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Quarton S, Livesey A, Pittaway H, Adiga A, Grudzinska F, McNally A, Dosanjh D, Sapey E, Parekh D. The clinical challenge of diagnosing Non-Ventilator Hospital Acquired Pneumonia and identifying causative pathogens - a narrative review. J Hosp Infect 2024:S0195-6701(24)00115-4. [PMID: 38621512 DOI: 10.1016/j.jhin.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Non-ventilated hospital acquired pneumonia (NV-HAP) is associated with significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurately identifying cases remains challenging. At present there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of both aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimise the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.
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Affiliation(s)
- Samuel Quarton
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.
| | - Alana Livesey
- National Institute for Health Research (NIHR) / Wellcome Trust Clinical Research Facility, University Hospitals Birmingham, Birmingham, UK
| | - Harriet Pittaway
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - Aditya Adiga
- Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - Frances Grudzinska
- Institute of Inflammation & Ageing, University of Birmingham, Birmingham, UK
| | - Alan McNally
- Institute of Microbiology & Infection, University of Birmingham, Birmingham, UK
| | - Davinder Dosanjh
- National Institute for Health Research (NIHR) Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK
| | - Elizabeth Sapey
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; National Institute for Health Research (NIHR) Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK; National Institute for Health Research (NIHR) Midlands Applied Research Collaborative, University of Birmingham, Birmingham, UK
| | - Dhruv Parekh
- Institute of Inflammation & Ageing, University of Birmingham, Birmingham, UK
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Ito A, Ishida T, Tachibana H, Nakanishi Y, Kawataki M, Yamazaki A, Washio Y. Identification rate of Legionella species in non-purulent sputum culture is comparable to that in purulent sputum culture in Legionella pneumonia. J Clin Microbiol 2024; 62:e0166523. [PMID: 38501659 PMCID: PMC11005338 DOI: 10.1128/jcm.01665-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/28/2024] [Indexed: 03/20/2024] Open
Abstract
Many Legionella pneumonia patients do not produce sputum, and it is unknown whether purulent sputum is required for the identification of Legionella species. This study aimed to evaluate the identification rate of Legionella species based on sputum quality and the factors predictive of Legionella infection. This study included Legionella pneumonia patients at Kurashiki Central Hospital from November 2000 to December 2022. Sputum quality, based on gram staining, was classified as the following: Geckler 1/2, 3/6 and 4/5. Geckler 4/5 was defined as purulent sputum. The sputa of 104 of 124 Legionella pneumonia patients were cultured. Fifty-four patients (51.9%) were identified with Legionella species, most of which were Legionella pneumophila serogroup 1 (81.5%). The identification rates of Legionella species according to sputum quality were 57.1% (16/28) in Geckler 1/2 sputum, 50.0% (34/68) in Geckler 3/6 sputum, and 50.0% (4/8) in Geckler 4/5 sputum, which were not significantly different (P = 0.86). On multivariate analysis, pre-culture treatment with anti-Legionella antimicrobials (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.06-0.91), Pneumonia Severity Index class ≥IV (OR 2.57 [95% CI 1.02-6.71]), and intensive care unit admission (OR 3.08, 95% CI 1.06-10.09) correlated with the ability to identify Legionella species, but sputum quality did not (OR 0.88, 95% CI 0.17-4.41). The identification rate of Legionella species in non-purulent sputum was similar to that in purulent sputum. For the diagnosis of Legionella pneumonia, sputum should be collected before administering anti-Legionella antibiotics and cultured regardless of sputum quality.
