimal antibiotic therapy of Legionella pneumonia (LP) in patients with cancer is uncertain. We studied retrospectively the risk factors, clinical manifestations, and outcome of 49 cancer patients with a positive Legionella culture or direct fluorescent antibody (DFA) over a 13-year period (1991-2003). The majority of patients (82%) had an underlying hematologic malignancy, and 37% were bone marrow transplant recipients; 80% of the patients had active malignancy. Lymphopenia (47%), use of systemic corticosteroids (41%), and chemotherapy (63%) were the most common underlying conditions. The laboratory diagnosis was established by positive Legionella culture (n = 8, 16%), DFA (n = 29, 59%), or both (n = 12, 25%). In 4 patients (8%), a positive DFA was deemed to represent false-positive results. There was no temporal or geographic clustering of cases. The majority of the cases had multilobar (61%) or bilateral (55%) pulmonary involvement. The mean time to response to therapy was 8 days; 18 patients (37%) developed complications requiring prolonged duration of treatment (mean, 25 d). The case-fatality rate was 31%. Two patients had relapse of LP despite appropriate therapy. Improved outcome, especially in those with severe pneumonia, seemed to correlate with the use of a combination of antibiotics. LP is an uncommon infection in our patient population but is associated with significant morbidity and mortality. Treatment of LP in cancer patients may require a prolonged course with a regimen that includes a newer macrolide or quinolone.
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Affiliation(s)
- Kalen L Jacobson
- From Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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81
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Prevotat A, Bure M, Bergoin C, Tavernier JY, Van Grunderbeeck N, Yazdanpanah Y, Lamblin C. Épidémie de légionellose dans le Pas-de-Calais (2003-2004) : analyse descriptive et facteurs prédictifs d’une évolution défavorable. Rev Mal Respir 2008; 25:285-94. [DOI: 10.1016/s0761-8425(08)71547-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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82
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Kakeya H, Ehara N, Fukushima K, Seki M, Izumikawa K, Yamamoto Y, Yanagihara K, Saito A, Kohno S. Severe Legionnaires' disease successfully treated using a combination of fluoroquinolone, erythromycin, corticosteroid, and sivelestat. Intern Med 2008; 47:773-7. [PMID: 18421197 DOI: 10.2169/internalmedicine.47.0677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The patient was a 67-year-old man with diabetes mellitus who had been to a hot spring spa a few days before his admission. The diagnosis of Legionella pneumonia was made using a urinary antigen assay. Intravenous pazufloxacin and oral clarithromycin were started. However, despite these treatments, he developed acute respiratory distress syndrome (ARDS). He was administered the combination of intravenous pazufloxacin and erythromycin, corticosteroid, and sivelestat for two weeks. Then he was successfully recovered. The outcome suggests that treatment with corticosteroid and sivelestat, in addition to a combination of appropriate anti-Legionella antibiotics, should be considered for patients with severe Legionella pneumonia with ARDS.
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Affiliation(s)
- Hiroshi Kakeya
- Division of Respiratory Diseases, Japanese Red Cross Nagasaki Genbaku Isahaya Hospital, Isahaya.
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83
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Diederen BMW. Legionella spp. and Legionnaires' disease. J Infect 2007; 56:1-12. [PMID: 17980914 DOI: 10.1016/j.jinf.2007.09.010] [Citation(s) in RCA: 269] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 09/18/2007] [Accepted: 09/19/2007] [Indexed: 11/24/2022]
Abstract
Infection with Legionella spp. is an important cause of community- and hospital-acquired pneumonia, occurring both sporadically and in outbreaks. Infection with Legionella spp. ranks among the three most common causes of severe pneumonia in the community setting, and is isolated in 1-40% of cases of hospital-acquired pneumonia. There are no clinical features unique to Legionnaires' disease. Macrolides and fluoroquinolones are the most widely used drugs in treatment. The availability of a good diagnostic repertoire, suitable for accurately diagnosing LD, constitutes the basis for the early recognition and treatment of the individual patient as well as for effective measures for prevention and control. This review summarizes the available information regarding the microbiology, clinical presentation, diagnosis and treatment of LD, with an emphasis on the laboratory diagnosis of infection with Legionella spp.
