Role of stagnation and obstruction of water flow in isolation of Legionella pneumophila from hospital plumbing

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.

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.

Real-Time Continuous Surveillance of Temperature and Flow Events Presents a Novel Monitoring Approach for Hospital and Healthcare Water Distribution Systems

Within hospitals and healthcare facilities opportunistic premise plumbing pathogens (OPPPs) are a major and preventable cause of healthcare-acquired infections. This study presents a novel approach for monitoring building water quality using real-time surveillance of parameters measured at thermostatic mixing valves (TMVs) across a hospital water distribution system. Temperature was measured continuously in real-time at the outlet of 220 TMVs located across a hospital over a three-year period and analysis of this temperature data was used to identify flow events. This real-time temperature and flow information was then compared with microbial water quality. Water samples were collected randomly from faucets over the three-year period. These were tested for total heterotrophic bacteria, Legionella spp. and L. pneumophila. A statistically significant association with total heterotrophic bacteria concentrations and the number of flow events seven days prior (rs[865] = -0.188, p < 0.01) and three days prior to sampling (rs[865] = -0.151, p < 0.01) was observed, with decreased heterotrophic bacteria linked to increased flushing events. Only four samples were positive for Legionella and statistical associations could not be determined; however, the environmental conditions for these four samples were associated with higher heterotrophic counts. This study validated a simple and effective remote monitoring approach to identifying changes in water quality and flagging high risk situations in real-time. This provides a complementary surveillance strategy that overcomes the time delay associated with microbial culture results. Future research is needed to explore the use of this monitoring approach as an indicator for different opportunistic pathogens.

Role of hot water temperature and water system use on Legionella control in a tertiary hospital: An 8-year longitudinal study

Although measures to minimize Legionella colonization in sanitary hot water installations are well established, there is little evidence of their long-term effectiveness in hospital buildings. During an 8-year period, hot water in a large hospital building was sampled monthly in areas with suitable dimensioning and recirculation and in areas with dead legs and low-use taps. In the former areas, the percentage of Legionella-negative samples was 83.2% when the temperature was ≥55%, 64.9% when between 50.1 °C and 54.0 °C, and 51.6% when ≤50 °C (p for trend <0.001). In the highest temperature group, no samples with ≥10³ cfu/L were observed. In poorly designed areas, only 44.7% of samples were negative, and 28.9% presented ≥10³ cfu/L although reaching 55 °C. In these areas, multivariate analysis showed that if hot water supplies were not used daily, the risk of Legionella colonization was greater than two-fold (odds ratio: 2.84; 95% confidence interval: 1.26-6.41), and the risk of finding Legionella concentrations ≥10³ cfu/L was more than three-fold (odds ratio: 3.18; 95% confidence interval: 1.36-7.46), regardless the temperature. These findings indicate that the effectiveness of maintaining sanitary hot water at a minimum temperature of 55 °C is significantly better than that at 50 °C for the environmental control of Legionella but only in installations with suitable dimensioning and recirculation. In installations that do not meet these conditions, high temperatures alone result in insufficient control.

Shotgun Metagenomics Reveals Taxonomic and Functional Shifts in Hot Water Microbiome Due to Temperature Setting and Stagnation

Hot water premise plumbing has emerged as a critical nexus of energy, water, and public health. The composition of hot water microbiomes is of special interest given daily human exposure to resident flora, especially opportunistic pathogens (OPs), which rely on complex microbial ecological interactions for their proliferation. Here, we applied shotgun metagenomic sequencing to characterize taxonomic and functional shifts in microbiomes as a function of water heater temperature setting, stagnation in distal pipes, and associated shifts in water chemistry. A cross-section of samples from controlled, replicated, pilot-scale hot water plumbing rigs representing different temperature settings (39, 42, and 51°C), stagnation periods (8 h vs. 7 days), and time-points, were analyzed. Temperature setting exhibited an overarching impact on taxonomic and functional gene composition. Further, distinct taxa were selectively enriched by specific temperature settings (e.g., Legionella at 39°C vs. Deinococcus at 51°C), while relative abundances of genes encoding corresponding cellular functions were highly consistent with expectations based on the taxa driving these shifts. Stagnation in distal taps diminished taxonomic and functional differences induced by heating the cold influent water to hot water in recirculating line. In distal taps relative to recirculating hot water, reads annotated as being involved in metabolism and growth decreased, while annotations corresponding to stress response (e.g., virulence disease and defense, and specifically antibiotic resistance) increased. Reads corresponding to OPs were readily identified by metagenomic analysis, with L. pneumophila reads in particular correlating remarkably well with gene copy numbers measured by quantitative polymerase chain reaction. Positive correlations between L. pneumophila reads and those of known protozoan hosts were also identified. Elevated proportions of genes encoding metal resistance and hydrogen metabolism were noted, which was consistent with elevated corrosion-induced metal concentrations and hydrogen generation. This study provided new insights into real-world factors influencing taxonomic and functional compositions of hot water microbiomes. Here metagenomics is demonstrated as an effective tool for screening for potential presence, and even quantities, of pathogens, while also providing diagnostic capabilities for assessing functional responses of microbiomes to various operational conditions. These findings can aid in informing future monitoring and intentional control of hot water microbiomes.

