scholarly journals Healthcare-associated Legionnaires’ disease: Limitations of surveillance definitions and importance of epidemiologic investigation

2017 ◽  
Vol 18 (6) ◽  
pp. 307-310 ◽  
Author(s):  
Laila M Castellino ◽  
Shantini D Gamage ◽  
Patti V Hoffman ◽  
Stephen M Kralovic ◽  
Mark Holodniy ◽  
...  

Healthcare-associated Legionnaires’ disease (HCA LD) causes significant morbidity and mortality, with varying guidance on prevention. We describe the evaluation of a case of possible HCA LD and note the pitfalls of relying solely on an epidemiologic definition for association of a case with a facility. Our detailed investigation led to the identification of a new Legionella pneumophila serogroup 1 sequence type, confirmed a healthcare association and helped build the framework for our ongoing preventive efforts. Our experience highlights the role of routine environmental cultures in the assessment of risk for a given facility. As clinicians increasingly rely on urinary antigen testing for the detection of L. pneumophila, our investigation emphasises the importance of clinical cultures in an epidemiologic investigation.

1998 ◽  
Vol 19 (12) ◽  
pp. 905-910 ◽  
Author(s):  
Lisa A. Lepine ◽  
Daniel B. Jernigan ◽  
Jay C. Butler ◽  
Janet M. Pruckler ◽  
Robert F. Benson ◽  
...  

2013 ◽  
Vol 5 (6) ◽  
pp. 96
Author(s):  
Celia Birkin ◽  
Chandra Shekhar Biyani ◽  
Anthony J. Browning

Legionnaires’ disease (LD) is an often overlooked but a possiblecause of sporadic community acquired pneumonia. High fever,cough and gastrointestinal symptoms are non-specific symptoms.Hyponatremia is more common in LD than pneumonia linkedwith other causes. A definitive diagnosis is usually confirmed byculture, urinary antigen testing for Legionella species. Macolideor quinolone antibiotic is the treatment of choice. We describe acase of Legionella pneumonia presenting with high fever, bilateralflank pain and oliguria. It is important for clinicians to be awareof this diagnosis when managing patients with flank pain. Thecase highlights the problems in differentiating LD from renal colicand the importance of proper history, physical examination withlaboratory tests for appropriate management.


2004 ◽  
Vol 25 (12) ◽  
pp. 1072-1076 ◽  
Author(s):  
Miquel Sabrià ◽  
Josep M. Mòdol ◽  
Marian Garcia-Nuñez ◽  
Esteban Reynaga ◽  
Maria L. Pedro-Botet ◽  
...  

AbstractObjective:To determine whether environmental cultures forLegionellaincrease the index of suspicion for legionnaires' disease (LD).Design:Five-year prospective study.Setting:Twenty hospitals in Catalonia, Spain.Methods:From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested forLegionella, Cases of hospital-acquired LD and availability of an “in-house”Legionellatest in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing.Results:Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and usedLegionellatests includingLegionellaurinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals,Legionellatests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) usedLegionellaurinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD.Conclusions:The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using theLegionellaurinary antigen test in their laboratories.


2019 ◽  
Vol 71 (6) ◽  
pp. 1427-1434 ◽  
Author(s):  
Jennifer J Schimmel ◽  
Sarah Haessler ◽  
Peter Imrey ◽  
Peter K Lindenauer ◽  
Sandra S Richter ◽  
...  

Abstract Background The Infectious Diseases Society of America recommends pneumococcal urinary antigen testing (UAT) when identifying pneumococcal infection would allow for antibiotic de-escalation. However, the frequencies of UAT and subsequent antibiotic de-escalation are unknown. Methods We conducted a retrospective cohort study of adult patients admitted with community-acquired or healthcare-associated pneumonia to 170 US hospitals in the Premier database from 2010 to 2015, to describe variation in UAT use, associations of UAT results with antibiotic de-escalation, and associations of de-escalation with outcomes. Results Among 159 894 eligible admissions, 24 757 (15.5%) included UAT performed (18.4% of intensive care unit [ICU] and 15.3% of non-ICU patients). Among hospitals with ≥100 eligible patients, UAT proportions ranged from 0% to 69%. Compared to patients with negative UAT, 7.2% with positive UAT more often had a positive Streptococcus pneumoniae culture (25.4% vs 1.9%, P < .001) and less often had resistant bacteria (5.2% vs 6.8%, P < .05). Of patients initially treated with broad-spectrum antibiotics, most were still receiving broad-spectrum therapy 3 days later, but UAT-positive patients more often had coverage narrowed (38.4% vs 17.0% UAT-negative and 14.6% untested patients, P < .001). Hospital rate of UAT was strongly correlated with de-escalation following a positive test. Only 3 patients de-escalated after a positive UAT result were subsequently admitted to ICU. Conclusions UAT is not ordered routinely in pneumonia, even in ICU. A positive UAT result was associated with less frequent resistant organisms, but usually did not lead to antibiotic de-escalation. Increasing UAT and narrowing therapy after a positive UAT result are opportunities for improved antimicrobial stewardship.


1998 ◽  
Vol 19 (12) ◽  
pp. 905-910
Author(s):  
Lisa A. Lepine ◽  
Daniel B. Jernigan ◽  
Jay C. Butler ◽  
Janet M. Pruckler ◽  
Robert F. Benson ◽  
...  

2018 ◽  
Vol 68 (12) ◽  
pp. 2026-2033 ◽  
Author(s):  
Shawna Bellew ◽  
Carlos G Grijalva ◽  
Derek J Williams ◽  
Evan J Anderson ◽  
Richard G Wunderink ◽  
...  

