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Nakamura I, Amemura-Maekawa J, Kura F, Kobayashi T, Sato A, Watanabe H, Matsumoto T. Persistent Legionella contamination of water faucets in a tertiary hospital in Japan. Int J Infect Dis 2020; 93:300-304. [PMID: 32147537 DOI: 10.1016/j.ijid.2020.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The feasibility of the decontamination procedure for Legionella pneumophila of water systems in healthcare facilities varies by water purification and disinfection methods in each country. We evaluated the efficacy of feasible decontamination strategies in Japan. METHODS This study was conducted at Tokyo Medical University Hospital (1015 beds) between 2015 and 2018. Samples from the water system and cooling tower were cultured periodically. Hyper-chlorination of cool tap water (>0.2 ppm), increases in the temperature of hot water (>55 °C), and flushing were used as decontamination strategies. The case of healthcare-associated legionellosis was surveyed. Environmental and clinical isolates were genotyped. RESULTS 1439 environmental samples were collected; 19 (1.3%) samples tested positive for L. pneumophila from water faucets of patient rooms, toilets, waste rooms, and water sourced from wells. Genotyping of 12 isolates confirmed that the same strains were present in eight environmental isolates and two isolates from patients over three years. Although the environmental contamination of the water system was persistent, the number of positive locations of hospital environments gradually decreased; eight in 2015, four in 2016, three in 2017, and four in 2018, respectively. CONCLUSIONS Monitoring contamination, hyper-chlorination, controlling temperature, and flushing were effective as a Legionella decontamination strategy.
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Affiliation(s)
- Itaru Nakamura
- Department of Infection Prevention and Control, Tokyo Medical University Hospital, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Junko Amemura-Maekawa
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1, Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan.
| | - Fumiaki Kura
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1, Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan; Division of Biosafety Control and Research, National Institute of Infectious Diseases, 1-23-1, Toyama, Shinjuku-ku, Tokyo, 162-8640, Japan.
| | - Takehito Kobayashi
- Department of Infection Prevention and Control, Tokyo Medical University Hospital, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Akihiro Sato
- Department of Infection Prevention and Control, Tokyo Medical University Hospital, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Hidehiro Watanabe
- Department of Infection Prevention and Control, Tokyo Medical University Hospital, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Tetsuya Matsumoto
- Department of Medicine, International University of Health and Welfare Narita, 4-3, Kouzunomori, Narita-shi, Chiba, 162-8640, Japan.
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Yoshida M, Furuya N, Hosokawa N, Kanamori H, Kaku M, Koide M, Higa F, Fujita J. Legionella pneumophila contamination of hospital dishwashers. Am J Infect Control 2018; 46:943-945. [PMID: 29502885 DOI: 10.1016/j.ajic.2018.01.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 01/30/2018] [Accepted: 01/30/2018] [Indexed: 11/28/2022]
Abstract
In a tertiary hospital, Legionella spp were isolated from taps and from ward dishwashers connected to contaminated tap piping. Our investigation revealed favorable conditions for growth of Legionella, and showed that Legionella pneumophila SG6 isolates from the taps and dishwashers were all genetically identical by repetitive-element polymerase chain reaction. These results suggest that contaminated dishwashers might be a potential reservoir for the spread of Legionella in health care facilities.
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Affiliation(s)
- Makiko Yoshida
- Department of Infection Control and Laboratory Diagnostics, Tohoku University Graduate School of Medicine, Sendai, Japan; Hospital Epidemiology & Infection Prevention Center, Kameda Medical Center, Kamogawa City, Japan.
| | - Naoko Furuya
- Hospital Epidemiology & Infection Prevention Center, Kameda Medical Center, Kamogawa City, Japan
| | - Naoto Hosokawa
- Hospital Epidemiology & Infection Prevention Center, Kameda Medical Center, Kamogawa City, Japan
| | - Hajime Kanamori
- Department of Infection Control and Laboratory Diagnostics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mitsuo Kaku
- Department of Infection Control and Laboratory Diagnostics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michio Koide
- Department of Infectious, Respiratory, and Digestive Medicine, Control and Prevention of Infectious Diseases, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Futoshi Higa
- National Hospital Organization, Okinawa National Hospital, Okinawa, Japan
| | - Jiro Fujita
- Department of Infectious, Respiratory, and Digestive Medicine, Control and Prevention of Infectious Diseases, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
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Legionella and risk management in hospitals—A bibliographic research methodology for people responsible for built environment and facility management. Int J Hyg Environ Health 2016; 219:890-897. [DOI: 10.1016/j.ijheh.2016.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/27/2016] [Accepted: 07/01/2016] [Indexed: 01/06/2023]
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van Heijnsbergen E, Schalk JAC, Euser SM, Brandsema PS, den Boer JW, de Roda Husman AM. Confirmed and Potential Sources of Legionella Reviewed. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2015; 49:4797-815. [PMID: 25774976 DOI: 10.1021/acs.est.5b00142] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Legionella bacteria are ubiquitous in natural matrices and man-made systems. However, it is not always clear if these reservoirs can act as source of infection resulting in cases of Legionnaires' disease. This review provides an overview of reservoirs of Legionella reported in the literature, other than drinking water distribution systems. Levels of evidence were developed to discriminate between potential and confirmed sources of Legionella. A total of 17 systems and matrices could be classified as confirmed sources of Legionella. Many other man-made systems or natural matrices were not classified as a confirmed source, since either no patients were linked to these reservoirs or the supporting evidence was weak. However, these systems or matrices could play an important role in the transmission of infectious Legionella bacteria; they might not yet be considered in source investigations, resulting in an underestimation of their importance. To optimize source investigations it is important to have knowledge about all the (potential) sources of Legionella. Further research is needed to unravel what the contribution is of each confirmed source, and possibly also potential sources, to the LD disease burden.
