Effect of flow regimes on the presence of Legionella within the biofilm of a model plumbing system

Biofilm Assessment and Metagenomic Analysis of Venoarterial Extracorporeal Membrane Oxygenation Cannulas and Membrane Oxygenators

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) exposes the patient to infectious complications related to the cannulas or the site of insertion. The aim of the current study was to investigate and compare the prevalence of cannula and membrane oxygenators colonization using three different methods: microbiological culture, scanning electron microscopy, and metagenomic (rRNA 16S analysis). A monocentric prospective study was conducted between December 2017 and June 2018. Consecutive patients undergoing VA-ECMO support for refractory cardiac arrest or cardiogenic shock were included. Ten patients were included with a median age of 64 (52-62) years. Venoarterial extracorporeal membrane oxygenation was inserted for refractory cardiac arrest in five (50%), cardiogenic shock in four (40%), and self-poisoning in one (10%) cases. Microbiological culture of all (8/8, 100%) membrane oxygenators was negative, whereas all (10/10, 100%) were colonized by biofilm, and eight (8/9, 89%) presented bacterial DNA. Three (3/9, 33%) arterial and venous cannulas were positive in culture and seven (7/9, 78%) were colonized by biofilm, respectively. Seven (7/9, 78%) arterial and four (4/9, 44%) venous cannulas presented bacterial DNA. Colonization of cannulas and membranes is more frequent when assessed by electron microscopy or metagenomic analysis than with culture. Membrane oxygenators are more often colonized than cannulas.

Assessing the health risks associated with the usage of water-atomization shower systems in buildings

In the context of climate change policies, buildings must implement solutions to reduce energy and water consumption. One such solution is showering with water atomization showerheads, which can significantly reduce water and energy usage. However, the lack of risk assessment for users' health has hindered the widespread adoption of this technology. To address this gap, we assess the risk of spreading bacteria, in particular the pathogenic bacterium Legionella pneumophila, from shower hose biofilms of different ages grown under controlled or uncontrolled conditions considering different levels of water hardness, during showering using water atomization showerheads (ECO) or continuous flow showerheads (STA). We compared the aerosol and bioaerosol emission - total, viable and cultivable - during a 10 min shower event between the two shower systems. We showed that the water-atomization showerhead emitted slightly more nanoparticles smaller than 0.45 µm and slightly fewer particles larger than 0.5 µm than the continuous flow showerhead. Additionally, ECO showerheads emitted fewer cultivable bacteria than STA, regardless of the biofilm's age or growth conditions. When Legionella pneumophila was detected in biofilms, ECO showerheads released slightly less cultivable Legionella in the first flush of shower water compared to the STA, ranging from 6.0 × 102 to 1.6 × 104 CFU·L-1. However, cultivable L. pneumophila was not detected in the aerosols emitted during showering with either showerhead. These findings suggest that emerging water-drop emission technologies might affect human exposure to aerosols differently than traditional systems, emphasizing the importance of assessing the health risks associated with any new shower system. Additionally, these findings provide valuable insights for achieving a balance between water and energy conservation.

Variable Legionella Response to Building Occupancy Patterns and Precautionary Flushing

When stay-at-home orders were issued to slow the spread of COVID-19, building occupancy (and water demand) was drastically decreased in many buildings. There was concern that widespread low water demand may cause unprecedented Legionella occurrence and Legionnaires’ disease incidence. In lieu of evidenced-based guidance, many people flushed their water systems as a preventative measure, using highly variable practices. Here, we present field-scale research from a building before, during, and after periods of low occupancy, and controlled stagnation experiments. We document no change, a > 4-log increase, and a > 1.5-log decrease of L. pneumophila during 3- to 7-week periods of low water demand. L. pneumophila increased by > 1-log after precautionary flushing prior to reoccupancy, which was repeated in controlled boiler flushing experiments. These results demonstrate that the impact of low water demand (colloquially called stagnation) is not as straight forward as is generally assumed, and that some flushing practices have potential unintended consequences. In particular, stagnation must be considered in context with other Legionella growth factors like temperature and flow profiles. Boiler flushing practices that dramatically increase the flow rate and rapidly deplete boiler temperature may mobilize Legionella present in biofilms and sediment.

Cooccurrence of Five Pathogenic Legionella spp. and Two Free-Living Amoebae Species in a Complete Drinking Water System and Cooling Towers

Pathogenic Legionella species grow optimally inside free-living amoebae to concentrations that increase risks to those who are exposed. The aim of this study was to screen a complete drinking water system and cooling towers for the occurrence of Acanthamoeba spp. and Naegleria fowleri and their cooccurrence with Legionella pneumophila, Legionella anisa, Legionella micdadei, Legionella bozemanii, and Legionella longbeachae. A total of 42 large-volume water samples, including 12 from the reservoir (water source), 24 from two buildings (influents to the buildings and exposure sites (taps)), and six cooling towers were collected and analyzed using droplet digital PCR (ddPCR). N. fowleri cooccurred with L. micdadei in 76 (32/42) of the water samples. In the building water system, the concentrations of N. fowleri and L. micdadei ranged from 1.5 to 1.6 Log₁₀ gene copies (GC)/100 mL, but the concentrations of species increased in the cooling towers. The data obtained in this study illustrate the ecology of pathogenic Legionella species in taps and cooling towers. Investigating Legionella’s ecology in drinking and industrial waters will hopefully lead to better control of these pathogenic species in drinking water supply systems and cooling towers.

