Choline Supplementation Sensitizes Legionella dumoffii to Galleria mellonella Apolipophorin III

The growth of Legionella dumoffii can be inhibited by Galleria mellonella apolipophorin III (apoLp-III) which is an insect homologue of human apolipoprotein E., and choline-cultured L. dumoffii cells are considerably more susceptible to apoLp-III than bacteria grown without choline supplementation. In the present study, the interactions of apoLp-III with intact L. dumoffii cells cultured without and with exogenous choline were analyzed to explain the basis of this difference. Fluorescently labeled apoLp-III (FITC-apoLp-III) bound more efficiently to choline-grown L. dumoffii, as revealed by laser scanning confocal microscopy. The cell envelope of these bacteria was penetrated more deeply by FITC-apoLp-III, as demonstrated by fluorescence lifetime imaging microscopy analyses. The increased susceptibility of the choline-cultured L. dumoffii to apoLp-III was also accompanied by alterations in the cell surface topography and nanomechanical properties. A detailed analysis of the interaction of apoLp-III with components of the L. dumoffii cells was carried out using both purified lipopolysaccharide (LPS) and liposomes composed of L. dumoffii phospholipids and LPS. A single micelle of L. dumoffii LPS was formed from 12 to 29 monomeric LPS molecules and one L. dumoffii LPS micelle bound two molecules of apoLp-III. ApoLp-III exhibited the strongest interactions with liposomes with incorporated LPS formed of phospholipids isolated from bacteria cultured on exogenous choline. These results indicated that the differences in the phospholipid content in the cell membrane, especially PC, and LPS affected the interactions of apoLp-III with bacterial cells and suggested that these differences contributed to the increased susceptibility of the choline-cultured L. dumoffii to G. mellonella apoLp-III.

Environmental surveillance of Legionella spp. colonization in the water system of a large academic hospital: Analysis of the four-year results on the effectiveness of the chlorine dioxide disinfection method

The prevention of Legionella colonization of water systems is one of the goals of hospital management. Among chemical disinfection methods, chlorine dioxide (ClO₂) has been largely used to control Legionella spp. in water systems. We performed a retrospective study to analyse data deriving from the surveillance plan of the water system in a large academic hospital in Rome (Italy) during the period August 2011 and August 2018. We collected the data deriving from the routine water samples used to monitor Legionella spp. colonization. Data from the water samples collected from 163 selected sampling points (hot water tanks, the return loop and distal outlets) was analysed using a life table analysis in order to investigate the duration of the effectiveness of the ClO₂ method in eradicating Legionella spp. The colonization of the water sample by Legionella spp. was considered as the outcome. Our results show that in 81,59% of the sampling points Legionella spp. were never detected at four years of follow up. Chemical and physical characteristics of the water were also compared between the samples which were positive for Legionella spp. and those which were not. No association was found between these factors. The knowledge of the duration over time of the effectiveness of the ClO₂ disinfection method could support decision-making processes in the framework of Risk Management activities in hospitals. Future studies could also be conducted in hospitals to compare the long-term cost-effectiveness of different Legionella spp. colonization prevention methods.

Antibiotic susceptibility of Legionella strains isolated from public water sources in Macau and Guangzhou

The purpose of this study was to investigate the susceptibility of waterborne strains of Legionella to eight antimicrobials commonly used in legionellosis therapy. The minimum inhibitory concentrations (MICs) of 66 environmental Legionella strains, isolated from fountains and cooling towers of public facilities (hotels, schools, and shopping malls) in Macau and Guangzhou, were tested using the microdilution method in buffered yeast extract broth. The MIC₅₀/MIC₉₀ values for erythromycin, cefotaxime (CTX), doxycycline (DOC), minocycline (MIN), azithromycin, ciprofloxacin, levofloxacin (LEV), and moxifloxacin were 0.125/0.5 mg/L, 4/8 mg/L, 8/16 mg/L, 4/8 mg/L, 0.125/0.5 mg/L, 0.031/0.031 mg/L, 0.031/0.031 mg/L, and 0.031/0.062 mg/L, respectively. Legionella isolates were inhibited by either low concentrations of macrolides and fluoroquinolones, or high concentrations of CTX and tetracycline drugs. LEV was the most effective drug against different Legionella species and serogroups of L. pneumophila isolates. The latter were inhibited in decreasing order by MIN > CTX >DOC, while non-L. pneumophila isolates were inhibited by CTX> MIN >DOC. In this study, we evaluated drug resistance of pathogenic bacteria from the environment. This may help predict the emergence of drug resistance, improve patient outcomes, and reduce hospitalization costs.

Peracetic Acid in the Disinfection of a Hospital Water System Contaminated With Legionella Species

Objective:

To assess the efficacy of an alternative disinfection method for hospital water distribution systems contaminated with Legionella.

Methods:

Disinfection with peracetic acid was performed in a small hospital contaminated with L. pneumophila serotype 1. The disinfectant was used at concentrations of 50 ppm (first three surveillance phases) and 1,000 ppm (fourth surveillance phase) for 30 minutes.

Results:

Environmental monitoring revealed that disinfection was maintained 1 week after treatment; however, levels of recontamination surpassing baseline values were detected after approximately 1 month. Comparison of water temperatures measured at the distal outlets showed a statistically significant association between temperature and bacterial load. The circulating water temperature was found to be lower in the two wards farthest away from the hot water production plant than in other wards. It was thought that the lower water temperature in the two wards promoted the bacterial growth even after disinfection.

Conclusion:

Peracetic acid may be useful in emergency situations, but does not provide definitive protection even if used monthly.

[Evaluation of chlorine dioxide concentrations needed to effectively control contamination by Legionella spp in hospital hot water distribution systems]

This aim of the study was to identify effective levels of ClO2 for control of Legionella spp. contamination in the hot water (45-55 °C.) distribution system of a 579-bed hospital in Ravenna (Italy). Overall, 663 hot water samples were collected from the hospital's sinks and shower taps and were analyzed. Trend line analysis, which describes the trend in the number of positive samples collected according to disinfectant concentration, shows that the lowest number of positive samples was achieved with concentrations of ClO2 between 0.22 and 0, 32 mg /l.

Strategies for the reduction of Legionella in biological treatment systems

A community-wide outbreak of Legionnaire's disease occurred in Warstein, Germany, in August 2013. The epidemic strain, Legionella pneumophila Serogruppe 1, was isolated from an industrial wastewater stream entering the municipal wastewater treatment plant (WWTP) in Wartein, the WWTP itself, the river Wäster and air/water samples from an industrial cooling system 3 km downstream of the WWTP. The present study investigated the effect of physical-chemical disinfection methods on the reduction of the concentration of Legionella in the biological treatment and in the treated effluent entering the river Wäster. Additionally, to gain insight into the factors that promote the growth of Legionella in biological systems, growth experiments were made with different substrates and temperatures. The dosage rates of silver micro-particles, hydrogen peroxide, chlorine dioxide and ozone and pH stress to the activated sludge were not able to decrease the number of culturable Legionella spp. in the effluent. Nevertheless, the UV treatment of secondary treated effluent reduced Legionella spp. on average by 1.6-3.4 log units. Laboratory-scale experiments and full-scale measurements suggested that the aerobic treatment of warm wastewater (30-35 °C) rich in organic nitrogen (protein) is a possible source of Legionella infection.

