Dr. Ramkesh Prasad
Department of Community Medicine
Gauhati Medical College
 Caused by Legionella pneumophila
 Ranks fourth among the causes of pneumonia
(S. pneumoniae, H. influenzae, Chlamydophi...
 Each year, between 8,000 and 18,000 people are
hospitalized with Legionnaires' disease in the
U.S.
 While Legionellae a...
Year City Venue Source Cases Deaths
Fatality
rate
July
1973
Benidorm, Spain Rio Park Hotel Not known 4 4 100%
July
1976
Ph...
Year City Venue Source Cases Deaths
Fatality
rate
April
2000
Melbourne
Australia
Melbourne
Aquarium
Cooling tower 95
July
...
The 1976 Philadelphia epidemic
 Legionnaires' disease was first recognized as a
distinct entity during an epidemic of
pne...
 On 30th July a physician in Bloomsburg, realized that the 3 patients he was
treating from similar condition had all atte...
 Legionella pneumophila
 Gram negative, aerobic bacteria
 bacterial cells are 0.5–1 µm wide and 2–50 µm long
and motile...
 Found in lakes, streams, and other bodies of water,
 Grows inside free living ameba (Acanthameba, Naegleria,
Hartmannel...
Risk Factors
 Age: Elderly are more susceptible
 cigarette smoking;
 chronic lung disease;
 advanced age;
 Immunosupp...
 Inhalation of Legionellae in aerosolized droplets is the primary means of
transmission
 These aerosolized droplets must...
 exposure to aquatic settings that promote
bacterial growth—the aquatic environment is
somewhat stagnant,
 the water is ...
 Legionella enters the lungs through aspiration or
direct inhalation.
 Attachment to host cells is mediated by bacterial...
 Fever
 Pleurisy
 Grossly purulent sputum
 Diarrhoea
 Renal failure
 Chest X-ray
 Culture
 Sputum
 Tracheal Aspirate
 Direct fluorescent antibody staining of sputum
 Urinary antigen te...
 Macrolide: Azithromycin, Clarithromycin,
 Fluoroquinolones: Levofloxacin,
Ciprofloxacin, Moxifloxacin, Levofloxacin
 T...
 Mortality rates vary with
 patient's underlying disease and its severity,
 the patient's immune status,
 the severity...
 There is no vaccine for legionellosis,
 Antibiotic prophylaxis is not effective always.
 Travelers at increased risk f...
 Routine environmental culture of hospital water
supplies is recommended as an approach to the
prevention of hospital-acq...
 Proper building and plumbing design and
construction can reduce frequency and intensity of L.
pneumophila contamination ...
 An acute, self-limiting, flu-like illness with an
incubation period of 24–48 h. Pneumonia does
not develop.
 Malaise, f...
Agrawal L, Dhunjibhoy KR, Nair KG. Isolation of
Legionella pneumophila from patients of respiratory tract
disease and envi...
Chaudhry R, Dhawan B, Dey AB. The incidence of
Legionella pneumophila: a prospective study in a tertiary
care hospital in ...
 Sero diagnosis of Legionella infection in community
acquired pneumonia, Sabah Javed, Rama Chaudhry, Kapil
Passi, Sutiksh...
Isolation of Legionella pneumophila from clinical &
environmental sources in a tertiary care hospital, S.
Anbumani, A. Gur...
A 53 years old British tourist had come to India in
November 2003, and had visited Delhi, Agra, Jaipur,
and Goa. He went b...
Thank You
 It was no ordinary microbe. It could not be grown
under typical conditions, being dependent upon
ridiculous demands: hig...
 Dr Carl Fliermans solved the first part of the puzzle
when he discovered that L pneumophila lipids
resembled those of th...