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Affiliation(s)
- Akihiro Ito
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiromasa Tachibana
- Department of Respiratory Medicine, National Hospital Organization, Minami Kyoto Hospital, Kyoto, Japan
| | - Yosuke Nakanishi
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masanori Kawataki
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Kurashiki, Japan
| | - Akio Yamazaki
- Department of Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yasuyoshi Washio
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Seto J, Takahashi J, Sampei M, Ikeda T, Mizuta K. A Case of Legionella pneumophila Serogroup 13 Pneumonia Based on the Detection of Serogroup-Specific Genes in Culture-Negative Sputum. Jpn J Infect Dis 2024; 77:118-120. [PMID: 38030269 DOI: 10.7883/yoken.jjid.2023.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Legionella pneumophila serogroup (SG) 1, the main cause of Legionnaires' disease, can be diagnosed using urinary antigen testing kits. However, lower respiratory tract specimen cultures are required to identify L. pneumophila SG 2-15. We attempted to detect L. pneumophila SG-specific genes in a culture-negative sputum specimen from a patient with pneumonia who was suspected to have Legionnaires' disease. Two multiplex PCR methods targeting L. pneumophila were modified and amplicons considered to be SG13 specific were detected. Direct sequencing revealed that the amplicons were identical to the nucleotide sequence of L. pneumophila SG13. Based on the presentation and clinical course (fever, muscle pain, disturbance of consciousness, high C-reactive protein titer, rhabdomyolysis, hypophosphatemia, and symptomatic improvement with levofloxacin treatment), in combination with the detection of L. pneumophila SG-specific genes, we suspected L. pneumophila SG13 pneumonia. L. pneumophila non-SG1 pneumonia is thought to be underestimated because of its difficult laboratory diagnosis. The modified multiplex PCR system for lower respiratory tract specimens revealed in this study is likely to improve the diagnosis of Legionnaires' disease caused by L. pneumophila SG13 and other SGs.
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Affiliation(s)
- Junji Seto
- Department of Microbiology, Yamagata Prefectural Institute of Public Health, Japan
| | - Jun Takahashi
- Department of General Medicine, Okitama Public General Hospital, Japan
| | - Mika Sampei
- Department of Microbiology, Yamagata Prefectural Institute of Public Health, Japan
| | - Tatsuya Ikeda
- Department of Microbiology, Yamagata Prefectural Institute of Public Health, Japan
| | - Katsumi Mizuta
- Department of Microbiology, Yamagata Prefectural Institute of Public Health, Japan
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Motokura Y, Ito A, Ishida T. Severe Legionella Pneumonia in Which Serial Testing by Ribotest ® Legionella was Useful for the Diagnosis. Intern Med 2023; 62:2989-2993. [PMID: 36889700 PMCID: PMC10641205 DOI: 10.2169/internalmedicine.0766-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/19/2022] [Indexed: 03/09/2023] Open
Abstract
A 79-year-old man presented with chest pain, and urinary antigen tests for Legionella pneumophila (ImmunoCatch® Legionella and Ribotest® Legionella) were negative on admission. The next day, rapid respiratory failure suggested Legionella pneumonia, and levofloxacin was added. Since a lung infiltration shadow appeared on the other side as well on day 4, non-infectious diseases were considered, and steroid therapy was started. Urinary antigen tests for Legionella pneumophila became positive on day 5. In the present case, retesting with Ribotest® Legionella, which could be negative early after the disease onset, was useful for diagnosing Legionella pneumonia, which led to the discontinuation of unnecessary steroid treatment.