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Affiliation(s)
- B M W Diederen
- Regional Laboratory of Public Health Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands.
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84
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Girard LP, Gregson DB. Community-acquired lung abscess caused by Legionella micdadei in a myeloma patient receiving thalidomide treatment. J Clin Microbiol 2007; 45:3135-7. [PMID: 17609324 PMCID: PMC2045249 DOI: 10.1128/jcm.02321-06] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Revised: 01/12/2007] [Accepted: 06/04/2007] [Indexed: 11/20/2022] Open
Abstract
Legionella infection causes 2 to 14% of community-acquired pneumonia (CAP). Legionella micdadei constitutes <1% of these infections. We describe a case of cavitary L. micdadei CAP in a myeloma patient receiving thalidomide treatment. The importance of considering pneumonia and problems in diagnosing pneumonia caused by L. micdadei in this patient population are reviewed.
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Affiliation(s)
- Louis P Girard
- Division of Medicine, University of Calgary, 9-3535 Research Road NW, Calgary, Alberta, Canada T2L 2K8
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85
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Gudiol C, Verdaguer R, Angeles Domínguez M, Fernández-Sevilla A, Carratalà J. Outbreak of Legionnaires' disease in immunosuppressed patients at a cancer centre: usefulness of universal urine antigen testing and early levofloxacin therapy. Clin Microbiol Infect 2007; 13:1125-8. [PMID: 17711483 DOI: 10.1111/j.1469-0691.2007.01805.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This report describes an outbreak of Legionnaires' disease in severely immunosuppressed patients hospitalised at a cancer centre. Universal urine antigen testing and early levofloxacin therapy appeared to lower case fatality rates in comparison with previous reports concerning this high-risk population. This diagnostic and therapeutic strategy should be considered when facing a nosocomial outbreak of Legionnaires' disease in immunosuppressed hosts.
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Affiliation(s)
- C Gudiol
- Infectious Disease Service, Hospital Universitari de Bellvitge, Barcelona, Spain
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86
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases in North America. The purpose of this review is to highlight recent advances in epidemiology, risk factors, severity criteria and antibiotic therapeutic regimens used for community-acquired pneumonia management. RECENT FINDINGS All guidelines recommend early and appropriate empiric therapy directed against common typical organisms, such as Streptococcus pneumoniae, and other atypical organisms, but clinicians should be aware of newer emerging pathogens such as community-acquired methicillin-resistant Staphylococcus aureus and Gram-negative pathogens. SUMMARY The optimum outcome in community-acquired pneumonia can be achieved by careful risk stratification using prediction rules together with appropriate antibiotic regimens. The mainstay of community-acquired pneumonia prevention is influenza and pneumococcal immunization. Promotion of smoking cessation will also help curtail the incidence of pneumococcal disease.
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Affiliation(s)
- Arunabh Talwar
- Department of Medicine, North Shore University Hospital, Manhasset, New York 11030, USA.
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87
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DeMello D, Kierol-Andrews L, Scalise PJ. Severe Sepsis and Acute Respiratory Distress Syndrome From Community-Acquired Legionella Pneumonia: Case Report. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.3.320] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A case of a young man with community-acquired pneumonia, severe acute respiratory distress syndrome, and sepsis is reported. Treatment with antibiotics and various modes of mechanical ventilation in the intensive care unit were unsuccessful. A urinary legionella antigen test was positive for Legionella pneumophila.