Controlling Legionella and Pseudomonas aeruginosa re-growth in therapeutic spas: implementation of physical disinfection treatments, including UV/ultrafiltration, in a respiratory hydrotherapy system

The study aimed to assess the efficacy of an integrated water safety plan (WSP) in controlling Legionella re-growth in a respiratory hydrotherapy system located in a spa centre, supplied with sulphurous water, which was initially colonized by Legionella pneumophila. Heterotrophic plate counts, Pseudomonas aeruginosa, Legionella spp. were detected in water samples taken 6-monthly from the hydrotherapy equipment (main circuit, entry to benches, final outlets). On the basis of the results obtained by the continuous monitoring and the changes in conditions, the original WSP, including physical treatments of water and waterlines, environmental surveillance and microbiological monitoring, was integrated introducing a UV/ultrafiltration system. The integrated treatment applied to the sulphurous water (microfiltration/UV irradiation/ultrafiltration), waterlines (superheated stream) and distal outlets (descaling/disinfection of nebulizers and nasal irrigators), ensured the removal of Legionella spp. and P. aeruginosa and a satisfactory microbiological quality over time. The environmental surveillance was successful in evaluating the hazard and identifying the most suitable preventive strategies to avoid Legionella re-growth. Ultrafiltration is a technology to take into account in the control of microbial contamination of therapeutic spas, since it does not modify the chemical composition of the water, thus allowing it to retain its therapeutic properties.

Use of copper-silver ionization for the control of legionellae in alkaline environments at health care facilities

BACKGROUND

There are multiple treatment options for the control of legionellae in premise hot water systems. Water chemistry plays a role in the efficacy of these treatments and should be considered when selecting a treatment. This study demonstrated the efficacy of copper-silver ionization (CSI) under alkaline water conditions in 2 health care facilities.

METHODS

Monitoring for copper (Cu) and silver (Ag) ions was performed, and the corresponding percentage of positive Legionella cultures was monitored. Low Legionella colony forming units (CFU), with a mean <10 CFU/100 mL, and ≤30% positive culture for each sampling period, along with no recurrent disease, were considered indicative of control.

RESULTS

CSI treatment was shown to reduce both the number of CFU found and the percentage of samples found to be culture positive. After treatment was established, culture positivity was, for example, reduced from 70% (>10(3) CFU/100 mL) to consistently <30% (38 CFU/100 mL).

CONCLUSION

Control of legionellae in premise water systems may be a complex process requiring long-term assessments for adequate control. This work found that CSI could be successful in controlling Legionella under alkaline water conditions, and the evidence suggests that Ag ions are responsible for the control of Legionella pneumophila 1, L pneumophila 6, and L anisa.

Effect of monochloramine treatment on colonization of a hospital water distribution system by Legionella spp.: a 1 year experience study

Contamination of hot water distribution systems by Legionella represents a great challenge due to difficulties associated with inactivating microorganisms, preserving the water characteristics. The aim of this study was to examine over the course of 1 year in 11 fixed sites, the impact of monochloramine disinfection on Legionella, heterotrophic bacteria (36 °C), Pseudomonas aeruginosa contamination, and chemical parameters of a plumbing system in an Italian hospital. Three days after installation (T0), in the presence of monochloramine concentration between 1.5 and 2 mg/L, 10/11 sites (91%) were contaminated by L. pneumophila serogroups 3 and 10. After these results, the disinfectant dosage was increased to between 6 and 10 mg/L, reducing the level of Legionella by three logarithmic unit by 2 months postinstallation (T2) until 6 months later (T3). One year later (T4), there was a significant reduction (p = 0.0002) at 8/11 (73%) sites. Our data showed also a significant reduction of heterotrophic bacteria (36 °C) in 6/11 (55%) sites at T4 (p = 0.0004), by contrast the contamination of P. aeruginosa found at T0 in two sites persisted up until T4. The results of the present study show that monochloramine is a promising disinfectant that can prevent Legionella contamination of hospital water supplies.

Safety and Efficacy of Chlorine Dioxide for Legionella Control in a Hospital Water System

In a 30-month prospective study, we evaluated the efficacy of chlorine dioxide to control Legionella organisms in a water distribution system of a hospital with 364 patient beds and 74 skilled nursing beds. The number of hot water specimens positive for Legionella organisms decreased from 12 (60%) of 20 to 2 (10%) of 20. An extended time (18 months) was needed to achieve a significant reduction in the rate of Legionella positivity among hot water specimens. At the time of writing, no cases of hospital-acquired Legionnaires disease have been detected at the hospital since the chlorine dioxide system was installed in January 2003. Use of chlorine dioxide was safe, based on Environmental Protection Agency limits regarding maximum concentrations of chlorine dioxide and chlorite.

Minimum inhibitory concentration distribution in environmental Legionella spp. isolates

In Greece standard tests are performed in the watering and cooling systems of hotels' units either as part of the surveillance scheme or following human infection. The purpose of this study was to establish the minimum inhibitory concentration (MIC) distributions of environmental Legionella isolates for six antimicrobials commonly used for the treatment of Legionella infections, by MIC-test methodology. Water samples were collected from 2004 to 2011 from 124 hotels from the four prefectures of Crete (Greece). Sixty-eight (68) Legionella isolates, comprising L. pneumophila serogroups 1, 2, 3, 5, 6, 8, 12, 13, 15, L. anisa, L. rubrilucens, L. maceachernii, L. quinlivanii, L. oakridgensis, and L. taurinensis, were included in the study. MIC-tests were performed on buffered charcoal yeast extract with α-ketoglutarate, L-cysteine, and ferric pyrophosphate. The MICs were read after 2 days of incubation at 36 ± 1 °C at 2.5% CO2. A large distribution in MICs was recorded for each species and each antibiotic tested. Rifampicin proved to be the most potent antibiotic regardless of the Legionella spp.; tetracycline appeared to have the least activity on our environmental isolates. The MIC-test approach is an easy, although not so cost-effective, way to determine MICs in Legionella spp. These data should be kept in mind especially since these Legionella species may cause human disease.

Anticipating challenges with in-building disinfection for control of opportunistic pathogens

A new American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standard for control of Legionella (ASHRAE Standard 188, 2013) emphasizes use of in-building disinfection techniques to reduce the exposure of at-risk consumers to opportunistic pathogens in premise plumbing (OPPPs). This standard and other recommendations for OPPP control have implications for scaling in and corrosion of plumbing systems, which can sometimes adversely affect the efficacy of the disinfection method and physical integrity of the plumbing system, prompting this proactive critical review of challenges associated with implementation of Standard 188.

