LEGIONELLA - World Health Organization

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Table . Compar son of methods for laboratory d agnos s of Leg onna res’ d sease Method Sens t v ty (%) Spec f c ty (%) Comments References Culture • “Gold standard” Sputum 5–70 100 • Requires 2–4 days, sometimes BAL or transtracheal aspirate 30–90 100 (rarely) up to 14 days • Highest specificity Lung biopsy 90–99 100 Blood 10–30 100 Serology • Seroconversion Seroconversion 70–90 95–99 may require 3–9 weeks Single specimen Ur nary ant gen (unknown) 50–70 75–99 99–100 • Only for L.p.sg1, limited data for other serogroups or species • Very rapid (15 min–3 h), frequently earliest positive finding, may remain positive for several weeks/months DFA test ng • Very rapid (2–4 h) Sputum 25–75 95–99 • Limited sensitivity or BAL • Experience needed Lung biopsy 80–90 99 • No validated reagents for nonpneumophila species Edelstein & Meyer, 1994; Stout & Yu 1997; Harrison et al., 1998; Maiwald, Helbig & Lück, 1998; Fields, Benson & Besser, 2002; Lück, Helbig & Schuppler, 2002 Edelstein & Meyer, 1994; Plouffe et al., 1995; Stout & Yu, 1997; Harrison et al., 1998; Fields, Benson & Besser, 2002; Lück, Helbig & Schuppler, 2002; Edelstein & Meyer, 1994; Stout & Yu, 1997; Harrison et al., 1998; Fields, Benson & Besser, 2002; Lück, Helbig & Schuppler, 2002; Uldum & Molbak, 2002 Edelstein & Meyer, 1994; Stout and Yu, 1997; Harrison et al., 1998; Fields, Benson & Besser, 2002 <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Method Sens t v ty (%) PCR • Rapid Respiratory tract specimen 85–92 94–99 Urine, serum 33–70 98–98 Spec f c ty (%) Comments References • Diagnostic validity of positive results without confirmation by other methods remains unclear • Detects all Legionella species • Not commercially available <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS Fields, Benson & Besser, 2002; Lück, Helbig & Schuppler, 2002; Uldum & Molbak, 2002; van der Zee et al., 2002; Roig & Rello, 2003 BAL = bronchoalveolar lavage; DFA = direct immunofluoresence assay; L.p.sg1 = Legionella pneumophila serogroup 1; PCR = polymerase chain reaction 11.2.1 Diagnosing legionellosis using culture media Before the development of an in vitro medium that could sustain legionellae (Feeley et al., 1978; Feeley et al., 1979), legionellae could only be grown by isolating them in guinea pigs or hen eggs (McDade et al., 1977; Morris et al., 1979). Currently, the preferred technique for checking other diagnostic methods is to grow the bacteria on direct culture. Primary isolation of Legionella spp. is carried out using a defined Legionella agar medium containing L-cysteine, such as buffered charcoal yeast extract (BCYE) agar. Supplements that reduce the background competing bacterial flora and yeasts may be added to increase selectivity of the media. These supplements include BCYE-agar with anisomycin (Dournon, 1988), BMPAα medium with buffered cefamandole, polymixin B, or anisomycin agar (Edelstein, 1981). It is best to use both selective and nonselective agars, because cefamandole may inhibit some Legionella species (Edelstein, 1981). Supplemented BCYE medium is the most commonly used. This medium can be easily prepared by any large clinical microbiological laboratory and can be made in a semiselective form. However, supplements need to be added carefully so that they are not overheated. The quality of each batch of the media (i.e. each flask) must be checked using Legionella strains that have not been adapted to laboratory media by successive subculture. This is because laboratory strains adapt to laboratory media and are less sensitive to poor-quality media than fresh isolates of Legionella from clinical and environmental samples. Culture yield is greatest in highly experienced laboratories using multiple media and preplating specimen decontamination. Culture plates are incubated at 36+/– 1 °C for up to 14 days and are examined every two or three days. Even the detection of one or a few colonies is sufficient to confirm the diagnosis. The appearance of colonies may be delayed if patients have received appropriate antibiotics, and if the specimen is contaminated with other microorganisms or another species (Stout & Yu, 1997; Lück, Helbig & Schuppler, 2002).
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LEGIONELLA AND THE PREVENTION OF LE
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LEGIONELLA AND THE PREVENTION OF LE
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Foreword Legionellosis is a collect
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Contents Foreword . . . . . . . . .