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Affiliation(s)
- Dominic DeMello
- Dominic DeMello is a second-year resident in internal medicine/primary care at the University of Connecticut in Farmington. Laura Kierol-Andrews is an acute care nurse practitioner in critical care medicine and manager of the medical rapid response team at The Hospital of Central Connecticut at New Britain General in New Britain, Conn. Paul J. Scalise is the chief of pulmonary medicine at the Hospital for Special Care in New Britain, Conn
| | - Laura Kierol-Andrews
- Dominic DeMello is a second-year resident in internal medicine/primary care at the University of Connecticut in Farmington. Laura Kierol-Andrews is an acute care nurse practitioner in critical care medicine and manager of the medical rapid response team at The Hospital of Central Connecticut at New Britain General in New Britain, Conn. Paul J. Scalise is the chief of pulmonary medicine at the Hospital for Special Care in New Britain, Conn
| | - Paul J. Scalise
- Dominic DeMello is a second-year resident in internal medicine/primary care at the University of Connecticut in Farmington. Laura Kierol-Andrews is an acute care nurse practitioner in critical care medicine and manager of the medical rapid response team at The Hospital of Central Connecticut at New Britain General in New Britain, Conn. Paul J. Scalise is the chief of pulmonary medicine at the Hospital for Special Care in New Britain, Conn
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88
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Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27-72. [PMID: 17278083 PMCID: PMC7107997 DOI: 10.1086/511159] [Citation(s) in RCA: 4232] [Impact Index Per Article: 235.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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89
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Dunbar LM, Farrell DJ. Activity of telithromycin and comparators against isolates of Legionella pneumophila collected from patients with community-acquired respiratory tract infections: PROTEKT Years 1-5. Clin Microbiol Infect 2007; 13:743-6. [PMID: 17403130 DOI: 10.1111/j.1469-0691.2007.01717.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The in-vitro activity of telithromycin and comparator antibacterial agents was determined against clinical isolates of Legionella pneumophila collected in the PROTEKT surveillance study. In total, 133 isolates were collected between 1999 and 2004 from 13 countries (Australia, Belgium, Czech Republic, France, Germany, Hungary, Ireland, Italy, Japan, Portugal, Spain, Sweden and the USA). MICs were determined by broth microdilution. Telithromycin maintained activity between Year 1 (MIC(90) 0.015 mg/L) and Year 5 (MIC(90) 0.03 mg/L), as did the comparator antibacterial agents. Telithromycin appears to be a candidate for coverage of legionellosis in the empirical treatment of community-acquired respiratory tract infection.
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Affiliation(s)
- L M Dunbar
- LSU Health Science Center, New Orleans, LA 70112, USA.
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90
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Community-Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD. INFECTIOUS DISEASES IN CRITICAL CARE 2007. [PMCID: PMC7121741 DOI: 10.1007/978-3-540-34406-3_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This chapter will review the two most common lower respiratory tract infections in the intensive care unit (ICU), community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In addition we will provide an overview of the topics including recommendations for the diagnosis and treatment.
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91
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Legionnaires’ Disease. INFECTIOUS DISEASES IN CRITICAL CARE 2007. [PMCID: PMC7122631 DOI: 10.1007/978-3-540-34406-3_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The incidence of legionnaires’ disease (LD) seems to increase with age, particularly in males [36]. It was considered an infrequent cause of pneumonia in the past, but it currently ranks second to pneumococcus in the list of etiologic agents of severe community-acquired pneumonia (CAP) of bacterial origin [2, 24, 60, 89]. Considering less severe cases, in a series of 145 pneumonias in which BCYE culture, serology and the Legionella urinary antigen (LUA) test were systematically applied, Vergis et al. [91] reported a prevalence of LD of 13.7%. In another series of 392 adult patients with CAP treated in a university hospital, Sopena et al. found a prevalence of 12.5%, and LD was the second cause of pneumonia [83].
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92
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases. CAP patients requiring intensive care unit (ICU) admission carry the highest mortality rates. This paper aims to review the current literature regarding epidemiology, risk factors, severity criteria and reasons for admitting the hospitalized patient to the ICU, and the empiric and specific antibiotic therapeutic regimens employed. RECENT FINDINGS Multiple sets of clinical practice guidelines have been published in the past few years addressing the treatment of CAP. The guidelines all agree that CAP patients admitted to the hospital represent a major concern, and appropriate empiric therapy should be instituted to improve clinical outcomes. SUMMARY The cost, morbidity and mortality of CAP patients requiring ICU admission remain unacceptably high. These are heterogeneous groups of patients, so it is important to use risk-stratification based on clinical parameters and prediction tools. Appropriate antibiotic therapy is an important component in the management of both groups of patients. In particular, it is essential to administer an appropriate antimicrobial agent from the initiation of therapy, so that the risks of treatment failure and the morbidity of CAP may be minimized.
