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Lung Ultrasound Monitoring of Legionella Ventilator-Associated Pneumonia in an Extremely Low-Birth-Weight Infant. Diagnostics (Basel) 2022; 12:diagnostics12092253. [PMID: 36140654 PMCID: PMC9497615 DOI: 10.3390/diagnostics12092253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 11/17/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is a common complication of different severe lung diseases that need to be treated with mechanical ventilation in newborn infants. However, VAP due to Legionella pneumophila infection is rarely reported in the literature, especially in extremely low-birth-weight (ELBW) infants. Lung ultrasound (LUS) has been used in the diagnosis of neonatal pneumonia, but there is no literature on the ultrasound characteristics of Legionella-VAP in ELBW infants. This paper introduced the typical LUS findings of Legionella-VAP in ELBW infants, which mainly includes severe and large-area lung consolidation and atelectasis in the bilateral lungs; whether there is blood supply in the consolidated area has an important reference value for predicting the prognosis. In addition, the treatment and management experience were also introduced together, thereby helping us to deepen the understanding of the disease and avoid missed diagnoses.
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Djordjevic Z, Folic M, Petrovic I, Zornic S, Stojkovic A, Miljanovic A, Randjelovic S, Jovanovic S, Jovanovic M, Jankovic S. An outbreak of Legionnaires' disease in newborns in Serbia. Paediatr Int Child Health 2022; 42:59-66. [PMID: 35944175 DOI: 10.1080/20469047.2022.2108672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Legionnaires' disease is an atypical pneumonia caused by inhaling small droplets of water containing the bacterium Legionella spp. In newborns, it is a rare event, usually associated with water births and the use of air conditioning systems or air humidifiers. A nosocomial outbreak of Legionnaires' disease in the maternity ward of a secondary-care hospital in Arandjelovac, Serbia is described.Two male newborns were found to be infected with Legionnella pneumophila. On Days 7 and 6 of life, respectively, they were transferred to a tertiary-care hospital with signs of severe pneumonia which was radiologically confirmed. L. pneumophila was detected in tracheal secretions from both infants by RT-PCR, and its antigens were also positive in urine samples. The source of infection in the secondary-care hospital was the internal hot water heating system, and the main contributory factor to the emergence of the infection was the low temperature of the hot water which did not kill the bacteria during the available exposure time.These two cases highlight the importance of being cautious about possible Legionnaires' disease in maternity wards with outdated or irregularly maintained internal water supply systems. The adoption of official guidelines for the control and regular maintenance of water supply systems, including the multidisciplinary cooperation of all relevant parties, forms the basis for direct monitoring for Legionella and the prevention of new outbreaks.Abbreviations: BCYE: buffered charcoal yeast extract agar; GVPC: glycine vancomycin polymyxin cycloheximide agar; LD - Legionnaires' disease; TR-PCR: Reverse transcription polymerase chain reaction.
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Affiliation(s)
- Zorana Djordjevic
- Department of Hospital Infection Control, University Clinical Centre Kragujevac, Kragujevac, Serbia
| | - Marko Folic
- Department of Clinical Pharmacology, University Clinical Centre of Kragujevac and Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Ivana Petrovic
- Department of Clinical Microbiology, University of Kragujevac Clinical Centre, Kragujevac, Serbia
| | - Sanja Zornic
- Department of Clinical Microbiology, University of Kragujevac Clinical Centre, Kragujevac, Serbia
| | - Andjelka Stojkovic
- Institute of Public Health Kragujevac, Centre for Disease Control and Prevention, Kragujevac, Serbia
| | - Ana Miljanovic
- Paediatric Clinic, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Sladjana Randjelovic
- Human Ecology and Ecotoxicology Laboratory, City Institute for Public Health Belgrade, Belgrade, Serbia
| | - Snezana Jovanovic
- Department of Medical Microbiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Milica Jovanovic
- Department of Medical Microbiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Slobodan Jankovic
- Department of Clinical Pharmacology, University Clinical Centre of Kragujevac and Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Zhang C, Lu J. Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems. FRONTIERS IN ENVIRONMENTAL SCIENCE 2021; 9:1-22. [PMID: 35004706 PMCID: PMC8740890 DOI: 10.3389/fenvs.2021.684319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).
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Affiliation(s)
- Chiqian Zhang
- Pegasus Technical Services, Inc., Cincinnati, OH, United States
| | - Jingrang Lu
- Office of Research and Development, United States Environmental Protection Agency, Cincinnati, OH, United States
- Correspondence: Jingrang Lu,
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Water Safety and Health Care: Preventing Infections Caused by Opportunistic Premise Plumbing Pathogens. Infect Dis Clin North Am 2021; 35:667-695. [PMID: 34362538 DOI: 10.1016/j.idc.2021.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Health care facility water systems have been associated with the transmission of opportunistic premise plumbing pathogens such as Legionella and nontuberculous mycobacteria. These pathogens can enter a building's water system in low numbers and then proliferate when conditions are conducive to their growth. Patients and residents in health care facilities are often at heightened risk for opportunistic infections, and cases and outbreaks in the literature highlight the importance of routine water management programs and occasions for intervention to prevent additional cases. A multidisciplinary proactive approach to water safety is critical for sustained prevention of health care-associated water-related infections.
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Hospital-acquired Legionella pneumonia outbreak at an academic medical center: Lessons learned. Am J Infect Control 2021; 49:1014-1020. [PMID: 33631307 DOI: 10.1016/j.ajic.2021.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND An outbreak of Legionella pneumonia occurred at a university hospital using copper-silver ionization for potable water disinfection. We present the epidemiological and laboratory investigation of the outbreak, and associated case-control study. METHODS Cases were defined by syndrome compatible with Legionella pneumonia with laboratory-confirmed Legionella infection. The water circuit and disinfection system were assessed, and water samples collected for Legionella culture. Whole genome multi-locus sequence typing (wgMLST) was used to compare the genetic similarity of patient and environmental isolates. A case-control study was conducted to identify risk factors for Legionella pneumonia. RESULTS We identified 13 cases of hospital-acquired Legionella. wgMLST revealed >99.9% shared allele content among strains isolated from clinical and water samples. Smoking (P= .008), steroid use (P= .007), and documented shower during hospitalization (P= .03) were risk factors for Legionella pneumonia on multivariable analysis. Environmental assessment identified modifications to the hospital water system had occurred in the month preceding the outbreak. Multiple mitigation efforts and application of point of use water filters stopped the outbreak. CONCLUSIONS Potable water system Legionella colonization occurs despite existing copper-silver ionization systems, particularly after structural disruptions. Multidisciplinary collaboration and direct monitoring for Legionella are important for outbreak prevention. Showering is a modifiable risk factor for nosocomial Legionella pneumonia. Shower restriction and point-of-use filters merit consideration during an outbreak.
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Abstract
Although many aspects of infection prevention and control (IPC) mirror institutional efforts, optimization of IPC practices in the neonatal intensive care unit requires careful consideration of its unique population and environment, addressed here for key IPC domains. In addition, innovative mitigation efforts to address challenges specific to limited resource settings are discussed.