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Legionnaire’s disease

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Legionnaire’s Disease

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Legionnaire’s disease

  1. 1. Dr. Ramkesh Prasad Department of Community Medicine Gauhati Medical College
  2. 2.  Caused by Legionella pneumophila  Ranks fourth among the causes of pneumonia (S. pneumoniae, H. influenzae, Chlamydophila pneumoniae )  One of the atypical pneumonias, Gram stained sputum smear does not show organisms.  Prevalent worldwide
  3. 3.  Each year, between 8,000 and 18,000 people are hospitalized with Legionnaires' disease in the U.S.  While Legionellae are ubiquitous in freshwater environments, and likely have been for centuries, it is their unique growth requirements in the environment coupled with the advent of human technology favoring complex water systems that has led to the designation of legionellosis as an emerging infectious disease in the late twentieth century.
  4. 4. Year City Venue Source Cases Deaths Fatality rate July 1973 Benidorm, Spain Rio Park Hotel Not known 4 4 100% July 1976 Philadelphia, Pennsylvania Bellevue- Stratford Hotel Air conditioning 221 34 15.4% April 1985 Stafford, England Stafford District Hospital Air conditioning 175 28 16.0% March 1999 Bovenkarspel, Netherlands Westfrisian Flora flower exhibition Hot tub 318 32 10.0% 2005 Toronto, Canada Seven Oaks Home for the Aged Cooling tower 127 21 16.5%
  5. 5. Year City Venue Source Cases Deaths Fatality rate April 2000 Melbourne Australia Melbourne Aquarium Cooling tower 95 July 2001 Murcia, Spain Hospital Cooling towers 800 (449) 10 17.8% 2002 Barrow –in- Furness Barrow –in- Furness Air conditioning 172 7 4.1% 2005 Fredrikstad, Norway Factory Air scrubber 56 4 4.2% 2008 New Jersey Saint Peter’s University Hospital Drinking water 6 3 0.3% Feb 2012 Calp, Spain AR Diamante Beach Hotel Not known 14 3 17%
  6. 6. The 1976 Philadelphia epidemic  Legionnaires' disease was first recognized as a distinct entity during an epidemic of pneumonia that occurred in Philadelphia, in the July1976.  About 4,000 members of the Pennsylvania State American Legion, an organization of former military veterans, met in July for American Bicentennial celebration, which lasted from 21 - 24 July.  On 27th July, one of the legionnaire died of a pneumonia like illness
  7. 7.  On 30th July a physician in Bloomsburg, realized that the 3 patients he was treating from similar condition had all attended the convention  On the same day, a nurse in Chambersburg Hospital noted a similar condition in 3 patients who had gone to the convention  By Aug 2nd it was realized that there was some undeniable connection  By August, 18 legionnaires had already died, it attracted huge media coverage  Out of the 221 cases - 72 were people who were not involved in the American Legion convention - people who had either been inside the Bellevue Stratford Hotel, or had walked past it.  On January 18, 1977 CDC announced that the cause of Legionnaire’s disease was isolated. (Thanks to the works of Dr Joseph McDade * )  The source of the breeding site of the organism traced to the cooling towers that were connected to the air conditioners of the hotel.
  8. 8.  Legionella pneumophila  Gram negative, aerobic bacteria  bacterial cells are 0.5–1 µm wide and 2–50 µm long and motile, with one or more polar or lateral flagella  Ubiquitous worldwide  Do not grow on routine microbiologic media.  Requires Iron, L cystiene and temperature 25-45 °C  Grown on Buffered charcoal yeast extract (BCYE) agar medium.
  9. 9.  Found in lakes, streams, and other bodies of water,  Grows inside free living ameba (Acanthameba, Naegleria, Hartmannell)  Grows best in warm water, like  in hot tubs,  cooling towers,  hot water tanks,  large plumbing systems, or  parts of the air-conditioning systems of large buildings.  Indoor ornamental fountains have been confirmed as a cause of Legionnaires' disease outbreaks, in which submerged lighting as a heat source was attributed to the outbreak in all documented cases.