Replicable simulation of distal hot water premise plumbing using convectively-mixed pipe reactors

A lack of replicable test systems that realistically simulate hot water premise plumbing conditions at the laboratory-scale is an obstacle to identifying key factors that support growth of opportunistic pathogens (OPs) and opportunities to stem disease transmission. Here we developed the convectively-mixed pipe reactor (CMPR) as a simple reproducible system, consisting of off-the-shelf plumbing materials, that self-mixes through natural convective currents and enables testing of multiple, replicated, and realistic premise plumbing conditions in parallel. A 10-week validation study was conducted, comparing three pipe materials (PVC, PVC-copper, and PVC-iron; n = 18 each) to stagnant control pipes without convective mixing (n = 3 each). Replicate CMPRs were found to yield consistent water chemistry as a function of pipe material, with differences becoming less discernable by week 9. Temperature, an overarching factor known to control OP growth, was consistently maintained across all 54 CMPRs, with a coefficient of variation <2%. Dissolved oxygen (DO) remained lower in PVC-iron (1.96 ± 0.29 mg/L) than in PVC (5.71 ± 0.22 mg/L) or PVC-copper (5.90 ± 0.38 mg/L) CMPRs as expected due to corrosion. Further, DO in PVC-iron CMPRs was 33% of that observed in corresponding stagnant pipes (6.03 ± 0.33 mg/L), demonstrating the important role of internal convective mixing in stimulating corrosion and microbiological respiration. 16S rRNA gene amplicon sequencing indicated that both bulk water (P_adonis = 0.001, R² = 0.222, P_betadis = 0.785) and biofilm (P_adonis = 0.001, R² = 0.119, P_betadis = 0.827) microbial communities differed between CMPR versus stagnant pipes, consistent with creation of a distinct ecological niche. Overall, CMPRs can provide a more realistic simulation of certain aspects of premise plumbing than reactors commonly applied in prior research, at a fraction of the cost, space, and water demand of large pilot-scale rigs.

Droplet digital PCR for the detection and monitoring of Legionella pneumophila

Legionella pneumophila(L. pneumophila is a harmful pathogen often found in water systems. In hospitals, the absence of L. pneumophila in water systems is mandatory by law, therefore, frequent and effective monitoring of water is of fundamental importance. Molecular methods based on reverse transcription-quantitative polymerase chain reaction (RT-qPCR) have been proposed for the detection of L. pneumophila, however, the sensitivity and accuracy of these methods have not been validated yet. Therefore, it is important to evaluate other strategies able to overcome the limits of culture-based and RT-qPCR methods. On these bases, we compared the sensitivity and accuracy of droplet digital PC (ddPCR) and RT-qPCR in water samples with known concentrations of L. pneumophila and in an in vitro model of water heat treatments. ddPCR showed a higher sensitivity rate and accuracy compared to RT-qPCR in detecting low bacterial load. In addition, ddPCR is not affected by the presence of fragmented DNA and showed higher accuracy than RT-qPC in monitoring the efficacy of heat shock treatments. In conclusion, ddPCR represents an innovative strategy to effectively detect L. pneumophila in water samples. Thanks to its high robustness, ddPCR could be applied also for the detection of L. pneumophila in patients with suspected legionellosis.

Interactive Effects of Copper Pipe, Stagnation, Corrosion Control, and Disinfectant Residual Influenced Reduction of Legionella pneumophila during Simulations of the Flint Water Crisis

Flint, MI experienced two outbreaks of Legionnaires' Disease (LD) during the summers of 2014 and 2015, coinciding with use of Flint River as a drinking water source without corrosion control. Using simulated distribution systems (SDSs) followed by stagnant simulated premise (i.e., building) plumbing reactors (SPPRs) containing cross-linked polyethylene (PEX) or copper pipe, we reproduced trends in water chemistry and Legionella proliferation observed in the field when Flint River versus Detroit water were used before, during, and after the outbreak. Specifically, due to high chlorine demand in the SDSs, SPPRs with treated Flint River water were chlorine deficient and had elevated L. pneumophila numbers in the PEX condition. SPPRs with Detroit water, which had lower chlorine demand and higher residual chlorine, lost all culturable L. pneumophila within two months. L. pneumophila also diminished more rapidly with time in Flint River SPPRs with copper pipe, presumably due to the bacteriostatic properties of elevated copper concentrations caused by lack of corrosion control and stagnation. This study confirms hypothesized mechanisms by which the switch in water chemistry, pipe materials, and different flow patterns in Flint premise plumbing may have contributed to observed LD outbreak patterns.