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Boczek LA, Tang M, Formal C, Lytle D, Ryu H. Comparison of two culture methods for the enumeration of Legionella pneumophila from potable water samples. JOURNAL OF WATER AND HEALTH 2021; 19:468-477. [PMID: 34152299 PMCID: PMC8358784 DOI: 10.2166/wh.2021.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Legionella infections have steadily increased in the United States over the last 20 years, and most of these infections have been attributed to contaminated water. The gold standard for confirmation of Legionella presence in water is culturing with Buffered Charcoal Yeast Extract (BCYE) agar. Following many modifications, this method is still time-consuming, expensive, and can take longer than 10 days for full confirmation. The Legiolert is a newer and simpler culture product that is claimed to be able to quantify Legionella pneumophila in 7 days with high sensitivity and specificity and does not need further confirmation for the presence of L. pneumophila. This study compared the culturability of L. pneumophila occurring in a simulated home plumbing system using both Legiolert and BCYE agar methods. Out of 185 water samples, Legiolert and BCYE method detected L. pneumophila in 83 and 85% of the samples, respectively. The two methods were determined to be statistically equivalent for culturability of L. pneumophila, though the detected levels by Legiolert were slightly higher than the BCYE method. The molecular confirmation of positive (n = 254) and negative wells (n = 82) with Legiolert also showed a high specificity of 96.5% (i.e., 3.5% false positives (9/254) and 0% false negatives (0/82)).
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Affiliation(s)
- Laura A Boczek
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA E-mail:
| | - Min Tang
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA E-mail:
| | - Casey Formal
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA E-mail:
| | - Darren Lytle
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA E-mail:
| | - Hodon Ryu
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, 26 West Martin Luther King Drive, Cincinnati, OH 45268, USA E-mail:
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Bédard E, Trigui H, Liang J, Doberva M, Paranjape K, Lalancette C, Allegra S, Faucher SP, Prévost M. Local Adaptation of Legionella pneumophila within a Hospital Hot Water System Increases Tolerance to Copper. Appl Environ Microbiol 2021; 87:e00242-21. [PMID: 33674435 PMCID: PMC8117758 DOI: 10.1128/aem.00242-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/25/2021] [Indexed: 11/20/2022] Open
Abstract
In large-building water systems, Legionella pneumophila is exposed to common environmental stressors such as copper. The aim of this study was to evaluate the susceptibility to copper of L. pneumophila isolates recovered from various sites: two clinical and seven environmental isolates from hot water system biofilm and water and from cooling tower water. After a 1-week acclimation in simulated drinking water, strains were exposed to various copper concentrations (0.8 to 5 mg/liter) for over 672 h. Complete loss of culturability was observed for three isolates following copper exposure to 5 mg/liter for 672 h. Two sequence type 1427 (ST1427)-like isolates were highly sensitive to copper, while the other two, isolated from biofilm samples, maintained higher culturability. The expression of the copper resistance gene copA evaluated by reverse transcription-quantitative PCR (RT-qPCR) was significantly higher for the biofilm isolates. All four ST1427-like isolates were recovered from the same water system during an outbreak. Whole-genome sequencing results confirmed that the four isolates are very close phylogenetically, differing by only 29 single nucleotide polymorphisms, suggesting in situ adaptation to microenvironmental conditions, possibly due to epigenetic regulation. These results indicate that the immediate environment within a building water distribution system influences the tolerance of L. pneumophila to copper. Increased contact of L. pneumophila biofilm strains with copper piping or copper alloys in the heat exchanger might lead to local adaptation. The phenotypic differences observed between water and biofilm isolates from the hot water system of a health care facility warrants further investigation to assess the relevance of evaluating disinfection performances based on water sampling alone.IMPORTANCELegionella pneumophila is a pathogen indigenous to natural and large building water systems in the bulk and the biofilm phases. The immediate environment within a system can impact the tolerance of L. pneumophila to environmental stressors, including copper. In health care facilities, copper levels in water can vary, depending on water quality, plumbing materials, and age. This study evaluated the impact of the isolation site (water versus biofilm, hot water system versus cooling tower) within building water systems. Closely related strains isolated from a health care facility hot water system exhibited variable tolerance to copper stress, shown by differential expression of copA, with biofilm isolates displaying highest expression and tolerance. Relying on the detection of L. pneumophila in water samples following exposure to environmental stressors such as copper may underestimate the prevalence of L. pneumophila, leading to inappropriate risk management strategies and increasing the risk of exposure for vulnerable patients.
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Affiliation(s)
- Emilie Bédard
- Department of Civil Engineering, Polytechnique Montréal, Montréal, Quebec, Canada
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Hana Trigui
- Department of Civil Engineering, Polytechnique Montréal, Montréal, Quebec, Canada
| | - Jeffrey Liang
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Margot Doberva
- Department of Civil Engineering, Polytechnique Montréal, Montréal, Quebec, Canada
| | - Kiran Paranjape
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Cindy Lalancette
- Laboratoire de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Séverine Allegra
- University of Lyon, UJM-Saint-Etienne, UMR 5600 CNRS, EVS-ISTHME, Saint-Etienne, France
| | - Sebastien P Faucher
- Department of Natural Resource Sciences, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Michèle Prévost
- Department of Civil Engineering, Polytechnique Montréal, Montréal, Quebec, Canada
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Masaka E, Reed S, Davidson M, Oosthuizen J. Opportunistic Premise Plumbing Pathogens. A Potential Health Risk in Water Mist Systems Used as a Cooling Intervention. Pathogens 2021; 10:pathogens10040462. [PMID: 33921277 PMCID: PMC8068904 DOI: 10.3390/pathogens10040462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/29/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022] Open
Abstract
Water mist systems (WMS) are used for evaporative cooling in public areas. The health risks associated with their colonization by opportunistic premise plumbing pathogens (OPPPs) is not well understood. To advance the understanding of the potential health risk of OPPPs in WMS, biofilm, water and bioaerosol samples (n = 90) from ten (10) WMS in Australia were collected and analyzed by culture and polymerase chain reaction (PCR) methods to detect the occurrence of five representative OPPPs: Legionella pneumophila, Pseudomonas aeruginosa, Mycobacterium avium, Naegleria fowleri and Acanthamoeba. P. aeruginosa (44%, n = 90) occurred more frequently in samples, followed by L. pneumophila serogroup (Sg) 2–14 (18%, n = 90) and L. pneumophila Sg 1 (6%, n = 90). A negative correlation between OPPP occurrence and residual free chlorine was observed except with Acanthamoeba, rs (30) = 0.067, p > 0.05. All detected OPPPs were positively correlated with total dissolved solids (TDS) except with Acanthamoeba. Biofilms contained higher concentrations of L. pneumophila Sg 2–14 (1000–3000 CFU/mL) than water samples (0–100 CFU/mL). This study suggests that WMS can be colonized by OPPPs and are a potential health risk if OPPP contaminated aerosols get released into ambient atmospheres.
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Lytle DA, Pfaller S, Muhlen C, Struewing I, Triantafyllidou S, White C, Hayes S, King D, Lu J. A comprehensive evaluation of monochloramine disinfection on water quality, Legionella and other important microorganisms in a hospital. WATER RESEARCH 2021; 189:116656. [PMID: 33249307 PMCID: PMC8133025 DOI: 10.1016/j.watres.2020.116656] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 05/22/2023]
Abstract
Opportunistic pathogens such as Legionella are of significant public health concern in hospitals. Microbiological and water chemistry parameters in hot water throughout an Ohio hospital were monitored monthly before and after the installation of a monochloramine disinfection system over 16 months. Water samples from fifteen hot water sampling sites as well as the municipal water supply entering the hospital were analyzed using both culture and qPCR assays for specific microbial pathogens including Legionella, Pseudomonas spp., nontuberculous Mycobacteria [NTM], as well as for heterotrophic bacteria. Legionella culture assays decreased from 68% of all sites being positive prior to monochloramine addition to 6% positive after monochloramine addition, and these trends were parallel to qPCR results. Considering all samples, NTMs by culture were significantly reduced from 61% to 14% positivity (p<0.001) after monochloramine treatment. Mycobacterium genus-specific qPCR positivity was reduced from 92% to 65%, but the change was not significant. Heterotrophic bacteria (heterotrophic bacteria plate counts [HPCs]) exhibited large variability which skewed statistical results on a per room basis. However, when all samples were considered, a significant decrease in HPCs was observed after monochloramine addition. Lastly, Pseudomonas aeruginosa and Vermamoeba vermiformis demonstrated large and significant decrease of qPCR signals post-chloramination. General water chemistry parameters including monochloramine residual, nitrate, nitrite, pH, temperature, metals and total trihalomethanes (TTHMs) were also measured. Significant monochloramine residuals were consistently observed at all sampling sites with very little free ammonia present and no water quality indications of nitrification (e.g., pH decrease, elevated nitrite or nitrate). The addition of monochloramine had no obvious impact on metals (lead, copper and iron) and disinfection by-products.
