Download Running head: LEGIONNAIRES` DISEASE WRITTEN PROTOCOL 1

Running head: LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Legionnaires' Disease Written Protocol
Christina Riggall
State University of New York Institute of Technology
1
2
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Pneumonia caused by the Legionella bacterium is called Legionnaires' disease (LD). It
was first recognized in 1976 when it caused the death of 34 delegates at an American Legion
Convention in Philadelphia, Pennsylvania (Lane, Ferrari, & Dreher, 2004). It wasn't until six
months later that the bacterium was actually identified (Lane, Ferrari, & Dreher, 2004).
Legionella continues to be a fairly common cause of community-acquired pneumonia and most
often causes illness in an immunocompromised host.
Pathophysiology & Etiology
Legionella is an aerobic gram-negative bacilli that causes both community-acquired and
hospital-acquired pneumonia. The disease is transmitted through the inhalation or aspiration of
the bacterium. There are over 50 species of legionella, L. pneumophila is the most common,
accounting for 80% of human infections. After being inhaled, the legionella attaches to the
respiratory epithelial cells and to the alveolar macrophages (Pedrot-Betot, Stout, & Yu, 2013).
Most often the bacteria causes pneumonia but can also cause a flu-like illness called Pontiac
fever. Legionnaires' disease occurs 2-14 days after exposure to the bacteria (Pedrot-Betot, Stout,
& Yu, 2013).
Incidence
Legionnaires' disease is thought to the be very under-reported and many cases may go
undiagnosed. It is estimated that "between 10,000 and 18,000 people become infected with
Legionella each year in the United States" (Legionella.org, 2012). Successful diagnosis requires
specialized testing media or Legionella antigen testing. It is believed that Legionnaires' disease
causes 2-9% of all community acquired pneumonia. The incidence of LD has tripled from 20002009 in both the United States and United Kingdom.
3
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Social & Environmental Considerations
Legionella grows in aquatic environments, especially man-made reservoirs but can also
be found in lakes and streams (Lane, Ferrari, & Dreher, 2004). Legionella grows and
proliferates in warm, stagnant waters (Lane, Ferrari, & Dreher, 2004). Temperatures 25-42°
Celsius are optimal for growth. Compost facilities or potting soil may also harbor this bacteria.
Legionella has been found in cooling towers, water faucets, sinks, ice machines, humidifiers and
hot tubs (Lane, Ferrari, & Dreher, 2004). In an observational cohort study completed by GarciaVidal et al. (2013), it was found that areas that have higher rainfall had a higher incidence of
community-acquired Legionella infection and that the rates were higher in the Summer months.
A societal consideration is the plumbing and water systems that are present in homes and
hospitals. An article in, Engineer's Notebook, states that Legionella can be found in piping
systems in homes and hospitals, and even new water systems are not resistant to this bacteria
(Freije, 2013). Legionella proliferates in the presence of rust and scale, and when water lines
have not been flushed prior to use (Lane, Ferrari, & Dreher, 2004). In a prospective study by von
Baum, et al. (2010), 9.2% of the 65 homes that were sampled had tap water that was positive for
Legionella, however none of the patients living in the homes ended up with Legionella infections
even though they had neutropenia. Legionella infections have also occurred in patients that have
travelled and the bacteria has been found in hotels and cruise ships (IDSA, 2013).
According to the Infectious Disease Society of America (IDSA), an outbreak of
Legionnaires' disease may be suspected when two patients are admitted to the hospital and both
are diagnosed with a Legionella infection (IDSA, 2013). In these cases, the patient should be
4
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
questioned about travel and if the patient hasn't travelled, "epidemiologic tracking" may be
completed to find the "environmental source of infection" (IDSA, 2013).
Screening & Risk Factors
Legionnaires' disease is considered an opportunistic infection because not all persons that
are exposed to the bacteria will acquire an illness (Lane, Ferrari & Dreher, 2004). According to
the Centers for Disease Control and Prevention (CDC) the following persons are at the highest
risk of acquiring Legionnaires' disease: immunocompromised persons, transplant recipients, age
>50, persons with chronic lung disease, smokers, people who repair domestic plumbing, travel,
people on immunosuppressants and neonates (CDC, 2013). In a study by Sopena et al. (2004),
alcoholism was shown to be an individual risk factor for Legionella infection (Sopena, et al.,
2004). According to Beauté, et al. (2012), 20% of reported Legionnaire's disease is associated
with travel and warm/wet climates have higher rates of LD (Beauté, et al, 2012).
