Nosocomial Legionellosis Research Articles

Outbreak of Nosocomial Legionellosis Managed by Adoption of Chlorine Dioxide Infusion System

Suryeong Go, Su Young Kim, Myoung Jin Shin, Eun Sil Lee, Yoon Jung Kim, Hong Bin Kim, Kyoung-Ho Song, Jeong Su Park, Sug Bae Park, Gun Young Park, Eu Suk Kim. Korean J healthc assoc Infect Control Prev 2023;28:135-42. https://doi.org/10.14192/kjicp.2023.28.1.135

Environmental Surveillance of Legionella spp. in an Italian University Hospital Results of 10 Years of Analysis

The occurrence of Legionella spp. in the water distribution systems of large hospitals and other healthcare facilities is considered particularly dangerous, due to the critical nature of the hospitalized patients. The aim of this study is to present a pluri-annual environmental surveillance in a large university hospital assessing the prevalence of Legionella spp. and underlining its variability over the years. The samples of water were collected in accordance with the Italian National Guidelines and the sampling sites considered in this study were selected favoring wards with very high-risk patients and with patients at increased risk. The laboratory analyzed a total of 305 water samples deriving from 24 different sampling points. Legionella spp. were detected in 39.4% of samples, the majority of which were contaminated by Legionella pneumophila serogroups 2–14 (68.7%). Statistically significant differences were found among different seasons with a linear trend in positive proportion from summer to spring. Several experimental interventions to prevent and reduce Legionella colonization were attempted, but there is no a definitive method for the complete eradication of this microorganism. The permanent monitoring of hospital water distribution systems is fundamental to preventing the potential risk of nosocomial Legionellosis and to implementing procedures to minimize the risk of Legionella spp. colonization.

Surveillance of hospital water systems to help predict the risk of nosocomial legionellosis-Consider other factors.

Surveillance of hospital water systems to help predict the risk of nosocomial legionellosis-Consider other factors.

Risks of legionella pneumonia in patients receiving immunosuppressive therapy

The legionellosis infection associated with medical care is usually registered for patients with reduced immunity, including those receiving immunosuppressive therapy. Prevention of nosocomial legionellosis in patients is essential due to high mortality. The aim . Analyze of the potential risks of legionellosis infection in patients of surgical departments. Materials and methods . Isolation of Legionella pneumophila from water supply systems in Moscow hospitals and serotyping of the isolated microorganism was performed using bacteriological, molecular genetic and enzyme immunoassay methods. Results and discussion . The study showed that there are potential risks of disease in surgical departments of hospitals that provide medical care, including immunocompromised patients. The content of Legionella pneumophila in water reached 10 5 CFU/l. The share of Legionella pneumophila SG 1, which causes up to 80 % of cases of legionellosis in the world, is 13 % in the water of the surveyed hospitals. The only action prevention of legionellosis is the biological safety of water. Conclusion . Due to the presence of potential risks, prevention of legionellosis is a necessary component of ensuring the safety of the treatment process for patients with immunosuppression.

Identification and isolation of homoserine lactones (HSLs) produced by Pseudomonas aeruginosa and the effects on Legionella pneumophila growth

Risk for infections from Legionella pneumophila represents a critical issue for immunocompromised individuals, especially when this species is present within the biofilm of the water distribution systems of hospitals or other health facilities where the complex ancient water network creates environmental conditions that are suitable for Legionella persistence and multiplication. The shock hyperchlorination and subsequent systemic continuous chlorination is a disinfection treatment reported in the Italian Guideline for prevention and control of nosocomial legionellosis as an effective procedure to reduce L. pneumophila colonization of hospital water sources. Although this disinfection strategy has been proven to be effective in the short-term, eradication of Legionella from water networks is usually not achieved. The objective of this study is the identification and purification of P. aeruginosa bacteriocins, such as homoserine lactones (HSLs), by the development of an experimental method by High performance-liquid chromatography (HPLC), coupled to diode array detection (DAD) and the evaluation of the effectiveness of these molecules in the managing of the persistence of L. pneumophila in experimental cocultures.