Anticipating challenges with in-building disinfection for control of opportunistic pathogens

A new American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standard for control of Legionella (ASHRAE Standard 188, 2013) emphasizes use of in-building disinfection techniques to reduce the exposure of at-risk consumers to opportunistic pathogens in premise plumbing (OPPPs). This standard and other recommendations for OPPP control have implications for scaling in and corrosion of plumbing systems, which can sometimes adversely affect the efficacy of the disinfection method and physical integrity of the plumbing system, prompting this proactive critical review of challenges associated with implementation of Standard 188.

Anti-Legionella activity of essential oil of Satureja cuneifolia

The essential oil of Satureja cuneifolia Ten. was characterized by a high concentration of the phenolic compounds carvacrol (21.3%) and thymol (9.2%). The in vitro activity of the essential oil against Legionela pneumophila serogroups (SG) I and 2-15 and Legionella spp. from different sources, using microdilution, showed that L. pneumofila is sensitive to the oil, with MICs ranging from 0.12 to 0.5%, v/v, and a MBC at 0.5 to 1%, v/v. The essential oil of S. cuneifolia was effective in the reduction of Legionellosis infections.

The effect of Galleria mellonella hemolymph polypeptides on Legionella gormanii

Among Legionella species, which are recognized to be pathogenic for humans, L. gormanii is the second prevalent causative agent of community-acquired pneumonia after L. pneumophila. Anti-L. gormanii activity of Galleria mellonella hemolymph extract and apolipophorin III (apoLp-III) was examined. The extract and apoLp-III at the concentration 0.025 mg/ml caused 75% and 10% decrease of the bacteria survival rate, respectively. The apoLp-III-induced changes of the bacteria cell surface were analyzed for the first time by atomic force microscopy. Our studies demonstrated the powerful anti-Legionella effects of the insect defence polypeptides, which could be exploited in drugs design against these pathogens.

Clinical Characteristics and Response to Newer Quinolones inLegionellaPneumonia: A Report of 28 Cases

Twenty-eight (11.6%) out of 241 Spanish patients enrolled in an international phase III clinical trial of mild to moderate community-acquired pneumonia (CAP) comparing gemifloxacin vs. trovafloxacin were diagnosed of Legionnaires' disease. A definite diagnosis was established by seroconversion in 13 patients of whom only 2 had a positive Legionella urinary antigen. The remaining 15 patients were possible Legionella infections based on a single elevated IgG titer (> or = 1:512). All patients had a radiologically confirmed diagnosis of pneumonia, 5 (19%) patients were older than 65, comorbidity was present in 9 (33%), and 10 (36%) had to be hospitalized. Fifteen patients were treated with oral gemifloxacin (320 mg/day) and 13 with oral trovafloxacin (200 mg/day). Overall, clinical success occurred in 25 (89.3%) patients after 7 days of treatment and only 1 patient needed a 14-day treatment. There were only one adverse event withdrawal and one clinical failure, and no patients died. In light of the favorable clinical outcome, the use of newer fluoroquinolones seems adequate for the treatment of suspected or proven Legionella pneumonia.

Influence of temperature, chlorine residual and heavy metals on the presence of Legionella pneumophila in hot water distribution systems

The microbiological colonisation of buildings and man-made structures often occurs on the walls of plumbing systems; therefore, monitoring of opportunistic pathogens such as Legionella pneumophila (L. pneumophila), both in water distribution mains and in consumers' plumbing systems, is an important issue according to the international and national guidelines that regulate the quality of drinking water. This paper investigates the presence of L. pneumophila in the Dalmatian County of Croatia and the relationship between L. pneumophila presence and heavy metals concentrations, free residual chlorine and water temperature in hot water distribution systems (WDS). Investigations were performed on a large number of hot water samples taken from taps in kitchens and bathrooms in hotels and homes for the elderly and disabled in the Split region. Of the 127 hot water samples examined, 12 (9.4%) were positive for Legionella spp. with median values concentration of 450 cfu × L(-1). Among positive isolates, 10 (83.3%) were L. pneumophila sg 1, and two of them (16.6%) belonged to the genera L. pneumophila sg 2-14. The positive correlation between the water temperature, iron and manganese concentrations, and L. pneumophila contamination was proved by statistical analysis of the experimental data. On the contrary, zinc and free residual chlorine had no observed influence on the presence of L. pneumophila. The presence of heavy metals in water samples confirms the corrosion of distribution system pipes and fittings, and suggests that metal plumbing components and associated corrosion products are important factors in the survival and growth of L. pneumophila in WDS.

Anti-Legionella activity of staphylococcal hemolytic peptides

A collection of various Staphylococci was screened for their anti-Legionella activity. Nine of the tested strains were found to secrete anti-Legionella compounds. The culture supernatants of the strains, described in the literature to produce hemolytic peptides, were successfully submitted to a two step purification process. All the purified compounds, except one, corresponded to previously described hemolytic peptides and were not known for their anti-Legionella activity. By comparison of the minimal inhibitory concentrations, minimal permeabilization concentrations, decrease in the number of cultivable bacteria, hemolytic activity and selectivity, the purified peptides could be separated in two groups. First group, with warnericin RK as a leader, corresponds to the more hemolytic and bactericidal peptides. The peptides of the second group, represented by the PSMα from Staphylococcus epidermidis, appeared bacteriostatic and poorly hemolytic.

Chemical disinfection of Legionella in hot water systems biofilm: a pilot-scale 1 study

Legionella bacteria encounter optimum growing conditions in hot water systems and cooling towers. A pilot-scale 1 unit was built in order to study the biofilm disinfection. It consisted of two identical loops, one used as a control and the other as a 'Test Loop'. A combination of a bio-detergent and a biocide (hydrogen peroxide + peracetic acid) was applied in the Test Loop three times under the same conditions at 100 and 1,000 mg/L with a contact time of 24 and 3-6 hours, respectively. Each treatment test was preceded by a three week period of biofilm re-colonization. Initial concentrations of culturable Legionella into biofilm were close to 10(3) CFU/cm2. Results showed that culturable Legionella spp. in biofilm were no longer detectable three days following each treatment. evertheless, initial Legionella spp. concentrations were recovered 7 days after the treatments (in two cases). Before the tests, Legionella spp. and L. pneumophila PCR counts were both about 10(4) GU/cm2 in biofilm and they both decreased by 1 to 2 log units 72 hours after each treatment. The three tests had a good but transient efficiency on Legionella disinfection in biofilm.