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Affiliation(s)
- Yumi Motokura
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Japan
| | - Akihiro Ito
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Japan
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Lombardi A, Borriello T, De Rosa E, Di Duca F, Sorrentino M, Torre I, Montuori P, Trama U, Pennino F. Environmental Monitoring of Legionella in Hospitals in the Campania Region: A 5-Year Study. Int J Environ Res Public Health 2023; 20:ijerph20085526. [PMID: 37107807 PMCID: PMC10138562 DOI: 10.3390/ijerph20085526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023]
Abstract
Legionella is a pathogen that colonizes soils, freshwater, and building water systems. People who are most affected are those with immunodeficiencies, so it is necessary to monitor its presence in hospitals. The purpose of this study was to evaluate the presence of Legionella in water samples collected from hospitals in the Campania region, Southern Italy. A total of 3365 water samples were collected from January 2018 to December 2022 twice a year in hospital wards from taps and showers, tank bottoms, and air-treatment units. Microbiological analysis was conducted in accordance with the UNI EN ISO 11731:2017, and the correlations between the presence of Legionella and water temperature and residual chlorine were investigated. In total, 708 samples (21.0%) tested positive. The most represented species was L. pneumophila 2-14 (70.9%). The serogroups isolated were 1 (27.7%), 6 (24.5%), 8 (23.3%), 3 (18.9%), 5 (3.1%), and 10 (1.1%). Non-pneumophila Legionella spp. represented 1.4% of the total. Regarding temperature, the majority of Legionella positive samples were found in the temperature range of 26.0-40.9 °C. An influence of residual chlorine on the presence of the bacterium was observed, confirming that chlorine disinfection is effective for controlling contamination. The positivity for serogroups other than serogroup 1 suggested the need to continue environmental monitoring of Legionella and to focus on the clinical diagnosis of other serogroups.
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Affiliation(s)
- Annalisa Lombardi
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Tonia Borriello
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Elvira De Rosa
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Fabiana Di Duca
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Michele Sorrentino
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Ida Torre
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Paolo Montuori
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
| | - Ugo Trama
- General Directorate of Health, Campania Region, Centro Direzionale C3, 80143 Naples, Italy
| | - Francesca Pennino
- Department of Public Health, University “Federico II”, Via Sergio Pansini N° 5, 80131 Naples, Italy
- Correspondence:
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Lupia T, Corcione S, Shbaklo N, Rizzello B, De Benedetto I, Concialdi E, Navazio AS, Penna M, Brusa MT, De Rosa FG. Legionella pneumophila Infections during a 7-Year Retrospective Analysis (2016-2022): Epidemiological, Clinical Features and Outcomes in Patients with Legionnaires' Disease. Microorganisms 2023; 11:microorganisms11020498. [PMID: 36838463 PMCID: PMC9965988 DOI: 10.3390/microorganisms11020498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Legionella pneumophila (LP) is one of the main causative agents of community-acquired pneumonia in Europe and its fifth bacterial cause in Italy (4.9%). We conducted a seven year retrospective analysis of LP infection serogroup 1 in Asti, Piedmont, between 2016 and 2022. Patients were included if they tested positive for the Legionella urinary antigen. Clinical, laboratory, and radiologic data were analyzed to describe the risk factors for mortality. Fifty patients with LD were collected, mainly male, with a median age of 69 years. The main comorbidities were cardiovascular diseases (50%), pulmonary diseases (26%), and neurological diseases (12%). The most common clinical presentations were fever, respiratory, gastrointestinal, and neurologic symptoms. Older age (p = 0.004), underlying cardiovascular diseases (p = 0.009), late diagnosis at admission (p = 0.035), and neurological symptoms at diagnosis (p = 0.046) were more common in the non-survivor group. Moreover, a septic-shock presentation or the need for non-invasive ventilation at admission were associated with a higher mortality. No considerable differences in the biochemical data were found between the two groups except for the median neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio, and PCT value. We did not find any differences in mortality related to the choice of antibiotic regimen. Differences in outcome were associated with the median duration of treatment (p =< 0.001) but not to the choice of antibiotic regimen (mainly levofloxacin or azithromycin). In conclusion, early individuation of the wide spectrum of clinical characteristics of LP infection such as respiratory, cardiac, and neurological manifestations of the patient's comorbidities, and significant biochemical data should help clinicians flag high risk patients and potentially improve their outcome.
