Hostname: page-component-cd9895bd7-dk4vv Total loading time: 0 Render date: 2024-12-23T03:52:30.612Z Has data issue: false hasContentIssue false

Role of Environmental Surveillance in Determining the Risk of Hospital-Acquired Legionellosis: A National Surveillance Study With Clinical Correlations

Published online by Cambridge University Press:  02 January 2015

Janet E. Stout
Affiliation:
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania University of Pittsburgh, Pittsburgh, Pennsylvania
Robert R. Muder
Affiliation:
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania University of Pittsburgh, Pittsburgh, Pennsylvania
Sue Mietzner
Affiliation:
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania University of Pittsburgh, Pittsburgh, Pennsylvania
Marilyn M. Wagener
Affiliation:
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania University of Pittsburgh, Pittsburgh, Pennsylvania
Mary Beth Perri
Affiliation:
William Beaumont Hospital, Royal Oak, Michigan
Kathleen DeRoos
Affiliation:
Veterans Affairs Medical Center, Omaha, Nebraska
Dona Goodrich
Affiliation:
Veterans Affairs Medical Center, Omaha, Nebraska
William Arnold
Affiliation:
Veterans Affairs Medical Center, Omaha, Nebraska
Theresa Williamson
Affiliation:
Southern Arizona Healthcare System, Tucson
Ola Ruark
Affiliation:
Veterans Affairs Medical Center, Wilmington, Delaware
Christine Treadway
Affiliation:
Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
Elizabeth C. Eckstein
Affiliation:
Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
Debra Marshall
Affiliation:
Veterans Affairs Medical Center, Dayton, Ohio
Mary Ellen Rafferty
Affiliation:
Stratton Veterans Affairs Medical Center, Albany, New York
Kathleen Sarro
Affiliation:
Veterans Affairs Medical Center, Butler, Pennsylvania
Joann Page
Affiliation:
Veterans Affairs Medical Center, Iowa City, Iowa
Robert Jenkins
Affiliation:
Veterans Affairs Medical Center, Gainesville, Florida
Gina Oda
Affiliation:
Veterans Affairs Palo Alto Health Care System, Palo Alto, California
Kathleen J. Shimoda
Affiliation:
Veterans Affairs Medical Center, Long Beach, California
Marcus J. Zervos
Affiliation:
William Beaumont Hospital, Royal Oak, Michigan
Marvin Bittner
Affiliation:
Veterans Affairs Medical Center, Omaha, Nebraska
Sharon L. Camhi
Affiliation:
Southern Arizona Healthcare System, Tucson
Anand P. Panwalker
Affiliation:
Veterans Affairs Medical Center, Wilmington, Delaware
Curtis J. Donskey
Affiliation:
Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio
Minh-Hong Nguyen
Affiliation:
Veterans Affairs Medical Center, Gainesville, Florida
Mark Holodniy
Affiliation:
Veterans Affairs Palo Alto Health Care System, Palo Alto, California
Victor L. Yu*
Affiliation:
University of Pittsburgh, Pittsburgh, Pennsylvania
*
Special Pathogens Laboratory, 1401 Forbes Ave., Ste. 209, Pittsburgh, PA 15219 ([email protected])

Abstract

Objective.

Hospital-acquired Legionella pneumonia has a fatality rate of 28%, and the source is the water distribution system. Two prevention strategies have been advocated. One approach to prevention is clinical surveillance for disease without routine environmental monitoring. Another approach recommends environmental monitoring even in the absence of known cases of Legionella pneumonia. We determined the Legionella colonization status of water systems in hospitals to establish whether the results of environmental surveillance correlated with discovery of disease. None of these hospitals had previously experienced endemic hospital-acquired Legionella pneumonia.

Design.

Cohort study.

Setting.

Twenty US hospitals in 13 states.

Interventions.

Hospitals performed clinical and environmental surveillance for Legionella from 2000 through 2002. All specimens were shipped to the Special Pathogens Laboratory at the Veterans Affairs Pittsburgh Medical Center.

Results.

Legionella pneumophila and Legionella anisa were isolated from 14 (70%) of 20 hospital water systems. Of 676 environmental samples, 198 (29%) were positive for Legionella species. High-level colonization of the water system (30% or more of the distal outlets were positive for L. pneumophila) was demonstrated for 6 (43%) of the 14 hospitals with positive findings. L. pneumophila serogroup 1 was detected in 5 of these 6 hospitals, whereas 1 hospital was colonized with L. pneumophila serogroup 5. A total of 633 patients were evaluated for Legionella pneumonia from 12 (60%) of the 20 hospitals: 377 by urinary antigen testing and 577 by sputum culture. Hospital-acquired Legionella pneumonia was identified in 4 hospitals, all of which were hospitals with L. pneumophila serogroup 1 found in 30% or more of the distal outlets. No cases of disease due to other serogroups or species (L. anisa) were identified.

