Nosocomial Legionellosis Detection and Prevention


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  • Bullet three – Mention it can be found in just about any water source, even saltwater.
    On this slide the key point to make is at bullet number 5.
    Legionella is essentially an intracellular organism. It lives and breeds within protozoa; and in humans it lives and breeds within macrophages.
    This intracellular aspect makes Legionella more difficult to eradicate from the environment, and makes it resistant to antibiotics that don’t have intracellular penetration (e.g. penecillins, cephalosporins, aminoglycosides).
    Legionella need the protozoa or other gram negative bacteria to break down nutrients for them.
    Because of they require this nutrient assistance, they don’t grow readily on routine bacteriology media. They need Buffered Charcoal Yeast Extract Agar to grow. It’s a black agar as seen in the photo here.
  • The initial outbreak that affected a Legionnaires convention in 1976 gave the bacteria it’s genus name. Not to go into detail, it was perhaps one of the most thorough and well published outbreaks of all time. They were able to identify the pathogen and develop test methods within a couple years.
    Today, approx 2000 cases of the Legionella pneumonia are reported each year in the U.S. CDC estimates that 4 to 10 times that many cases are missed each year.
    The reason many cases are missed is because symptoms are no different for other pneumonias, and test methods are limited, and frequently not even performed. I will discuss this in upcoming slides.
  • Legionellosis simply means infection with Legionella.
    Two kinds of Legionellosis predominate:…
    I try to avoid using the “Legionnaires disease” only because I think it misrepresents a national organization. I prefer to use the term Legionella pneumonia.
  • Interestingly, the outbreak that gave Pontiac Fever its name happened eight years before the Philadelphia outbreak, but they were never able to determine the source, until they looked at saved water and serum specimens years later.
  • ** Some reports think onset can be as late as 21 days later (i.e. the current issue of Mandel’s Infectious Diseases)
    But CDC uses a 10 incubation period.
    Symptoms of Legionella pneumonia are not unlike other pneumonias. One somewhat distinctive finding is hyponatremia. It’s not unique to Legionella but it occurs more frequently with Legionella than any other kind of pneumonia.
  • There’s a lot of words on this slide. Don’t worry about it
    I included it just so you will have the case definition in your handout.
    It’s important to note that the case definition was revised by CDC effective 1/1/2006.
    The main changes from the 1996 definition is that it breaks the case definition into confirmed and suspect. DFA diagnoses are now considered suspect rather than confirmed.
    In terms of reporting, both confirmed and suspect cases should be reported to the health department.
    I’m going to go over the individual diagnostic test in the next few slides.
  • Suspect case definitions -
  • Just read
    Also Mention -
    Good Points:
    Recovery of the organism allows you to match to environmental isolates on PFGE studies.
    Bad Points:
    Remember Legionella is an intracellular organism. It’s primarily tied up in macrophages and tissues of the Lung, not on the surface of the airway. Patients often do not produce sputum, so recovery in culture is not easy. Brochoalveolar lavage can sometime be helpful specimen for obtaining Legionella.
  • There are different assays for urine antigen out there:
    RIA – Radio immuno assay
    EIA – Enzyme Immuno assay
    ICT - Immuno chromagraphic test (~pregnancy test).
    They are all good and all have similar sensitivity and specificity.
  • When we talk about serology there are ELISA and IFA methods out there to detect patient immune response.
    ELISAs typically give you a signal value and not a titer. If you recall the CDC definition asks for four fold increases in titer, so you can’t really make case definition. Some kits give you means of extrapolating signal to a titer value, but the accuracy of this is uncertain.
    IFA (Bottom photo) allows you to measure titer, and some kits detect IgM. IFA can be difficult to read and some non specific staining can occur.
  • Some DFA staining assays on respiratory specimens (top photo) can have low sensitivity and specificity. That’s why it has been demoted to “suspect” in the case definition.
    PCR is something that could be very helpful in clinical diagnosis. It is still not widely available yet though. NYSDOH offers it if needed in an outbreak.
    Some Environmental Testing Consultants offer PCR. Be careful of this. PCR will detect dead organisms that are of no public health relevance. If you have human cases, PCR will not enable you to link the cases epidemiologically.