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Affiliation(s)
- Tommaso Lupia
- Unit of Infectious Diseases, Cardinal Massaia, 14100 Asti, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy
- School of Medicine, Tufts University, Boston, MA 02111, USA
- Correspondence: ; Tel.: +39-0141-489974
| | - Nour Shbaklo
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy
| | - Barbara Rizzello
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy
| | - Ilaria De Benedetto
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy
| | - Erika Concialdi
- Microbiology Unit, Cardinal Massaia Hospital, 14100 Asti, Italy
| | | | - Maurizio Penna
- Microbiology Unit, Cardinal Massaia Hospital, 14100 Asti, Italy
| | | | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, Cardinal Massaia, 14100 Asti, Italy
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy
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Bai L, Yang W, Li Y. Clinical and Laboratory Diagnosis of Legionella Pneumonia. Diagnostics (Basel) 2023; 13. [PMID: 36673091 DOI: 10.3390/diagnostics13020280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023] Open
Abstract
Legionella pneumonia is a relatively rare but extremely progressive pulmonary infection with high mortality. Traditional cultural isolation remains the gold standard for the diagnosis of Legionella pneumonia. However, its harsh culture conditions, long turnaround time, and suboptimal sensitivity do not meet the clinical need for rapid and accurate diagnosis, especially for critically ill patients. So far, pathogenic detection techniques including serological assays, urinary antigen tests, and mass spectrometry, as well as nucleic acid amplification technique, have been developed, and each has its own advantages and limitations. This review summarizes the clinical characteristics and imaging findings of Legionella pneumonia, then discusses the advances, advantages, and limitations of the various pathogenetic detection techniques used for Legionella pneumonia diagnosis. The aim is to provide rapid and accurate guiding options for early identification and diagnosis of Legionella pneumonia in clinical practice, further easing healthcare burden.
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Iliadi V, Staykova J, Iliadis S, Konstantinidou I, Sivykh P, Romanidou G, Vardikov DF, Cassimos D, Konstantinidis TG. Legionella pneumophila: The Journey from the Environment to the Blood. J Clin Med 2022; 11:jcm11206126. [PMID: 36294446 PMCID: PMC9605555 DOI: 10.3390/jcm11206126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/26/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022] Open
Abstract
An outbreak of a potentially fatal form of pneumonia in 1976 and in the annual convention of the American Legion was the first time that Legionella spp. was identified. Thereafter, the term Legionnaires’ disease (LD) was established. The infection in humans is transmitted by the inhalation of aerosols that contain the microorganisms that belong to the Legionellaceae family and the genus Legionella. The genus Legionella contains genetically heterogeneous species and serogroups. The Legionella pneumophila serogroup 1 (Lp1) is the most often detected strain in outbreaks of LD. The pathogenesis of LD infection initiates with the attachment of the bacterial cells to the host cells, and subsequent intracellular replication. Following invasion, Legionella spp. activates its virulence mechanisms: generation of specific compartments of Legionella-containing vacuole (LCV), and expression of genes that encode a type IV secretion system (T4SS) for the translocation of proteins. The ability of L. pneumophila to transmigrate across the lung’s epithelium barrier leads to bacteremia, spread, and invasion of many organs with subsequent manifestations, complications, and septic shock. The clinical manifestations of LD depend on the bacterial load in the aerosol, the virulence factors, and the immune status of the patient. The infection has two distinct forms: the non- pneumatic form or Pontiac fever, which is a milder febrile flu-like illness, and LD, a more severe form, which includes pneumonia. In addition, the extrapulmonary involvement of LD can include heart, brain, abdomen, and joints.