The limitations of hydrodynamic removal of biofilms from the dead-ends in a model drinking water distribution system

Biofilm formation and removal from dead-ends is a particularly difficult and understudied area of water distribution system biology. In this work, we have built a model drinking water distribution system to probe the effect of different hydrodynamic flow regimes on biofilm formation and removal in the main pipe and in the dead-end. The test rig was built to include all major drinking water distribution system components with materials and dimensions used in standard plumbing systems. We have simulated the effect of stagnant, laminar, turbulent, and intense turbulent flushing conditions on the growth and removal of biofilms from the main pipe and the dead-end. The growth of the biofilm in the main pipe was not prevented at a volumetric flow rate of 9.4 L min^-1 and flow velocity of 2 m s^-1. Mature biofilms were more difficult to remove. Biofilms grown under shear stress conditions could withstand significantly higher shear stresses than those to which they were exposed to during growth. The biofilms grew twice as fast in the dead-end when flow in the main pipe was turbulent compared to stagnant conditions. Biofilms in the dead-end were not affected by the flushing conditions in the main pipe (Q = 52 L min^-1, Re = 9.0 · 10⁴). The computational fluid dynamics simulation suggests that biofilms cannot be hydrodynamically removed from the dead-end at depths that are larger than one pipe diameter. Biofilms beyond this limit present a possible source for reinoculation and recolonization of the rest of the water distribution system.

Legionella pneumophila and Protozoan Hosts: Implications for the Control of Hospital and Potable Water Systems

Legionella pneumophila is an opportunistic waterborne pathogen of public health concern. It is the causative agent of Legionnaires’ disease (LD) and Pontiac fever and is ubiquitous in manufactured water systems, where protozoan hosts and complex microbial communities provide protection from disinfection procedures. This review collates the literature describing interactions between L. pneumophila and protozoan hosts in hospital and municipal potable water distribution systems. The effectiveness of currently available water disinfection protocols to control L. pneumophila and its protozoan hosts is explored. The studies identified in this systematic literature review demonstrated the failure of common disinfection procedures to achieve long term elimination of L. pneumophila and protozoan hosts from potable water. It has been demonstrated that protozoan hosts facilitate the intracellular replication and packaging of viable L. pneumophila in infectious vesicles; whereas, cyst-forming protozoans provide protection from prolonged environmental stress. Disinfection procedures and protozoan hosts also facilitate biogenesis of viable but non-culturable (VBNC) L. pneumophila which have been shown to be highly resistant to many water disinfection protocols. In conclusion, a better understanding of L. pneumophila-protozoan interactions and the structure of complex microbial biofilms is required for the improved management of L. pneumophila and the prevention of LD.

Wide-scale study of 206 buildings in the Netherlands from 2011 to 2015 to determine the effect of drinking water management plans on the presence of Legionella spp

Previous analysis of the Dutch National Legionella Outbreak Detection Program 2002-2012 has shown that buildings required to maintain a Legionella control plan for their drinking water installation are more likely to test positive for Legionella spp. Than buildings without such a plan (38% versus 22% of samples). To clarify this discrepancy, we analysed the results of mandatory water sample testing conducted as part of risk assessments in 206 buildings in the Netherlands from 2011 to 2015. Of the 6171 samples analysed, 16.2% exceeded the Dutch drinking water standard for Legionella spp. of 100 CFU/litre. In buildings with ≤50 tap points, the average percentage of samples containing ≥100 CFU/litre was 28.2%, and from buildings with >50 tap points, it was 12.2%. Analysis of serial samples (taken every 6 months) from each building showed that 33.2% of all buildings tested positive for at least one sample every 6 months. The overall increase was 4.4% per year. Analysis of Legionella subgroups showed that while the majority of positive samples contained L. non-pneumophila (96.9%), some samples did contain L. pneumophila serogroup 1 (1.0%) and serogroups 2-14 (2.1%). Our data suggest that the Dutch mandatory risk assessment and drinking water management plan is not sufficiently effective in preventing the proliferation of Legionella spp. and may even contribute to proliferation. This analysis should now be expanded to include other areas of the Netherlands in order to understand the geographical differences that we observed in our results, and why smaller buildings appear to be more likely to test positive for Legionella spp.

Overview and comparison of Legionella regulations worldwide

BACKGROUND

Legionnaires disease occurs worldwide. Many authorities have guidelines and regulations to prevent and control Legionella in water systems. These regulations are based on often very limited field and laboratory observations and measurements. They are, therefore, very different from country to country. This article aims to map the existing regulatory framework of worldwide Legionella control to assess the feasibility of regulatory unification.