Water Stagnation and Flow Obstruction Reduces the Quality of Potable Water and Increases the Risk of Legionelloses

Legionella is an opportunistic waterborne pathogen associated with Legionnaires' disease and Pontiac fever. Despite improved public awareness, the incidence of Legionella associated infections has been increasing. Aerosols generated from engineered potable water systems are a demonstrated cause of both nosocomial and community-acquired legionellosis. The ecology of Legionella in these systems is complex with multiple factors impacting their colonization and persistence. Flow dynamics has been identified as an important factor and stagnation in cooling towers is an accepted risk for increased Legionella growth; however, less is known about the impact of flow dynamic on Legionella in potable water systems. This is especially complex due to the inherent intermittent and variable usage observed within outlets of a potable water system. This systematic literature review examines the role of fluid dynamics and stagnation on the colonization and growth of Legionella in potable water systems. Twenty two of 24 identified studies show a positive association between stagnation zones and increased colonization of Legionella. These zones included dead legs, dead ends, storage tanks, and obstructed water flow (such as intermittent usage or flow restriction). Prolonged stagnation in building plumbing systems also deteriorates the quality of thermally or chemically treated potable water. This stimulates the colonization of Legionella established biofilms. Such biofilms are intrinsically resistant to disinfection procedures and accelerate the rate of decay of chemical disinfectants. Sub-lethal doses of disinfectants and the presence of protozoan hosts in stationary water promote generation of viable but non-culturable Legionella cells. This results in false negatives in surveillance methods that use culture methodology. In conclusion, elimination of temporal and permanent stagnation points can improve the quality of potable water, efficacy of disinfectants, and reduce the risk of legionellosis. Current guidelines and water safety plans recognize the risks associated with permanent stagnation point (dead ends and dead legs); however, there is a need for greater emphasis on controlling temporal stagnation arising from intermittent usage.

Prevention of nosocomial legionellosis by best water management: comparison of three decontamination methods

Since 2000, the National Health System has adopted international guidelines for assessing Legionella spp. in hospital water systems. The control of water contamination by Legionella spp. is still a matter of research concerning the most effective method in preventing nosocomial infections. To compare three different decontamination methods by monitoring colony-forming unit count and number of hospital-acquired legionellosis cases. A secondary objective was to evaluate the long-term effects of the preventive measures on the water pipes. A protocol was developed for the selection of high-risk sampling sites and for the testing of three disinfection methods over the course of 19 years: hyperchlorination and thermal shock (period A, 2000-2005); copper-silver ionization (period B, 2006-2010); and integration of pre-filtering, filtering, pipe-protecting products, and remote control with chlorine dioxide (ClO2) (period C, 2011-2018). The use of shock disinfection and hyperchlorination led to a decrease in contamination level immediately after the procedure, but then it rose again to the previous level in two months. Both copper-silver ionization and ClO2 disinfection showed a stable and durable decrease in contamination level. Throughout these three phases, six cases of Legionella spp. occurred during period A, six cases during period B, and three cases during period C. With regard to the damage of water pipes, effective copper-silver levels caused corrosion and calcification in water pipes. Both copper-silver ionization and ClO2 properly controlled Legionella spp. contamination. ClO2 significantly reduced the number of positive sites (P < 0.001) without damaging the pipelines.

1622. Clinical and Environmental Surveillance of Legionella pneumophila in a Tertiary Healthcare Center in India

BackgroundLegionellosis is a form of pneumonia caused by Gram-negative bacilli belonging to the Legionella genus. In India, sporadic cases of legionellosis have been reported, but the incidence of this infection is still believed to be underestimated. We conducted a proactive clinical–environmental surveillance in a tertiary healthcare center to determine the frequency of legionellosis, and to identify the pathogen in the hospital water systems.MethodsDuring February 2015–February 2019, we enrolled 533 cases (310 males, 223 females) with a diagnosis of pneumonia; a respiratory secretion was collected from each patient and tested for L.pneumophila by using a real-time PCR targeting mip gene. To identify Legionella spp. present in hospital water systems, we collected 201 hospital water samples and were analyzed by cultivation in BCYE agar. Legionella speciation and identification of Lp1 was done by real-time PCR assay.ResultsAmong 533 cases, 11(2.1%) [6 male, 5 female] tested positive for L.pneumophila by real-time PCR. Of these, all were community-acquired sporadic cases not associated with a cluster or outbreak. Risk factors including smoking, alcohol use, malignancy, underlying respiratory disease, hypertension were identified in 8 (72.7%) cases. The duration of hospitalization for Legionella patients was 8–24 days; 5/11 (45.5%) patients were admitted to intensive care units. Of 11 patients 8 (72.7%) survived, and 3(27.3%) died. Among the 201 water samples tested, 38 (18.9%) tested positive for L.pneumophila by culture. The presence of Lp1 was detected in 25 (12.4%) water samples. Legionella spp. was recurrently isolated from patient areas, cooling towers, residential areas, and other areas inside the hospital campus.ConclusionThe study indicates a low prevalence of legionellosis in this region. Even though Legionella colonization was detected in the hospital water system, no cases of hospital-acquired legionellosis were discovered during the study period. However, considering the risk of nosocomial legionellosis to patients we formulated Legionella control strategies in this hospital. Point-of-use filters were installed to the potable water units from where Legionella was isolated and repeat sampling from these sites were found to be negative for the contagion.Disclosures All authors: No reported disclosures.