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Chapter 5 Cooling towers and evapor
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Chapter 9 Disease surveillance and
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Tables Table 1.1 Main characteristi
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Figure 8.1 Visible biofilm on inter
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Acknowledgements The World Health O
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• John Newbold, Health and Safety
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Executive summary Legionellosis is
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• Health-care facilities — Chap
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Chapter 1 Legionellosis Britt Horne
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Legionnaires’ disease is often in
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1.1.2 Pontiac fever Symptoms Pontia
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Table . Extrapulmonary nfect ons ca
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Proteins produced by the body’s i
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Aspiration may occur in patients wi
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Table . R sk factors for Legionella
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In the outbreak of Legionnaires’
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Table . Potent al treatments for d
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1.4.2 Species and serogroups associ
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Other causes of infection In Europe
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The interaction of virulent legione
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1.5.2 Surface structures involved i
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1.5.4 Host defence The host defence
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Chapter 2 Ecology and environmental
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L. pneumophila is thermotolerant an
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2.2.3 Environmental factors and vir
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Figure 2.1 Biofilm formation Biofil
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2.4 Sources of Legionella infection
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Chapter 3 Approaches to risk manage
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Table . Cool ng tower outbreaks Fac
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Even when a source reaches a state
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The WSP should be prepared in conju
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Identify control measures Control m
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F gure . Dec mal reduct on t mes fo
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Method Advantages D sadvantages Dos
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Validate effectiveness of water saf
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• clear statements of responsibil
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Chapter 4 Potable water and in-buil
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The remainder of this chapter provi
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4.3.1 Document and describe the sys
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Construction materials — risk fac
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Where temperature controls (discuss
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4.4.2 Monitor control measures This
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Chapter 5 Cooling towers and evapor
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5.1.1 Cross-flow cooling towers As
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water treatments (including chemica
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5.3 System assessment This section
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Spray drift — risk factors Even w
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The section on control measures for
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• periodic or continuous bleed-of
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Box . Po nts to be noted when clean
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In certain circumstances, samples m
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Table . Example documentat on for m
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Chapter 6 Health-care facilities Ma
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For 1999 and 2000, a total of 384 c
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6.3 System assessment This section
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Table . Type of colon zat on of wat
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6.4.1 Identify control measures Thi
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6.5.1 Prepare management procedures
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Until the situation is under contro
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Chapter 7 Hotels and ships Roisin R
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F gure . Detected and reported case
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Table . Rev ew of outbreaks (more t
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7.2 Water safety plan overview WSPs
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The risk of legionellosis is increa
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Kingdom to 66% in Spain (Starlinger
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Agency, Legionella Section, United
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Given the complexity of distributio
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Chapter 8 Natural spas, hot tubs an
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Spas “Natural spa”, denotes fac
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Rare cases of Legionnaires’ disea
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Process step P pework Water n hot t
Page 151 and 152: Hosepipes may sometimes be used to
Page 153 and 154: Hot tubs that are not effectively d
Page 155 and 156: Nutrients — control measures Bath
Page 157 and 158: Various additives may also be used
Page 159 and 160: • descriptions of any significant
Page 161 and 162: Table . Examples of m crob olog cal
Page 163 and 164: Chapter 9 Disease surveillance and
Page 165 and 166: Exposure histories allow cases to b
Page 167 and 168: F gure . Invest gat ng a s ngle cas
Page 169 and 170: Box . (cont nued) Since the incepti
Page 171 and 172: Country United Kingdom All reported
Page 173 and 174: F gure . Annual reported cases, - 0
Page 175 and 176: Training opportunities Trainees in
Page 177 and 178: Box . Example of terms of reference
Page 179 and 180: ecause doing anything more could un
Page 181 and 182: 9.4 Case studies This section descr
Page 183 and 184: 9.4.4 Concrete batcher process on a
Page 185 and 186: Chapter 10 Regulatory aspects David
Page 187 and 188: • validation of the effectiveness
Page 189 and 190: • operating conditions, such as t
Page 191 and 192: 10.4.6 Outbreak investigation and n
Page 193 and 194: hot water (e.g. health-care facilit
Page 195 and 196: General prevent on Country DW Wp SB
Page 197 and 198: Country General prevent on DW Wp SB
Page 199 and 200: Chapter 11 Laboratory aspects of Le
Page 201: • detection of the bacterium in t
Page 205 and 206: 11.2.2 Detecting Legionella antigen
Page 207 and 208: DFA has been used successfully with
Page 209 and 210: • Serologic testing can be used f
Page 211 and 212: Although not all strains can be rel
Page 213 and 214: Generally, any water source that ma
Page 215 and 216: During outbreak investigations, swa
Page 217 and 218: • other Legionella species that d
Page 219 and 220: Appendix 1 Example of a water syste
Page 221 and 222: Weekly water system check list Week
Page 223 and 224: Appendix 2 Example of a 2-week foll
Page 225 and 226: Travel Work/travel in the UK: ❑ Y
Page 227 and 228: Checklist of local places Health/sp
Page 229 and 230: Appendix 3 Example of a national su
Page 231 and 232: Strictly Confidential 2 Hospital Ac
Page 233 and 234: Glossary aerobic bacteria Bacteria
Page 235 and 236: health-care acquired Legionellosis
Page 237 and 238: surveillance The process of systema
Page 239 and 240: References Abu KY, Eisenstein BI, E
Page 241 and 242: Barbaree JM et al. (1987). Protocol
Page 243 and 244: Blatt SP et al. (1994). Legionnaire
Page 245 and 246: Byrne B, Swanson MS (1998). Express
Page 247 and 248: Crespi S (1993). Legionella y legio
Page 249 and 250: Edelstein PH (1982b). Comparative s
Page 251 and 252: Falguera M et al. (2001). Nonsevere
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Gaia V et al. (2003). Sequence-base
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Hayden RT et al. (2001). Direct det
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Ingram JG, Plouffe JF (1994). Dange
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Ko KS et al. (2003). Molecular evol
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Loret JF et al. (2003). Comparison
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McEvoy M et al. (2000). A cluster o
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Olaechea PM et al. (1996). A predic
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Regan CM et al. (2003). Outbreak of
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Schulze-Robbecke R, Rodder M, Exner
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Surman SB, Morton LHG, Keevil CW (1
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Tully M, Williams A, Fitzgeorge RB
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Welti M et al. (2003). Development
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