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.

Ten Questions Concerning the Aerosolization and Transmission of Legionella in the Built Environment

Legionella is a genus of pathogenic Gram-negative bacteria responsible for a serious disease known as legionellosis, which is transmitted via inhalation of this pathogen in aerosol form. There are two forms of legionellosis: Legionnaires' disease, which causes pneumonia-like symptoms, and Pontiac fever, which causes influenza-like symptoms. Legionella can be aerosolized from various water sources in the built environment including showers, faucets, hot tubs/swimming pools, cooling towers, and fountains. Incidence of the disease is higher in the summertime, possibly because of increased use of cooling towers for air conditioning systems and differences in water chemistry when outdoor temperatures are higher. Although there have been decades of research related to Legionella transmission, many knowledge gaps remain. While conventional wisdom suggests that showering is an important source of exposure in buildings, existing measurements do not provide strong support for this idea. There has been limited research on the potential for Legionella transmission through heating, ventilation, and air conditioning (HVAC) systems. Epidemiological data suggest a large proportion of legionellosis cases go unreported, as most people who are infected do not seek medical attention. Additionally, controlled laboratory studies examining water-to-air transfer and source tracking are still needed. Herein, we discuss ten questions that spotlight current knowledge about Legionella transmission in the built environment, engineering controls that might prevent future disease outbreaks, and future research that is needed to advance understanding of transmission and control of legionellosis.

Biofilm Composition and Threshold Concentration for Growth of Legionella pneumophila on Surfaces Exposed to Flowing Warm Tap Water without Disinfectant

Legionella pneumophila in potable water installations poses a potential health risk, but quantitative information about its replication in biofilms in relation to water quality is scarce. Therefore, biofilm formation on the surfaces of glass and chlorinated polyvinyl chloride (CPVC) in contact with tap water at 34 to 39°C was investigated under controlled hydraulic conditions in a model system inoculated with biofilm-grown L. pneumophila The biofilm on glass (average steady-state concentration, 23 ± 9 pg ATP cm-2) exposed to treated aerobic groundwater (0.3 mg C liter-1; 1 μg assimilable organic carbon [AOC] liter-1) did not support growth of the organism, which also disappeared from the biofilm on CPVC (49 ± 9 pg ATP cm-2) after initial growth. L. pneumophila attained a level of 4.3 log CFU cm-2 in the biofilms on glass (1,055 ± 225 pg ATP cm-2) and CPVC (2,755 ± 460 pg ATP cm-2) exposed to treated anaerobic groundwater (7.9 mg C liter-1; 10 μg AOC liter-1). An elevated biofilm concentration and growth of L. pneumophila were also observed with tap water from the laboratory. The Betaproteobacteria Piscinibacter and Methyloversatilis and amoeba-resisting Alphaproteobacteria predominated in the clones and isolates retrieved from the biofilms. In the biofilms, the Legionella colony count correlated significantly with the total cell count (TCC), heterotrophic plate count, ATP concentration, and presence of Vermamoeba vermiformis This amoeba was rarely detected at biofilm concentrations of <100 pg ATP cm-2 A threshold concentration of approximately 50 pg ATP cm-2 (TCC = 1 × 106 to 2 × 106 cells cm-2) was derived for growth of L. pneumophila in biofilms.IMPORTANCELegionella pneumophila is the etiologic agent in more than 10,000 cases of Legionnaires' disease that are reported annually worldwide and in most of the drinking water-associated disease outbreaks reported in the United States. The organism proliferates in biofilms on surfaces exposed to warm water in engineered freshwater installations. An investigation with a test system supplied with different types of warm drinking water without disinfectant under controlled hydraulic conditions showed that treated aerobic groundwater (0.3 mg liter-1 of organic carbon) induced a low biofilm concentration that supported no or very limited growth of L. pneumophila Elevated biofilm concentrations and L. pneumophila colony counts were observed on surfaces exposed to two types of extensively treated groundwater, containing 1.8 and 7.9 mg C liter-1 and complying with the microbial water quality criteria during distribution. Control measures in warm tap water installations are therefore essential for preventing growth of L. pneumophila.