  10. 10. Risk Factors  Age: Elderly are more susceptible  cigarette smoking;  chronic lung disease;  advanced age;  Immunosuppression/immunodeficiency  transplantation,  HIV infection  treatment with glucocorticoids or tumor necrosis factor antagonists
  11. 11.  Inhalation of Legionellae in aerosolized droplets is the primary means of transmission  These aerosolized droplets must be of a respirable size (1–5 μm).  No person-to-person transmission of Legionnaires’ disease has been documented.  A number of devices have been implicated as sources of aerosol transmission of Legionellae.  These sources are associated with both potable and non-potable water.  Sources producing aerosols of contaminated potable water include showers, faucets, and respiratory therapy equipment.  Sources utilizing non-potable water include cooling towers, heated spas, decorative fountains, humidifiers, ultrasonic mist machines, and industrial manufacturing systems.
  12. 12.  exposure to aquatic settings that promote bacterial growth—the aquatic environment is somewhat stagnant,  the water is warm (25°C – 42°C),  the water must be aerosolized so that the bacteria can be inhaled into the lungs  These 3 conditions are met almost exclusively in developed or industrialized settings
  13. 13.  Legionella enters the lungs through aspiration or direct inhalation.  Attachment to host cells is mediated by bacterial type IV pili, heat-shock proteins, a major outer- membrane protein, and complement.  Because the organism possesses pili that mediate adherence to respiratory tract epithelial cells, conditions that impair mucociliary clearance, including cigarette smoking, lung disease, or alcoholism, predispose to Legionnaires' disease.
  14. 14.  Fever  Pleurisy  Grossly purulent sputum  Diarrhoea  Renal failure
  15. 15.  Chest X-ray  Culture  Sputum  Tracheal Aspirate  Direct fluorescent antibody staining of sputum  Urinary antigen testing  Antibody serolgy - fourfold seroconversion
  16. 16.  Macrolide: Azithromycin, Clarithromycin,  Fluoroquinolones: Levofloxacin, Ciprofloxacin, Moxifloxacin, Levofloxacin  Tetracycline,
  17. 17.  Mortality rates vary with  patient's underlying disease and its severity,  the patient's immune status,  the severity of pneumonia, and  the timing of administration of appropriate antimicrobial therapy.  With appropriate and timely antibiotic treatment, mortality rates in immunocompetent patients range from 0 to 11%;  without treatment, the figure may be as high as 31%
  18. 18.  There is no vaccine for legionellosis,  Antibiotic prophylaxis is not effective always.  Travelers at increased risk for infection, such as the elderly or those with immunocompromising conditions such as cancer or diabetes, may choose to avoid high-risk areas, such as whirlpool spas.  If exposure cannot be avoided, travelers should be advised to seek medical attention promptly if they develop symptoms of Legionnaires’ disease or Pontiac fever  Chemoprophylaxis with a macrolide antibiotic has been effective in immunocompromised patients during nosocomial epidemics of the disease
  19. 19.  Routine environmental culture of hospital water supplies is recommended as an approach to the prevention of hospital-acquired Legionnaires' disease  Hyperchlorination and superheating of water can help control the multiplication of legionellae in water and in air-conditioning systems.  Use of monochloramine, rather than chlorine to treat public drinking water to reduce colonization
  20. 20.  Proper building and plumbing design and construction can reduce frequency and intensity of L. pneumophila contamination of potable water.  Proper insulation of hot water pipes to prevent warming of water in adjacent cold water pipes.  Maintaining hot water temperature above 50 °C and cold water below 20 °C  Recreational spas must be properly constructed, regularly maintained and closely monitored to prevent high level of bacterial growth.
  21. 21.  An acute, self-limiting, flu-like illness with an incubation period of 24–48 h. Pneumonia does not develop.  Malaise, fatigue, and myalgia are the most common symptoms.  Complete recovery occurs within a few days; antibiotic therapy is unnecessary.