  • Again as mentioned earlier, Legionella is an intracellular organism. It can only be treated with antibiotics that have good intracellular penetration.
    Tetracycline is not really your first choice of treatment here. We had one case of a Legionella pneumophila serogroup 5 in Westchester that responded to this. Initially they were treating on the concern that the patient had a resistant gram negative organism.
  • Now what are the sources of nosocomial Legionella infections?
    Remember the habitats and conditions that are ideal for Legionella.
    Cooling towers and water systems are historically the most common sources, but decorative fountains and hot tubs and whirlpool baths can be sources too.
  • For those of you who do not know what a cooling tower is. This is what they look like. There is a good chance your facility has one.
    They are used in systems that utilize water to cool large air conditioning units or machinery. The coolant water circulates in the tower trickling down the sides of the tower while a fan blows the air out the top to dissipate the heat from the water
  • Just read.
  • The danger of hot water systems is a little more obvious.
    Sources of aerosol like showers immediately comes to mind. But the simple act of drinking is thought to be a risk too via micro-aerosolization. Other sources like nebulizers, bipap machines, and humidifiers can be overlooked in the clinical setting and can also be a risk if not used and cleaned properly.
    But keep in mind, when you think about the risk of the hot water system, don’t just think about the water exposure routes. It is important to think about is where the Legionella are breeding, and you need to look at the system as a whole
    Hot water tanks (like that to the right of Janet Leigh) store large volumes of hot water can be dangerous if not maintained properly. Older buildings tend to have these. Newer building usually have instantaneous heaters which are less troublesome. In an instantaneous hot water system the water is not stored, instead it is heated on demand by coiling through a heat source like steam.
    But no mater the water source, if your system has dead legs (areas where there is no water flow, you can be in trouble.)
  • This is an illustration of a dead leg. You have an old sink here that isn’t used anymore. The pipe leading to it is kept warm because it is still connected to the system, but the water doesn’t flow through it. The biofilm that accumulates in the pipe then bleeds into the rest of the system.
    Sometimes the sink may not be there anymore. It may have been removed during a renovation, but the piping may still exist and become a dead leg. If you’ve had renovations, you may want to make sure that all the pipe has been cut at the main line.
  • Now if you take all the factors I just mentioned about Legionella you can understand why it can be a particular problem for Hospitals and Nursing Homes.
    Legionella is apt to infect compromised hosts – Hospitals and Nursing Homes have many patients that are compromised.
    Old water systems accumulate biofilm and allow growth of Legionella. Many of the hospitals and nursing homes in our area have old water systems.
    Most hospitals and some nursing homes are large enough to require a cooling tower for their air conditioning.
    On top of this, medicine continues to be progressive. Steps in immune suppressive therapy, chemotherapy, and other methods of sustaining compromised individuals have become more and more common.
    In the past three years there have been thirty different facilities identified with nosocomial Legionellosis.
  • Prior to 2000 nosocomial Legionella was a somewhat rare event. As this chart shows it has become progressively more common this decade. My office typically receives one case a month now.
  • This chart shows how rates of Legionella have climbed in the past 13 years.
    The charts includes community cases too. The line represents the rate per 100,000.
    We are not sure why this is. Increases were seen over the eastern seaboard in 2003. Some speculated that heavy rain, run-off, and reservoir turbidity had something to do with it. Others suspect there is more testing being performed, or more sensitive tests being used.
  • Does anyone see a pattern on this chart?
    These peaks tend to occur in late summer early autumn.
    It’s unclear why they occur. One thought is that cooling towers are running hard at that time and may have been running been running a few months by late summer. They are more like likely to become contaminated later in the season if untreated.
    Higher water consumption, turbid water supplies, and subsequent infection by aspiration may also play a role.
    But this is all speculation at this point.
  • Now ,
    Everyone should have a handout of the July 14, 2005 Legionellosis Guidelines for Acute Care Facilities.
    Were going to go over this in the next few slides.
    Just because it is geared for acute care facilities doesn’t mean the Long term care people should disregard it. (Don’t get up and leave just yet) There is a Long Term Care guideline expected in 2006, but many of the key points for LTC are in this document too.
    One of the main points of control in health care facilities is that the ICP cannot do this alone. You need a team approach.
    Medicine and Nursing need to identify and test suspects properly
    Infection control needs to monitor this.