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.

Opportunistic Premise Plumbing Pathogens: Increasingly Important Pathogens in Drinking Water

Opportunistic premise plumbing pathogens are responsible for a significant number of infections whose origin has been traced to drinking water. These opportunistic pathogens represent an emerging water borne disease problem with a major economic cost of at least $1 billion annually. The common features of this group of waterborne pathogens include: disinfectant-resistance, pipe surface adherence and biofilm formation, growth in amoebae, growth on low organic concentrations, and growth at low oxygen levels. Their emergence is due to the fact that conditions resulting from drinking water treatment select for them. As such, there is a need for novel approaches to reduce exposure to these pathogens. In addition to much-needed research, controls to reduce numbers and human exposure can be instituted independently by utilities and homeowners and hospital- and building-operators.

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.

Impact of drinking water conditions and copper materials on downstream biofilm microbial communities and Legionella pneumophila colonization

AIMS

This study examined the impact of pipe materials and introduced Legionella pneumophila on downstream Leg. pneumophila colonization and microbial community structures under conditions of low flow and low chlorine residual.

METHODS AND RESULTS

CDC biofilm(™) reactors containing either unplasticized polyvinylchloride (uPVC) or copper (Cu) coupons were used to develop mature biofilms on Norprene(™) tubing effluent lines to simulate possible in-premise biofilm conditions. The microbial communities were characterized through 16S and 18S rRNA gene clone libraries and Leg. pneumophila colonization was determined via specific qPCR assays. The Cu significantly decreased downstream microbial diversity, approximately halved bacterial and eukaryotic abundance, with some groups only detected in uPVC-reactor tubing biofilms. However, some probable amoeba-resisting bacteria (ARB) like Mycobacterium spp. and Rhodobacteraceae were significantly more abundant in the Cu than uPVC-reactor tubing biofilms. In particular, Leg. pneumophila only persisted (postinoculation) within the Cu-reactor tubing biofilms, and the controlled low chlorine residue and water flow conditions led to a general high abundance of possible free-living protozoa in all tubing biofilms. The higher relative abundance of ARB-like sequences from Cu-coupons vs uPVC may have been promoted by amoebal selection and subsequent ARB protection from Cu inhibitory effects.

CONCLUSIONS

Copper pipe and low flow conditions had significant impact on downstream biofilm microbial structures (on plastic pipe) and the ability for Leg. pneumophila colonization post an introduction event.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report that compares the effects of copper and uPVC materials on downstream biofilm communities grown on a third (Norprene(™)) surface material. The downstream biofilms contained a high abundance of free-living amoebae and ARB, which may have been driven by a lack of residual disinfectant and periodic stagnant conditions. Given the prevalence of Cu-piping in buildings, there may be increased risk from drinking water exposures to ARB following growth on pipe/fixture biofilms within premise drinking water systems.

The Legionella pneumophila collagen-like protein mediates sedimentation, autoaggregation, and pathogen-phagocyte interactions

Although only partially understood, multicellular behavior is relatively common in bacterial pathogens. Bacterial aggregates can resist various host defenses and colonize their environment more efficiently than planktonic cells. For the waterborne pathogen Legionella pneumophila, little is known about the roles of autoaggregation or the parameters which allow cell-cell interactions to occur. Here, we determined the endogenous and exogenous factors sufficient to allow autoaggregation to take place in L. pneumophila. We show that isolates from Legionella species which do not produce the Legionella collagen-like protein (Lcl) are deficient in autoaggregation. Targeted deletion of the Lcl-encoding gene (lpg2644) and the addition of Lcl ligands impair the autoaggregation of L. pneumophila. In addition, Lcl-induced autoaggregation requires divalent cations. Escherichia coli producing surface-exposed Lcl is able to autoaggregate and shows increased biofilm production. We also demonstrate that L. pneumophila infection of Acanthamoeba castellanii and Hartmanella vermiformis is potentiated under conditions which promote Lcl dependent autoaggregation. Overall, this study shows that L. pneumophila is capable of autoaggregating in a process that is mediated by Lcl in a divalent-cation-dependent manner. It also reveals that Lcl potentiates the ability of L. pneumophila to come in contact, attach, and infect amoebae.

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.