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Affiliation(s)
- Marcos I Restrepo
- Division of Pulmonary and Crit Care Med, South Texas Veterans Healthcare System, Audie L. Murphy Division, University of Texas Health Science Center at San Antonio 78229, USA
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93
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Falcó V, Molina I, Juste C, Crespo M, Almirante B, Pigrau C, Ferrer A, Bravo C, Palomar M, Pahissa A. [Treatment for Legionnaires' disease. Macrolides or quinolones?]. Enferm Infecc Microbiol Clin 2006; 24:360-4. [PMID: 16792936 DOI: 10.1157/13089688] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Macrolides and fluoroquinolones are the recommended treatment for Legionnaires' disease. The aim of our study was to analyze the clinical efficacy of clarithromycin, azithromycin and levofloxacin in patients with Legionnaires' disease. METHODS Prospective, observational study involving all adult patients with Legionella pneumophila pneumonia attended at Hospital Universitario Vall d'Hebron (Barcelona, Spain) from January 2001 to December 2004. Duration of fever, length of hospital stay and mortality were compared among 52 patients treated with clarithromycin, 43 with azithromycin and 18 with levofloxacin. RESULTS The proportion of patients with risk factors for Legionnaires' disease, the initial severity of the pneumonia and the number of patients who required intensive care unit admission were similar in patients treated with clarithromycin, azithromycin and levofloxacin. In-hospital mortality was 5.3%. There were no significant differences in fever duration, length of hospital stay or mortality among the 3 groups of patients. CONCLUSION In our experience, clarithromycin, azithromycin and levofloxacin were all efficacious for the treatment of Legionnaires' disease.
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Affiliation(s)
- Vicenç Falcó
- Servicios de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, España.
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94
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Waterer GW, Rello J. Choosing the right combination therapy in severe community-acquired pneumonia. Crit Care 2006; 10:115. [PMID: 16469123 PMCID: PMC1550800 DOI: 10.1186/cc3976] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recent studies have suggested that combination antibiotic therapy is preferable to monotherapy for severe community-acquired pneumonia (CAP). In this issue Mortensen and colleagues present retrospective data suggesting that combination therapy with a cephalosporin and a fluoroquinolone is inferior to combination therapy with a cephalosporin and a macrolide. Several mechanisms exist by which quinolones could be inferior to macrolides in combination therapy, so if these findings are confirmed by other groups they have significant implications for physicians treating patients with severe CAP.
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Affiliation(s)
- Grant W Waterer
- School of Medicine and Pharmacology, University of Western Australia, MRF Building, Royal Perth Hospital, GPO Box X2213, Perth 6847, Australia.
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95
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Roig J, Casal J, Gispert P, Gea E. 13 – Antibiotic therapy of community-acquired pneumonia (CAP) caused by atypical agents. Med Mal Infect 2006; 36:680-9. [PMID: 17095177 DOI: 10.1016/j.medmal.2006.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 07/21/2006] [Indexed: 11/28/2022]
Abstract
Macrolides, fluoroquinolones, doxycycline, and ketolides show a good intrinsic activity against intracellular pathogens which are responsible for a variable percentage of community-acquired pneumonia (CAP). These therapeutic agents all seem effective in treating most cases of CAP caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, or Legionella spp. Among quinolones, the more recent fluoroquinolones, such as gemifloxacin or moxifloxacin, generally show a better intrinsic activity than the older ones. Among macrolides, azithromycin, and clarithromycin show a better pharmacokinetic profile. Both of them are available in intravenous form. It is quite common for M. pneumoniae and C. pneumoniae to continue to be shed in respiratory secretions, weeks after an effective therapy. The clinical relevance of this finding is not clear since most of these patients have a good outcome. Azithromycin, due to its advantageous pharmacokinetic profile, seems the best option when antibiotic prophylaxis is considered in some epidemiological settings. It has been proved effective in closed M. pneumoniae outbreaks.
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Affiliation(s)
- J Roig
- Pulmonary Division, Hospital Nostra Senyora de Meritxell, 1-13 Fiter Rossell, Escaldes, Andorra AD700.