Conclusion.

Environmental monitoring followed by clinical surveillance was successful in uncovering previously unrecognized cases of hospital-acquired Legionella pneumonia.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Benin, AL, Benson, RF, Besser, RE. Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis. Clin Infect Dis 2002;35:10391046.Google Scholar
2.Butler, JC, Fields, BS, Breiman, RF. Prevention and control of legionellosis. Infect Dis Clin Pract 1997;6:458464.CrossRefGoogle Scholar
3.Joseph, C. Surveillance of legionnaires disease in Europe. In: Marrie, R, ed. Legionella. Washington, DC: American Society for Microbiology; 2002:311317.Google Scholar
4.Squier, CL, Stout, JE, Krystofiak, S, et al.A proactive approach to prevention of healthcare-acquired legionnaires disease: the Allegheny County (Pittsburgh) experience. Am J Infect Control 2005;33:360367.Google Scholar
5.Allegheny County Health Department. Approaches to Prevention and Control of Legionella Infection in Allegheny County Health Care Facilities. 2nd ed. Pittsburgh, PA: Allegheny County Health Department; 1997:115. Available at: http://www.legionella.org. Accessed June 1, 2007.Google Scholar
6.Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia, 2003. MMWR Morb Mortal Wkly Rep 2004;53(RR-3):136.Google Scholar
7.Yu, VL. Resolving the controversy on environmental cultures for Legionella. Infect Control Hosp Epidemiol 1998;19:893897.CrossRefGoogle ScholarPubMed
8.O'Neill, E, Humphreys, H. Surveillance of hospital water and primary prevention of nosocomial legionellosis: what is the evidence? J Hosp Infect 2005;59:273279.CrossRefGoogle ScholarPubMed
9.Ruef, C. Nosocomial legionnaires disease—strategies for prevention. J Microbiol Methods 1998;33:8191.Google Scholar
10.Stout, JE, Rihs, JD, Yu, VL. Legionella. In: Murray, PR, Baron, EJ, Jorgensen, JH, Pfaller, MA, Yolken, RH, eds. Manual of Clinical Microbiology. Washington, DC: ASM Press; 2003:809823.Google Scholar
11.Drenning, SD, Stout, JE, Joly, JR, Yu, VL. Unexpected similarity of pulsed-field gel electrophoresis patterns of unrelated clinical isolates of Legionella pneumophila, serogroup 1. J Infect Dis 2001;183:628632.CrossRefGoogle ScholarPubMed
12.Kool, JL, Bergmire-Sweat, D, Butler, JC, et al.Hospital characteristics associated with colonization of water systems by Legionella and risk of nosocomial legionnaires disease: a cohort study of 15 hospitals. Infect Control Hosp Epidemiol 1999;20:798805.CrossRefGoogle ScholarPubMed
13.Best, M, Yu, VL, Stout, J, Goetz, A, Muder, RR, Taylor, F. Legionellaceae in the hospital water supply—epidemiological link with disease and evaluation of a method of control of nosocomial legionnaires disease and Pittsburgh pneumonia. Lancet 1983;2:307310.CrossRefGoogle ScholarPubMed
14.Sabria, M, Modol, JM, Garcia-Nunez, M, et al.Environmental cultures and hospital-acquired legionnaires disease: a 5-year prospective study in 20 hospitals in Catalonia, Spain. Infect Control Hosp Epidemiol 2004;25:10721076.Google Scholar
15.Boccia, S, Laurenti, P, Borella, P, et al.Prospective 3-year surveillance for nosocomial and environmental legionella: implications for infection control. Infect Control Hosp Epidemiol 2006;27:459465.CrossRefGoogle ScholarPubMed
16.Formica, N, Yates, M, Beers, M, et al.The impact of diagnosis by Legionella urinary antigen test on the epidemiology and outcomes of legionnaires disease. Epidemiol Infect 2001;127:275280.CrossRefGoogle ScholarPubMed
17.Fields, BS, Benson, RF, Besser, RE. Legionella and legionnaires disease: 25 years of investigation. Clin Microbiol Rev 2002;15:506526.CrossRefGoogle ScholarPubMed