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Affiliation(s)
- Darren A Lytle
- U.S. Environmental Protection Agency, ORD, Center for Environmental Solutions and Emergency Response (CESER), 26 W. Martin Luther King Drive, Cincinnati, OH, 45268, United States.
| | - Stacy Pfaller
- U.S. Environmental Protection Agency, ORD, Center for Environmental Solutions and Emergency Response (CESER), 26 W. Martin Luther King Drive, Cincinnati, OH, 45268, United States
| | - Christy Muhlen
- U.S. Environmental Protection Agency, ORD, Center for Environmental Solutions and Emergency Response (CESER), 26 W. Martin Luther King Drive, Cincinnati, OH, 45268, United States
| | - Ian Struewing
- U.S. Environmental Protection Agency, ORD, Center for Environmental Measurement and Modelling (CEMM), 26 W. Martin Luther King Drive, Cincinnati, OH 45268, United States
| | - Simoni Triantafyllidou
- U.S. Environmental Protection Agency, ORD, Center for Environmental Solutions and Emergency Response (CESER), 26 W. Martin Luther King Drive, Cincinnati, OH, 45268, United States
| | - Colin White
- Ohio Environmental Protection Agency, Emerging Contaminants Section, Division of Drinking and Ground Waters, 50 West Town Street, Suite 700 Columbus, OH 43215, United States
| | - Sam Hayes
- U.S. Environmental Protection Agency, ORD, Center for Environmental Solutions and Emergency Response (CESER), 26 W. Martin Luther King Drive, Cincinnati, OH, 45268, United States
| | - Dawn King
- U.S. Environmental Protection Agency, ORD, Center for Environmental Solutions and Emergency Response (CESER), 26 W. Martin Luther King Drive, Cincinnati, OH, 45268, United States
| | - Jingrang Lu
- U.S. Environmental Protection Agency, ORD, Center for Environmental Measurement and Modelling (CEMM), 26 W. Martin Luther King Drive, Cincinnati, OH 45268, United States
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Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 26:E1-E11. [PMID: 30969279 DOI: 10.1097/phh.0000000000000986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories. PROGRAM The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations. IMPLEMENTATION Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness. EVALUATION It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program. DISCUSSION Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.
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Assadian O, Zatorska B, Presterl E, Diab-El Schahawi M. A novel micellar formulation based on natural plant extracts enhances the efficacy of hydrogen peroxide against biofilms of Staphylococcus spp. and Pseudomonas aeruginosa. BIOFOULING 2020; 36:576-586. [PMID: 32586132 DOI: 10.1080/08927014.2020.1782388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 06/11/2023]
Abstract
The antibacterial efficacy of hydrogen peroxide encapsulated in micelles (mH2O2) against biofilms was compared with that of hydrogen peroxide alone and of three commercially available aqueous biocides. The activity of mH2O2 on 24-h biofilms of reference strains of Staphylococcus spp. and Pseudomonas aeruginosa was tested in a static microtiter plate model. The biofilms were incubated with mH2O2 (17% v/v H2O2, 2% lactic acid, 0.3% phytoextract, H2O) and its individual ingredients and compared with three aqueous biocides at different concentrations and times of exposure. After 5-min exposure, 10% mH2O2 (corresponding to 1.7% v/v H2O2) achieved > 8 log10 reductions against all the test strains, while 1.7% H2O2 achieved a maximum of 1.5 log10 reduction. After 5-min exposure, none of the commercially available biocides tested showed themselves to be capable of completely eliminating the test strains embedded in biofilms. Hydrogen peroxide encapsulated in micelles demonstrated enhanced activity against planktonic cells and biofilms of Staphylococcus spp. and P. aeruginosa.
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Affiliation(s)
- Ojan Assadian
- Department of Infection Control and Hospital Epidemiology, Medical University Vienna, Vienna, Austria
| | - Beata Zatorska
- Department of Infection Control and Hospital Epidemiology, Medical University Vienna, Vienna, Austria
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University Vienna, Vienna, Austria
| | - Magda Diab-El Schahawi
- Department of Infection Control and Hospital Epidemiology, Medical University Vienna, Vienna, Austria
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13
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Scanlon MM, Gordon JL, McCoy WF, Cain MF. Water Management for Construction: Evidence for Risk Characterization in Community and Healthcare Settings: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2168. [PMID: 32214051 PMCID: PMC7143259 DOI: 10.3390/ijerph17062168] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 12/26/2022]
Abstract
Construction activities are a known risk contributing to the growth and spread of waterborne pathogens in building water systems. The purpose of the study is to integrate evidence for categorizing construction activity risk factors contributing to waterborne disease in community and healthcare settings, establish severity of such risk factors and identify knowledge gaps. Using a systematic review, the inclusion criteria were: 1) studies with disease cases suspected to be associated with construction activities and waterborne pathogens, and 2) active construction work described in a community or healthcare setting. Each construction activity risk factor was correlated across all studies with the number of disease cases and deaths to establish risk severity. The eligibility review and quantitative synthesis yielded 31 studies for inclusion (community, n = 7 and healthcare, n = 24). From 1965 to 2016, a total of 894 disease cases inclusive of 112 deaths were associated with nine construction activity risk factors and waterborne pathogens. The present study findings support the need for building owners, water management teams and public health professionals to address construction activity risk factors and the analysis of current knowledge deficiencies within the scope of an ongoing water management program. The impact of construction activities on waterborne disease is preventable and should no longer be considered incidental nor accidental.
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Affiliation(s)
- Molly M. Scanlon
- Phigenics, LLC, 3S701 West Avenue, Suite 100, Warrenville, IL 60555, USA; (W.F.M.); (M.F.C.)
- Department of Community, Environment, and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85724, USA
| | | | - William F. McCoy
- Phigenics, LLC, 3S701 West Avenue, Suite 100, Warrenville, IL 60555, USA; (W.F.M.); (M.F.C.)
| | - Melissa F. Cain
- Phigenics, LLC, 3S701 West Avenue, Suite 100, Warrenville, IL 60555, USA; (W.F.M.); (M.F.C.)
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Puri S, Boudreaux-Kelly M, Walker JD, Clancy CJ, Decker BK. Clinical Presentation of Community-Acquired Legionella Pneumonia Identified by Universal Testing in an Endemic Area. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E533. [PMID: 31952117 PMCID: PMC7013928 DOI: 10.3390/ijerph17020533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/08/2020] [Accepted: 01/12/2020] [Indexed: 11/16/2022]
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 were non-discriminatory.
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Affiliation(s)
- Shruti Puri
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Monique Boudreaux-Kelly
- Statcore, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (M.B.-K.); (J.D.W.); (C.J.C.)
| | - Jon D. Walker
- Statcore, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (M.B.-K.); (J.D.W.); (C.J.C.)
| | - Cornelius J. Clancy
- Statcore, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (M.B.-K.); (J.D.W.); (C.J.C.)
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Brooke K. Decker
- Statcore, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA; (M.B.-K.); (J.D.W.); (C.J.C.)