Environmental factors associated with nosocomial legionellosis after anti-tumor necrosis factor therapy: case study

In response to 2 reported cases of nosocomial legionellosis after anti-tumor necrosis factor (TNF) treatment, the environmental controls and testing facilities in a 221-bed acute care hospital were investigated. This investigation led to the implementation of a series of specific preventive measures adapted from protocols used to protect immunosuppressed patients. These 2 cases of legionellosis might be related to 2 concurrent events: treatment of hospitalized patients with anti-TNF drugs and secondary environmental changes related to major construction work. Patients undergoing anti-TNF treatment may be at increased risk for developing opportunistic infections during construction work, renovations, or water supply perturbations and require specific preventive measures.

Potentially pathogenic amoeba-associated microorganisms in cooling towers and their control

Cooling towers provide a favorable environment for the proliferation of microorganisms. Cooling towers generate a biofilm and often aerosolize contaminated water, thereby increasing the risk of microorganism dissemination by human inhalation. This pathogen dissemination was first revealed by the epidemics of Legionnaires’ disease that were directly related to the presence of cooling towers, and since then, the ecology of Legionella pneumophila has been well studied. Each country has specific standards regarding the acceptable amount of microorganisms in cooling tower systems. However, those standards typically only concern L. pneumophila, even though many other microorganisms can also be isolated from cooling towers, including protozoa, bacteria and viruses. Microbiological control of the cooling tower system can be principally achieved by chemical treatments and also by improving the system’s construction. Several new treatments are being studied to improve the efficiency of disinfection. However, as most of these treatments continue to focus solely on L. pneumophila, reports of other types of pathogens continue to increase. Therefore, how their dissemination affects the human populous health should be addressed now.

Do contaminated dental unit waterlines pose a risk of infection?

OBJECTIVES

To review the evidence that the dental unit waterlines are a source of occupational and healthcare acquired infection in the dental surgery.

DATA

Transmission of infection from contaminated dental unit waterlines (DUWL) is by aerosol droplet inhalation or rarely imbibing or wound contamination in susceptible individuals. Most of the organisms isolated from DUWL are of low pathogenicity. However, data from a small number of studies described infection or colonisation in susceptible hosts with Legionella spp., Pseudomonas spp. and environmental mycobacteria isolated from DUWL. The reported prevalence of legionellae in DUWL varies widely from 0 to 68%. The risk from prolonged occupational exposure to legionellae has been evaluated. Earlier studies measuring surrogate evidence of exposure to legionellae in dental personnel found a significant increase in legionella antibody levels but in recent multicentre studies undertaken in primary dental care legionellae were isolated at very low rate and the corresponding serological titres were not above background levels. Whereas, a case of fatal Legionellosis in a dental surgeon concluded that the DUWL was the likely source of the infection. The dominant species isolated from dental unit waterlines (DUWL) are Gram-negative bacteria, which are a potent source of cell wall endotoxin. A consequence of indoor endotoxin exposure is the triggering or exacerbation of asthma. Data from a single large practice-based cross-sectional study reported a temporal association between occupational exposure to contaminated DUWL with aerobic counts of >200cfu/mL at 37 degrees C and development of asthma in the sub-group of dentists in whom asthma arose following the commencement of dental training.

SOURCES

Medline 1966 to February 2007 was used to identify studies for this paper.

STUDY SELECTION

Design criteria included randomised control trials, cohort, and observational studies in English.

CONCLUSIONS

Although the number of published cases of infection or respiratory symptoms resulting from exposure to water from contaminated DUWL is limited, there is a medico-legal requirement to comply with potable water standards and to conform to public perceptions on water safety.

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

AIMS

Stagnation is widely believed to predispose water systems to colonization by Legionella. A model plumbing system was constructed to determine the effect of flow regimes on the presence of Legionella within microbial biofilms.

METHODS AND RESULTS

The plumbing model contained three parallel pipes where turbulent, laminar and stagnant flow regimes were established. Four sets of experiments were carried out with Reynolds number from 10,000 to 40,000 and from 355 to 2,000 in turbulent and laminar pipes, respectively. Legionella counts recovered from biofilm and planktonic water samples of the three sampling pipes were compared with to determine the effect of flow regime on the presence of Legionella. Significantly higher colony counts of Legionella were recovered from the biofilm of the pipe with turbulent flow compared with the pipe with laminar flow. The lowest counts were in the pipe with stagnant flow.

CONCLUSIONS

We were unable to demonstrate that stagnant conditions promoted Legionella colonization.

SIGNIFICANCE AND IMPACT OF THE STUDY

Plumbing modifications to remove areas of stagnation including deadlegs are widely recommended, but these modifications are tedious and expensive to perform. Controlled studies in large buildings are needed to validate this unproved hypothesis.