[Disinfectants and main sanitary and preventive measures for protection of ventilation and air-conditioning systems from Legionella contamination]

The study was devoted to selection and assessment of disinfecting preparations for prevention of contamination by Legionella. Using system of criteria for quality assessment of disinfectants, seven newdomestic ones belonging to quaternary ammonium compounds class or to oxygen-containing preparations and designed for disinfecting of air-conditioning and ventilation systems were selected. Antibacterial and disinfecting activities of working solutions of disinfectants were tested in laboratory on the test-surfaces and test-objects of premises' air-conditioning and ventilation systems contaminated with Legionella. High antimicrobial and disinfecting activity of new preparations "Dezactiv-M", "ExtraDez", "Emital-Garant", "Aquasept Plus", "Samarovka", "Freesept", and "Ecobreeze Oxy" during their exposure on objects and materials contaminated with Legionella was shown. Main sanitary and preventive measures for defending of air-conditioning and ventilation systems from contamination by Legionella species were presented.

Is copper–silver ionisation safe and effective in controlling legionella?

Copper-silver ionisation is gaining popularity worldwide as a water disinfection method. We review the literature that supports the effectiveness and safety of the copper-silver ionisation pertaining to legionella control in water distribution systems. A search between January 1997 and January 2007 was conducted in relevant health databases: Medline, Embase, NHS CRD, Cochrane Library Plus, Web of Knowledge, IME (Spanish Medical Index) and IBECS (Health Sciences Bibliographic Index). Ten published studies were selected according to inclusion and exclusion criteria previously established; most of these were experimental. Legionella levels decrease with the application of any of the procedures used in these studies and the procedures can be combined to obtain better outcomes. No studies containing an economic evaluation were found. We conclude that copper-silver ionisation is an effective method to control legionella, bearing in mind that eradication cannot be achieved by any method in isolation. Maintaining high temperatures in the water system can maximise effectiveness of the method. Copper-silver appears to be safe, as long as ion levels are monitored and kept within international recommended levels. More studies with concurrent control group, long follow-up and economic evaluation are required to properly assess this procedure.

The dps gene of symbiotic "Candidatus Legionella jeonii" in Amoeba proteus responds to hydrogen peroxide and phagocytosis

To survive in host cells, intracellular pathogens or symbiotic bacteria require protective mechanisms to overcome the oxidative stress generated by phagocytic activities of the host. By genomic library tagging, we cloned a dps (stands for DNA-binding protein from starved cells) gene of the symbiotic "Candidatus Legionella jeonii" organism (called the X bacterium) (dps(X)) that grows in Amoeba proteus. The gene encodes a 17-kDa protein (pI 5.19) with 91% homology to Dps and DNA-binding ferritin-like proteins of other organisms. The cloned gene complemented the dps mutant of Escherichia coli and conferred resistance to hydrogen peroxide. Dps(X) proteins purified from E. coli transformed with the dps(X) gene were in oligomeric form, formed a complex with pBlueskript SKII DNA, and protected the DNA from DNase I digestion and H(2)O(2)-mediated damage. The expression of the dps(X) gene in "Candidatus Legionella jeonii" was enhanced when the host amoeba was treated with 2 mM H(2)O(2) and by phagocytic activities of the host cell. These results suggested that the Dps protein has a function protective of the bacterial DNA and that its gene expression responds to oxidative stress generated by phagocytic activities of the host cell. With regard to the fact that invasion of Legionella sp. into respiratory phagocytic cells causes pneumonia in mammals, further characterization of dps(X) expression in the Legionella sp. that multiplies in a protozoan host in the natural environment may provide valuable information toward understanding the protective mechanisms of intracellular pathogens.

Enhanced antifungal effect of the selective medium for the detection of Legionella species by a combination of cycloheximide, amphotericin B and thiabendazole

The accurate detection of Legionella from environmental water samples using conventional plate culture methods is often made difficult by the overgrowth of non-target microorganisms on the selective agar plates. Acid pretreatment is a very effective pretreatment to decrease the overgrowth of heterotrophic bacteria. However, acid pretreatment would not be expected to eliminate molds. We evaluated the effects of four kinds of antifungal agents, individually and in combination, on the growth of Legionella strains and molds. Consequently, it was demonstrated that the combination of cycloheximide, amphotericin B and thiabendazole was very effective in eliminating molds on agar plates, and resulted in the improved detection of Legionella. Examination of 214 cooling tower water samples using the enhanced antifungal selective medium (CAT alpha) instead of GVPC alpha selective medium demonstrated a decrease in contamination by molds from 13.6% to 1.9% without affecting the growth of Legionella.

Reducing Legionella colonization in water systems with monochloramine

Monochloramine reduced colonization in building hot water systems.

Monochloramine disinfection of municipal water supplies is associated with decreased risk for Legionnaires' disease. We conducted a 2-year, prospective, environmental study to evaluate whether converting from chlorine to monochloramine for water disinfection would decrease Legionella colonization of hot water systems. Water and biofilm samples from 53 buildings were collected for Legionella culture during 6 intervals. Prevalence ratios (PRs) comparing Legionella colonization before and after monochloramine disinfection were adjusted for water system characteristics. Legionella colonized 60% of the hot water systems before monochloramine versus 4% after conversion (PR 0.07, 95% confidence interval 0.03–0.16). The median number of colonized sites per building decreased with monochloramine disinfection. Increased prevalence of Legionella colonization was associated with water heater temperatures <50°C, buildings taller than 10 stories, and interruptions in water service. Increasing use of monochloramine in water supplies throughout the United States may reduce Legionella transmission and incidence of Legionnaires' disease.

Introduction of monochloramine into a municipal water system: impact on colonization of buildings by Legionella spp

Legionnaires' disease (LD) outbreaks are often traced to colonized potable water systems. We collected water samples from potable water systems of 96 buildings in Pinellas County, Florida, between January and April 2002, during a time when chlorine was the primary residual disinfectant, and from the same buildings between June and September 2002, immediately after monochloramine was introduced into the municipal water system. Samples were cultured for legionellae and amoebae using standard methods. We determined predictors of Legionella colonization of individual buildings and of individual sampling sites. During the chlorine phase, 19 (19.8%) buildings were colonized with legionellae in at least one sampling site. During the monochloramine phase, six (6.2%) buildings were colonized. In the chlorine phase, predictors of Legionella colonization included water source (source B compared to all others, adjusted odds ratio [aOR], 6.7; 95% confidence interval [CI], 2.0 to 23) and the presence of a system with continuously circulating hot water (aOR, 9.8; 95% CI, 1.9 to 51). In the monochloramine phase, there were no predictors of individual building colonization, although we observed a trend toward greater effectiveness of monochloramine in hotels and single-family homes than in county government buildings. The presence of amoebae predicted Legionella colonization at individual sampling sites in both phases (OR ranged from 15 to 46, depending on the phase and sampling site). The routine introduction of monochloramine into a municipal drinking water system appears to have reduced colonization by Legionella spp. in buildings served by the system. Monochloramine may hold promise as community-wide intervention for the prevention of LD.

