LEGIONELLA - World Health Organization

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Evaluation of antimicrobial agents When extracellular, legionellae are susceptible to a wide range of antimicrobial agents. However, in an infection, where the microorganism is inside the cell; the only antimicrobial agents that are clinically useful are those that achieve high intracellular concentrations. Therefore, new drugs have to be evaluated in regard to: • their minimum inhibitory concentration values against Legionella spp. • their activity in cellular culture systems • their activity in animal studies • the clinical context. Suggested treatments Only a few small, controlled clinical studies of antibiotic treatment for Legionnaires’ disease have been completed; hence, the evidence for treatment recommendations is limited (Thornsberry, Baker & Kirven, 1978; Yoo et al., 2004; Yu et al., 2004). One small clinical study showed that treatment with fluoroquinolone pefloxacin gives patients a higher survival rate than treatment with erythromycin (Dournon et al., 1990). The new macrolide antibiotics, such as clarithromycin and azithromycin, show more effective in-vitro activity and a better intracellular and tissue penetration than erythromycin, as do the quinolones. Beta-lactam antibiotics are not effective against Legionnaires’ disease, but are the first choice of antibiotics for pneumococcal pneumonia, and are used together with macrolides to treat severe pneumonia. Where a rapid diagnostic test for Legionnaires’ disease is not in use, many people presenting with this disease are simply treated with macrolides plus betalactam antibiotics, because a delay in the application of appropriate therapy for Legionella pneumonia significantly increases mortality (Stout & Yu, 1997). Table 1.8 lists the various treatments for different groups of patients with Legionnaires’ disease. <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS
Table . Potent al treatments for d fferent pat ent groups Treatment Pat ent group Reference Comments Respiratory fluoroquinolone Rifampicin with erythromycin, clarithromycin, or a tetracycline Highly active fluoroquinolone (e.g. levofloxacin, ciprofloxacin, moxifloxacin, and probably gatifloxacin) or azithromycin Imipenem, clindamycin, and trimethoprimsulfamethoxazole Broad-spectrum antibiotic Intravenous azithromycin or a respiratory quinolone; or doxycycline (200 mg twice a day) New transplant recipients Severely ill patients Vesley, Pien & Pien (1998) Severely ill patients Ewig, Tuschy & Fatkenheuer (2002) <strong>LEGIONELLA</strong> AND THE PREVENTION OF LEGIONELLOSIS Generally recommended, because of the pharmacological interaction of the macrolides and rifampicin with immunosuppressive medication, and with each other No clinical evidence Removes need for rifampicin therapy General use Stout & Yu (1997) Have been used for treatment with mixed success; their use for treatment of Legionnaires’ disease is not reliable Patients with mild Legionnaires’ disease Patients who are immunocompromised or have a potentially life-threatening infection Erythromycin Patients with extrapulmonary legionellosis Edelstein (1994); Beovic et al. (2003) Muder (2005); Tompkins et al. (1988); Brouqui & Raoult (2001) Lowry & Tompkins (1993); Park, Pugliese & Cunha (1994); Brouqui & Raoult (2001) Drainage of purulent material or surgical intervention also commonly needed
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 and 30: 1.1.2 Pontiac fever Symptoms Pontia
Page 31 and 32: Table . Extrapulmonary nfect ons ca
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: In the outbreak of Legionnaires’
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
Page 81 and 82: Chapter 4 Potable water and in-buil
Page 83 and 84: The remainder of this chapter provi
Page 85 and 86: 4.3.1 Document and describe the sys
Page 87 and 88: Construction materials — risk fac
Page 89 and 90: 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
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Welti M et al. (2003). Development
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LEGIONELLA - World Health Organization

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