Clinical Findings
Legionella can cause pneumonia or a self-limiting flu-like illness called Pontiac fever
(Domino, 2014). Legionella can also cause wound infections if the wound comes in contact with
contaminated water (Carson & Mumford, 2012). Symptoms of Legionnaires' disease are
pneumonia, fevers, cough, pleuritic chest pain, headaches, watery diarrhea, neurologic symptoms
like seizures, disorientation, insomnia, and confusion (Domino, 2014). According to Morelli,
Battaglia, & Lattuada, (2006), "In patients with Legionnaires' disease 40-50% will develop
neurological signs and symptoms". Neurologic symptoms include "confusion, disorientation,
stupor and coma" (Morelli, Battaglia & Lattuada, 2006).
On chest X-ray it is common to see "multilobar involvement" (Sadashivaiah & Carr,
2009). Clinical improvement will precede improvement on X-ray (Sadashivaiah & Carr, 2009).
5
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Symptoms of Pontiac fever include malaise, fever, body aches without pneumonia (CDC, 2013).
Differential diagnoses are as follows: Legionnaires’ disease (482.84), Pneumonia due to other
gram neg. bacteria (482.83), Pneumonia, unspecified organism (486).
Laboratory Tests
The most common laboratory test for Legionella infection is the urine antigen test (Lane,
Ferrari, & Dreher, 2004) . The CDC recommends Legionella antigen testing and culture of the
organism for positive diagnosis (CDC, 2013). Legionella antigen urine testing is 70-100%
sensitive and 100% specific for Legionella infection (CDC, 2013). Culture of the organism is
only 20-80% sensitive but again has 100% specificity (CDC, 2013). Legionella identification
can also be completed through direct fluorescent antibody staining and serology (antibody titers)
(Lane, Ferrari & Dreher, 2004). The bacterium will only grow on specialized media such as
buffered charcoal yeast extract (Lane, Ferrari & Dreher, 2004).
Management and Treatment Guidelines
The Infectious Diseases Society of America (IDSA) would be considered the credible
authority on the topic for treatment guidelines. They recommend that any patient that presents
with severe community acquired pneumonia should have blood cultures taken, urine antigen
testing for Legionella and Streptococcus performed and sputum cultures. Level one evidence for
outpatient treatment of community-acquired pneumonia in a patient that has co-morbidities is a
respiratory fluoroquinolone (moxifloxacin, gemifloxacin or levofloxacin) or a beta-lactam (high
dose amoxicillin or augmentin) plus a macrolide (azithromycin, clarithromycin or erythomycin )
(IDSA, 2013).
According to the, Internet Journal of Emergency & Intensive Care Medicine, "Empiric
initial therapy for hospitalized patients with community-acquired pneumonia should always
6
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
include coverage for Legionella, because delays in starting appropriate treatment has been
associated with increased mortality (Orsini, Yunen, Lalane, & Izarnotegui, 2010). Treatment
duration of LD should be 7-14 days however if the patient is immunocompromised they may
need treatment for 21 days or more (Orsini, Yunen, Lalane & Izarnotegui, 2010).
Non-pharmacological treatment of Legionnaires' disease includes supportive therapy.
Hydration and electrolyte status should be assessed and treated appropriately. Activity as
tolerated, rest, and deep breathing can promote recovery. Treatment with oxygen may be
necessary if patient's oxygen saturation decreases and antipyretics can be given for fevers (Lane,
Ferrari & Dreher, 2004).
Complications & Follow-up
Complications of Legionnaires' disease include respiratory failure, dehydration,
extrapulmonary disease, disseminated intravascular coagulation, multi-organ dysfunction, coma
and death (Domino, 2014). In a retrospective study of outcomes completed by Wingfield, et al.
(2013), 88% of the patients with Legionnaires' ended up with hyponatremia, 35% had neurologic
manifestations and 54% had acute kidney injury (Wingfield, et al., 2013).
A study was conducted in the Netherlands to determine if there was any residual effects
after the resolution of Legionnaires' disease. 122 patients with confirmed LD filled out
questionnaires to determine any persistence of symptoms and assess quality of life after
resolution of the disease (Lettinga, et al, 2002). Patients self-reported symptoms at 2, 6 and 17
months after resolution of the pneumonia. At 17 months after resolution of the pneumonia, 75%
of patients reported persistent fatigue and 66% reported neurologic symptoms such as headache,
dizziness, loss of concentration or memory (Lettinga, et al, 2002). 63% reported neuromuscular
symptoms such as weakness, paresthesias in the hands and feet, or muscle pain and 39% reported
7
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
persistent cough (Lettinga, et al, 2002). This study showed there were significant and lasting
effects of having Legionnaires' disease or a severe pneumonia. The study did not test patients
with pneumonia from any other cause to assess for differences (Lettinga, et al, 2002).