Environmental Surveillance of Legionellosis within an Italian University Hospital-Results of 15 Years of Analysis.

Legionnaires’ disease is normally acquired by inhalation of legionellae from a contaminated environmental source. Water systems of large and old buildings, such as hospitals, can be contaminated with legionellae and therefore represent a potential risk for the hospital population. In this study, we demonstrated the constant presence of Legionella in water samples from the water system of a large university hospital in Messina (Sicily, Italy) consisting of 11 separate pavilions during a period of 15 years (2004–2018). In total, 1346 hot water samples were collected between January 2004 and December 2018. During this period, to recover Legionella spp. from water samples, the standard procedures reported by the 2000 Italian Guidelines were adopted; from May 2015 to 2018 Italian Guidelines revised in 2015 (ISS, 2015) were used. Most water samples (72%) were positive to L. pneumophila serogroups 2–14, whereas L. pneumophila serogroup 1 accounted for 18% and non-Legionella pneumophila spp. Accounted for 15%. Most of the positive samples were found in the buildings where the following critical wards are situated: (Intensive Care Unit) ICU, Neurosurgery, Surgeries, Pneumology, and Neonatal Intensive Unit Care. This study highlights the importance of the continuous monitoring of hospital water samples to prevent the potential risk of nosocomial legionellosis.

Preventing Healthcare-Associated Legionellosis: Results after 3 Years of Continuous Disinfection of Hot Water with Monochloramine and an Effective Water Safety Plan.

The purpose of this study is to report the experience of the implementation and application of a 3-year Water Safety Plan (WSP) together with the secondary disinfection of water by monochloramine to control and prevent healthcare-associated legionellosis in an Italian hospital strongly colonized by Legionella. Risk assessment was carried out by the WSP team. The main critical control points focused on in developing the WSP for the control of Legionella was the water distribution system. A sampling plan for the detection of Legionella was implemented. A widespread contamination of the hot water distribution system by L. pneumophila sg5 was found. Results after 3 years of the continuous disinfection of hot water with monochloramine indicate the eradication of Legionella. The implementation and application of a WSP in a hospital, together with the disinfection of the water distribution system with monochloramine, can be effective in controlling the growth of Legionella and in preventing nosocomial legionellosis.

Whole-Genome Sequencing Detects Nosocomial Legionellosis

Nosocomial legionellosis, usually caused by Legionella pneumophila serogroup 1 (LPS1), is acquired by inhaling aerosol from contaminated hospital water-delivery systems. Detecting nosocomial legionellosis can be difficult, but whole-genome sequencing (WGS) yields detailed genetic analysis of both patient and environmental strains, allowing for assessment of transmission events. In 2013, two …

Legionella prevalence and risk of legionellosis in Hungarian hospitals.

Nosocomial legionellosis is a growing concern worldwide. In Hungary, about 20% of the reported cases are health-care associated, but in the absence of legal regulation, environmental monitoring of Legionella is not routinely performed in hospitals. In the present study, 23 hospitals were investigated. The hot water distribution system was colonized by Legionella in over 90%; counts generally exceeded the public health limit value. Hot water temperature was critically low in all systems (<45 °C), and large differences (3-38 °C temperature drop) were observed within buildings, indicating insufficient circulation. Most facilities were older than 30 years (77%); however, new systems (n = 3) were also shown to be rapidly colonized at low hot water temperature. Vulnerable source of drinking water, complex distribution system, and large volume hot water storage increased the risk of Legionella prevalence (OR = 28.0, 27.3, 27.7, respectively). Risk management interventions (including thermal or chemical disinfection) were only efficient if the system operation was optimized. Though the risk factors were similar, in those hospitals where nosocomial legionellosis was reported, Legionella counts and the proportion of L. pneumophila sg 1 isolates were significantly higher. The results of environmental prevalence of legionellae in hospitals suggest that the incidence of nosocomial legionellosis is likely to be underreported. The observed colonization rates call for the introduction of a mandatory environmental monitoring scheme.

Trend of Legionella colonization in hospital water supply.