    Engineering needs to care for the water and cooling system
    And administration needs to be involved to provide support where needed,
  • The guideline identifies patients of particular risk that need to be monitored and tested if necessary.
    This is in attachment one, one page 1, third paragraph of the guidelines
  • If you identify someone in the risk group with a nosocomial pneumonia they should be tested properly. By Culture and Urine antigen.
    A good specimen for culture is a bronchoscopy as shown in the middle photo
    Nursing home patients hospitalized with pneumonia should be tested routinely.
  • For Long Term Care it is only those hospitalized with pneumonia that we would strongly recommend testing.
    On LTC facilities we put on surveillance following a recognized nosocomial case, we also ask they consider a patient not responding to therapy that is not effective against Legionella (like a cephalosporin).
  • One of the main infection control steps you can take is to care for respiratory equipment.
    Top photo is a Bipap machine.
    Some of this may be second nature to you, but it is worthy of reminder to all; do not use room humidifiers. If you douse them, fill them only with sterile water, and disinfect them daily.
  • Hematopoietic stem cell, and organ transplant units require special care.
    These are the only type of units where CDC (and NYSDOH) recommend routine culturing,
    …And water restriction if positives are found in those cultures.
    Water would need to remain restricted until three months of negative cultures have been demonstrated.
  • Now, Environmental Maintenance:
  • Just read,
    That is a thermometer/ chlorometer/ pH probe device on the upper right. You should invest in something like this to monitor your disinfections.
    pH level is important for hyperchlorination. Chlorine could be ineffective at extremes of the pH scale.
  • You can avoid the need for semi-annual disinfections if you have long tem.
    Each long term measure could be a lecture on to itself, but briefly here are some of the good and bad points
    1) Chlorine injection involves keeping increased amounts of amounts free chlorine in your water. Usually about 1-2ppm It will kill Legionella, but can be damaging to your pipes, there is a possibility of creating chlorinated hydrocarbons which may be cancerous. You also have to keep large drums of sodium hypochlorite to feed the lines which could be acutely dangerous.
    2) Chlorine dioxide: Pros: Less dangerous to pipes, works at lower concentrations, penetrates biofilms. Cons include: takes time (18 months) to be effective, you still have storage of corrosive chemicals, and you need to monitor the system closely. Treatment failures in large facilities have been reported.
    3) Copper Silver: Pros: Effective, no dangerous chemicals in storage. Cons: Expensive to set up, requires monitoring (pH and Cu-Ag levels).
    4) Mixing valves: Pros: No dangerous chemicals. For a small increase in temperature (124 F circulating; 140 F for storage tanks) you can keep your pipes at a temperature that is inhospitable to Legionella. It may be a cheaper option to for a small facility. No intricate monitoring required. Cons: You need to buy good valves to avoid failure. Cost to retro fit could be expensive.
    NYS Bureau of Architecture now requires mixing valves be in place for new construction in health care facilities. ICPs should bring up this point up in any plans for construction.
    All these options really require you remove dead legs to be effective.
  • For environmental culturing, again it is only the hematopoietic stem cell and organ transplants where it is recommended to culture routinely.
  • That’s not to say that you shouldn’t culture other areas of your facility if you wish.
    If you do decide to culture your water system there are steps that you should take.
    When planning test sites the general rule it to culture water coming to and from your water heater (be it a HW tank or and instantaneous heater).
    Then for a facility with 500 or less beds, collect at least 10 distal sites. At least 2 additional sites for every 100 beds over 500.
    Plan to test areas representative of the system and where your most compromised patients are (ex a dialysis unit).
  • For cooling towers….
    ASHRAE = American Society of Heating, Refrigeration, and Air Conditioning Engineers
    CTI= Cooling Tower Institute.
    Cooling towers are complex devices and the measures for disinfection and care are too numerous to list here. Water contractors typically take care of them.
    One of thing you could do is make sure that the water contractor reports biocide levels to you, and you can monitor the dip slide levels (that measure bacterial counts).
    Just because you have a contractor, does not mean you are not responsible for your tower.