METHODS

This article gives an overview of the different standards, guidelines, and recommendations as well as how various authorities and/or countries deal with Legionella infection. A 3-step process is followed to identify current regulations.

RESULTS

Although Legionella is a global concern with a common scientific base, the regulatory framework is different from country to country. The current guidelines and standards are not the best possible. Despite different regulatory frameworks, there is still broad unification of underlying principles. Common principles across regulations are avoiding and monitoring critical spots, avoiding water stagnation, and maintaining sufficiently high temperature (above 60°C, below 25°C). Differences between regulations are target group and dangerous Legionella concentration levels.

CONCLUSIONS

The comparative analysis of the framework is a good starting point for reaching future regulatory unification based on common ground.

Migration of Acanthamoeba castellanii Through Legionella Biofilms

The amoeba-resistant bacterium Legionella pneumophila infects humans through aerosols and thereby can cause a life-threatening pneumonia termed Legionnaires' disease. In the environment L. pneumophila forms and colonizes biofilms, which usually comprise complex multispecies communities. In these biofilms L. pneumophila persists and replicates intracellularly in protozoa, such as the amoeba Acanthamoeba castellanii. The interactions between sessile L. pneumophila in biofilms and their natural protozoan hosts are not understood on a molecular level. Here, we describe a method to visualize by confocal microscopy the formation and architecture of mono-species L. pneumophila biofilms. Furthermore, we describe and quantify the migration or "grazing" of A. castellanii in the biofilm. This allows investigating on a molecular and cellular level L. pneumophila biofilm formation and Legionella-amoeba interactions within biofilms.

Drip irrigation biofouling with treated wastewater: bacterial selection revealed by high-throughput sequencing

Clogging of drippers due to the development of biofilms weakens the advantages and impedes the implementation of drip irrigation technology. The objective of this study was to characterise the bacterial community of biofilms that develop in a drip irrigation system supplied with treated wastewater. High-throughput sequencing of 16S rRNA gene amplicons indicated that the bacterial community composition differed between drippers and pipes, mainly due to changes in the abundance of the genus Aquabacterium. Cyanobacteria were found to be involved in the biological fouling of drippers. Moreover, bacterial genera including opportunistic pathogenic bacteria such as Legionella and Pseudomonas were more abundant in dripper and pipe biofilms than in the incoming water. Some genera such as Pseudomonas were mostly recovered from drippers, while others (ie Bacillus, Brevundimonas) mainly occurred in pipes. Variations in the hydraulic conditions and properties of the materials likely explain the shift in bacterial communities observed between pipes and drippers.

Prevalence of Legionella in retirement homes and group homes water distribution systems

BACKGROUND

Although historically the focus has been placed above all on hospital infections and travel-associated outbreaks, most of the cases of Legionella infection are sporadic and occur in community-dwellers.

OBJECTIVES

To evaluate the presence and load of Legionella in hot water systems of non-healthcare facilities that host closed communities. Furthermore, we tried to verify the association between Heterotrophic Plate Counts (HPCs) and presence of Legionella.

METHODS

We collected hot water and biofilm samples from the showerheads of retirement homes and group homes. Samples were tested by culture method for the presence of Legionella. Confirmation and identification were carried out through Latex test and PCR. We determined the HPCs at 22 and 37 °C by the pour plate method. Statistics performed through STATA.

RESULTS

We collected 140 hot water and biofilm samples, 95 from 26 retirement homes and 35 from 9 group homes. Legionella was found in 36.8% samples collected from retirement homes and only in 10.3% group homes' samples (p = 0.01). Legionella was identified more frequently in water than in biofilm (29.8% vs 16.9%); just in one case the pathogen was found in the biofilm only. L. pneumophila sg 1 was the pathogen more frequently isolated (65.8%), with an average load of 2720 CFU/L (SD = 8393 CFU/L). We have often noticed a high microbial contamination (67% of HPCs >200 CFU/mL) and identified a higher prevalence of Legionella for intermediate values of HPC 22 °C (p = 0.011). 32% of people hosted in retirement homes were exposed to Legionella.

CONCLUSIONS

Colonization of water-systems of retirement homes and group homes is anything but occasional, and in our survey it mainly affects the former, moreover often due to L. pneumophila sg 1. The search for the pathogen in the biofilm has proved to be of little use. The relationship between HPC and Legionella deserves further studies.