After initiation of treatment, the patient should follow up with their primary care
physician to ensure improvement. A follow-up chest X-ray should be completed after the full
course of treatment to ensure resolution of the pneumonia (Domino, 2014).
Counseling, Education, Consultation & Referral
Those at high risk for Legionella infection should be educated that water temperatures in
hot water tanks should be above 140° F and above 122°F at the faucet (Lane, Ferrari & Dreher,
2004). People at high risk may also benefit from taking tub baths rather than showers because
less bacteria becomes aerosolized in the tub (Lane, Ferrari & Dreher, 2004). People that own hot
tubs should be educated about the proper cleaning and chemical levels. There are test kits
available at multiple retail locations to ensure proper chemical levels.
The local department of health will need to be contacted with any confirmed case of
Legionella infection. Collaboration may occur with local public health officials to assess
environmental risks, especially in areas such as apartment complexes (Silk, et al., 2013). The
New York State Department of Health (NYS DOH) does not necessarily investigate individual
episode of Legionella but if more than one case develops they will investigate to assess for an
outbreak (NYS DOH, 2004).
One example of how an outbreak was investigated in order to find the source was
published in the Scandinavian Journal of Medicine. In this particular case, four people became
infected with a Legionella infection and they all spent time in the same home (Euser, Pelgrim, &
den Boer, 2010). Samples were taken from various aquatic areas around the home such as the
8
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
shower, garden hoses, whirlpool spa and bathroom. Then people were interviewed to find out
where they spent time in the home. Also, what bathrooms they had used, if they went in the spa,
if they used the hose at all. All four cases had either spent time in the whirlpool spa or were
standing very close to it. The water samples from the spa came back positive for Legionella
bacteria and therefore this was deemed the source of infection (Euser, Pelgrim, & den Boer,
2010).
The Occupational Safety & Health Administration (OSHA), recommends that "a level
one investigation" should be completed when a workplace water source is suspected to be
contaminated with Legionella or if a Legionella infection has been reported (OSHA, 2013). This
includes an overview of the water systems, a inspection to ensure that all water tanks are kept at
the appropriate temperature, and water samples taken if needed (OSHA, 2013).
Review of Literature
The literature review was completed using State University of New York Institute of
Technology's database. Using CINHAL Plus with Full Text, MEDLINE with Full Text, Health
Source: Nursing/Academic Addition and Environment Complete, the search was limited to 20092013 but then expanded to the year 2000 to retrieved more information. Terms that were used
were: Legionnaires' disease, Legionella, pneumonia, antibiotics for Legionella and pneumonia
treatment.
In reviewing literature, some of the more comprehensive articles on the topic were
almost ten years old. Many of the pharmacological studies were also very dated. The really
current literature seemed to be lacking in overall discussion of the topic and were based upon
specific case reports from around the world.
9
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
There were a few slight differences in the preferable treatment for Legionnaires' within
the literature, some of the articles available were almost ten years old and this may add to some
of the differences. The Internet Journal of Emergency & Intensive Care Medicine, discussed
that using a quinolone over a macrolide for treatment of Legionnaires' may be more beneficial
due to faster recovery with the quniolones and a shorter hospital stay (Orsini, Yunen, Lalane &
Izarnotegui, 2010). Yu, et al. (2004) tested the efficacy of Levaquin on Legionnaires' disease and
found that it led to "clinical success in over 90% of patients" (Yu, et al., 2004). This study
recommended high dose, short duration therapy, ie. Levaquin 750mg PO or IV daily for five
days, to prevent resistance and promote a higher plasma concentration of the drug (Yu, et al.,
2004). An article in Drugs & Therapy Perspectives (2004), suggested that Rifampin could be
used in addition to erythomycin or a fluoroquinolone to reduce the rate of resistance (Drugs &
Therapy Perspectives, 2004). Rifampin in combination with either a macrolide or
fluoroquinolone was also suggested in the article by Lane, Ferrari & Dreher (2004), in cases of
severe pneumonia. In the article by Kolditz, Halank, & Höffken (2006), combination therapy
was preferred over monotherapy due to the high mortality rate associated with severe pneumonia
(Kolditz, Halank, & Höffken, 2006). The Infectious Disease Society of America didn't
specifically state the treatment for Legionnaires' only that the initial treatment of communityacquired pneumonia should cover Legionella (IDSA, 2013).
There are multiple similarities within all the articles about how Legionnaires' disease is
acquired. Many of the articles list aquatic environments but there is a difference in how warm
hot water tanks should be kept. According to Silk et al.(2013) above 130°F is sufficient for
protection from Legionella but according to Lane, Ferrari & Dreher, (2004) the hot water tank
should be kept above 140°F and to maintain faucet temperature above 122°F. The OSHA
10
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
recommendations agree with Lane, Ferrari & Dreher but add that cold water temperatures should
fall below 68°F (OSHA, 2013).