  22. 22. Agrawal L, Dhunjibhoy KR, Nair KG. Isolation of Legionella pneumophila from patients of respiratory tract disease and environmental samples. Indian J Med Res 1991; 93: 364-5.  In this preliminary study, 45 patients suffering from pneumonia were screened for L. pneumophila.  17 random environmental samples, water from a cooling system used for air conditioning units, and samples from a respirator-humidifier were screened.  Four of the 45 clinical specimens (9 %) and 13 of the 17 environmental samples (76 %) showed the presence of L. pneumophila. This is the 1st report from India of the isolation of L. pneumophila
  23. 23. Chaudhry R, Dhawan B, Dey AB. The incidence of Legionella pneumophila: a prospective study in a tertiary care hospital in India. Trop Doct 2000; 30: 197-200.  Between April 1997 and December 1998, 60 patients with CAP admitted to the All India Institute of Medical Sciences were included in the study.  Etiological diagnosis was based on the results of routine microbiological blood culture for bacteria and serological test by ELISA for L. pneumophila serogroup 1-7.  Eight patients (13 %) had a conventional bacterial etiology and 9 patients (15 %) had serological evidence of recent infection with L. pneumophila.
  24. 24.  Sero diagnosis of Legionella infection in community acquired pneumonia, Sabah Javed, Rama Chaudhry, Kapil Passi, Sutikshan Sharma, Padmaja K., Benu Dhawan & A.B. Dey, Indian J Med Res 131, January 2010, pp 92-96  All 113 clinical samples of paediatric (27) and adult (86) patients were collected during May 2005 to January 2008 on their first visit to the AIIMS, New Delhi, with the symptoms of pneumonia  Thirty one of the 113 cases (27.43%) were serologically positive.
  25. 25. Isolation of Legionella pneumophila from clinical & environmental sources in a tertiary care hospital, S. Anbumani, A. Gururajkumar & A. Chaudhury, Indian J Med Res 131, June 2010, pp 761-764 Study done at Sri Venkateswara Institute of Medical Sciences, Tirupati, India  A total of 470 lower respiratory tract samples and 24 water samples from hospital outlets were examined. Culture was done on buffered charcoal yeast extract agar with supplements and identification of the isolates was done by microscopy and biochemical tests.  L. pneumophila could be isolated from 12 (2.55%) patients suffering from community-acquired lower respiratory tract infection, unassociated with other aetiological agents of bacterial pneumonia. Of the 24 water samples tested, 8 (33.3%) grew the same organism.
  26. 26. A 53 years old British tourist had come to India in November 2003, and had visited Delhi, Agra, Jaipur, and Goa. He went back to the United Kingdom on 5 Dec 2003 and died 2 days later. According to the British High Commission, the person died of Legionnaire’s disease
  27. 27. Thank You
  28. 28.  It was no ordinary microbe. It could not be grown under typical conditions, being dependent upon ridiculous demands: high levels of the amino acid cysteine and inorganic iron supplements, low sodium concentrations, as well as activated charcoal to absorb free radicals. In addition, it preferred elevated temperatures, which was highly abnormal among pathogens, who preferred near- body temperatures.  It did not help that the team of CDC researchers had been using the wrong animal model at the start, and had only gotten results when they switched from mice to guinea pigs
  29. 29.  Dr Carl Fliermans solved the first part of the puzzle when he discovered that L pneumophila lipids resembled those of the thermophilic bacteria he'd found in the thermal regions of the Yellowstone National Park, and that this bacteria tended to live as biofilm (scum) associated with certain species of algae. Subsequently, Fliermans began poking around aquatic habitats and found - guess what? - this bacteria residing in thermal waters discharged from a nuclear reactor at Savannah River Laboratory.  This bacteria was later found to be living in natural hot springs all over the United States and, most importantly, in air-conditioning cooling towers.
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