Present-day monitoring underestimates the risk of exposure to pathogenic bacteria from cold water storage tanks

Water-borne bacteria, found in cold water storage tanks, are causative agents for various human infections and diseases including Legionnaires’ disease. Consequently, regular microbiological monitoring of tank water is undertaken as part of the regulatory framework used to control pathogenic bacteria. A key assumption is that a small volume of water taken from under the ball valve (where there is easy access to the stored water) will be representative of the entire tank. To test the reliability of this measure, domestic water samples taken from different locations of selected tanks in London properties between November 2015 and July 2016 were analysed for TVCs, Pseudomonas and Legionella at an accredited laboratory, according to regulatory requirements. Out of ~6000 tanks surveyed, only 15 were selected based on the ability to take a water sample from the normal sampling hatch (located above the ball valve) and from the far end of the tank (usually requiring disassembly of the tank lid with risk of structural damage), and permission being granted by the site manager to undertake the additional investigation and sampling. Despite seasonal differences in water temperature, we found 100% compliance at the ball valve end. In contrast, 40% of the tanks exceeded the regulatory threshold for temperature at the far end of the tank in the summer months. Consequently, 20% of the tanks surveyed failed to trigger appropriate regulatory action based on microbiological analyses of the water sample taken under the ball valve compared to the far end sample using present-day standards. These data show that typical water samples collected for routine monitoring may often underestimate the microbiological status of the water entering the building, thereby increasing the risk of exposure to water bourne pathogens with potential public health implications. We propose that water storage tanks should be redesigned to allow access to the far end of tanks for routine monitoring purposes, and that water samples used to ascertain the regulatory compliance of stored water in tanks should be taken at the point at which water is abstracted for use in the building.

Factors Mediating Environmental Biofilm Formation by Legionella pneumophila

Legionella pneumophila (L. pneumophila) is an opportunistic waterborne pathogen and the causative agent for Legionnaires' disease, which is transmitted to humans via inhalation of contaminated water droplets. The bacterium is able to colonize a variety of man-made water systems such as cooling towers, spas, and dental lines and is widely distributed in multiple niches, including several species of protozoa In addition to survival in planktonic phase, L. pneumophila is able to survive and persist within multi-species biofilms that cover surfaces within water systems. Biofilm formation by L. pneumophila is advantageous for the pathogen as it leads to persistence, spread, resistance to treatments and an increase in virulence of this bacterium. Furthermore, Legionellosis outbreaks have been associated with the presence of L. pneumophila in biofilms, even after the extensive chemical and physical treatments. In the microbial consortium-containing L. pneumophila among other organisms, several factors either positively or negatively regulate the presence and persistence of L. pneumophila in this bacterial community. Biofilm-forming L. pneumophila is of a major importance to public health and have impact on the medical and industrial sectors. Indeed, prevention and removal protocols of L. pneumophila as well as diagnosis and hospitalization of patients infected with this bacteria cost governments billions of dollars. Therefore, understanding the biological and environmental factors that contribute to persistence and physiological adaptation in biofilms can be detrimental to eradicate and prevent the transmission of L. pneumophila. In this review, we focus on various factors that contribute to persistence of L. pneumophila within the biofilm consortium, the advantages that the bacteria gain from surviving in biofilms, genes and gene regulation during biofilm formation and finally challenges related to biofilm resistance to biocides and anti-Legionella treatments.

Impact of water heater temperature setting and water use frequency on the building plumbing microbiome

Hot water plumbing is an important conduit of microbes into the indoor environment and can increase risk of opportunistic pathogens (for example, Legionella pneumophila). We examined the combined effects of water heater temperature (39, 42, 48, 51 and 58 °C), pipe orientation (upward/downward), and water use frequency (21, 3 and 1 flush per week) on the microbial composition at the tap using a pilot-scale pipe rig. 16S rRNA gene amplicon sequencing indicated that bulk water and corresponding biofilm typically had distinct taxonomic compositions (R²_Adonis=0.246, P_Adonis=0.001), yet similar predicted functions based on PICRUSt analysis (R²_Adonis=0.087, P_Adonis=0.001). Although a prior study had identified 51 °C under low water use frequency to enrich Legionella at the tap, here we reveal that 51 °C is also a threshold above which there are marked effects of the combined influences of temperature, pipe orientation, and use frequency on taxonomic and functional composition. A positive association was noted between relative abundances of Legionella and mitochondrial DNA of Vermamoeba, a genus of amoebae that can enhance virulence and facilitate replication of some pathogens. This study takes a step towards intentional control of the plumbing microbiome and highlights the importance of microbial ecology in governing pathogen proliferation.

Water heater temperature set point and water use patterns influence Legionella pneumophila and associated microorganisms at the tap

BACKGROUND

Lowering water heater temperature set points and using less drinking water are common approaches to conserving water and energy; yet, there are discrepancies in past literature regarding the effects of water heater temperature and water use patterns on the occurrence of opportunistic pathogens, in particular Legionella pneumophila. Our objective was to conduct a controlled, replicated pilot-scale investigation to address this knowledge gap using continuously recirculating water heaters to examine five water heater set points (39-58 °C) under three water use conditions. We hypothesized that L. pneumophila levels at the tap depend on the collective influence of water heater temperature, flow frequency, and the resident plumbing ecology.