Introduction of a boost of Legionella pneumophila into a stagnant-water model by heat treatment

An environmentally representative stagnant-water model was developed to monitor the growth dynamics of Legionella pneumophila. This model was evaluated for three distinct water treatments: untreated tap water, heat-treated tap water, and heat-treated tap water supplemented with Pseudomonas putida, a known biofilm-forming bacterium. Bringing heat-treated tap water after subsequent cooling into contact with a densely formed untreated biofilm was found to promote the number of L. pneumophila by 4 log units within the biofilm, while the use of untreated water only sustained the L. pneumophila levels. Subsequent colonization of the water phase by L. pneumophila was noticed in the heat-treated stagnant-water models, with concentrations as high as 1 x 10(10) mip gene copies L(-1) stagnant water. Denaturing gradient gel electrophoresis in combination with clustering analysis of the prokaryotic community in the water phase and in the biofilm phase suggests that the different water treatments induced different communities. Moreover, boosts of L. pneumophila arising from heat treatment of water were accompanied by shifts to a more diverse eukaryotic community. Stimulated growth of L. pneumophila after heating of the water may explain the rapid recolonization of L. pneumophila in water systems. These results highlight the need for additional or alternative measures to heat treatment of water in order to prevent or abate potential outbreaks of L. pneumophila.

Influence of temperature on growth of Legionella pneumophila biofilm determined by precise temperature gradient incubator

Bacterial growth is influenced by several different culture conditions. Temperature is one of an essential component which regulates bacterial growth and their morphology. The influence of temperature on the length of bacteria was investigated in broth and on agar in a temperature range from 30.0 degrees C to 47.0 degrees C in 0.5 degrees C steps using a newly developed temperature gradient incubator. The incubator is able to reach a set temperature within 2 h and maintain temperature as accurate as +/-0.1 degrees C of the set temperature. Three Legionella pneumophila serotype 1 strains were incubated for 48 h in BCYE-alpha agar at various temperatures ranging from 30.0 degrees C to 48.0 degrees C and length of bacteria grown at each temperature was microscopically measured. Ability of bacteria to multiply at a given temperature was also determined. L. pneumophila serotype 1 strains ATCC 33152, a clinical isolate Okinawa 02-001 were going to elongate to longer than 100 mum when cultured higher than at 39.5 degrees C and at 41.5 degrees C, respectively. Each strain was unable to multiply when cultured higher than at 44.2 degrees C (ATCC 33152) or at 44.0 degrees C (Okinawa 02-001). Those data would provide insights for establishing regulations in terms of maintaining hot water temperature in a facility where a circulating hot water supply-system is available and contamination with Legionella spp. is likely to happen.

Influence of amoebae and physical and chemical characteristics of water on presence and proliferation of Legionella species in hospital water systems

The reservoir for hospital-acquired Legionnaires' disease has been shown to be the potable water distribution system. The objectives of the present study were as follows: (1) to examine the possible relationship between physical-chemical characteristics of water such as temperature, pH, hardness, conductivity, and residual chlorine and the presence of amoebae as growth-promoting factors for Legionella species and (2) to determine eradication measures for water distribution systems to seek ways of reducing the risk of legionellosis. Ten hospitals in southwest France took part in this study. Water samples were collected from 106 hot water faucets, showers, hot water tanks, and cooling towers. Two analyses were performed to analyze the association between water characteristics and (1) the presence of Legionella species and (2) the proliferation of Legionella species. Of the 106 water samples examined, 67 (63.2%) were positive for Legionella species. Amoebae were detected in 73 of 106 (68.9%) samples and in 56 of 67 (86.6%) Legionella species-positive samples (P < 10(-6)). In these positive samples, conductivity was lower than 500 microOmega(-1).cm(-1) in 58.2% (P = .026), temperature was below 50 degrees C in 80.6% (P = .004), and hardness was significantly higher (P = 002) than in Legionella species-negative samples. Neither Legionella species nor amoebae were isolated from any sampling point in which the water temperature was above 58.8 degrees C. Multivariate analysis shows that high hardness and presence of amoebae were strongly correlated statistically with the presence of Legionella when showers, tanks, pH, and temperature promoted their proliferation. This study shows the importance of water quality evaluation in assessing environmental risk factors and in selecting the most appropriate prevention and control measures in hospital water systems.