18.Helbig, JH, Bernander, S, Castellani-Pastoris, M, et al.Pan-European study on culture-proven legionnaires disease distribution of Legionella pneumophila serogroups and monoclonal subgroups. Eur J Clin Microbiol Infect Dis 2002;21:710716.Google Scholar
19.Yu, VL, Plouffe, JF, Castellani-Pastoris, M, et al.Distribution of Legionella species and serogroups isolated by culture in consecutive patients with community acquired pneumonia: an international collaborative survey. J Infect Dis 2002;186:127128.Google Scholar
20.Doleans, A, Aureli, H, Reyrolle, M, et al.Clinical and environmental distributions of Legionella strains in France are different. J Clin Microbiol 2004;42:458460.CrossRefGoogle ScholarPubMed
21.Chang, FY, lacobs, SL, Colodny, SM, Stout, JE, Yu, VL. Nosocomial legionnaires disease caused by Legionella pneumophila serogroup 5: laboratory and epidemiological implications. J Infect Dis 1996;174:11161119.Google Scholar
22.Muder, RR, Yu, VL. Infection due to Legionella species other than L. pneumophila. Clin Infect Dis 2002;35:990998.Google Scholar
23.Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR Morb Mortal Wkly Rep 1997;46:3134.Google Scholar
24.Fiore, AE, Butler, JC, Emori, TG, Gaynes, RP. A survey of methods to detect nosocomial legionellosis among participants in the National Nosocomial Infectious Surveillance System. Infect Control Hosp Epidemiol 1999;20:412416.CrossRefGoogle ScholarPubMed
25.Lin, YE, Vidic, RD, Stout, JE, Yu, VL. Legionella in water distribution systems. J Am Water Works Assoc 1998;90:112121.CrossRefGoogle Scholar
26.Butler, JC, Fields, BS, Breiman, RF. Issues in the control of nosocomial legionellosis. Infect Dis Clin Pract 1997;7:117118.CrossRefGoogle Scholar
27.Muder, RR, Yu, VL, McClure, J, Kominos, S. Nosocomial legionnaires disease uncovered in a prospective pneumonia study: implications for underdiagnosis. JAMA 1983;249:31843188.CrossRefGoogle Scholar
28.Yu, VL, Beam, TR, Lumish, RM, et al.Routine culturing for Legionella in the hospital environment may be a good idea: a three-hospital prospective study. Am J Med Sci 1987;294:9799.CrossRefGoogle ScholarPubMed
29.Joly, J, Alary, M. Occurrence of nosocomial legionnaires disease in hospitals with contaminated potable water supply. In: Barbaree, JD, Breiman, RF, Dufour, AP, eds. Legionella: Current Status and Emerging Perspectives. Washington, DC: American Society for Microbiology; 1993:3940.Google Scholar
30.Rudin, J, Wing, E. Prospective study of pneumonia: unexpected incidence of legionellosis. South Med J 1986;79:417419.CrossRefGoogle ScholarPubMed
31.Goetz, AM, Stout, JE, Jacobs, SL, et al.Nosocomial legionnaires disease discovered in community hospitals following cultures of the water system: seek and ye shall find. Am J Infect Control 1998;26:611.Google Scholar
32.Johnson, JT, Yu, VL, Best, M, et al.Nosocomial legionellosis uncovered in surgical patients with head and neck cancer: implications for epidemiologic reservoir and mode of transmission. Lancet 1985;2:298300.Google Scholar
33.Plouffe, JR, Para, MF, Maher, WE, Hackman, B, Webster, L. Subtypes of Legionella pneumophila serogroup 1 associated with different atack rates. Lancet 1983;2:649650.CrossRefGoogle Scholar
34.Dournon, E, Bibb, WF, Rajagopalan, P, et al.Monoclonal antibody reactivity as a virulence marker for Legionella pneumophila serogroup 1 strains. J Infect Dis 1988;157:496501.Google Scholar
35.Kool, JL, Carpenter, JC, Fields, BS. Effect of monochloramine disinfection of municipal drinking water on risk of nosocomial legionnaires' disease. Lancet 1999;35:272277.Google Scholar
36.Heffelfinger, JD, Kool, JL, Fridkin, S, et al.Risk of hospital-acquired legionnaires disease in cities using monochloramine versus other water disinfectants. Infect Control Hosp Epidemiol 2003;24:569574.Google Scholar