Abstract Background Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. Methods We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. Results Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49–71%) and 39% specificity (95% CI 37–41%) for SP, and 63% sensitivity (95% CI 44–79%) and 35% specificity (95% CI 33–37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. Conclusions Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.


1998 ◽  
Vol 19 (12) ◽  
pp. 905-910 ◽  
Author(s):  
Lisa A. Lepine ◽  
Daniel B. Jernigan ◽  
Jay C. Butler ◽  
Janet M. Pruckler ◽  
Robert F. Benson ◽  
...  

2004 ◽  
Vol 25 (12) ◽  
pp. 1072-1076 ◽  
Author(s):  
Miquel Sabrià ◽  
Josep M. Mòdol ◽  
Marian Garcia-Nuñez ◽  
Esteban Reynaga ◽  
Maria L. Pedro-Botet ◽  
...  

AbstractObjective:To determine whether environmental cultures forLegionellaincrease the index of suspicion for legionnaires' disease (LD).Design:Five-year prospective study.Setting:Twenty hospitals in Catalonia, Spain.Methods:From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested forLegionella, Cases of hospital-acquired LD and availability of an “in-house”Legionellatest in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing.Results:Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and usedLegionellatests includingLegionellaurinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals,Legionellatests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) usedLegionellaurinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD.Conclusions:The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using theLegionellaurinary antigen test in their laboratories.


Author(s):  
Shayna R. Deecker ◽  
Malene L. Urbanus ◽  
Beth Nicholson ◽  
Alexander W. Ensminger

Legionella pneumophila is a ubiquitous freshwater pathogen and the causative agent of Legionnaires’ disease. L. pneumophila growth within protists provides a refuge from desiccation, disinfection, and other remediation strategies. One outstanding question has been whether this protection extends to phages. L. pneumophila isolates are remarkably devoid of prophages and to date no Legionella phages have been identified. Nevertheless, many L. pneumophila isolates maintain active CRISPR-Cas defenses. So far, the only known target of these systems is an episomal element that we previously named Legionella Mobile Element-1 (LME-1). The continued expansion of publicly available genomic data promises to further our understanding of the role of these systems. We now describe over 150 CRISPR-Cas systems across 600 isolates to establish the clearest picture yet of L. pneumophila ’s adaptive defenses. By searching for targets of 1,500 unique CRISPR-Cas spacers, LME-1 remains the only identified CRISPR-Cas targeted integrative element. We identified 3 additional LME-1 variants - all targeted by previously and newly identified CRISPR-Cas spacers - but no other similar elements. Notably, we also identified several spacers with significant sequence similarity to microviruses, specifically those within the subfamily Gokushovirinae . These spacers are found across several different CRISPR-Cas arrays isolated from geographically diverse isolates, indicating recurrent encounters with these phages. Our analysis of the extended Legionella CRISPR-Cas spacer catalog leads to two main conclusions: current data argue against CRISPR-Cas targeted integrative elements beyond LME-1, and the heretofore unknown L. pneumophila phages are most likely lytic gokushoviruses. IMPORTANCE Legionnaires’ disease is an often-fatal pneumonia caused by Legionella pneumophila , which normally grows inside amoebae and other freshwater protists. L. pneumophila trades diminished access to nutrients for the protection and isolation provided by the host. One outstanding question is whether L. pneumophila is susceptible to phages, given the protection provided by its intracellular lifestyle. In this work, we use Legionella CRISPR spacer sequences as a record of phage infection to predict that the “missing” L. pneumophila phages belong to the microvirus subfamily Gokushovirinae . Gokushoviruses are known to infect another intracellular pathogen, Chlamydia . How do gokushoviruses access L. pneumophila (and Chlamydia ) inside their “cozy niches”? Does exposure to phages happen during a transient extracellular period (during cell-to-cell spread) or is it indicative of a more complicated environmental lifestyle? One thing is clear, 100 years after their discovery, phages continue to hold important secrets about the bacteria upon which they prey.


2016 ◽  
Vol 38 (3) ◽  
pp. 306-313 ◽  
Author(s):  
Louise K. Francois Watkins ◽  
Karrie-Ann E. Toews ◽  
Aaron M. Harris ◽  
Sherri Davidson ◽  
Stephanie Ayers-Millsap ◽  
...  

OBJECTIVESTo define the scope of an outbreak of Legionnaires’ disease (LD), to identify the source, and to stop transmission.DESIGN AND SETTINGEpidemiologic investigation of an LD outbreak among patients and a visitor exposed to a newly constructed hematology-oncology unit.METHODSAn LD case was defined as radiographically confirmed pneumonia in a person with positive urinary antigen testing and/or respiratory culture forLegionellaand exposure to the hematology-oncology unit after February 20, 2014. Cases were classified as definitely or probably healthcare-associated based on whether they were exposed to the unit for all or part of the incubation period (2–10 days). We conducted an environmental assessment and collected water samples for culture. Clinical and environmental isolates were compared by monoclonal antibody (MAb) and sequence-based typing.RESULTSOver a 12-week period, 10 cases were identified, including 6 definite and 4 probable cases. Environmental sampling revealedLegionella pneumophilaserogroup 1 (Lp1) in the potable water at 9 of 10 unit sites (90%), including all patient rooms tested. The 3 clinical isolates were identical to environmental isolates from the unit (MAb2-positive, sequence type ST36). No cases occurred with exposure after the implementation of water restrictions followed by point-of-use filters.CONCLUSIONSContamination of the unit’s potable water system with Lp1 strain ST36 was the likely source of this outbreak. Healthcare providers should routinely test patients who develop pneumonia at least 2 days after hospital admission for LD. A single case of LD that is definitely healthcare associated should prompt a full investigation.Infect Control Hosp Epidemiol2017;38:306–313


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