Biofilm formation and multiplication of Legionella in a model warm water system with pipes of copper, stainless steel and cross-linked polyethylene

Legionella pneumophila was grown in a model warm water system with pipes of copper (Cu), stainless steel (SS) and cross-linked polyethylene (PEX) during recirculation of tap water at 25--35 degrees C. Subsequently, domestic use of warm (37 degrees C) water was simulated using tap water with a low AOC concentration (<10 microg C/L). Two times each week the temperature of the water in the electric heaters (not in the pipes) was elevated to 70 degrees C for 30 min. ATP concentrations in the water sampled from the pipes over a 2-year period were significantly different for the pipe materials, with median values of 2.1 ng/l (Cu), 2.5 ng/l (SS) and 4.5 ng/l (PEX), respectively. Median values of the biofilm concentration were similar on Cu and SS (about 630 pg ATP/cm(2)) and 1870 pg ATP/cm(2) on PEX. Legionella multiplied in these biofilms and median values of Legionella concentrations in water were 1500 CFU/l (Cu) and about 4300 CFU/l for SS and PEX. Legionella to ATP ratios in water had median values of about 0.8 CFU/pg. Hot water flushing (70 degrees C) of the pipes on day 552, followed by 2 weeks of recirculation at 37 degrees C, caused strongly increased concentrations of ATP (up to 300 ng/l) and Legionella (>10(7)CFU/l), with about 100 CFU/pg ATP. Concentrations declined to original levels within 1 week of domestic water use, etc. Legionella concentrations in water and biofilms were at the same levels for all materials after 2 years. Hence, copper temporarily limited the growth of Legionella under the applied conditions and a rapid biomass development strongly increased the Legionella to ATP ratio.

Prevalence of legionella waterline contamination and Legionella pneumophila antibodies in general dental practitioners in London and rural Northern Ireland

OBJECTIVES

To determine the prevalence of legionellae in dental unit waterlines (DUWL) in general dental practices in London and rural Northern Ireland and whether the organism occurs at a high enough frequency and magnitude in DUWL to represent a threat to dentists' health.

MATERIALS AND METHOD

Two hundred and sixty six (166 London, 100 Northern Ireland) randomly selected dental surgeries were recruited. Standardised 250 ml water samples were taken from the DUWL and 1 litre samples from the surgery cold water tap to measure the prevalence of legionellae. The dentists provided a blood sample for legionella serology.

RESULTS

The prevalence of legionellae was very low (0.37%). Legionellae were not isolated from DUWL or surgery basin taps in Northern Ireland. Legionella spp were isolated from the DUWL and surgery basin of one practice in London and from the cold water supply of a further three practices. The prevalence of Legionella pneumophila antibodies was less than that seen in a comparable group of London blood donors.

CONCLUSION

The risk to dentists' health from potential exposure to legionellae in this cohort of dentists was very low and this was confirmed by the very low seroprevalence and antibody titres to legionella detected in the dentists.

Effect of monochloramine disinfection of municipal drinking water on risk of nosocomial Legionnaires' disease

BACKGROUND

Many Legionella infections are acquired through inhalation or aspiration of drinking water. Although about 25% of municipalities in the USA use monochloramine for disinfection of drinking water, the effect of monochloramine on the occurrence of Legionnaires' disease has never been studied.

METHODS

We used a case-control study to compare disinfection methods for drinking water supplied to 32 hospitals that had had outbreaks of Legionnaires' disease with the disinfection method for water supplied to 48 control-hospitals, with control for selected hospital characteristics and water treatment factors.

FINDINGS

Hospitals supplied with drinking water containing free chlorine as a residual disinfectant were more likely to have a reported outbreak of Legionnaires' disease than those that used water with monochloramine as a residual disinfectant (odds ratio 10.2 [95% CI 1.4-460]). This result suggests that 90% of outbreaks associated with drinking water might not have occurred if monochloramine had been used instead of free chlorine for residual disinfection (attributable proportion 0.90 [0.29-1.00]).

INTERPRETATION

The protective effect of monochloramine against legionella should be confirmed by other studies. Chloramination of drinking water may be a cost-effective method for control of Legionnaires' disease at the municipal level or in individual hospitals, and widespread implementation could prevent thousands of cases.