RESULTS

We confirmed temperature setting to be a critical factor in suppressing L. pneumophila growth both in continuously recirculating hot water lines and at distal taps. For example, at 51 °C, planktonic L. pneumophila in recirculating lines was reduced by a factor of 28.7 compared to 39 °C and was prevented from re-colonizing biofilm. However, L. pneumophila still persisted up to 58 °C, with evidence that it was growing under the conditions of this study. Further, exposure to 51 °C water in a low-use tap appeared to optimally select for L. pneumophila (e.g., 125 times greater numbers than in high-use taps). We subsequently explored relationships among L. pneumophila and other ecologically relevant microbes, noting that elevated temperature did not have a general disinfecting effect in terms of total bacterial numbers. We documented the relationship between L. pneumophila and Legionella spp., and noted several instances of correlations with Vermamoeba vermiformis, and generally found that there is a dynamic relationship with this amoeba host over the range of temperatures and water use frequencies examined.

CONCLUSIONS

Our study provides a new window of understanding into the microbial ecology of potable hot water systems and helps to resolve past discrepancies in the literature regarding the influence of water temperature and stagnation on L. pneumophila, which is the cause of a growing number of outbreaks. This work is especially timely, given society's movement towards "green" buildings and the need to reconcile innovations in building design with public health.

Legionnaires' Disease in Hotels and Passenger Ships: A Systematic Review of Evidence, Sources, and Contributing Factors

BACKGROUND

Travel-associated Legionnaires' disease (LD) is a serious problem, and hundreds of cases are reported every year among travelers who stayed at hotels, despite the efforts of international and governmental authorities and hotel operators to prevent additional cases.

METHODS

A systematic review of travel-associated LD events (cases, clusters, outbreaks) and of environmental studies of Legionella contamination in accommodation sites was conducted. Two databases were searched (PubMed and EMBASE). Data were extracted from 50 peer-reviewed articles that provided microbiological and epidemiological evidence for linking the accommodation sites with LD. The strength of evidence was classified as strong, possible, and probable.

RESULTS

Three of the 21 hotel-associated events identified and four of nine ship-associated events occurred repeatedly on the same site. Of 197 hotel-associated cases, 158 (80.2%) were linked to hotel cooling towers and/or potable water systems. Ship-associated cases were most commonly linked to hot tubs (59/83, 71.1%). Common contributing factors included inadequate disinfection, maintenance, and monitoring; water stagnation; poor temperature control; and poor ventilation. Across all 30 events, Legionella concentrations in suspected water sources were >10,000 cfu/L, <10,000 cfu/L, and unknown in 11, 3, and 13 events, respectively. In five events, Legionella was not detected only after repeated disinfections. In environmental studies, Legionella was detected in 81.1% of ferries (23/28) and 48.9% of hotels (587/1,200), while all 12 cruise ships examined were negative.

CONCLUSIONS

This review highlights the need for LD awareness strategies targeting operators of accommodation sites. Increased standardization of LD investigation and reporting, and more rigorous follow-up of LD events, would help generate stronger, more comparable evidence on LD sources, contributing factors, and control measure effectiveness.

Necessity and effect of combating Legionella pneumophila in municipal shower systems

The objective was to obtain research-based, holistic knowledge about necessity and effect of practiced measures against L. pneumophila in municipal shower systems in Stavanger, Norway. The effects of hot water treatment and membrane-filtering were investigated and compared to no intervention at all. The studies were done under real-world conditions. Additionally, a surveillance pilot study of municipal showers in Stavanger was performed. The validity of high total plate count (TPC) as an indication of L. pneumophila was evaluated. A simplified method, named "dripping method", for detection and quantification of L. pneumophila was developed. The sensitivity of the dripping method is 5 colony-forming units of L. pneumophila/ml. The transference of L. pneumophila from shower water to aerosols was studied. Interviews and observational studies among the stakeholders were done in order to identify patterns of communication and behavior in a Legionella risk perspective. No substantial effects of the measures against L. pneumophila were demonstrated, except for a distally placed membrane filter. No significant positive correlation between TPC and L. pneumophila concentrations were found. L. pneumophila serogroup 2-14 was demonstrated in 21% of the 29 buildings tested in the surveillance pilot. Relatively few cells of L. pneumophila were transferred from shower water to aerosols. Anxiety appeared as the major driving force in the risk governance of Legionella. In conclusion, the risk of acquiring Legionnaires' disease from municipal shower systems is evaluated as low and uncertain. By eliminating ineffective approaches, targeted Legionella risk governance can be practiced. Risk management by surveillance is evaluated as appropriate.

Biofilms: the stronghold of Legionella pneumophila

Legionellosis is mostly caused by Legionella pneumophila and is defined as a severe respiratory illness with a case fatality rate ranging from 5% to 80%. L. pneumophila is ubiquitous in natural and anthropogenic water systems. L. pneumophila is transmitted by inhalation of contaminated aerosols produced by a variety of devices. While L. pneumophila replicates within environmental protozoa, colonization and persistence in its natural environment are also mediated by biofilm formation and colonization within multispecies microbial communities. There is now evidence that some legionellosis outbreaks are correlated with the presence of biofilms. Thus, preventing biofilm formation appears as one of the strategies to reduce water system contamination. However, we lack information about the chemical and biophysical conditions, as well as the molecular mechanisms that allow the production of biofilms by L. pneumophila. Here, we discuss the molecular basis of biofilm formation by L. pneumophila and the roles of other microbial species in L. pneumophila biofilm colonization. In addition, we discuss the protective roles of biofilms against current L. pneumophila sanitation strategies along with the initial data available on the regulation of L. pneumophila biofilm formation.