Comparison of disinfectants for biofilm, protozoa and Legionella control

The aim of this study was to compare the efficiency of different disinfectants applicable to Legionella control in domestic water systems. A domestic water supply simulation unit that allowed simulation of real-world conditions was developed for this purpose. The system, consisting of seven identical rigs, was used to compare treatment efficiency under equivalent conditions of system design, materials, hydraulics, water quality, temperature and initial contamination. During the study, each of six loops received continuous application of one of the following disinfectants: chlorine, electro-chlorination, chlorine dioxide, monochloramine, ozone, or copper/silver. The seventh loop was used as a control and remained untreated. Performance evaluation of these disinfectants was based on their ability to reduce not only Legionella, but also protozoa and biofilms, which contribute to the establishment and dissemination of these bacteria in water systems, and their resistance to treatments. Regarding these criteria, chlorine dioxide and chlorine (as bleach or obtained by electro-chlorination) were the most effective treatments in this study. However, in comparison with chlorine, chlorine dioxide showed a longer residual activity in the system, which constituted an advantage in the perspective of an application to extensive pipework systems.

In vitro activity of pazufloxacin, tosufloxacin and other quinolones against Legionella species

OBJECTIVES

The activities of pazufloxacin and tosufloxacin against Legionella spp. were evaluated in vitro and compared with those of other quinolones, macrolides and azithromycin.

METHODS

The conventional MICs were determined by the microbroth dilution method. Intracellular activities of drugs were evaluated by a cfu count. The minimal extracellular concentration inhibiting intracellular growth of bacteria (MIEC) was determined by a colorimetric cytopathic assay.

RESULTS

MICs of pazuloxacin and tosufloxacin at which 90% (MIC90) of isolates are inhibited in 76 different Legionella spp. strains (38 ATCC strains and 38 clinical isolates) were 0.032 and 0.016 mg/L, whereas the MIC90s of levofloxacin, ciprofloxacin, garenoxacin, erythromycin, clarithromycin and azithromycin were 0.032, 0.032, 0.032, 2.0, 0.125 and 2.0 mg/L, respectively. Pazufloxacin and tosufloxacin at 4x MIC inhibited intracellular growth of Legionella pneumophila SG1 (80-045 strain), as did other quinolones, clarithromycin and azithromycin, whereas erythromycin at 4x MIC did not. MIECs of pazufloxacin, tosufloxacin, levofloxacin, ciprofloxacin and garenoxacin for the strain were 0.063, 0.004, 0.016, 0.032 and 0.008 mg/L respectively, which were superior to those of macrolides and azithromycin. Pazufloxacin showed potent activity against three additional clinical isolates of L. pneumophila SG1, one clinical isolate each of L. pneumophila SG3 and SG5, as well as Legionella micdadei, Legionella dumoffii and Legionella longbeachae SG1.

CONCLUSIONS

Pazufloxacin and tosufloxacin, as well as other quinolones, were more potent than macrolides and an azalide. Present data warrant further study on the efficacy of these drugs in the treatment of Legionella infections.

In vitro and intracellular activities of LBM415 (NVP PDF-713) against Legionella pneumophila

LBM415 activity against extracellular and intracellular Legionella pneumophila was studied. The LBM415 MIC50 for 20 Legionella sp. strains was 4 microg/ml, versus 0.06, 0.25, and <or=0.03 microg/ml for azithromycin, erythromycin, and levofloxacin, respectively. LBM415 (0.5 and 16 microg/ml) reversibly prevented intracellular growth of two L. pneumophila strains and was less active than erythromycin.

Antibacterial activities of gemifloxacin, levofloxacin, gatifloxacin, moxifloxacin and erythromycin against intracellular Legionella pneumophila and Legionella micdadei in human monocytes

OBJECTIVES

The antibacterial activity of a new fluoroquinolone, gemifloxacin, was tested against intracellular Legionella pneumophila and Legionella micdadei and was compared with the activities of levofloxacin, gatifloxacin, moxifloxacin and erythromycin.

METHODS

For intracellular assays, bacteria were used to infect human monocyte-derived macrophages prepared from heparinized blood of healthy volunteers. Antibiotics were added following phagocytosis. Numbers of viable bacteria were determined at 0, 24, 48, 72 and 96 h.

RESULTS

The intracellular antibacterial activity of gemifloxacin was concentration- and time-dependent. All of the quinolones had similar activities against L. pneumophila and L. micdadei at 10 x MIC, but there were minor differences: at 24 h moxifloxacin was significantly more active than the other quinolones against L. pneumophila, while gemifloxacin was more active against L. micdadei (P < 0.01). All of the quinolones were markedly more active than erythromycin (P < 0.01). The antibacterial effect of gemifloxacin against L. pneumophila following drug removal at 24 h persisted for 72 h at 20 x MIC but not at 10 x MIC, while for L. micdadei the antibacterial effect persisted for 24 h at 10 x MIC.

CONCLUSIONS

All of the quinolones had similar activities against intracellular L. pneumophila and L. micdadei and were markedly more effective than erythromycin.

Comparative activity of quinolones, macrolides and ketolides against Legionella species using in vitro broth dilution and intracellular susceptibility testing

The comparative in vitro activity of quinolones (trovafloxacin, gemifloxacin, levofloxacin, ciprofloxacin, moxifloxacin and grepafloxacin), ketolides (ABT-773 and telithromycin) and macrolides (clarithromycin, azithromycin and erythromycin) were evaluated against Legionella pneumophila by broth dilution and an HL-60 intracellular model. The MIC90 of the quinolones, clarithromycin and ABT-773 were more than eight times lower than for erythromycin. Telithromycin, ABT-773 and azithromycin had significantly greater intracellular activity against L. pneumophila than erythromycin at 1xMIC and 8xMIC. The rank order of intracellular activity against L. pneumophila serogroup 1 was quinolones>ketolides>macrolides. Clinical trials to determine the clinical efficacy of ketolides for the treatment of Legionnaires' disease are warranted.

Legionellosis

Community-acquired legionnaires' disease (CALD) has dramatically increased in the Legionella urinary antigen (LUA) era. However, its incidence in each country depends on the specific techniques used for the diagnosis of LD and the mandatory reporting of cases to the local health surveillance system. Moreover, the most recent studies have demonstrated that no clinical data are discriminative enough for the diagnosis of LD. Clinical differences have been observed in sporadic and outbreak-reported cases demonstrating that the earlier the diagnosis of Legionella infection, the more nonspecific the clinical appearance. Fluoroquinolones are the most efficacious drugs against Legionella. The combination of these drugs with azithromycin seems to be promising in the treatment of patients with severe LD. Although outbreaks of LD will continue, the most important objective of the public health authorities should be to reduce their number and size.