Growth, respiration and survival of Legionella pneumophila at high temperatures

The optimum temperature for multiplication of legionella strains in culture media is around 37 degrees C. The effect of high temperatures on the growth of strains isolated from various environments is poorly known. We studied the growth (cell multiplication, respiration) of clinical and environmental Legionella pneumophila strains in liquid media at intervals of 0.5 degrees C in the temperature range from 41.6 to 51.6 degrees C using a temperature gradient incubator. Cell multiplication and CO2 production decreased markedly with all the strains at temperatures above 44-45 degrees C. CO2 continued to be produced up to 51.6 degrees C even if cell multiplication generally stopped at around 48.4-50.0 degrees C. Thus, legionella retained its metabolic activity beyond the maximum temperature for cell multiplication. The CO2 production per bacterial cell (metabolic quotient, qCO2) increased with increasing temperature up to 45 degrees C, whereafter it decreased, the turning point being almost at the same at which the rate of cell multiplication decreased. The difference in qCO2 between the strains] may reflect their different physiological capacities for tolerating high temperatures.

Detecting Legionella pneumophila in water systems: a comparison of various dental units

The authors sampled 194 dental units over a 44-month period to detect the presence of Legionella pneumophila. They found L. pneumophila, usually in very low numbers, in 25 percent of the units over this time. However, higher counts were collected from 4 percent of the units, primarily from one model. The authors document colony counts collected from nine different models and those collected from air/water syringes vs. high-speed outlets, and they describe the effectiveness of disinfection.

Risk factors for contamination of domestic hot water systems by legionellae

To assess risk factors associated with the contamination of the domestic environment by legionellae, 211 houses in the Quebec City area were randomly selected and water samples were collected from the hot water tank, the shower heads, and the most frequently used faucet. After centrifugation, concentrated samples were seeded in triplicate on BCYE and GPV media. Data on the characteristics of the hot water system and plumbing in the house and on the personal habits of the occupants were collected for each house. Among these 211 houses, hot water was provided by either an oil or gas heater in 33 and by an electric heater in 178. Legionellae were isolated from none of the samples from houses with oil or gas heaters and from 39% (69 of 178) of those with electric water heaters (P less than 0.0001). This association remained highly significant after control for water temperature and other variables in a stratified analysis. In the 178 houses with an electric heater, 12% of the faucets, 15% of the shower heads, and 37% of the water heaters were contaminated. Legionella pneumophila serogroups 2 and 4 were the most frequently isolated strains. Logistic regression showed that factors associated with electric water heater contamination were (i) location of the house in older districts of the city (P less than 0.0001), (ii) old age of the water heater (P = 0.003), and (iii) low water temperature (P = 0.05). Contamination of the water heater was the only factor significantly associated with the contamination of peripheral outlets (P less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Sequential culturing method improves recovery of Legionella spp. from contaminated environmental samples

Investigations were undertaken to improve detection and isolation of Legionella spp. from samples containing a large number of non-legionellae isolates. The direct fluorescent antibody staining technique was used in conjunction with a sequential culturing method which was developed to improve the recovery rate of Legionella spp. from such samples. The technique for enrichment and isolation of Legionella spp. from environmental samples includes storage at 4 degrees C and repeated culture on freshly prepared media. Heat and acid treatments were included when deemed appropriate. A DNA probe was used for confirmation of Legionella. Treatment of the water samples, as described, and co-cultivation with amoebae naturally present in the samples are concluded to be responsible for increased success in recovery of Legionella isolates.

The effect of a self-regulating trace heating element on Legionella within a shower

A self-regulating trace heating element was assessed for its ability to maintain a temperature of 50 degrees C in the mixer valve and dead-legs of a shower, and for its effect on legionellas colonizing the shower. The trace heating element maintained a temperature of 50 degrees C +/- 1.5 degrees C in dead-legs when the circulating hot water supply remained above 45 degrees C. Legionellas appeared in a trace heated dead-leg when the temperature of the dead-leg reached 45 degrees C and the hot water supply dropped below this temperature. Legionellas were eradicated or significantly reduced in sections of the shower where a temperature of 50 degrees C was consistently achieved. The mixer valve which was trace heated but not insulated remained colonized with Legionellas. Legionellas were found in shower water throughout the study.

The efficacy of chlorination and filtration in the control and eradication of Legionella from dental chair water systems

The apparent failure of hyperchlorination and continuous dosing with chlorine to eliminate legionellae from a dental teaching hospital water supply prompted a prospective study to evaluate charcoal filters as a means of decontamination. Legionella pneumophila serogroup 10 and L. bozemanii serogroup 2 were isolated from dental units yielding 10(1)-10(3) colony forming units (cfu) ml-1 with total bacterial counts in the range 10(2)-greater than 10(4) cfu ml-1. After chair-side installation of charcoal filters bacterial contamination of the dental unit water was prevented and legionellae were initially not detected, but after 7 days the total count returned to pre-filtration levels of greater than 10(4) cfu ml-1; L. pneumophila serogroup 10 was eliminated but L. bozemanii serogroup 2 persisted. These results suggest that neither chlorination nor charcoal filtration deal adequately with the potential hazard of Legionella spp. in dental water.