Role of Hot Water System Design on Factors Influential to Pathogen Regrowth: Temperature, Chlorine Residual, Hydrogen Evolution, and Sediment

Residential water heating is linked to growth of pathogens in premise plumbing, which is the primary source of waterborne disease in the United States. Temperature and disinfectant residual are critical factors controlling increased concentration of pathogens, but understanding of how each factor varies in different water heater configurations is lacking. A direct comparative study of electric water heater systems was conducted to evaluate temporal variations in temperature and water quality parameters including dissolved oxygen levels, hydrogen evolution, total and soluble metal concentrations, and disinfectant decay. Recirculation tanks had much greater volumes of water at temperature ranges with potential for increased pathogen growth when set at 49°C compared with standard tank systems without recirculation. In contrast, when set at the higher end of acceptable ranges (i.e., 60°C), this relationship was reversed and recirculation systems had less volume of water at risk for pathogen growth compared with conventional systems. Recirculation tanks also tended to have much lower levels of disinfectant residual (standard systems had 40-600% higher residual), 4-6 times as much hydrogen, and 3-20 times more sediment compared with standard tanks without recirculation. On demand tankless systems had very small volumes of water at risk and relatively high levels of disinfectant residual. Recirculation systems may have distinct advantages in controlling pathogens via thermal disinfection if set at 60°C, but these systems have lower levels of disinfectant residual and greater volumes at risk if set at lower temperatures.

Legionella pneumophila persists within biofilms formed by Klebsiella pneumoniae, Flavobacterium sp., and Pseudomonas fluorescens under dynamic flow conditions

Legionella pneumophila, the agent of Legionnaires' disease pneumonia, is transmitted to humans following the inhalation of contaminated water droplets. In aquatic systems, L. pneumophila survives much of time within multi-organismal biofilms. Therefore, we examined the ability of L. pneumophila (clinical isolate 130 b) to persist within biofilms formed by various types of aquatic bacteria, using a bioreactor with flow, steel surfaces, and low-nutrient conditions. L. pneumophila was able to intercalate into and persist within a biofilm formed by Klebsiella pneumoniae, Flavobacterium sp. or Pseudomonas fluorescens. The levels of L. pneumophila within these biofilms were as much as 4 × 10(4) CFU per cm(2) of steel coupon and lasted for at least 12 days. These data document that K. pneumoniae, Flavobacterium sp., and P. fluorescens can promote the presence of L. pneumophila in dynamic biofilms. In contrast to these results, L. pneumophila 130 b did not persist within a biofilm formed by Pseudomonas aeruginosa, confirming that some bacteria are permissive for Legionella colonization whereas others are antagonistic. In addition to colonizing certain mono-species biofilms, L. pneumophila 130 b persisted within a two-species biofilm formed by K. pneumoniae and Flavobacterium sp. Interestingly, the legionellae were also able to colonize a two-species biofilm formed by K. pneumoniae and P. aeruginosa, demonstrating that a species that is permissive for L. pneumophila can override the inhibitory effect(s) of a non-permissive species.

An in-premise model for Legionella exposure during showering events

An exposure model was constructed to predict the critical Legionella densities in an engineered water system that result in infection from inhalation of aerosols containing the pathogen while showering. The model predicted the Legionella densities in the shower air, water and in-premise plumbing biofilm that might result in a deposited dose of Legionella in the alveolar region of the lungs associated with infection for a routine showering event. Processes modeled included the detachment of biofilm-associated Legionella from the in-premise plumbing biofilm during a showering event, the partitioning of the pathogen from the shower water to the air, and the inhalation and deposition of particles in the lungs. The range of predicted critical Legionella densities in the air and water was compared to the available literature. The predictions were generally within the limited set of observations for air and water, with the exception of Legionella density within in-premise plumbing biofilms, for which there remains a lack of observations for comparison. Sensitivity analysis of the predicted results to possible changes in the uncertain input parameters identified the target deposited dose associated with infections, the pathogen air-water partitioning coefficient, and the quantity of detached biofilm from in-premise pluming surfaces as important parameters for additional data collection. In addition, the critical density of free-living protozoan hosts in the biofilm required to propagate the infectious Legionella was estimated. Together, this evidence can help to identify critical conditions that might lead to infection derived from pathogens within the biofilms of any plumbing system from which humans may be exposed to aerosols.

Legionella--every infection preventionist's dream--or is it?