Resistance of Legionella to disinfection in hot water distribution systems

The efficiency of various disinfection treatments against Legionella was tested on a hot water distribution system (HWDS) pilot unit. The results demonstrated clearly that most Legionella in the networks were fixed in the biofilm at the surface of the pipe (more than 98% for each loop). Chemical treatments (continuous chlorination, hyperchlorination, hydrogen peroxide and peracetic acid mixing) commonly used for the eradication of Legionella in hot water distribution networks appeared to be inadequate for eradicating the bacteria in the biofilm. Unfortunately, the biofilm contained most of the pathogens in an HWDS whereas legislation is only restricted to the Legionella concentration in the water phase. Thermal treatment appeared to be efficient to disinfect most of the biofilm but seemed to promote the biofilm re-growth as well. It was then concluded that the best solution to prevent Legionella contamination in hot water distribution systems would be to have perfect control of the temperature in the networks (temperature > 55 degrees C at all points). Nevertheless, in many cases it is difficult to have such control, so during the time necessary to modify networks, the best solution to control Legionella proliferation appears to be to apply a treatment shock (thermal or chlorination as a function of pipe characteristics). These treatments must be followed by a continuous chlorination that is totally controlled and equipped with alarm systems. This study demonstrates that biofilm sampling devices must be installed in hot water distribution systems to anticipate Legionella contamination and correctly determine the efficiency of the treatments.

[Infections due to Legionella non-pneumophila]

Legionella species other than Legionella pneumophila may cause pneumonias and extrapulmonary infections. Most infections are nosocomial or observed in immunocompromised patients and often remain undiagnosed because of the failure of confirmatory culture methods. The therapy is based on macrolides and fluoroquinolones; rifampin and tetracycline are also used.

[Disinfection of water of remove Legionella species: evaluation of an antimicrobial ceramic]

To evaluate the efficacy of an antimicrobial ceramic for killing Legionella strains in vitro, bacteria were exposed to the ceramic soaked in PBS at 25 degrees C or 42 degrees C. The number of L. pneumophila began to decrease significantly after 4 h of exposure at 25 degrees C and reached < 10 log cfu/ml after 12 h. A similar significant decrease was also observed after exposure at 42 degrees C. Furthermore, it was found that the antimicrobial ceramic showed bactericidal activity against six strains of Legionella isolated from various water sources, including L. pneumophila (serotype 1-4), L. micdadei, and L. dumoffii, after 24 h of exposure. The antimicrobial activity against L. pneumophila of the supernatant obtained by soaking the ceramic in PBS for 24 h was also assessed. Bactericidal activity of this supernatant was also noted. Analysis of the supernatant by ICP-MS resulted in the detection of eight metals (Mg, Al, Ca, Mn, Zn, Sr, Ag, and Ba) at a maximum concentration of 2.5 mg/l. When reconstituted PBS was made with all eight metals at the same concentrations as in the supernatant, the reconstituted PBS containing Ag alone and all metals showed significantly bactericidal activity against L. pneumophila, but PBS with only one metal component except Ag or a combination of Ag with Zn and/or Ca did not. These findings suggest that the antimicrobial ceramic possesses strong bactericidal activity against Legionella species and that eight metals released from the ceramic have a synergistic bactericidal effect against Legionella. When the antimicrobial ceramic was placed in hot spring water or cooling tower water instead of PBS, the number of L. pneumophila in the water decreased to < 10 log cfu/ml after 24 h of exposure and the bactericidal activity persisted for 5 weeks. These results indicate that the antimicrobial ceramic can be used to eradicate Legionella species contaminating various water sources.

Biological Activity of β-Dolabrin, γ-Thujaplicin, and 4-Acetyltropolone, Hinokitiol-Related Compounds

Beta-dolabrin, gamma-thujaplicin, and 4-acetyltropolone, the components of Aomori Hiba (Thujopsis dolabrata SIEB. et ZUCC. var. hondai MAKINO), showed antifungal activity on seven kinds of plant-pathogenic fungi, antibacterial activity against two kinds of Legionella sp., and in vitro cytotoxic effect on murine P388 lymphocytic leukemia cell line. Firstly, beta-dolabrin, gamma-thujaplicin and 4-acetyltropolone had clear antifungal activity against seven kinds of plant-pathogenic fungi tested. In particular, beta-dolabrin and 4-acetyltropolone showed strong antifungal activity against Pythium aphanidermatum IFO 32440, with minimum inhibitory concentration (MIC) values of 6.0 microg/ml. Secondly, beta-dolabrin, gamma-thujaplicin and 4-acetyltropolone had obvious growth-inhibitory effect on two kinds of Legionella sp. 4-Acetyltropolone especially had strong antibacterial activity toward Legionella pneumophila SG 1, and its MIC value was 3.1 microg/ml. These three compounds showed cytotoxic effects against murine P388 lymphocytic leukemia cell line in vitro. The cytotoxic effect of three compounds in the murine P388 lymphocytic leukemia cell line were clear when cell growth was measured using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) method. At 48 h after treatment, gamma-thujaplicin and 4-acetyltropolone at 0.63 microg/ml inhibited cell growth of murine P388 lymphocytic leukemia by 85% and 65%, respectively. At the same time after treatment, the growth of the murine P388 lymphocytic leukemia cell line was completely suppressed by the three compounds at concentrations higher than 5.0 microg/ml. Among these three compounds, gamma-thujaplicin had the strongest cytotoxic activity on the growth of this tumor cell line in vitro.

In vitro and in vivo activity of olamufloxacin (HSR-903) against Legionella spp

The activity of the fluoroquinolone olamufloxacin (HSR-903) against Legionella spp. was studied in vitro and in vivo. The olamufloxacin MIC at which 50% of isolates are inhibited (MIC50) for 81 different Legionella spp. strains (59 type strains and 22 clinical isolates) was 0.008 mg/L, which was identical to sparfloxacin, whereas the MIC50s for erythromycin, levofloxacin and ciprofloxacin were 0.25, 0.032 and 0.032 mg/L, respectively. Olamufloxacin and sparfloxacin (at 0.008 mg/L) inhibited intracellular growth and subsequent cytotoxicity of L. pneumophila 80-045 in J774.1 macrophages, whereas levofloxacin and ciprofloxacin did not, at the same concentration. When olamufloxacin was given to the infected guinea pigs orally (5 mg/kg of body weight), peak levels in the lung were 3.02 mg/kg at 2 h post-administration, with a half-life of 3.41 h and an AUC0-12 of 12.31 mg.h/kg. The 2 day post-infection bacterial burden of the lung in the animals treated with olamufloxacin (5 and 1.25 mg/kg given orally twice a day) was much lower than in those treated with levofloxacin (same dose as olamufloxacin) or erythromycin (10 mg/kg given orally twice a day). When treated with olamufloxacin (5 mg/kg given orally twice a day) for 7 days, 11 of 12 L. pneumophila-infected guinea pigs survived for 14 days post-infection, as did all 12 guinea pigs treated with levofloxacin (5 mg/kg given orally twice a day) for 7 days. In contrast, only two of 12 animals treated with erythromycin survived and 10 of 11 died in the physiological saline group. Olamufloxacin was as effective as levofloxacin in a guinea pig model of Legionnaires' disease. These data warrant further study of whether olamufloxacin is an option for the treatment of Legionella infections.