Inactivation of Legionella pneumophila by monochloramine

Chloramination which is used in South Australia to control the growth of Naegleria fowleri, was investigated to see if it would also control that of Legionella pneumophila. It was found that L. pneumophila was more sensitive than Escherichia coli to monochloramine. At 1.0 mg/l, a 99% kill of L. pneumophila was achieved in 15 min compared with 37 min for a 99% kill of E. coli. Combined with the stability of monochloramine, even at elevated temperatures, the results suggest that this disinfectant would control the growth of L. pneumophila in water distribution systems.

Microbial contamination of hospital showers and shower water: the effect of an automatic drain valve

The installation of a valve to drain away water on the completion of showering was found to have no significant effect on the numbers of microorganisms in shower water and on the internal surfaces of shower fittings.

Legionnaires disease: historical perspective

In the summer of 1976, a mysterious epidemic of fatal respiratory disease in Philadelphia launched an intensive investigation that resulted in the definition of a new family of pathogenic bacteria, the Legionellaceae. In retrospect, members of the family had been isolated from clinical specimens as early as 1943. Unsolved epidemics of acute respiratory disease dating to the 1950s were subsequently attributed to the newly described pathogens. In the intervening years, the Legionellaceae have been firmly established as important causes of sporadic and epidemic respiratory disease. The sources of the infecting bacteria are environmental, and geographic variation in the frequency of infection has been documented. Airborne dissemination of bacteria from cooling towers and evaporative condensers has been responsible for some epidemics, but potable water systems are perhaps more important sources. The mode of transmission from drinking water is unclear. The Legionellaceae are gram-negative, facultative, intracellular pathogens. The resident alveolar macrophage, usually an effective antibacterial defense, is the primary site of growth. Cell-mediated immunity appears to be the most important immunological defense; the role of humoral immunity is less clear. Erythromycin remains the antibiotic of choice for therapy of infected patients, but identification and eradication of environmental sources are also essential for the control of infection.

Protocol for sampling environmental sites for legionellae

A protocol for sampling environmental sites was developed and used to identify possible sources of Legionella species in support of epidemiologic investigations at two hospitals. In hospital A, legionellae were isolated from 43 of 106 (40%) different sites. Three separate Legionella pneumophila serotypes and a previously unrecognized species were present in different combinations in the positive samples. Two of five cooling towers contained the same L. pneumophila serogroup 1 monoclonal type (1,2,4,5) as was isolated from patients. The same monoclonal type was also isolated from make-up water for the two cooling towers, a hot water tank, water separators in four main air compressor systems for respiratory therapy, and cold and hot water faucets. In hospital B, 13 of 37 (38%) sample sites contained legionellae, all of which were L. pneumophila serogroup 1. The monoclonal type matching isolates from patients (1,2,4,5) was found at the highest concentration in a hot water tank, but it was also present at four other sample sites. Since legionellae not related to disease may be found in many of the sites sampled, an epidemiologic association with the probable source should be established before intervention methods, such as disinfection, are undertaken.

Survival and multiplication of Legionella pneumophila in municipal drinking water systems

Studies were conducted to investigate the survival and multiplication of Legionella spp. in public drinking water supplies. An attempt was made, over a period of several years, to isolate legionellae from a municipal system. Sampling sites included the river water supply, treatment plant, finished water reservoir system, mains, and distribution taps. Despite the use of several isolation techniques, Legionella spp. could not be detected in any of the samples other than those collected from the river. It was hypothesized that this was due to the maintenance of a chlorine residual throughout the system. To investigate the potential for Legionella growth, additional water samples, collected from throughout the system, were dechlorinated, pasteurized, and inoculated with Legionella pneumophila. Subsequent growth indicated that many of these samples, especially those collected from areas affected by an accumulation of algal materials, exhibited a much greater ability to support Legionella multiplication than did river water prior to treatment. Chemical analyses were also performed on these samples. Correlation of chemical data and experimental growth results indicated that the chemical environment significantly affects the ability of the water to support multiplication, with turbidity, organic carbon, and certain metals being of particular importance. These studies indicate that the potential exists for Legionella growth within municipal systems and support the hypothesis that public water supplies may contaminate the plumbing systems of hospitals and other large buildings. The results also suggest that useful methods to control this contamination include adequate treatment plant filtration, maintenance of a chlorine residual throughout the treatment and distribution network, and effective covering of open reservoirs.