Legionella is an underreported disease challenge within the hospital setting. In order to combat Legionella during times of construction and renovation, infection preventionists must become construction experts. The infection preventionist must be able to plan for potential waterborne disease outbreaks and protect the hospital staff, patients and visitors from waterborne pathogens. Legionella's history, signs and symptoms, diagnostic testing and treatment will be discussed. The hospital's convening of a multidisciplinary Legionella task force to work cohesively to develop a waterborne pathogens plan will also be discussed. This article was written from the perspective of the infection preventionist and employee health nurse at the time of the Legionella outbreak at their hospital.

Ecological behaviour of three serogroups of Legionella pneumophila within a model plumbing system

Three Legionella pneumophila strains isolated from water samples and belonging to serogroups (sgs) 1, 6 and 9 were analysed for their capacity to colonise an experimental model simulating a domestic hot water distribution system. Ecological factors that could influence the persistence of the sgs such as intracellular life within protozoan hosts and bacterial interference by the production of antagonistic compounds were also studied. Viable counts of L. pneumophila increased both in the planktonic and in the sessile phases. Sg 6 showed a marked prevalence during the whole experiment and exhibited the highest host infection efficiency. Sg 1 was significantly less represented, but showed the highest capacity to reproduce in the protozoan hosts. Sg 9 was poorly represented and less adapted to intracellular life. Among the 14 bacteria constantly isolated in the system, five (35.7%) produced antagonistic substances against Legionella, with differences according to the bacterial strain and L. pneumophila sgs.

Sessile Legionella pneumophila is able to grow on surfaces and generate structured monospecies biofilms

Currently, models for studying Legionella pneumophila biofilm formation rely on multi-species biofilms with low reproducibility or on growth in rich medium, where planktonic growth is unavoidable. The present study describes a new medium adapted to the growth of L. pneumophila monospecies biofilms in vitro. A microplate model was used to test several media. After incubation for 6 days in a specific biofilm broth not supporting planktonic growth, biofilms consisted of 5.36 ± 0.40 log (cfu cm(-2)) or 5.34 ± 0.33 log (gu cm(-2)). The adhered population remained stable for up to 3 weeks after initial inoculation. In situ confocal microscope observations revealed a typical biofilm structure, comprising cell clusters ranging up to approximately 300 μm in height. This model is adapted to growing monospecies L. pneumophila biofilms that are structurally different from biofilms formed in a rich medium. High reproducibility and the absence of other microbial species make this model useful for studying genes involved in biofilm formation.

Biofilms: the environmental playground of Legionella pneumophila

Legionella pneumophila, the aetiological agent of 90% of legionellosis cases, is a common inhabitant of natural and anthropogenic freshwater environments, where it resides in biofilms. Biofilms are defined as complex, natural assemblages of microorganisms that involve a multitude of trophic interactions. A thorough knowledge and understanding of Legionella ecology in relation to biofilm communities is of primary importance in the search for innovative and effective control strategies to prevent the occurrence of disease cases. This review provides a critical update on the state-of-the-art progress in understanding the mechanisms and factors affecting the biofilm life cycle of L. pneumophila. Particular emphasis is given to discussing the different strategies this human pathogen uses to grow and retain itself in biofilm communities. Biofilms develop not only at solid-water interfaces (substrate-associated biofilms), but also at the water-air interface (floating biofilms). Disturbance of the water surface can lead to liberation of aerosols derived from the floating biofilm into the atmosphere that allow transmission of biofilm-associated pathogens over considerable distances. Recent data concerning the occurrence and replication of L. pneumophila in floating biofilms are also elaborated and discussed.

Retention of a model pathogen in a porous media biofilm

The inadvertent or the deliberate introduction of pathogens into drinking water can lead to public health consequences. Distribution system sampling strategies are needed to provide information on the identity, source and fate of the introduced pathogens. Porous media biofilm reactors conditioned with undefined drinking water biofilms were tested for their ability to immobilize Escherichia coli 0157:H7. Biofilms were established by applying continuous flow of biologically activated carbon treated water with natural microflora and supplemented nutrient solution (0.5 mg l(-1) C) for 2 or 3 weeks. Control reactors were clean and were not colonized with biofilm. All reactors were injected with slug doses of approximately 1 x 10(9) cfu E. coli O157:H7. On the basis of the plate count enumeration of the introduced pathogen, reactors pre-colonized for 2 or 3 weeks retained significantly more cells (0.75 and 9.37% of the introduced spike dose, respectively) compared with uncolonized control reactors (0.22%). Compared with cultivation, microscopic direct counts and quantitative PCR suggested significantly higher and lower numbers of pathogens, respectively. Plate counts were thus considered as the method of choice for pathogen enumeration in this study. In addition to providing general insights into interactions between pathogens and drinking water biofilms, the study concluded that engineered biofilm systems may be considered as a device to capture pathogens from the bulk flow for monitoring purposes.