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Affiliation(s)
- Valeria Iliadi
- Izhevsk State Medical Academy, Kommunarov Street 281, 426034 Izhevsk, Russia
| | - Jeni Staykova
- Faculty of Public Health, Medical University of Sofia, Byalo More Str. 8, 1527 Sofia, Bulgaria
| | - Sergios Iliadis
- Izhevsk State Medical Academy, Kommunarov Street 281, 426034 Izhevsk, Russia
| | | | - Polina Sivykh
- State Budgetary Health City Polyclinic No 2 (GBUZ GB2) of Krasnodar, Seleznev Street 4/10, 350059 Krasnodar, Russia
| | - Gioulia Romanidou
- Nephrology Department, General Hospital “Sismanogleio”, 69100 Komotini, Greece
| | - Daniil F. Vardikov
- Russian Research Center for Radiology and Surgical Technologies of the Ministry of Health of the Russian Federation, Tkachey Str. 70-16, 192029 St. Petersburg, Russia
| | - Dimitrios Cassimos
- Pediatric Department, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Theocharis G. Konstantinidis
- Blood Transfusion Center, University General Hospital of Alexandroupolis Dragana Campus, 68100 Alexandroupolis, Greece
- Correspondence: ; Tel.: +30-2551-352005
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Okada K, Horikoshi Y, Nishimura N, Ishii S, Nogami H, Motomura C, Miyairi I, Tsumura N, Mori T, Ito K, Honma S, Nagai K, Tanaka H, Hayakawa T, Abe C, Ouchi K. Clinical evaluation of a new rapid immunochromatographic test for detection of Bordetella pertussis antigen. Sci Rep 2022; 12:8069. [PMID: 35577904 PMCID: PMC9109659 DOI: 10.1038/s41598-022-11933-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 05/03/2022] [Indexed: 11/08/2022] Open
Abstract
A more rapid and less complicated test to diagnose pertussis is required in clinical settings. We need to detect Bordetella pertussis, which mainly causes pertussis, as early as possible, because pertussis is more likely to become severe in infants, and people around them can easily become a source of infection due to its strong infectivity. Nevertheless, methods that can detect B. pertussis rapidly and efficiently are lacking. Therefore, we developed a new immunochromatographic antigen kit (ICkit) for the early diagnosis of pertussis. The ICkit detects B. pertussis antigens in a nasopharyngeal swab without equipment and provides the result in about 15 min with a simple procedure. Additionally, a prospective study to evaluate the ICkit was conducted in 11 medical institutions, involving 195 cases with suspected pertussis. Compared with the real-time polymerase chain reaction (rPCR), the sensitivity and specificity of the ICkit were 86.4% (19/22) and 97.1% (168/173), respectively. The ICkit detected the antigen in both children and adults. Furthermore, the ICkit detected the antigen until the 25th day from the onset of cough, when rPCR detected the antigen. Thus, the ICkit demonstrated a high correlation with rPCR and would help diagnose pertussis more rapidly and efficiently.
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Affiliation(s)
- Kenji Okada
- Division of Basic Nursing, Fukuoka Nursing College, Fukuoka, Japan
| | - Yuho Horikoshi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Naoko Nishimura
- Department of Pediatrics, Konan Kosei Hospital, Aichi, Japan
| | - Shigeki Ishii
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Hiroko Nogami
- Department of Respiratory Medicine, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Chikako Motomura
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | | | - Toshihiko Mori
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Kenta Ito
- Department of General Pediatrics, Aichi Children's Health and Medical Center, Aichi, Japan
| | | | | | - Hiroshi Tanaka
- Sapporo Cough Asthma and Allergy Center, Hokkaido, Japan
| | - Toru Hayakawa
- Diagnostics Department, Asahi Kasei Pharma Corporation, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006, Japan.