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96
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97
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Abstract
Levofloxacin is a broad-spectrum, rapid-acting bactericidal agent that exhibits concentration-dependent killing activity as well as a postantibiotic effect. Its activity includes enteric Gram-negative bacilli, Acinetobacter spp., Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus aureus and most species of streptococci, including Streptococcus pneumoniae. With increasing age, there is a natural decline in renal function by approximately 1 ml/min/year after the age of 30 years, or an average decrease in creatinine clearance of 40% by the age of 80 years. This decline in renal function can have a significant impact on antibiotics that are predominantly eliminated from the body via the kidneys, such as levofloxacin. The favorable pharmacodynamic, safety and efficacy profiles, in addition to in vitro activity versus the usual respiratory pathogens, make levofloxacin among the first-line agents for the management of pneumonia, and an option for other respiratory bacterial infections in which more resistant organisms are a consideration, such as in the elderly population.
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Affiliation(s)
- Diane M Cappelletty
- The Medical University of Ohio,The University of Toledo, College of Pharmacy, MS 609, 2801 W. Bancroft St, Toledo, OH 43606, USA
| | - Mark Zervos
- Henry Ford Health System, 2799 West Grand Blvd, Detroit, MI 48202, USA
- Wayne State University School of Medicine, Detroit, MI, USA
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98
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Pea F, Viale P. The antimicrobial therapy puzzle: could pharmacokinetic-pharmacodynamic relationships be helpful in addressing the issue of appropriate pneumonia treatment in critically ill patients? Clin Infect Dis 2006; 42:1764-71. [PMID: 16705585 DOI: 10.1086/504383] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Accepted: 02/21/2006] [Indexed: 11/03/2022] Open
Abstract
Until recently, the in vitro susceptibility of microorganisms was considered the only fundamental aspect for antibiotic efficacy in treating pneumonia. However, the relevance of pharmacokinetic-pharmacodynamic relationships in optimizing drug exposure has been progressively highlighted. Antimicrobial agents were divided into concentration-dependent or time-dependent groups, with the most consistently relevant pharmacodynamic parameters for efficacy being either the ration of the plasma peak concentration to the minimum inhibitory concentration or the time the plasma concentration persists above the minimum inhibitory concentration of the etiological agent, respectively. For the adequate treatment of pneumonia, optimal pharmacodynamic exposure should be ensured also at the infection site. To investigate this, a methodologically correct approach may be to detect drug concentration levels in the epithelial lining fluid and in the alveolar macrophages for extracellular and intracellular pathogens, respectively. From this perspective, the pharmacokinetic factors--only in some instances--support the achievement of optimal exposure during the treatment of pneumonia with fixed standard dosing regimens of antimicrobials; conversely, in other instances, the pharmacokinetic factors suggest the need for an implemented dosage regimen or even the choice of a different drug.
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Affiliation(s)
- Federico Pea
- Institute of Clinical Pharmacology and Toxicology, Department of Experimental and Clinical Pathology and Medicine, University of Udine, Udine, Italy.
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99
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100
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Abstract
Following the first outbreaks of legionnaire's disease, erythromycin emerged as the treatment of choice without the foundation of rigorous clinical trials. The number of therapeutic failures with erythromycin, as well as the side-effects and drug interactions, led to the consideration of other drugs such as the new macrolides and quinolones for the treatment of legionnaire's disease in the 1990s. In this article, 19 studies in in-vitro intracellular models and seven animal studies that compared macrolides to quinolones were reviewed. Quinolones were found to have greater activity in intracellular models and improved efficacy in animal models compared with macrolides. No randomised trials comparing the clinical efficacy of the new macrolides and new quinolones have ever been performed. Three observational studies totalling 458 patients with legionnaire's disease have compared the clinical efficacy of macrolides (not including azithromycin) and quinolones (mainly levofloxacin). The results suggested that quinolones may produce a superior clinical response compared with the macrolides (erythromycin and clarithromycin) with regard to defervescence, complications, and length of hospital stay. Little data exist for direct comparison of quinolones and azithromycin.
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Affiliation(s)
- L Pedro-Botet
- Infectious Diseases Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, Barcelona, Spain
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