In many nosocomial Legionella outbreaks water distribution systems are the most frequent source of infection. Considering the hospital waterline old age, an investigation on colonization by Legionella spp was carried out in order to evaluate the pipeline system weaknesses and to implement environmental preventive measures. From 2004 to 2010, overall 97 samples from the water line were collected. The samples were analyzed according to the italian Legionella spp standard methods; water temperature, pH and residual free chlorine were determined at the time of collection. X2 test, exact-test and t-test were used to compare proportions and means. Overall 28 samples (23.7%) were positive for Legionella spp, and five of them (17.9%) exceeded the threshold level >104 cfu/L. The number of positive samples varied along the years, showing a significant increasing trend (X2 for trend = 11.5; p<0.01), but most occurred in 2008 (53,6%), when the hospital underwent major building reconstruction. Samples positive for Legionella spp by comparison to negative ones showed a lower free chlorine concentration (0.08 mg/L vs 0.15 mg/L) and a higher water temperature (46.1° vs 42.7°). Actually the percentage of positive samples decreased significantly with the increasing in free chlorine in the water (X2 for trend = 8.53; p<0.01). The samples collected at the connection between public water line with the hospital supply network were always free from Legionella. All hospital buildings were colonized by Legionella spp, although 80% of samples >104 cfu/L occurred in the C-building. No cases of nosocomial legionellosis were reported during the study period. Hospital water system showed a diffuse colonization by Legionella spp, although the degree of contamination reached the threshold level (>104 cfu/L) only in a small percentage of samples, showing a substantial effectiveness of the control measures applied.

Combination of two methods for Legionella disinfection of water systems (cooling towers and potable water) in a Spanish hospital

This field study assesses the effectiveness of the installation of the Pastormaster system in potable water systems and a photo-catalyst in the cooling system as strategy for Legionella control in a Spanish hospital. Monthly, water samples were collected from taps in the Haematological Unit and the hospital cooling tower from 30-March-2005 to 31-December-2010. In the pre-installation period, all Legionella isolates from taps belonged to serogroups 2-14, and the isolation rate was 100% reduced after the Pastormaster system installation. In the cooling system, L. pneumophila serogroup 1 accounted for 80.0% of all Legionella isolates in the pre-installation period. After the photo-catalyst installation, isolation of L. pneumophila serogroup 1 was 57.2% reduced, but there was a significant increase in the isolation of Legionella isolates belonging to other serogroups or species. This study shows that the strategy implemented was highly effective in reducing serogroup 2-14 Legionella isolation from taps, thus potentially preventing nosocomial legionellosis, but not in reducing overall Legionella isolation in cooling towers.

Surveillance of Legionella species in hospital water systems: the significance of detection method for environmental surveillance data

Monitoring of hospital water systems to prevent and control nosocomial legionellosis is important from a public health perspective. This study was conducted to survey the prevalence of Legionella contamination of hospital waters. A total of 44 water samples from the hot-water system of 11 hospitals were tested for Legionella by a culture method and a nested polymerase chain reaction (PCR) assay with Legionella-specific primers to identify the more sensitive method. Some physicochemical parameters and heterotrophic plate counts of water samples for possible association with Legionella contamination were also determined. The contamination rate of hospitals in our study varied between 64% (eight of 11)-100% based on culture method and nested PCR, respectively. Of the 44 water samples examined, 23% were positive for Legionella spp. by the culture method, while the nested PCR assay using the primers LEG448-JRP revealed 66% of the water samples being positive. Given the importance of monitoring hospital water systems for the presence of Legionella spp., the present PCR assay proved highly applicable for practical and sensitive surveillance of Legionella in such water systems. In addition, rapid monitoring of Legionella contamination could eliminate the potential exposure of high-risk patients through effective control measures.

An unprecedented outbreak investigation for nosocomial and community-acquired legionellosis in Hong Kong.

The environmental sources associated with community-acquired or nosocomial legionellosis were not always detectable in the mainland of China and Hong Kong, China. The objective of this study was to illustrate the control measures implemented for nosocomial and community outbreaks of legionellosis, and to understand the environmental distribution of legionella in the water system in Hong Kong, China. We investigated the environmental sources of two cases of legionellosis acquired in the hospital and the community by extensive outbreak investigation and sampling of the potable water system using culture and genetic testing at the respective premises. The diagnosis of nosocomial legionellosis was suspected in a patient presenting with nosocomial pneumonia not responsive to multiple beta-lactam antibiotics with subsequent confirmation by Legionella pneumophila serogroup 1 antigenuria. High counts of Legionella pneumophila were detected in the potable water supply of the 70-year-old hospital building. Another patient on continuous ambulatory peritoneal dialysis presenting with acute community-acquired pneumonia and severe diarrhoea was positive for Legionella pneumophila serogroup 1 by polymerase chain reaction (PCR) testing on both sputum and nasopharyngeal aspirate despite negative antigenuria. Paradoxically the source of the second case was traced to the water system of a newly commissioned office building complex. No further cases were detected after shock hyperchlorination with or without superheating of the water systems. Subsequent legionella counts were drastically reduced. Point-of-care infection control by off-boiled or sterile water for mouth care and installation of water filter for showers in the hospital wards for immunocompromised patients was instituted. Territory wide investigation of the community potable water supply showed that 22.1% of the household water supply was positive at a mean legionella count of 108.56 CFU/ml (range 0.10 to 639.30 CFU/ml). Potable water systems are open systems which are inevitably colonized by bacterial biofilms containing Legionella species. High bacterial counts related to human cases may occur with stagnation of flow in both old or newly commissioned buildings. Vigilance against legionellosis is important in healthcare settings with dense population of highly susceptible hosts.