| | - Chiharu Abe
- Diagnostics Department, Asahi Kasei Pharma Corporation, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006, Japan
| | - Kazunobu Ouchi
- Department of Medical Welfare for Children, Kawasaki University of Medical Welfare, Okayama, Japan
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Viasus D, Gaia V, Manzur-Barbur C, Carratalà J. Legionnaires' Disease: Update on Diagnosis and Treatment. Infect Dis Ther 2022. [PMID: 35505000 DOI: 10.1007/s40121-022-00635-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Legionellosis is the infection caused by bacteria of the genus Legionella, including a non-pneumonic influenza-like syndrome, and Legionnaires’ disease is a more serious illness characterized by pneumonia. Legionellosis is becoming increasingly important as a public health problem throughout the world; although it is an underreported disease, studies have consistently documented a high incidence. In addition, health costs associated with the disease are high. Diagnosis of Legionnaires’ disease is based mainly on the detection of Legionella pneumophila serogroup 1 antigen in urine. However, there have been advances in detection tests for patients with legionellosis. New methodologies show greater sensitivity and specificity, detect more species and serogroups of Legionella spp., and have the potential for use in epidemiological studies. Testing for Legionella spp. is recommended at hospital admission for severe community-acquired pneumonia, and antibiotics directed against Legionella spp. should be included early as empirical therapy. Inadequate or delayed antibiotic treatment in Legionella pneumonia has been associated with a worse prognosis. Either a fluoroquinolone (levofloxacin or moxifloxacin) or a macrolide (azithromycin preferred) is the recommended first-line therapy for Legionnaires’ disease; however, little information is available regarding adverse events or complications, or about the duration of antibiotic therapy and its association with clinical outcomes. Most published studies evaluating antibiotic treatment for Legionnaires’ disease are observational and consequently susceptible to bias and confounding. Well-designed studies are needed to assess the usefulness of diagnostic tests regarding clinical outcomes, as well as randomized trials comparing fluoroquinolones and macrolides or combination therapy that evaluate outcomes and adverse events.
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Kim P, Deshpande A, Rothberg MB. Urinary Antigen Testing for Respiratory Infections: Current Perspectives on Utility and Limitations. Infect Drug Resist 2022; 15:2219-2228. [PMID: 35510157 PMCID: PMC9058651 DOI: 10.2147/idr.s321168] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
Pneumonia is a leading cause of hospitalization and death due to infection worldwide. Streptococcus pneumoniae and Legionella pneumophila remain among the most commonly identified bacterial pathogens. Unfortunately, more than half of all pneumonia cases today lack an etiologic diagnosis due to limitations in traditional microbiological methods like blood and sputum cultures, which are affected by poor sample collection, prior antibiotic administration, and delayed processing. Urinary antigen tests (UATs) for S. pneumoniae and L. pneumophila have emerged as powerful tools for improving the diagnosis of bacterial respiratory infections, enabling physicians to administer early directed therapy and improve antimicrobial stewardship. UATs are simple, rapid, and non-invasive diagnostic tests with high specificity (>90%) and moderate sensitivity (<80%). The potential impact of urinary antigen testing is especially significant for respiratory infections caused by Legionella. While all recommended community-acquired pneumonia (CAP) therapies are adequate for treating pneumococcal pneumonia, only certain antibiotics are effective against Legionella. Delayed therapy for Legionella is associated with worse clinical outcomes, which underscores the importance of rapid diagnostic methods like UATs. Despite their potential impact, current American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines argue against the routine use of urinary antigen testing for S. pneumoniae and L. pneumophila, except in patients with severe CAP and those with epidemiological risk factors for Legionella. Further research is necessary to evaluate the impact of early targeted treatment due to positive UAT results, as well as optimal strategies for UAT utilization. The purpose of this review is to summarize the UATs available for bacterial respiratory infections, describe current guidelines on their usage, and assess their impact on clinical outcomes and targeted therapy.
