LEGIONELLA - World Health Organization

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Symptoms The clinical manifestations of extrapulmonary Legionella infections are often dramatic. Legionella have been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis, most often in immunocompromised patients (Eitrem, Forsgren & Nilsson, 1987; Stout & Yu, 1997). Lowry & Tompkins (1993) reported 13 extrapulmonary infections, including brain abscesses and sternal wound infections. The most commonly affected site is the heart (e.g. myocarditis, pericarditis, postcardiomyotomy syndrome and endocarditis) (Stout & Yu, 1997). Endocarditis due to Legionella spp. has been cited in only a few publications, and in all reported cases patients had a prosthetic valve (McCabe et al., 1984; Tompkins et al., 1988; Chen, Schapiro & Loutit, 1996). The patients showed low-grade fever, night sweats, weight loss, malaise, symptoms of congestive heart failure, and vegetation on echocardiography (Brouqui & Raoult, 2001). Legionella rarely spreads into the nervous system; more frequently, it leads to neurological manifestations of encephalomyelitis, cerebellum involvement and peripheral neuropathy (Shelburne, Kielhofner & Tiwari, 2004). Legionella meningoencephalitis may mimic the symptoms of herpes encephalitis (Karim, Ahmed & Rossoff, 2002). Diagnosis Legionellosis should be considered in the differential diagnosis of patients showing a combination of neurological, cardiac and gastrointestinal symptoms, particularly in the presence of radiographic pneumonia (Shelburne, Kielhofner & Tiwari, 2004). Causative agent Among the four species of Legionella responsible for extrapulmonary infections, L. pneumophila was the most commonly isolated bacteria (Lowry & Tompkins, 1993). <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Table . Extrapulmonary nfect ons caused by Leg onella spec es Number of cases Age (years) 1 40 Maxillary sinus 1 62 Cutaneous abscess S te of nfect on Leg onella spec es <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS Nosocom al Transm ss on L. pneumophila sg 1 No Unknown L. micdadei No Seeding from pneumonia 1 33 Brain abscess L. jordanis No Unknown 1 70 Bowel, liver, kidney, spleen, peritonitis L. pneumophila sg 1 No Possible oral ingestion 1 71 Hip wound L. pneumophila sg 4 Yes Water contact 1 51 Myocarditis Legionella (not speciated) No Unknown 1 22 Pericardial effusion Legionella (not speciated) No Unknown 1 43 Pericardial L. pneumophila sg 3 No Seeding from effusion pneumonia 1 33 Pericardial L. pneumophila No Seeding from effusion not serotyped) pneumonia 1 27 Bovine A-V- L. pneumophila sg 1 No Seeding from fistula infection pneumonia 1 69 Synthetic A-V- L. pneumophila sg 1 No Seeding from fistula infection pneumonia 1 62 Acute L. pneumophila sg 4 Yes Seeding from pyelonephritis with abscess pneumonia 1 46 Perirectal abscess L. pneumophila sg 3 Yes Water contact 7 51 Prosthetic L. pneumophila sg 1 Yes Unknown (mean) valve endocarditis (2 strains) and L. dumoffii 3 3 weeks, Sternal wound L. pneumophila sg 1 Yes Water contact 27, 85 sg = serogroup infection and L. dumoffii Source: Reprinted from Lowry & Tompkins, 1993, with permission from the Association for Professionals in Infection Control & Epidemiology, Inc.
Page 1 and 2: LEGIONELLA AND THE PREVENTION OF LE
Page 3 and 4: LEGIONELLA AND THE PREVENTION OF LE
Page 5 and 6: Foreword Legionellosis is a collect
Page 7 and 8: Contents Foreword . . . . . . . . .