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA 15261, USA
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15
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Cloutman-Green E, Barbosa VL, Jimenez D, Wong D, Dunn H, Needham B, Ciric L, Hartley JC. Controlling Legionella pneumophila in water systems at reduced hot water temperatures with copper and silver ionization. Am J Infect Control 2019; 47:761-766. [PMID: 30661910 DOI: 10.1016/j.ajic.2018.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/30/2018] [Accepted: 12/01/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Hospital-acquired Legionnaires' disease is associated with the presence of Legionella pneumophila in hospital water systems. In the United Kingdom, the Department of Health recommends maintaining hot water temperatures >55°C and cold water temperatures <20°C at the point of delivery to prevent proliferation of L pneumophila in water systems. In this study, we evaluated the efficacy of copper and silver ionization to control L pneumophila at deliberately reduced hot water temperatures (43°C) within a newly installed water system in a new building linked to a large health care facility in the United Kingdom. METHODS One thousand, five hundred ninety-eight water samples were collected between September 2011 and June 2017. Samples were tested using accredited methods for L pneumophila, copper and silver ion levels, and total viable counts. Energy consumption and water usage data were also collected to permit carbon emission calculations. RESULTS The results of 1,598 routine samples from September 2011 to June 2017, and the recordings of temperatures at outlets in this facility, demonstrated effective (100%) L pneumophila control throughout the study period with an average hot water temperature of 42°C. The energy savings and reduction of carbon emissions were calculated to amount to 33% and 24%, respectively, compared to an equivalent temperature-controlled system. Water system management interventions were required to achieve consistently adequate levels of copper and silver across outlets. CONCLUSIONS This study demonstrated that it is possible to control L pneumophila independent of temperature when copper and silver ionization is introduced into a new building in conjunction with an appropriately managed water system.
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16
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Sutarjono B, Alexis J, Sachidanandam JC. Legionella pneumonia complicated by rhabdomyolysis. BMJ Case Rep 2019; 12:12/6/e229243. [PMID: 31227570 DOI: 10.1136/bcr-2019-229243] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Legionnaires' disease is a recognised but rare cause of rhabdomyolysis. It can be further complicated with renal impairment. In this case report, we describe a previously healthy, semiactive 50-year-old man who within days was reduced to having periods of dyspnea after minutes of walking in addition to near fatal acute renal failure. He was found to have the rare triad of Legionella pneumonia, renal failure and rhabdomyolysis, which is associated with high morbidity and mortality. He was treated according to guidelines with azithromycin monotherapy and aggressive fluid hydration. 20 days after admission, the patient was walking independently and discharged home.
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Affiliation(s)
- Bayu Sutarjono
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, New York, USA.,Saba University School of Medicine, Devens, Massachusetts, USA
| | - Janeah Alexis
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, New York, USA.,New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
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17
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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 diagnosis.
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18
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Edens C, Alden NB, Danila RN, Fill MMA, Gacek P, Muse A, Parker E, Poissant T, Ryan PA, Smelser C, Tobin-D’Angelo M, Schrag SJ. Multistate analysis of prospective Legionnaires' disease cluster detection using SaTScan, 2011-2015. PLoS One 2019; 14:e0217632. [PMID: 31145765 PMCID: PMC6542510 DOI: 10.1371/journal.pone.0217632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/15/2019] [Indexed: 01/09/2023] Open
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.
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Affiliation(s)
- Chris Edens
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Nisha B. Alden
- Colorado Department of Public Health and Environment, Denver, Colorado, United States of America
| | - Richard N. Danila
- Minnesota Department of Health, St. Paul, Minnesota, United States of America
| | | | - Paul Gacek
- Connecticut Department of Public Health, Hartford, Connecticut, United States of America
| | - Alison Muse
- New York State Department of Health, Albany, New York, United States of America
| | - Erin Parker
- California Emerging Infections Program, Oakland, California, United States of America
| | - Tasha Poissant
- Oregon Health Authority, Portland, Oregon, United States of America
| | - Patricia A. Ryan
- Maryland Department of Health, Baltimore, Maryland, United States of America
| | - Chad Smelser
- New Mexico Department of Health, Santa Fe, New Mexico, United States of America
| | | | - Stephanie J. Schrag
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Gamage SD, Ambrose M, Kralovic SM, Simbartl LA, Roselle GA. Legionnaires Disease Surveillance in US Department of Veterans Affairs Medical Facilities and Assessment of Health Care Facility Association. JAMA Netw Open 2018; 1:e180230. [PMID: 30646071 PMCID: PMC6324594 DOI: 10.1001/jamanetworkopen.2018.0230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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.
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Affiliation(s)
- Shantini D. Gamage
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meredith Ambrose
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
| | - Stephen M. Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati VA Medical Center, Cincinnati, Ohio
| | - Loretta A. Simbartl
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
| | - Gary A. Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati VA Medical Center, Cincinnati, Ohio
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20
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Skerrett SJ. Prevention of Health Care-Associated Legionnaires Disease. JAMA Netw Open 2018; 1:e180232. [PMID: 30646069 DOI: 10.1001/jamanetworkopen.2018.0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Shawn J Skerrett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
- Harborview Medical Center, University of Washington School of Medicine, Seattle
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21
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Hamilton KA, Prussin AJ, Ahmed W, Haas CN. Outbreaks of Legionnaires’ Disease and Pontiac Fever 2006–2017. Curr Environ Health Rep 2018; 5:263-271. [DOI: 10.1007/s40572-018-0201-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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22
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Rattanakul S, Oguma K. Inactivation kinetics and efficiencies of UV-LEDs against Pseudomonas aeruginosa, Legionella pneumophila, and surrogate microorganisms. WATER RESEARCH 2018; 130:31-37. [PMID: 29195159 DOI: 10.1016/j.watres.2017.11.047] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/18/2017] [Accepted: 11/23/2017] [Indexed: 05/26/2023]
Abstract
To demonstrate the effectiveness of UV light-emitting diodes (UV-LEDs) to disinfect water, UV-LEDs at peak emission wavelengths of 265, 280, and 300 nm were adopted to inactivate pathogenic species, including Pseudomonas aeruginosa and Legionella pneumophila, and surrogate species, including Escherichia coli, Bacillus subtilis spores, and bacteriophage Qβ in water, compared to conventional low-pressure UV lamp emitting at 254 nm. The inactivation profiles of each species showed either a linear or sigmoidal survival curve, which both fit well with the Geeraerd's model. Based on the inactivation rate constant, the 265-nm UV-LED showed most effective fluence, except for with E. coli which showed similar inactivation rates at 265 and 254 nm. Electrical energy consumption required for 3-log10 inactivation (EE,3) was lowest for the 280-nm UV-LED for all microbial species tested. Taken together, the findings of this study determined the inactivation profiles and kinetics of both pathogenic bacteria and surrogate species under UV-LED exposure at different wavelengths. We also demonstrated that not only inactivation rate constants, but also energy efficiency should be considered when selecting an emission wavelength for UV-LEDs.
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Affiliation(s)
- Surapong Rattanakul
- Research Center for Advanced Science and Technology, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8904, Japan
| | - Kumiko Oguma
- Research Center for Advanced Science and Technology, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8904, Japan.