[Fundamental studies on legionellosis--the growth with in Acanthamoeba sp. and antibiotics susceptibility of Legionella spp. isolated from soil samples in Japan]

As part of an epidemiological study of legionellosis, we investigated the growth within Acanthamoeba sp. and antibiotic susceptibility of 62 strains of Legionella spp. isolated from surface soils nationwide in 2001. 1) All strains tested grew in Acanthamoeba sp., suggesting that the strains were pathogenic. The minimum bacterial number required for the growth in the amoeba was 10(3)-10(8) CFU/ml and there were differences between the strains. 2) Susceptibility to 10 drugs was investigated using the Etest. The MIC90 values of imipenem, as a beta-lactam, and rifampicin, as an antitubercular agent, were 0.047 microgram/ml and 0.064 microgram/ml, respectively, showing high sensitivity. In contrast, sensitivity to minocycline, as a tetracycline, and piperacillin, as a beta-lactam, was low and the MIC90 values were 12 micrograms/ml and 16 micrograms/ml, respectively. Sensitivity to minocycline was particularly low, with a MIC value of 32 micrograms/ml, in two strains. The above findings suggested that all soil-derived strains were pathogenic, and susceptibility of the strains tended to be slightly lower than that of clinical isolates.

In vitro antimycobacterial and antilegionella activity of licochalcone A from Chinese licorice roots

Licochalcone A, extracted and purified from Chinese licorice roots, showed in vitro inhibitory effect on human pathogenic Mycobacteria species and Legionella species. M. tuberculosis, M. bovis and BCG were inhibited by < 20 mg/l licochalcone A, whereas all non- M. tuberculosis complex species were resistant to > 20 mg/l Legionella pneumophila (serogroups 1 - 7) and L. bozemanii, L. dumoffii, L. feelei, L. longbeacheae and L. wadsworthii were inhibited by licochalcone A 1 - 4 mg/l, whereas L. gormanii and L. micdadei were inhibited by licochalcone A 500 - 1000 mg/l. These data indicate that licochalcone A might be of interest as a new class of antibacterial drug in the treatment of severe lung-infections.

In vitro susceptibility study of BMS-284756 against Legionella species

Legionella organisms are often associated with respiratory infections, and Legionella pneumonia results in significant mortality unless it is promptly and effectively treated. The present study was undertaken to compare the in vitro activity of BMS-284756 (T-3811ME), a novel des-F(6)-quinolone, against Legionella species versus the activity of other fluoroquinolones (levofloxacin, moxifloxacin, and ciprofloxacin) and of the macrolides erythromycin, clarithromycin, and azithromycin. The most potent agents tested against Legionella pneumophila serogroup 1, the largest group tested, were BMS-284756, moxifloxacin, and levofloxacin (MIC(90) = 0.016 mg/L). The MIC(90) range for BMS-284756 was 0.008-0.03 mg/L against the total panel of L pneumophila serogroups 1-9 and 12, with the lowest MIC(90) observed for serogroup 7 and the highest for serogroup 2. BMS-284756 was one of the most potent agents tested against isolates of L micdadei, L longbeachae, and other Legionella species (MIC(90) range: 0.008-0.06 mg/L). These results and the high intrinsic activity of BMS-284756 against other respiratory pathogens support its use as empiric monotherapy for a wide range of respiratory infections.

Comparative in vitro bacteriostatic and bactericidal activity of trovafloxacin, levofloxacin and moxifloxacin against clinical and environmental isolates of Legionella spp

The susceptibility of 140 Legionella spp isolates (106 clinical and 34 environmental isolates) to trovafloxacin (TRFX), levofloxacin (LEVX), moxifloxacin (MOFX), ciprofloxacin (CIPX), ofloxacin (OFLX), erythromycin (ERY), azithromycin (AZI) and rifampicin (RIF) was studied using a standard microdilution method and buffered yeast extract broth (BYE) supplemented with 0.1% alpha-ketoglutarate. The post-antibiotic effects (PAEs) of the study drugs against 10 clinical isolates of Legionella pneumophila sg.1 were compared. The MIC inhibiting 90% of strains tested on BYEalpha broth were 0.008, 0.016, 0.016, 0.06, 0.125, 0.5, 0.5, and 0.004 mg/l for TRFX, LEVX, MOXX, CIP, OFLX, ERY, AZI, and RIF, respectively. The MBC/MIC ratios ranged from one to eight depending on the antibiotic tested: TRFX [1x-2 x MIC], LEVX, MOFX, CIPX and OFLX [1x-4 x MIC], RIF [2x-4 x MIC], ERY and AZI [2x-8 x MIC]. TRFX, RIF, LEVX, MOFX, CIPX, OFLX, ERY and AZI showed similar activity against Legionella species other than L. pneumophila. One-hour exposures to the study antimicrobial agents at a concentration of 4 x MIC resulted in PAEs as follows (average in hours): TRFX: 2.68 h; RIF: 2.63 h; CIPX: 2.62 h; MOFX: 2.56 h; LEVX: 2.41 h; OFLX: 2.25 h; AZI: 1.65 h; and ERY: 1.54 h. In conclusion, our in vitro data confirm that trovafloxacin, levofloxacin, moxifloxacin and rifampicin have excellent bacteriostatic and bactericidal activity against Legionella spp and show significant post-antibiotic effect.

Activity of BMS284756 (T-3811) tested against anaerobic bacteria, Campylobacter jejuni, Helicobacter pylori and Legionella spp

BMS284756, a novel des-fluoro (6) quinolone (formerly T-3811), was tested for activity and spectrum using reference agar dilution (AD) and Etest (AB BIODISK, Solna, Sweden) methods. The antimicrobial activities of BMS284756, ciprofloxacin, gatifloxacin, levofloxacin, and trovafloxacin were evaluated against Campylobacter jejuni (38 strains), Helicobacter pylori (21 strains), Legionella spp. (66 strains), and 197 anaerobic isolates. BMS284756 (MIC(90), 0.008 microg/mL) was four-fold more active than gatifloxacin and trovafloxacin against H. pylori strains. Gatifloxacin and BMS284756 (MIC(50), 0.03 microg/mL) were > or = two-fold more active than levofloxacin against C. jejuni, but their spectrums were judged equivalent overall (89.4% susceptible). Against the Legionella spp., ciprofloxacin and levofloxacin (MIC(90), 0.25 microg/mL) had two-fold greater activity compared to gatifloxacin or BMS284756, but all strains were considered inhibited at clinically achievable levels. BMS284756 and trovafloxacin (MIC(90), 2 and 4 microg/mL, respectively) were four-to-eight-fold more potent than other comparators against the Gram-negative anaerobic species. Against the Gram-positive anaerobes (dominated by Clostridium difficile; 61 strains), BMS284756 activity was generally reduced, but equivalent or superior to trovafloxacin (68% inhibited at < or = 4 microg/mL). Inter-method comparisons (Etest versus AD) of BMS284756 MIC values showed a high correlation for C. jejuni and anaerobes (93.3 to 97.6% +/- two log (2) dilution steps). In conclusion, BMS284756 was very active against C. jejuni, H. pylori, Legionella spp. and most anaerobes, thus the potential role of this des-fluoro compound for treatment of infections caused by these fastidious species warrants further investigation.