  • Nosocomial Legionellosis Detection and Prevention

    1. 1. Nosocomial Legionellosis Detection and Prevention Philip Kurpiel MT, MPH New York State Department of Health Regional Epidemiology Program February 2006
    2. 2. What Is Legionella ? • It is a gram-negative bacteria. • 42 known species, and 70 serogroups. • Enjoys warm water environments. • Requires protozoa and other gram negative bacteria to proliferate. • Requires special media in order to be cultured.
    3. 3. Legionella and Human Disease • Initially discovered in 1976 after an outbreak in a Philadelphia hotel that hosted a July 4th American Legion celebration  221 attendees ill.  34 died  Legionella bacteria discovered in lung tissue and cooling tower. • Today:  ~ 2,000 cases of Legionella pneumonia are reported in the United States each year An estimated 8,000 – 18,000 are thought to occur . Estimated to cause 2-15% of community acquired pneumonias.  In New York State 200 – 300 cases have been reported yearly the past two years.
    4. 4. Legionellosis DEFINITION Legionellosis: an infection with Legionella. • Two manifestations predominate: 1. Legionella Pneumonia (“Legionnaires’ Disease”). 2. Pontiac Fever . Extra pulmonary and wound infections have been reported too but are very rare.
    5. 5. Pontiac Fever Pontiac Fever Is a self limited illness due to Legionella exposure in immune competent host So named after an outbreak in Pontiac Michigan 1968  It can occur in any individual.  Symptoms begin a few hours to a few days after exposure.  Symptoms include fever, malaise, myalgia, and headache.  Illness is self limited, and lasts 2-5 days. Diagnosis: • Primarily by serology and symptoms. • Pontiac Fever patients may not have detectable levels of urinary antigen.
    6. 6. Legionella Pneumonia Legionella Pneumonia: Onset 2-10 days after exposure. ►Symptoms include: • Moderate to severe pneumonia with infiltrates. • Fever • Non- productive cough • Hyponatremia (low sodium) ►Occurs primarily in immune compromised hosts. • Elderly, immune suppressed, chronically ill (COPD, diabetic). – Immune suppression and hematological malignancy seem to be the highest risks. ►Mortality 5-20%
    7. 7. CDC Case Definitions Legionellosis Case Definitions for CDC - NNDSS (Revised 1/1/2006) Confirmed: 1) Culture of any Legionella organism from respiratory secretions, lung tissue, pleural fluid, or other sterile fluid 2) Detection of Legionella pneumophila serogroup 1 antigen by urinary antigen using valid reagents. 3) Seroconversion with fourfold or greater rise in specific serum antibody titer to Legionella pneumophila serogroup 1 using validated reagents.
    8. 8. CDC Case Definitions Case Definitions for CDC - NNDSS (Revised 1/1/2006) Suspect: 1) Seroconversion with fourfold or greater rise in antibody titer to specific species of Legionella other than Legionella pneumophila serogroup 1 using validated reagents. 2) Seroconversion with fourfold or greater rise in antibody titer to multiple Legionella species using pooled antigen and validated reagents. 3) Detection of specific Legionella antigen or staining if the organism in respiratory secretions, lung tissue, or pleural fluid by direct fluorescent antibody DFA staining, immunohistochemistry, or similar method using validated reagents. 4) Detection of Legionella species by validated nucleic assay.
    9. 9. Culture  Good Points • Gold Standard – leaves no doubt for diagnosis. • Recovery allows you to match for sources  Draw backs • Requires special media: BCYE agar • Requires time 5-7 days to grow. • Infection intracellular, patients do not often produce sputum.
    10. 10. Urine Antigen  Good Points • High sensitivity (80-90%) High specificity (~100%) • Rapid – only takes a few hours  Draw backs • Antigen can be shed for months after infection which can distort source and timing. • Only detects L. pneumophila 1. (Although some assays can cross- reacts with serogroup 3). • Some patients can’t produce urine (e.g. ESRD patients)
    11. 11. Legionella Serology   Good Points • Allows for retrospective studies • Some IFAs detect IgM • Most Kits detect L. pneumophila serogroups 1-6   Draw backs • Requires months to make a diagnosis. • IFA has lower specificity • Single positive titers can be meaningless! • Won’t detect other than serogroups 1-6
    12. 12. PCR and DFA • DFA:  Low sensitivity and specificity.  Should only be used as additional evidence • PCR:  Not widely available.  Theoretically it could be clinically valuable.  Be careful if using for environmental testing
    13. 13. Treatment of Legionella • Effective Agents:  Macrolides  Fluoroquinalones  Tetracyclines • Non-Effective Agents:  Penicillins  Cephalosporins  Aminoglycosides • Agents of Uncertain Efficacy:  Trimethoprim sulfamethoxazol  Glycopeptides  Carbapenems
    14. 14. Sources of Legionella Infection  Any stagnant warm water can be a reservoir for Legionella.  Ideal breeding temperature is between 77o F and 115o F.  Historically, two main sources of published outbreaks have been: 1) Cooling Towers 2) Domestic Hot Water Systems.