Page 9 and 10: Chapter 5 Cooling towers and evapor
Page 11 and 12: Chapter 9 Disease surveillance and
Page 13 and 14: Tables Table 1.1 Main characteristi
Page 15 and 16: Figure 8.1 Visible biofilm on inter
Page 17 and 18: Acknowledgements The World Health O
Page 19 and 20: • John Newbold, Health and Safety
Page 21 and 22: Executive summary Legionellosis is
Page 23 and 24: • Health-care facilities — Chap
Page 25 and 26: Chapter 1 Legionellosis Britt Horne
Page 27 and 28: Legionnaires’ disease is often in
Page 29: 1.1.2 Pontiac fever Symptoms Pontia
Page 33 and 34: Proteins produced by the body’s i
Page 35 and 36: Aspiration may occur in patients wi
Page 37 and 38: Table . R sk factors for Legionella
Page 39 and 40: In the outbreak of Legionnaires’
Page 41 and 42: Table . Potent al treatments for d
Page 43 and 44: 1.4.2 Species and serogroups associ
Page 45 and 46: Other causes of infection In Europe
Page 47 and 48: The interaction of virulent legione
Page 49 and 50: 1.5.2 Surface structures involved i
Page 51 and 52: 1.5.4 Host defence The host defence
Page 53 and 54: Chapter 2 Ecology and environmental
Page 55 and 56: L. pneumophila is thermotolerant an
Page 57 and 58: 2.2.3 Environmental factors and vir
Page 59 and 60: Figure 2.1 Biofilm formation Biofil
Page 61 and 62: 2.4 Sources of Legionella infection
Page 63 and 64: Chapter 3 Approaches to risk manage
Page 65 and 66: Table . Cool ng tower outbreaks Fac
Page 67 and 68: Even when a source reaches a state
Page 69 and 70: The WSP should be prepared in conju
Page 71 and 72: Identify control measures Control m
Page 73 and 74: F gure . Dec mal reduct on t mes fo
Page 75 and 76: Method Advantages D sadvantages Dos
Page 77 and 78: Validate effectiveness of water saf
Page 79 and 80: • 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
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Hosepipes may sometimes be used to
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Hot tubs that are not effectively d
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Nutrients — control measures Bath
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Various additives may also be used
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• descriptions of any significant
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Table . Examples of m crob olog cal
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Chapter 9 Disease surveillance and
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Exposure histories allow cases to b
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F gure . Invest gat ng a s ngle cas
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Box . (cont nued) Since the incepti
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Country United Kingdom All reported
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F gure . Annual reported cases, - 0
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Training opportunities Trainees in
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Box . Example of terms of reference
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ecause doing anything more could un
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9.4 Case studies This section descr
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9.4.4 Concrete batcher process on a
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Chapter 10 Regulatory aspects David
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• validation of the effectiveness
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• operating conditions, such as t
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10.4.6 Outbreak investigation and n
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hot water (e.g. health-care facilit
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General prevent on Country DW Wp SB
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Country General prevent on DW Wp SB
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Chapter 11 Laboratory aspects of Le
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• detection of the bacterium in t
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Method Sens t v ty (%) PCR • Rapi
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11.2.2 Detecting Legionella antigen
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DFA has been used successfully with
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• Serologic testing can be used f
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Although not all strains can be rel
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Generally, any water source that ma
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During outbreak investigations, swa
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• other Legionella species that d
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Appendix 1 Example of a water syste
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Weekly water system check list Week
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Appendix 2 Example of a 2-week foll
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Travel Work/travel in the UK: ❑ Y
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Checklist of local places Health/sp
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Appendix 3 Example of a national su
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Strictly Confidential 2 Hospital Ac
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Glossary aerobic bacteria Bacteria
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health-care acquired Legionellosis
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surveillance The process of systema
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References Abu KY, Eisenstein BI, E
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Barbaree JM et al. (1987). Protocol
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Blatt SP et al. (1994). Legionnaire
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Byrne B, Swanson MS (1998). Express
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Crespi S (1993). Legionella y legio
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Edelstein PH (1982b). Comparative s
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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
Page 275 and 276:
Welti M et al. (2003). Development
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LEGIONELLA - World Health Organization

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