Legionella pneumophila: risk assessment and strategy for the prevention and control of nosocomial infections

The term “Legionellosis” includes all forms of disease caused by microorganisms of the genus Legionella; it may manifest as a flu-like shape (Pontiac fever), or with severe pneumonia with high mortality (Legionnaires Disease). The causative agent was Legionella pneumophila in the literature although other strains of the genus Legionella are classified as pathogens, mode of transmission is through inhalation of aerosol particles produced by hot water or air conditioning systems: for this reason in community settings and nosocomial L. pneumophila represents a serious public health problem. In the light of epidemiological data since the year 2000 the Italian State has issued a series of provisions laws concerning the prevention and control of nosocomial Legionellosis environment and community.The present work aims to evaluate the presence of Legionella species and L. pneumophila comparing the different approaches proposed by the Guidelines of the regions of Lombardy and Piedmont in terms of assessment and prevention of risk “Legionellosis” in the field of nosocomial infection. The analytical methods used are those provided by the Regional Guidelines: the official method in the second CSR April 4 Method 2000 and UNI EN ISO 11731-1: 2008. Checks have been performed on equipment for the comparison of cold water, hot water and air conditioning in nursing homes, retirement homes and hospitals.The results obtained show that the method CSR April 4, 2000 restricts the search to L. pneumophila permitting, than the method EN ISO 11731-1: 2008, to carry out a risk assessment well targeted to the actual pathogen.The culture method for the detection of L. pneumophila allows you to not only prevention, but also to implement a series of targeted interventions following the directions of the legislation.

ANALYSIS OF THE LEVEL AND RATE OF LEGIONELLA PNEUMOPHILA CONTAMINATION OF HOT WATER SUPPLY SYSTEMS IN THE THERAPEUTIC-AND-PROPHYLACTIC INSTITUTIONS OF MOSCOW

The specific features of Legionella colonization of water supply systems were studied in the large healthcare facilities (HCF) of Moscow. Examination of 16 buildings of 5 Moscow multidisciplinary HCFs, including their risk-group units, revealed the high level (68%) of Legionella pneumophila contamination of hot water supply systems. Among the Legionella pneumophila strains circulating in the hot water supply systems of Moscow HCFs, there was a preponderance of its serogroup 6 (44%), 5 (26%), and 1 (13%) strains. The findings suggest that it is necessary to arrange a set of prophylactic measures for microbiological monitoring and protection of water systems in the HCFs, which are aimed at preventing nosocomial legionellosis.

Legionella pneumophila contamination in a steam towel warmer in a hospital setting

For prevention of nosocomial legionellosis, environmental investigation to identify possible infectious sources is essential. An environmental study in a ward of our hospital revealed that a steam towel warmer was contaminated with legionella whereas no legionella was detected in tap water supplies and shower heads. Water in the apparatus may be a reservoir of legionella. We abandoned the use of all steam towel warmers in our hospital. Based on this finding, we recommend that steam towel warmers in hospital settings be avoided. Otherwise, the apparatus should be drained, cleaned and dried everyday.

Environmental factors associated with nosocomial legionellosis after anti–tumor necrosis factor therapy: Case study

In response to 2 reported cases of nosocomial legionellosis after anti-tumor necrosis factor (TNF) treatment, the environmental controls and testing facilities in a 221-bed acute care hospital were investigated. This investigation led to the implementation of a series of specific preventive measures adapted from protocols used to protect immunosuppressed patients. These 2 cases of legionellosis might be related to 2 concurrent events: treatment of hospitalized patients with anti-TNF drugs and secondary environmental changes related to major construction work. Patients undergoing anti-TNF treatment may be at increased risk for developing opportunistic infections during construction work, renovations, or water supply perturbations and require specific preventive measures.