    15. 15. Sources of Legionella Infection: Cooling Towers
    16. 16. Sources of Legionella Infection Trouble with cooling towers: ► Require careful maintenance. ► Large volumes of water and high powered fans enable wide dispersal. ► The largest outbreaks of legionellosis on record have been due to contaminated cooling towers.
    17. 17. Sources of Legionella Infection Trouble with Hot Water Systems:  Showering, drinking, or anything creating an aerosol can be an exposure source  Hot water “dead legs”, and water tanks can provide ideal refuge for breeding. .
    18. 18. Sources of Legionella Infection: Hot Water Systems Dead Leg
    19. 19. Legionella Problems in Healthcare Facilities • Why? – Compromised patients are easy targets for Legionella – Old buildings, old water systems, modern medicine. • Nosocomial Legionella in MARO 2003-2005: – 20 different Hospitals reported cases. – 10 nursing homes reported cases.
    20. 20. Number of Facilities Reporting Nosocomial Legionella in New York State 2001-2005 Year Long Term Care Hospitals 2001 3 2 2002 2 7 2003 6 6 2004 7 5 2005 11 14 Total 29 34
    21. 21. Yearly Rates* of Reported Legionellosis Cases in New York State 1992-2004 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate Year* Rates Per 100,000
    22. 22. Frequency of Legionellosis in New York State by Diagnosis Date Jan 2002 – May 2005 0 10 20 30 40 50 60 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M 2002 2003 2004 2005
    23. 23. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities  Released July 14, 2005  Calls for clinical and environmental measures to be taken to identify and prevent nosocomial Legionellosis  Key Principle: Your facility should have a multidisciplinary Legionella workgroup. • Medicine, Nursing • Infection control • Engineering, Maintenance • Administration
    24. 24. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Clinical Surveillance: 1) Identify the Risk Groups – Highest Risk:  Patients with severe immune suppression.  End stage renal disease patients.  Hematological malignancy patients. – Moderate Risk:  Diabetic patients  Chronic lung disease Patients  Non-hematological malignant cancer patients  HIV patients  Elderly  Cigarette smokers
    25. 25. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Clinical Surveillance: 2) Testing • Patients in moderate and high risk groups with facility acquired pneumonia should be tested for Legionella by culture and urine antigen. • Acute care facilities receiving long term care facility patients with pneumonia should test them for Legionella by culture and urine antigen.
    26. 26. NYSDOH Legionellosis Guidelines for Surveillance and Control in Long Term Care – Guidelines Coming Soon… LTC Clinical Surveillance: Testing • LTC residents hospitalized with pneumonia should be tested for Legionella by culture and urine antigen. • Consider testing patients with pneumonia if they do not respond to antibiotic therapy.
    27. 27. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Infection Control 1) Respiratory Equipment  Rinse respiratory equipment with sterile water after it has been cleaned and disinfected  Use sterile water to fill nebulizer reservoirs.  Avoid room humidifier units. If use cannot be avoided,  Fill only with sterile water.  Sterilize or use high level disinfection on the device daily
    28. 28. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Infection Control 2) Protective environments: Hematopoietic stem cell transplant, and Solid organ transplant units. If environmental samples are positive disinfect, remove aerators and restrict tap water use.
    29. 29. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Environmental Maintenance 1) Domestic Hot Water: a. Remove Dead legs from the system. b. If no long-term controls exist: Perform hot water system disinfections twice a year by: – Heat and Flush or Hyperchlorination c. Flush the system when it is open for repair/construction or subject to water pressure changes.