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Affiliation(s)
- Priscilla Kim
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Correspondence: Michael B Rothberg, Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, Mail Code G10, Cleveland, OH, 44195, USA, Tel +1 216-445-5556, Email
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Kawasaki T, Nakagawa N, Murata M, Yasuo S, Yoshida T, Ando K, Okamori S, Okada Y. Diagnostic accuracy of urinary antigen tests for legionellosis: A systematic review and meta-analysis. Respir Investig 2021; 60:205-214. [PMID: 34972680 DOI: 10.1016/j.resinv.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/20/2021] [Accepted: 11/24/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Urinary antigen tests (UATs) have been used for the early detection of legionellosis and have demonstrated moderate sensitivity and high specificity. However, the most recent systematic review and meta-analysis published in 2009 evaluated the accuracy of UATs; since then, UAT accuracy may have changed owing to advances and developments in UAT technology and epidemiological changes in the frequency of Legionella species that cause legionellosis. Therefore, this systematic review and meta-analysis aimed to update the accuracy of UATs for legionellosis among patients with suspected pneumonia. METHODS Overall, 1326 studies were screened, 21 of which fulfilled the eligibility criteria for quality assessment and meta-analysis. Data from 5772 patients, including 1368 (23.7%) with the target condition (i.e., suspected legionellosis), were included in the analysis. The overall quality of the included studies, which was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, was unclear. RESULTS The calculated pooled sensitivity and specificity were 0.79 (95% confidence interval [CI], 0.71-0.85) and 1.00 (95% CI, 0.99-1.00), respectively. Subpopulation analysis revealed that the accuracy of UATs for sensitivity and specificity for Legionella pneumophilia serogroup 1 was 0.86 (95% CI, 0.78-0.91) and 1.00 (95% CI, 0.99-1.00), respectively. CONCLUSIONS This study demonstrated that the sensitivity and specificity of UATs were moderate and high, respectively, which is comparable to the results reported in 2009. Therefore, UATs may be a useful method for the early detection of legionellosis caused by Legionella pneumophila serogroup 1. CLINICAL TRIAL REGISTRATION The review protocol was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000041080).
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Affiliation(s)
- Takeshi Kawasaki
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Natsuki Nakagawa
- Department of Respiratory Medicine, Tokyo University, Tokyo, Japan.
| | - Maki Murata
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shunsuke Yasuo
- Department of Emergency and Critical Care Medicine, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Takuo Yoshida
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Okamori
- Department of Medicine, Division of Pulmonary Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Preventive Services, School of Public Health, Kyoto University, Kyoto, Japan
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Kinjo T, Ito A, Ishii M, Komiya K, Yamasue M, Yamaguchi T, Imamura Y, Iwanaga N, Tateda K, Kawakami K. National survey of physicians in Japan regarding their use of diagnostic tests for legionellosis. J Infect Chemother 2021:S1341-321X(21)00344-5. [PMID: 34933785 DOI: 10.1016/j.jiac.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/20/2021] [Accepted: 12/10/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Bacterial culture remains the gold standard for the diagnosis of legionellosis. However, past reports indicate that most physicians use the urinary antigen test (UAT) alone. Combining it with other tests is important, especially in patients with negative UAT results. The aim of this study was to investigate the current situation of legionellosis diagnostics and clarify the issues that need to be addressed. METHODS Between March 1, 2021 and April 30, 2021, a questionnaire survey was conducted in an anonymous manner among physicians working in Japan. Questionnaires were generated on a website and asked questions in a multiple-choice format. RESULTS Valid responses were received from 309 physicians during the study period. Most (92.9%) physicians reported using UAT as the initial test for patients suspected of having legionellosis, and <10% reported using other tests (e.g., culture, nucleic acid amplification test [NAAT], Gimenez staining, and serum antibody titer measurement [ATM]). When the initial test result was negative, 63% of physicians reported not conducting additional tests. Even when they chose to run additional tests, at most 27.8%, 23.6%, 12.3%, and 10.4% of all physicians used NAAT, culture, Gimenez staining, and serum ATM, respectively. The major reasons for not using tests other than UAT were "unavailability in the medical facility," "long turn-around time," and "difficult to collect sputum." CONCLUSIONS The present survey revealed that most physicians in Japan used UAT alone for diagnosing legionellosis. Eliminating barriers to creating a reasonable environment and edification of physicians are needed to improve the current situation.