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23
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Kozak-Muiznieks NA, Morrison SS, Mercante JW, Ishaq MK, Johnson T, Caravas J, Lucas CE, Brown E, Raphael BH, Winchell JM. Comparative genome analysis reveals a complex population structure of Legionella pneumophila subspecies. INFECTION GENETICS AND EVOLUTION 2018; 59:172-185. [PMID: 29427765 DOI: 10.1016/j.meegid.2018.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
Abstract
The majority of Legionnaires' disease (LD) cases are caused by Legionella pneumophila, a genetically heterogeneous species composed of at least 17 serogroups. Previously, it was demonstrated that L. pneumophila consists of three subspecies: pneumophila, fraseri and pascullei. During an LD outbreak investigation in 2012, we detected that representatives of both subspecies fraseri and pascullei colonized the same water system and that the outbreak-causing strain was a new member of the least represented subspecies pascullei. We used partial sequence based typing consensus patterns to mine an international database for additional representatives of fraseri and pascullei subspecies. As a result, we identified 46 sequence types (STs) belonging to subspecies fraseri and two STs belonging to subspecies pascullei. Moreover, a recent retrospective whole genome sequencing analysis of isolates from New York State LD clusters revealed the presence of a fourth L. pneumophila subspecies that we have termed raphaeli. This subspecies consists of 15 STs. Comparative analysis was conducted using the genomes of multiple members of all four L. pneumophila subspecies. Whereas each subspecies forms a distinct phylogenetic clade within the L. pneumophila species, they share more average nucleotide identity with each other than with other Legionella species. Unique genes for each subspecies were identified and could be used for rapid subspecies detection. Improved taxonomic classification of L. pneumophila strains may help identify environmental niches and virulence attributes associated with these genetically distinct subspecies.
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Affiliation(s)
- Natalia A Kozak-Muiznieks
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Shatavia S Morrison
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jeffrey W Mercante
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Maliha K Ishaq
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Taccara Johnson
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jason Caravas
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Claressa E Lucas
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ellen Brown
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Brian H Raphael
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jonas M Winchell
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
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Improving the Diagnosis of Legionella Pneumonia within a Healthcare System through a Systematic Consultation and Testing Program. Ann Am Thorac Soc 2018; 13:1289-93. [PMID: 27243279 DOI: 10.1513/annalsats.201510-715bc] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
RATIONALE Legionella testing is not recommended for all patients with pneumonia, but rather for particular patient subgroups. As a result, the overall incidence of Legionella pneumonia may be underestimated. OBJECTIVES To determine the incidence of Legionella pneumonia in a veteran population in an endemic area after introduction of a systematic infectious diseases consultation and testing program. METHODS In response to a 2011-2012 outbreak, the VA Pittsburgh Healthcare System mandated infectious diseases consultations and testing for Legionella by urine antigen and sputum culture in all patients with pneumonia. MEASUREMENTS AND MAIN RESULTS Between January 2013 and December 2015, 1,579 cases of pneumonia were identified. The incidence of pneumonia was 788/100,000 veterans per year, including 352/100,000 veterans per year and 436/100,000 veterans per year with community-associated pneumonia (CAP) and health care-associated pneumonia, respectively. Ninety-eight percent of patients with suspected pneumonia were tested for Legionella by at least one method. Legionella accounted for 1% of pneumonia cases (n = 16), including 1.7% (12/706) and 0.6% (4/873) of CAP and health care-associated pneumonia, respectively. The yearly incidences of Legionella pneumonia and Legionella CAP were 7.99 and 5.99/100,000 veterans, respectively. The sensitivities of urine antigen and sputum culture were 81% and 60%, respectively; the specificity of urine antigen was >99.97%. Urine antigen testing and Legionella cultures increased by 65% and 330%, respectively, after introduction of our program. CONCLUSIONS Systematic testing of veterans in an endemic area revealed a higher incidence of Legionella pneumonia and CAP than previously reported. Widespread urine antigen testing was not limited by false positivity.
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25
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Stachel A, Pinto G, Stelling J, Fulmer Y, Shopsin B, Inglima K, Phillips M. Implementation and evaluation of an automated surveillance system to detect hospital outbreak. Am J Infect Control 2017; 45:1372-1377. [PMID: 28844384 DOI: 10.1016/j.ajic.2017.06.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The timely identification of a cluster is a critical requirement for infection prevention and control (IPC) departments because these events may represent transmission of pathogens within the health care setting. Given the issues with manual review of hospital infections, a surveillance system to detect clusters in health care settings must use automated data capture, validated statistical methods, and include all significant pathogens, antimicrobial susceptibility patterns, patient care locations, and health care teams. METHODS We describe the use of SaTScan statistical software to identify clusters, WHONET software to manage microbiology laboratory data, and electronic health record data to create a comprehensive outbreak detection system in our hospital. We also evaluated the system using the Centers for Disease Control and Prevention's guidelines. RESULTS During an 8-month surveillance time period, 168 clusters were detected, 45 of which met criteria for investigation, and 6 were considered transmission events. The system was felt to be flexible, timely, accepted by the department and hospital, useful, and sensitive, but it required significant resources and has a low positive predictive value. CONCLUSIONS WHONET-SaTScan is a useful addition to a robust IPC program. Although the resources required were significant, this prospective, real-time cluster detection surveillance system represents an improvement over historical methods. We detected several episodes of transmission which would have eluded us previously, and allowed us to focus infection prevention efforts and improve patient safety.
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26
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Water Cultures Are More Sensitive Than Swab Cultures for the Detection of Environmental Legionella. Infect Control Hosp Epidemiol 2017; 39:108-110. [PMID: 29173230 DOI: 10.1017/ice.2017.235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Water cultures were significantly more sensitive than concurrently collected swab cultures (n=2,147 each) in detecting Legionella pneumophila within a Veterans Affairs healthcare system. Sensitivity for water versus swab cultures was 90% versus 30% overall, 83% versus 48% during a nosocomial Legionnaires' disease outbreak, and 93% versus 22% post outbreak. Infect Control Hosp Epidemiol 2018;39:108-110.
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27
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Messi P, de Niederhäusern S, Anacarso I, Iseppi R, Sabia C, Bondi M. Legionella pneumophila in healthcare settings: sensitivity to biocidal treatments in mono- and multi-species biofilms. J Hosp Infect 2017; 97:200-201. [DOI: 10.1016/j.jhin.2017.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
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28
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Abstract
Legionella pneumophila and influenza types A and B viruses can cause either community-acquired pneumonia with respiratory failure, or Legionella infection could attribute to influenza infection with potentially fatal prognosis. Copathogenesis between pandemic influenza and bacteria is characterized by complex interactions between coinfecting pathogens and the host. Understanding the underlying reason of the emersion of the secondary bacterial infection during an influenza infection is challenging. The dual infection has an impact on viral control and may delay viral clearance. Effective vaccines and antiviral therapy are crucial to increase resistance toward influenza, decrease the prevalence of influenza, and possibly interrupt the potential secondary bacterial infections.
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Affiliation(s)
- Eleni E Magira
- 1st Department of Critical Care Medicine, Evangelismos General Hospital, National and Kapodistrian University of Athens, 45-47 Ispilandou Street, Athens 10675, Greece.
| | - Sryros Zakynthinos
- 1st Department of Critical Care and Pulmonary Services, Center of Sleep Disorders, Evangelismos General Hospital, National and Kapodistrian University of Athens, 45-47 Ipsilantou Street, Athens 10676, Greece
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29
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Ryu S, Yang K, Chun BC. Community-acquired Legionnaires' Disease in a Newly Constructed Apartment Building. J Prev Med Public Health 2017; 50:274-277. [PMID: 28768406 PMCID: PMC5541279 DOI: 10.3961/jpmph.17.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/12/2017] [Indexed: 11/13/2022] Open
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.