    30. 30. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Environmental Maintenance Heat and Flush: a. Heat hot water >160 oF b. Flush through ALL fixtures at this temperature for >= 5 minutes. c. Flow should be about the width of a pencil. Hyperchlorination: a. Add chlorine to the hot water system. b. Flush chlorine through all fixtures until it is >=2.0 ppm free chlorine, and pH is between 7.0 and 8.0 c. Keep fixture closed for 2-24 hours, then flush thoroughly.
    31. 31. Long Term Control Measures 1) Chlorine Injection - Drawbacks: corrosive to pipes, dangerous chemicals 2) Chlorine Dioxide - Drawbacks: takes time, treatment failures have been reported, dangerous chemicals, needs monitoring 3) Copper Silver Ionization System - Drawbacks: Expensive, needs monitoring 4) Anti-scald Mixing Valves: - Drawbacks: Valve failure?
    32. 32. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Environmental Surveillance 2) Testing Domestic Hot Water?  Quarterly water cultures are recommended for hematopoietic stem cell units and organ transplant protective units.  Assess needs in other units
    33. 33. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Environmental Surveillance If you decide to culture other areas routinely:  Decide how you will react to positives before you test.  Plan your test sites carefully. Use established culture methods.  Avoid PCR and DFA testing.
    34. 34. NYSDOH Legionellosis Guidelines for Surveillance and Control in Acute Care Facilities Environmental Maintenance 3) Cooling Tower Maintenance Consult ASHRAE and CTI standards as well as manufacturer standards for tower maintenance. Seek professional engineering guidance Some Good Ideas  Have a designee who follows cooling tower maintenance records.  Monitor biocide levels and dip-slide levels weekly. Dip Slide
    35. 35. You Have a Case of Nosocomial Legionellosis.. Now What? Nosocomial Legionellosis defined: A case of Legionellosis by CDC definition that is … Definite: Spent all days 2-10 of incubation period in a healthcare facility. Possible: Spent some of days 2-10 in a health care facility.
    36. 36. You Have a Case of Nosocomial Legionellosis.. Now What?  Review patient’s history in the facility and the locations where they stayed. Evaluate possible exposures.  Perform a 1 month retrospective surveillance of nosocomial pneumonia cases. ►Try to test past nosocomial cases by urine antigen if applicable.
    37. 37. You Have a Case of Nosocomial Legionellosis.. Now What? • Conduct prospective surveillance for at least six months beyond the last case.  Acute Care Facilities: • Monitor frequency of Legionella testing of nosocomial pneumonia patients who are in the moderate and high risk groups.  Long Term Care Facilities: • Assure that residents hospitalized with pneumonia get tested. • Test returning residents by urine antigen if necessary.
    38. 38. You Have a Nosocomial Legionellosis.. Now What? QUIZ TIME: • Should you culture your water system, and cooling tower? 1) If your case was culture positive? – Yes • Culture your hot water system • Culture your cooling tower if applicable 2) If your case was urine antigen positive? May not be necessary for one case. • If you detect another case in the surveillance period do water testing.
    39. 39. You Have a Nosocomial Legionellosis.. Now What? QUIZ TIME: • Should you disinfect you hot water system? - Yes, if you have no long term control and you have not disinfected in prior 6 months. - No, If you have a long term control in place. - Yes, if you have a case and positive water cultures.
    40. 40. You Have a Nosocomial Legionellosis.. Now What? QUIZ TIME: • You have a case, and you have Legionella in your water. Should you restrict water use? • Yes, – IF… positives samples are found on organ or hematopoietic stem cell transplant unit, then restrict water use on that unit. Water restrictions can be imposed to protect other immune compromised patients. The circumstances of the outbreak, and the risk level of the patients need to be considered.
    41. 41. Other Questions? • There are other issues covered by CDC and NYSDOH Guidelines not covered in this slide set. • Please consult these references. – CDC MMWR, Guidelines for Environmental Infection Control in Health-Care Facilities. June 6, 2003 – CDC MMWR, Guidelines for Preventing Health-Care Associated Pneumonia. March 26, 2004 – New York State Department of Health Guidelines for Surveillance and Control of Legionellosis in Acute Care Facilities. July 14, 2005
    42. 42. The End Thank You