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Affiliation(s)
- Eri van Heijnsbergen
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Johanna A C Schalk
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Sjoerd M Euser
- ‡Regional Public Health Laboratory Kennemerland, Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | - Petra S Brandsema
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Jeroen W den Boer
- ‡Regional Public Health Laboratory Kennemerland, Haarlem, Boerhaavelaan 26, 2035 RC Haarlem, The Netherlands
| | - Ana Maria de Roda Husman
- †National Institute for Public Health and the Environment, A. van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
- §Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, 3584 CM Utrecht, The Netherlands
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Whiley H, Keegan A, Fallowfield H, Ross K. Uncertainties associated with assessing the public health risk from Legionella. Front Microbiol 2014; 5:501. [PMID: 25309526 PMCID: PMC4174118 DOI: 10.3389/fmicb.2014.00501] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/05/2014] [Indexed: 11/13/2022] Open
Abstract
Legionella is an opportunistic pathogen of public health concern. Current regulatory and management guidelines for the control of this organism are informed by risk assessments. However, there are many unanswered questions and uncertainties regarding Legionella epidemiology, strain infectivity, infectious dose, and detection methods. This review follows the EnHealth Risk Assessment Framework, to examine the current information available regarding Legionella risk and discuss the uncertainties and assumptions. This review can be used as a tool for understanding the uncertainties associated with Legionella risk assessment. It also serves to highlight the areas of Legionella research that require future focus. Improvement of these uncertainties will provide information to enhance risk management practices for Legionella, potentially improving public health protection and reducing the economic costs by streamlining current management practices.
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Affiliation(s)
- Harriet Whiley
- Health and the Environment, Flinders UniversityAdelaide, SA, Australia
| | | | | | - Kirstin Ross
- Health and the Environment, Flinders UniversityAdelaide, SA, Australia
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Abstract
Nosocomial waterborne pathogens may reach patients through several modes of transmission. Colonization of healthcare facility waterworks can occur in the proximal infrastructure, in the distal water outlets, or both. Infections with waterborne organisms such as Legionella, mycobacteria, Pseudomonas, and others cause significant morbidity and mortality, particularly in immunocompromised patients. Hospitals should have prospective water safety plans that include preventive measures, as prevention is preferable to remediation of contaminated hospital water distribution systems. Whole-genome sequencing may provide more informative epidemiologic data to link patient infections with hospital water isolates.
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Affiliation(s)
- Brooke K Decker
- National Institutes of Health Clinical Center, 10 Center Drive, 12C103A, Bethesda, MD, 20892, USA
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A case of nosocomial Legionella pneumonia associated with a contaminated hospital cooling tower. J Infect Chemother 2013; 20:68-70. [PMID: 24462430 DOI: 10.1016/j.jiac.2013.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 07/16/2013] [Accepted: 07/23/2013] [Indexed: 11/20/2022]
Abstract
We report the epidemiological investigation of a nosocomial pneumonia case due to Legionella pneumophila linked to a contaminated hospital cooling tower in an immune-compromised patient. A 73-year-old female patient was diagnosed with nosocomial Legionella pneumonia proven by a culture of L. pneumophila serogroup 1 from bronchoalveolar lavage fluid. Two strains isolated from the patient and two strains isolated from two cooling towers were found to be identical using repetitive-sequence-based-PCR with a 95% probability. This Legionella pneumonia case might be caused by aerosol from cooling towers on the roof of the hospital building which was contaminated by L. pneumophila. We increased up the temperature of hot water supply appropriately for prevention of Legionella breeding in an environment of patients' living. On the other hand, as the maintenance of cooling tower, we increased the frequency of Legionella culture tests from twice a year to three times a year. In addition, we introduced an automated disinfectants insertion machine and added one antiseptic reagent (BALSTER ST-40 N, Tohzai Chemical Industry Co., Ltd., Kawasaki, Japan) after this Legionella disease, and thereafter, we have no additional cases of Legionella disease or detection of Legionella spp. from the cooling tower or hot water supply. This case demonstrates the importance of detecting the infection source and carrying out environmental maintenance in cooperation with the infection control team.
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Abstract
PURPOSE OF REVIEW The aim is to discuss the epidemiology of infections that arise from contaminated water in healthcare settings, including Legionnaires' disease, other Gram-negative pathogens, nontuberculous mycobacteria, and fungi. RECENT FINDINGS Legionella can colonize a hospital water system and infect patients despite use of preventive disinfectants. Evidence-based measures are available for secondary prevention. Vulnerable patients can develop healthcare-associated infections with waterborne organisms that are transmitted by colonization of plumbing systems, including sinks and their fixtures. Room humidifiers and decorative fountains have been implicated in serious outbreaks, and pose unwarranted risks in healthcare settings. SUMMARY Design of hospital plumbing must be purposeful and thoughtful to avoid the features that foster growth and dissemination of Legionella and other pathogens. Exposure of patients who have central venous catheters and other invasive devices to tap water poses a risk for infection with waterborne pathogens. Healthcare facilities must conduct aggressive clinical surveillance for Legionnaires' disease and other waterborne infections in order to detect and remediate an outbreak promptly. Hand hygiene is the most important measure to prevent transmission of other Gram-negative waterborne pathogens in the healthcare setting.
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