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Nakamura A, Fukuda S, Kusuki M, Watari H, Shimura S, Kimura K, Nishi I, Komatsu M. Evaluation of five Legionella urinary antigen detection kits including new Ribotest Legionella for simultaneous detection of ribosomal protein L7/L12. J Infect Chemother 2021; 27:1533-1535. [PMID: 34088604 DOI: 10.1016/j.jiac.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/10/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Urinary antigen tests are a widely used rapid diagnostic method for Legionella pneumonia. However, conventional urinary antigen tests are unable to detect anything other than Legionella pneumophila serogroup 1. The Ribotest Legionella (Ribotest) can detect all serogroups by using antibodies recognizing L. pneumophila ribosomal protein L7/L12 in addition to the conventional L. pneumophila serogroup 1 lipopolysaccharide. The aim of this study was to evaluate the performance of Ribotest against conventional urinary antigen tests, including the detection of Legionellaceae other than L. pneumophila. We investigated the detection sensitivity of various kits using in-vitro culture-soluble antigen extracts of ATCC strains and 22 clinical isolates collected from multiple medical facilities in the Kinki region of Japan. For L. pneumophila serogroup 1, four kits, including Ribotest, had a detection sensitivity of 105 CFU/mL, with only Check Legionella having a sensitivity of 106 CFU/mL. L. pneumophila non-serogroup 1 and Legionellaceae of other species were undetectable by the four conventional kits, whereas Ribotest could detect them with a sensitivity of 105-108 CFU/mL. The Ribotest was also able to detect other species such as Legionella hackeliae, Legionella feeleii, Legionella anisa, Fluoribacter bozemanae, and Fluoribacter dumoffii, but the detection sensitivity of L. hackeliae and L. feeleii was 108 CFU/mL, which was much lower than that of the other strains. The Ribotest has high potential to be applied as a rapid diagnostic method for pneumonia caused by other species of Legionella and Fluoribacter.
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Affiliation(s)
- Akihiro Nakamura
- Department of Clinical Laboratory Science, Faculty of Health Care, Tenri Health Care University, Tenri, Japan.
| | - Saori Fukuda
- Department of Clinical Laboratory, Tenri Hospital, Tenri, Japan
| | - Mari Kusuki
- Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan
| | - Hideo Watari
- Department of Clinical Laboratory, Otemae Hospital, Osaka, Japan
| | - Satoshi Shimura
- Department of Clinical Laboratory, Otemae Hospital, Osaka, Japan
| | - Keigo Kimura
- Laboratory for Clinical Investigation, Osaka University Hospital, Osaka, Japan
| | - Isao Nishi
- Laboratory for Clinical Investigation, Osaka University Hospital, Osaka, Japan
| | - Masaru Komatsu
- Department of Clinical Laboratory Science, Faculty of Health Care, Tenri Health Care University, Tenri, Japan
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Wong AYW, Johnsson ATA, Iversen A, Athlin S, Özenci V. Evaluation of Four Lateral Flow Assays for the Detection of Legionella Urinary Antigen. Microorganisms 2021; 9:493. [PMID: 33652772 DOI: 10.3390/microorganisms9030493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/18/2021] [Accepted: 02/23/2021] [Indexed: 11/29/2022] Open
Abstract
Urinary antigen tests (UATs) are often used to diagnose Legionnaires’ disease as they are rapid and easy to perform on readily obtainable urine samples without the need for specialized skills compared to conventional methods. Recently developed automated readers for UATs may provide objective results interpretation, especially in cases of weak result bands. Using 53 defined patient urine samples, we evaluated the performance of the BinaxNOW Legionella Antigen Card (Abbott), ImmuView S. pneumoniae and Legionella (SSI Diagnostica), STANDARD F Legionella Ag FIA (SD Biosensor), and Sofia Legionella FIA (Quidel) simultaneously with their respective automated readers. Automatic and visual interpretation of result bands were also compared for the immunochromatography-based BinaxNOW and ImmuView UATs. Overall sensitivity and specificity of Legionella UATs were 53.9–61.5% and 90.0–94.9%, respectively. All four UATs successfully detected all samples from L. pneumophila serogroup 1-positive patients, but most failed to detect samples for Legionella spp., or other serogroups. Automatic results interpretation of results was found to be mostly concordant with visual results reading. In conclusion, the performance of the four UATs were similar to each other in the detection of Legionella urinary antigen with no major difference between automated or visual results reading.
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