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Affiliation(s)
- Sukhyun Ryu
- Division of Infectious Disease Control, Gyeonggi Provincial Government, Suwon, Korea.,Department of Epidemiology and Medical Informatics, School of Public Health, Korea University, Seoul, Korea
| | - Kyungho Yang
- Division of Infectious Disease Control, Gyeonggi Provincial Government, Suwon, Korea
| | - Byung Chul Chun
- Department of Epidemiology and Medical Informatics, School of Public Health, Korea University, Seoul, Korea.,Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
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30
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Soda EA, Barskey AE, Shah PP, Schrag S, Whitney CG, Arduino MJ, Reddy SC, Kunz JM, Hunter CM, Raphael BH, Cooley LA. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data From 20 States and a Large Metropolitan Area-United States, 2015. Am J Transplant 2017; 17:2215-2220. [PMID: 28724206 DOI: 10.1111/ajt.14407] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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.
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Affiliation(s)
- E A Soda
- Epidemic Intelligence Service, CDC, Atlanta, GA.,Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
| | - A E Barskey
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
| | - P P Shah
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
| | - S Schrag
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
| | - C G Whitney
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
| | - M J Arduino
- Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, GA
| | - S C Reddy
- Division of Healthcare Quality and Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, GA
| | - J M Kunz
- Division of Emergency and Environmental Health Services, National Center for Environmental Health, CDC, Atlanta, GA
| | - C M Hunter
- Division of Emergency and Environmental Health Services, National Center for Environmental Health, CDC, Atlanta, GA
| | - B H Raphael
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
| | - L A Cooley
- Division of Bacterial Diseases, National Center of Immunization and Respiratory Diseases, CDC, Atlanta, GA
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Gamage SD, Ambrose M, Kralovic SM, Roselle GA. Water Safety and Legionella in Health Care: Priorities, Policy, and Practice. Infect Dis Clin North Am 2017; 30:689-712. [PMID: 27515143 DOI: 10.1016/j.idc.2016.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Health care facility water distribution systems have been implicated in the transmission of pathogens such as Legionella and nontuberculous mycobacteria to building occupants. These pathogens are natural inhabitants of water at low numbers and can amplify in premise plumbing water, especially if conditions are conducive to their growth. Because patients and residents in health care facilities are often at heightened risk for opportunistic infections, a multidisciplinary proactive approach to water safety is important to balance the various water priorities in health care and prevent water-associated infections in building occupants.
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Affiliation(s)
- Shantini D Gamage
- National Infectious Diseases Service, Specialty Care Services, Patient Care Services, Veterans Health Administration, Department of Veterans Affairs (VA), 810 Vermont Avenue, NW, Washington, DC 20420, USA; Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
| | - Meredith Ambrose
- National Infectious Diseases Service, Specialty Care Services, Patient Care Services, Veterans Health Administration, Department of Veterans Affairs (VA), 810 Vermont Avenue, NW, Washington, DC 20420, USA
| | - Stephen M Kralovic
- National Infectious Diseases Service, Specialty Care Services, Patient Care Services, Veterans Health Administration, Department of Veterans Affairs (VA), 810 Vermont Avenue, NW, Washington, DC 20420, USA; Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Medical Service, Cincinnati VA Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA
| | - Gary A Roselle
- National Infectious Diseases Service, Specialty Care Services, Patient Care Services, Veterans Health Administration, Department of Veterans Affairs (VA), 810 Vermont Avenue, NW, Washington, DC 20420, USA; Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Medical Service, Cincinnati VA Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA
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Rhoads WJ, Pruden A, Edwards MA. Interactive Effects of Corrosion, Copper, and Chloramines on Legionella and Mycobacteria in Hot Water Plumbing. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2017; 51:7065-7075. [PMID: 28513143 DOI: 10.1021/acs.est.6b05616] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Complexities associated with drinking water plumbing systems can result in undesirable interactions among plumbing components that undermine engineering controls for opportunistic pathogens (OPs). In this study, we examine the effects of plumbing system materials and two commonly applied disinfectants, copper and chloramines, on water chemistry and the growth of Legionella and mycobacteria across a transect of bench- and pilot-scale hot water experiments carried out with the same municipal water supply. We discovered that copper released from corrosion of plumbing materials can initiate evolution of >1100 times more hydrogen (H2) from water heater sacrificial anode rods than does presence of copper dosed as soluble cupric ions. H2 is a favorable electron donor for autotrophs and causes fixation of organic carbon that could serve as a nutrient for OPs. Dosed cupric ions acted as a disinfectant in stratified stagnant pipes, inhibiting culturable Legionella and biofilm formation, but promoted Legionella growth in pipes subject to convective mixing. This difference was presumably due to continuous delivery of nutrients to biofilm on the pipes under convective mixing conditions. Chloramines eliminated culturable Legionella and prevented L. pneumophila from recolonizing biofilms, but M. avium gene numbers increased by 0.14-0.76 logs in the bulk water and were unaffected in the biofilm. This study provides practical confirmation of past discrepancies in the literature regarding the variable effects of copper on Legionella growth, and confirms prior reports of trade-offs between Legionella and mycobacteria if chloramines are applied as secondary disinfectant residual.
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Affiliation(s)
- William J Rhoads
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University , 418 Durham Hall, Blacksburg, Virginia 24061, United States
| | - Amy Pruden
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University , 418 Durham Hall, Blacksburg, Virginia 24061, United States
| | - Marc A Edwards
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University , 418 Durham Hall, Blacksburg, Virginia 24061, United States
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Soda EA, Barskey AE, Shah PP, Schrag S, Whitney CG, Arduino MJ, Reddy SC, Kunz JM, Hunter CM, Raphael BH, Cooley LA. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2017; 66:584-589. [PMID: 28594788 PMCID: PMC5720245 DOI: 10.15585/mmwr.mm6622e1] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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.
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34
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Isolation, identification, characterization and antibiotic sensitivity profile of pathogenic Legionella pneumophila isolates from different water sources. Asian Pac J Trop Biomed 2017. [DOI: 10.1016/j.apjtb.2016.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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35
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Agarwal S, Abell V, File TM. Nosocomial (Health Care–Associated) Legionnaire's Disease. Infect Dis Clin North Am 2017; 31:155-165. [DOI: 10.1016/j.idc.2016.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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36
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Lu J, Buse H, Struewing I, Zhao A, Lytle D, Ashbolt N. Annual variations and effects of temperature on Legionella spp. and other potential opportunistic pathogens in a bathroom. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2017; 24:2326-2336. [PMID: 27815848 PMCID: PMC6155451 DOI: 10.1007/s11356-016-7921-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/16/2016] [Indexed: 05/22/2023]
Abstract
Opportunistic pathogens (OPs) in drinking water, like Legionella spp., mycobacteria, Pseudomonas aeruginosa, and free-living amobae (FLA) are a risk to human health, due to their post-treatment growth in water systems. To assess and manage these risks, it is necessary to understand their variations and environmental conditions for the water routinely used. We sampled premise tap (N cold = 26, N hot = 26) and shower (N shower = 26) waters in a bathroom and compared water temperatures to levels of OPs via qPCR and identified Legionella spp. by 16S ribosomal RNA (rRNA) gene sequencing. The overall occurrence and cell equivalent quantities (CE L-1) of Mycobacterium spp. were highest (100 %, 1.4 × 105), followed by Vermamoeba vermiformis (91 %, 493), Legionella spp. (59 %, 146), P. aeruginosa (14 %, 10), and Acanthamoeba spp. (5 %, 6). There were significant variations of OP's occurrence and quantities, and water temperatures were associated with their variations, especially for Mycobacterium spp., Legionella spp., and V. vermiformis. The peaks observed for Legionella, mainly consisted of Legionella pneumophila sg1 or Legionella anisa, occurred in the temperature ranged from 19 to 49 °C, while Mycobacterium spp. and V. vermiformis not only co-occurred with Legionella spp. but also trended to increase with increasing temperatures. There were higher densities of Mycobacterium in first than second draw water samples, indicating their release from faucet/showerhead biofilm. Legionella spp. were mostly at detectable levels and mainly consisted of L. pneumophila, L. anisa, Legionella donaldsonii, Legionella tunisiensis, and an unknown drinking water isolate based on sequence analysis. Results from this study suggested potential health risks caused by opportunistic pathogens when exposed to warm shower water with low chlorine residue and the use of Mycobacterium spp. as an indicator of premise pipe biofilm and the control management of those potential pathogens.