[Susceptibility testing of clinical strains of Legionella spp. isolated in Japan]

We determined antimicrobial susceptibilities of 23 strains of Legionella spp. clinically isolated in Japan, between September 1994 through November 1999 by using Etest. The MICs of all isolates against macrorides, fluoroquinolones and rifampicin showed 1 microgram/ml or less. Especially rifampicin showed the most potent activity, of which the MICs of all isolates showed 0.064 microgram/ml or less. Although we could not find resistant strains against any antibiotics tested in this study, we think it is important to follow up the susceptibilities of clinical isolates of Legionella.

GyrA sequence-based typing of Legionella

Comparative sequence analysis of a 423-bp segment of the gyrA gene including a region homologous to the quinolone resistance-determining region (QRDR) of other species was evaluated as a novel typing method for Legionella strains. The study was performed with 29 reference strains representing 11 different Legionella species, with various serogroups, and with 13 clinical isolates of L. pneumophila. Pulsed-field gel electrophoresis and serotyping were employed for comparison of the clinical isolates. QRDR sequencing proved to be a highly discriminative tool for typing Legionellae, and permitted identification of species, serogroups and even different strains within serogroup 1. None of the isolates were resistant to quinolones in vitro and this correlated with dissence of mutations in the QRDR region. The data show that comparative sequence analysis of a short fragment of the gyrA gene is a potentially useful tool for typing of Legionella beyond the serogroup level. It is anticipated that mutations of the QRDR may arise in Legionella as a consequence of the introduction of quinolones as the agents of choice for the treatment of infections with this agent in immunocompromised patients. The employment of QRDR-typing maybe helpful in uncovering such mutations.

Comparative in vitro activity and post-antibiotic effect of gemifloxacin against Legionella spp

The comparative in vitro potency and post-antibiotic effect (PAE) of gemifloxacin (SB-265805), moxifloxacin, trovafloxacin, grepafloxacin, levofloxacin, ofloxacin, ciprofloxacin, azithromycin, clarithromycin, erythromycin and rifampicin were evaluated against Legionella pneumophila serogroups 1-9 and 12 (n = 204) and other Legionella spp. (n = 34). MICs were determined by standard two-fold agar dilution. PAE was determined by exposing the isolates to the test agents at 4 x MIC for 1 h. Trovafloxacin was the most potent agent overall (MIC range < or =0.004-0.016 mg/L, MIC(90) < or =0.008 mg/L). Of the other quinolones tested, gemifloxacin, moxifloxacin, grepafloxacin and levofloxacin were more potent (MIC(90) 0.016 mg/L) against L. pneumophila than ciprofloxacin and ofloxacin (MIC(90) 0. 03 mg/L). Against Legionella spp., the test quinolones were more potent (MIC range < or =0.004-0.06 mg/L) than either erythromycin or azithromycin (MIC(90) 0.5 and 0.25 mg/L, respectively). Gemifloxacin had the longest PAE (4.65 h) of the agents tested against erythromycin-resistant L. pneumophila. Of the quinolones, only gemifloxacin, grepafloxacin, levofloxacin and ofloxacin had PAEs of >3 h against erythromycin-resistant Legionella spp. Azithromycin, erythromycin and clarithromycin had PAEs of <3 h against all erythromycin-resistant strains. Against erythromycin-susceptible L. pneumophila, only gemifloxacin, moxifloxacin, ofloxacin and ciprofloxacin had PAEs of >3 h, and only rifampicin, ofloxacin, gemifloxacin and erythromycin had PAEs of >2 h against erythromycin-susceptible Legionella spp. The superior potency of gemifloxacin compared with erythromycin indicates that it may be of use in the treatment of legionellosis. The significant PAE described here, combined with favourable pharmacokinetics, supports once-daily dosing for gemifloxacin in the treatment of legionella infections.

In vitro activity of quinupristin/dalfopristin (Synercid, RP 59500) against Legionella spp

The activities of quinupristin/dalfopristin (Synercid), erythromycin and azithromycin against 22 Legionella spp. isolates were measured by a microbroth dilution method. The MICs that inhibited 90% of strains tested were 0.5, 0.35, and 0.5 microg/mL for quinupristin/dalfopristin, erythromycin, and azithromycin, respectively. Quinupristin/dalfopristin was only partially active against intracellular L. pneumophila at high (2 microg/mL), but not low (1 microg/mL) concentration. Activity of the drug in a guinea pig model of Legionnaires' disease could not be accurately determined because of drug toxicity for the guinea pig, although there was evidence that the drug has in vivo activity.

Susceptibility of Legionella species to five antibiotics and development of resistance by exposure to erythromycin, ciprofloxacin, and rifampicin

The minimal inhibitory concentration (MIC) values of erythromycin, ciprofloxacin, ofloxacin, rifampicin, and clindamycin were determined for 56 strains of Legionella pneumophila (38 patient, 3 environmental, and 15 reference strains) and 37 strains of other Legionella species (7 patient, 2 environmental, and 28 reference strains) using the epsilon-test system on BCYEalpha agar plates. High-level resistance (MIC > or = 4 microg/mL) was found only for clindamycin (57%), with MIC values ranging from 0.25-32 microg/mL. Low-level resistance was found for erythromycin (18%) (0.5 < MIC < 8), ciprofloxacin (1%) (1 < MIC < 4), and clindamycin (40%) (0.5 < MIC < 4), but not for ofloxacin and rifampicin. MIC50 for the 45 Danish clinical Legionella strains were 0.25 microg/mL (erythromycin), 0.25 microg/mL (ciprofloxacin), 0.19 microg/mL (ofloxacin), below 0.016 microg/mL (rifampicin), and 4 microg/mL (clindamycin). Of the clinical isolates, 64% were resistant to clindamycin. There were no significant differences between the MIC50 values obtained for clinical and nonclinical Legionella strains. Selected susceptible strains were exposed to increasing concentrations of either erythromycin, ciprofloxacin, or rifampicin to select for resistance. Isolates resistant to erythromycin (MIC 0.75-32 microg/mL) or ciprofloxacin (MIC 2-3 microg/mL) could be selected by a two-step procedure. One single strain recovered from media containing 50 microg/mL of erythromycin had an MIC value higher than 256 microg/mL to erythromycin. In contrast, high-level resistance toward rifampicin with MIC > or = 256 microg/mL developed as a one-step phenomenon in several strains.