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Affiliation(s)
- Jingrang Lu
- US EPA, Office of Research and Development, 26W Martin Luther King Dr., Cincinnati, OH, 45268, USA.
| | - Helen Buse
- Pegasus Technical Services, Inc., Cincinnati, OH,, USA
| | - Ian Struewing
- Pegasus Technical Services, Inc., Cincinnati, OH,, USA
| | - Amy Zhao
- US EPA, Office of Research and Development, 26W Martin Luther King Dr., Cincinnati, OH, 45268, USA
| | - Darren Lytle
- US EPA, Office of Research and Development, 26W Martin Luther King Dr., Cincinnati, OH, 45268, USA
| | - Nicholas Ashbolt
- School of Public Health, University of Alberta, Edmonton, Canada
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37
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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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38
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Triantafyllidou S, Lytle D, Muhlen C, Swertfeger J. Copper-silver ionization at a US hospital: Interaction of treated drinking water with plumbing materials, aesthetics and other considerations. WATER RESEARCH 2016; 102:1-10. [PMID: 27318299 PMCID: PMC7384302 DOI: 10.1016/j.watres.2016.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/28/2016] [Accepted: 06/03/2016] [Indexed: 05/29/2023]
Abstract
Tap water sampling and surface analysis of copper pipe/bathroom porcelain were performed to explore the fate of copper and silver during the first nine months of copper-silver ionization (CSI) applied to cold and hot water at a hospital in Cincinnati, Ohio. Ions dosed by CSI into the water at its point of entry to the hospital were inadvertently removed from hot water by a cation-exchange softener in one building (average removal of 72% copper and 51% silver). Copper at the tap was replenished from corrosion of the building's copper pipes but was typically unable to reach 200 μg/L in first-draw and flushed hot and cold water samples. Cold water lines had >20 μg/L silver at most of the taps that were sampled, which further increased after flushing. However, silver plating onto copper pipe surfaces (in the cold water line but particularly in the hot water line) prevented reaching 20 μg/L silver in cold and/or hot water of some taps. Aesthetically displeasing purple/grey stains in bathroom porcelain were attributed to chlorargyrite [AgCl(s)], an insoluble precipitate that formed when CSI-dosed Ag(+) ions combined with Cl(-) ions that were present in the incoming water. Overall, CSI aims to control Legionella bacteria in drinking water, but plumbing material interactions, aesthetics and other implications also deserve consideration to holistically evaluate in-building drinking water disinfection.
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Affiliation(s)
- Simoni Triantafyllidou
- Oak Ridge Institute for Science and Education at US Environmental Protection Agency, Office of Research and Development, Cincinnati, OH 45268, USA.
| | - Darren Lytle
- US Environmental Protection Agency, Office of Research and Development, National Risk Management Research Laboratory, Water Supply and Water Resources Division, Cincinnati, OH 45268, USA
| | - Christy Muhlen
- US Environmental Protection Agency, Office of Research and Development, National Risk Management Research Laboratory, Water Supply and Water Resources Division, Cincinnati, OH 45268, USA
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Garrison LE, Kunz JM, Cooley LA, Moore MR, Lucas C, Schrag S, Sarisky J, Whitney CG. Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires’ Disease-North America, 2000-2014. Am J Transplant 2016. [DOI: 10.1111/ajt.14024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L. E. Garrison
- Division of Bacterial Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta GA
| | - J. M. Kunz
- Division of Emergency and Environmental Health Services; National Center for Environmental Health; CDC; Atlanta GA
| | - L. A. Cooley
- Division of Bacterial Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta GA
| | - M. R. Moore
- Division of Bacterial Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta GA
| | - C. Lucas
- Division of Bacterial Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta GA
| | - S. Schrag
- Division of Bacterial Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta GA
| | - J. Sarisky
- Division of Emergency and Environmental Health Services; National Center for Environmental Health; CDC; Atlanta GA
| | - C. G. Whitney
- Division of Bacterial Diseases; National Center for Immunization and Respiratory Diseases; CDC; Atlanta GA
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Energy Conservation and the Promotion of Legionella pneumophila Growth: The Probable Role of Heat Exchangers in a Nosocomial Outbreak. Infect Control Hosp Epidemiol 2016; 37:1475-1480. [PMID: 27640674 PMCID: PMC5197645 DOI: 10.1017/ice.2016.205] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the source of a Legionella pneumophila serogroup 5 nosocomial outbreak and the role of the heat exchanger installed on the hot water system within the previous year. SETTING A 400-bed tertiary care university hospital in Sherbrooke, Canada. METHODS Hot water samples were collected and cultured for L. pneumophila from 25 taps (baths and sinks) within wing A and 9 taps in wing B. Biofilm (5) and 2 L water samples (3) were collected within the heat exchangers for L. pneumophila culture and detection of protists. Sequence-based typing was performed on strain DNA extracts and pulsed-field gel electrophoresis patterns were analyzed. RESULTS Following 2 cases of hospital-acquired legionellosis, the hot water system investigation revealed a large proportion of L. pneumophila serogroup 5 positive taps (22/25 in wing A and 5/9 in wing B). High positivity was also detected in the heat exchanger of wing A in water samples (3/3) and swabs from the heat exchanger (4/5). The outbreak genotyping investigation identified the hot water system as the source of infections. Genotyping results revealed that all isolated environmental strains harbored the same related pulsed-field gel electrophoresis pattern and sequence-based type. CONCLUSIONS Two cases of hospital-acquired legionellosis occurred in the year following the installation of a heat exchanger to preheat hospital hot water. No cases were reported previously, although the same L. pneumophila strain was isolated from the hot water system in 1995. The heat exchanger promoted L. pneumophila growth and may have contributed to confirmed clinical cases. Infect. Control Hosp. Epidemiol. 2016;1475–1480
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Garrison LE, Kunz JM, Cooley LA, Moore MR, Lucas C, Schrag S, Sarisky J, Whitney CG. Vital Signs: Deficiencies in Environmental Control Identified in Outbreaks of Legionnaires’ Disease — North America, 2000–2014. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2016; 65:576-84. [DOI: 10.15585/mmwr.mm6522e1] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Culture positivity and bacterial burden thresholds for Legionella in hospital water: Proceed with caution. Am J Infect Control 2016; 44:730. [PMID: 26851195 DOI: 10.1016/j.ajic.2015.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/23/2022]
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43
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Three Genome Sequences of Legionella pneumophila subsp. pascullei Associated with Colonization of a Health Care Facility. GENOME ANNOUNCEMENTS 2016; 4:4/3/e00335-16. [PMID: 27151801 PMCID: PMC4859183 DOI: 10.1128/genomea.00335-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Here, we report the complete genome sequences of three Legionella pneumophila subsp. pascullei strains (including both serogroup 1 and 5 strains) that were found in the same health care facility in 1982 and 2012.
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44
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Combination of Heat Shock and Enhanced Thermal Regime to Control the Growth of a Persistent Legionella pneumophila Strain. Pathogens 2016; 5:pathogens5020035. [PMID: 27092528 PMCID: PMC4931386 DOI: 10.3390/pathogens5020035] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 11/16/2022] Open
Abstract
Following nosocomial cases of Legionella pneumophila, the investigation of a hot water system revealed that 81.5% of sampled taps were positive for L. pneumophila, despite the presence of protective levels of copper in the water. A significant reduction of L. pneumophila counts was observed by culture after heat shock disinfection. The following corrective measures were implemented to control L. pneumophila: increasing the hot water temperature (55 to 60 °C), flushing taps weekly with hot water, removing excess lengths of piping and maintaining a water temperature of 55 °C throughout the system. A gradual reduction in L. pneumophila counts was observed using the culture method and qPCR in the 18 months after implementation of the corrective measures. However, low level contamination was retained in areas with hydraulic deficiencies, highlighting the importance of maintaining a good thermal regime at all points within the system to control the population of L. pneumophila.
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45
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Kruse EB, Wehner A, Wisplinghoff H. Prevalence and distribution of Legionella spp in potable water systems in Germany, risk factors associated with contamination, and effectiveness of thermal disinfection. Am J Infect Control 2016; 44:470-4. [PMID: 26775932 DOI: 10.1016/j.ajic.2015.10.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/20/2015] [Accepted: 10/28/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Worldwide, Legionella spp are a common cause of community-acquired pneumonia. Potable water systems are a main reservoir; however, exposure in the community is unknown. METHODS Water samples from 718 buildings in Germany were collected. Possible risk factors were prospectively recorded. All samples were tested for Legionella spp using cultural microbiologic methods. Samples were assigned to 1 of 5 levels of contamination. Statistical analysis was performed to determine the influence of risk factors for contamination and, in a subgroup of buildings, for unsuccessful thermal disinfection. RESULTS In total, 4,482 water samples from 718 different water supply systems were analyzed. In 233 buildings (32.7%), Legionella spp were identified, 148 (63.5%) of which had a medium or higher level of contamination. The most common species was Legionella pneumophila (94%). Contamination was strongly associated with temperature in the circulation, but not with the size of the building, time of the year, or transport time to the laboratory. Thermal disinfection was successful in fewer than half of the buildings. CONCLUSIONS There is relevant exposure to Legionella spp in the community. Water systems are not always up to current technical standards. Although microbiological risk assessment remains a challenge, there is a case for monitoring for Legionella spp outside of hospitals.
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Affiliation(s)
| | | | - Hilmar Wisplinghoff
- Wisplinghoff Laboratories, Cologne, Germany; Institute for Medical Microbiology, Immunology, and Hygiene, University of Cologne, Cologne, Germany
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46
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Kanamori H, Weber DJ, Rutala WA. Healthcare Outbreaks Associated With a Water Reservoir and Infection Prevention Strategies. Clin Infect Dis 2016; 62:1423-35. [DOI: 10.1093/cid/ciw122] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/19/2016] [Indexed: 12/13/2022] Open
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47
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Abstract
Legionella species are emerging opportunistic pathogens in hematopoietic stem cell and solid organ transplant recipients, associated with significant morbidity and mortality. The clinical and radiological features of Legionella infections can mimic other opportunistic pathogens in these profoundly immunocompromised patients. Diagnosis in transplant patients is challenging as non-pneumophila Legionella infections, for which these patients are at risk, cannot be identified using the urinary antigen test. Changes in management of transplant recipients and changes in Legionella epidemiology suggest that the number of transplant patients potentially exposed to Legionella spp. may be on the rise. Yet, evidence-based, transplant-specific guidelines for managing and preventing Legionella infections are not currently available. In this article, we review the epidemiology, clinical features, diagnostic challenges, treatment options, and preventive strategies of Legionella infections in these high-risk patient populations.
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Affiliation(s)
- Shobini Sivagnanam
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, E4-100, Seattle, WA, 98109, USA
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, E4-100, Seattle, WA, 98109, USA. .,Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA. .,Infection Prevention, Seattle Cancer Care Alliance, Seattle, WA, USA.
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48
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49
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Cassier P, Bénet T, Nicolle MC, Brunet M, Buron F, Morelon E, Béraud L, Descours G, Jarraud S, Vanhems P. Community-acquired Legionnaires' disease in a renal transplant recipient with unclear incubation period: the importance of molecular typing. Transpl Infect Dis 2015; 17:756-60. [PMID: 26256573 DOI: 10.1111/tid.12432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/13/2015] [Accepted: 07/26/2015] [Indexed: 11/29/2022]
Abstract
Transplant recipients are at risk of developing Legionnaires' disease (LD) because of impaired cellular immunity. Here, we describe a renal transplant recipient who developed LD at least 10 days after hospital admission and transplantation. The hospital water network was initially suspected, but further testing determined that the probable source was the patient's domestic water supply. Our report also suggests that the patient's immunosuppressed state may have switched potential colonization to pneumonia.
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Affiliation(s)
- P Cassier
- Hospices Civils de Lyon, Unité d'Hygiène et d'Epidémiologie, Groupement Hospitalier Edouard Herriot, Lyon, France.,Hospices Civils de Lyon, Centre National de Reference des Legionelles, Centre de Biologie Est Hospices Civils de Lyon, Bron, France.,CIRI, International Center for Infectiology Research, Legionella Pathogenesis Team, Université de Lyon, Lyon, France.,Inserm, U1111, Lyon, France.,Ecole Normale Supérieure de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, Université de Lyon 1, Lyon, France
| | - T Bénet
- Hospices Civils de Lyon, Unité d'Hygiène et d'Epidémiologie, Groupement Hospitalier Edouard Herriot, Lyon, France.,Laboratoire d'épidémiologie et de santé publique, CNRS, UMR5308, Université de Lyon 1, Lyon, France
| | - M C Nicolle
- Hospices Civils de Lyon, Unité d'Hygiène et d'Epidémiologie, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - M Brunet
- Hospices Civils de Lyon, Transplantation, Néphrologie et Immunologie Clinique, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - F Buron
- Hospices Civils de Lyon, Transplantation, Néphrologie et Immunologie Clinique, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - E Morelon
- Hospices Civils de Lyon, Transplantation, Néphrologie et Immunologie Clinique, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - L Béraud
- Hospices Civils de Lyon, Centre National de Reference des Legionelles, Centre de Biologie Est Hospices Civils de Lyon, Bron, France
| | - G Descours
- Hospices Civils de Lyon, Centre National de Reference des Legionelles, Centre de Biologie Est Hospices Civils de Lyon, Bron, France.,CIRI, International Center for Infectiology Research, Legionella Pathogenesis Team, Université de Lyon, Lyon, France.,Inserm, U1111, Lyon, France.,Ecole Normale Supérieure de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, Université de Lyon 1, Lyon, France
| | - S Jarraud
- Hospices Civils de Lyon, Centre National de Reference des Legionelles, Centre de Biologie Est Hospices Civils de Lyon, Bron, France.,CIRI, International Center for Infectiology Research, Legionella Pathogenesis Team, Université de Lyon, Lyon, France.,Inserm, U1111, Lyon, France.,Ecole Normale Supérieure de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, Université de Lyon 1, Lyon, France
| | - P Vanhems
- Hospices Civils de Lyon, Unité d'Hygiène et d'Epidémiologie, Groupement Hospitalier Edouard Herriot, Lyon, France.,Hospices Civils de Lyon, Centre National de Reference des Legionelles, Centre de Biologie Est Hospices Civils de Lyon, Bron, France.,CIRI, International Center for Infectiology Research, Legionella Pathogenesis Team, Université de Lyon, Lyon, France.,Inserm, U1111, Lyon, France.,Ecole Normale Supérieure de Lyon, Lyon, France.,Centre International de Recherche en Infectiologie, Université de Lyon 1, Lyon, France.,Laboratoire d'épidémiologie et de santé publique, CNRS, UMR5308, Université de Lyon 1, Lyon, France
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Garrison LE, Lucas CE, Demirjian A, Sonel AF, Hicks LA. Reply to Gamage et al. Clin Infect Dis 2015. [DOI: 10.1093/cid/civ591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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