Conclusion
Legionnaires' disease is a type of pneumonia which is acquired through the inhalation or
aspiration of the Legionella bacterium. There is treatment for Legionnaires' disease but due to the
elusive nature of this bacteria and inability to confirm diagnosis without specific testing, this
microorganism may not always be identified. Not everyone that is exposed to this bacteria will
acquire the illness but if the patient is immunocompromised or has other risk factors, the
provider should have this in their differential.
11
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Multiple Choice Questions
1.
True or False: Legionella can be identified using routine bacteriologic media?
a. True
b. False
2.
Who is at most risk to develop Legionnaires’ disease?
a. 65 year old transplant recipient
b. 14 year old swimming in a lake
c. 90 year old living in an apartment complex
3.
Out of these three medications the preferred treatment for Legionnaires’ is ________.
a. Erythomycin
b. Rifampin
c. Azithromycin
4.
True or False: The CDC recommends urine antigen testing only for the diagnosis of
Legionnaires disease?
a. True
b. False
5.
Who should be tested for Legionnaires?
a. In a person that has travelled in the last 2 weeks.
b. Severe pneumonia
c. A pt that has failed antibiotic therapy
d. All of the above
6.
NYS will most likely investigate cases of Legionella infection when:
a. Someone is diagnosed with the condition
b. A patient dies from the disease
c. An outbreak is suspected
7.
True or False: Legionnaires Disease should be reported to the Department of Health.
a. True
b. False
8.
Complications of Legionnaires’ disease include:
a. Fevers
b. Respiratory failure
c. Death
d. All of the above
9.
True or false: Legionella infection can be transmitted person to person.
a. True
b. False
12
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
10.
Domestic water heaters should be kept at temperatures:
a. Below 140 degrees F
b. Above 140 degrees F
Answers & Rationale
1. b. False- Specialized media like buffered charcoal yeast extract must be used.
2. a. Transplant recipients are at a high risk for LD due to anti-rejection medications.
3. c. Azithromycin
4. b. False- Both culture and urine antigen testing is recommended by the CDC.
5. d. All of the above
6. c. When an outbreak is suspected
7. a. True
8. d. All of the above
9. b. False
10. a. Above 140 degrees F (60 degrees C)
.
13
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
References
Beauté, J., Zucs, P., & de Jong, B. (2012). Risk for Travel-associated Legionnaires' Disease,
Europe, 2009. Emerging Infectious Diseases, 18(11), 1811-1816.
Carson, P., & Mumford, C. (2010). Legionnaires' disease: causation, prevention and control.
Loss Prevention Bulletin, (216), 20-29.
Centers for Disease Control & Prevention. (2013). Legionnaires’ disease for clinicians. Retrieved
from http://www.cdc.gov/legionella/clinicians.html
Domino, F. (2014). The 5-Minute Clinical Consult. (22nd ed.) Philadelphia: Lippincott Williams
& Wilkins.
Drugs & Therapy Perspectives. (2004) When Legionnaires' disease is suspected, specific
diagnostic tests and empirical antibacterial treatment should be given. Drugs & Therapy
Perspectives, 20(5), 9-12.
Euser, S., Pelgrim, M., & den Boer, J. (2010). Legionnaires' disease and Pontiac fever after using
a private outdoor whirlpool spa. Scandinavian Journal Of Infectious Diseases, 42(11/12),
910-916. doi:10.3109/00365548.2010.509331
Freije, M.R. (2012). Legionella: Don’t assume. Engineer’s Notebook: ASHRAA Journal, 54
(10),100-101.
Garcia-Vidal, C., Labori, M., Viasus, D., Simonetti, A., Garcia-Somoza, D. et al. (2013).
Rainfall is a risk factor for sporadic cases of Legionella pneumophila pneumonia. Plos
ONE, 8(4), 1-5. doi:10.1371/journal.pone.0061036
Infectious Diseases Society of America. (2013). Infectious Society of America/American
thoracic society consensus guidelines on the management of community-acquired
14
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
pneumonia in adults. Retrieved from
http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full
Jespersen, S., Søgaard, O. S., Schønheyder, H. C., Fine, M. J., & Østergaard, L. (2010). Clinical
features and predictors of mortality in admitted patients with community-and hospitalacquired legionellosis: A Danish historical cohort study. BMC Infectious Diseases, 10(1),
124-135. doi:10.1186/1471-2334-10-124
Johansson, N., Kalin, M., & Hedlund, J. (2011). Clinical impact of combined viral and bacterial
infection in patients with community-acquired pneumonia. Scandinavian Journal Of
Infectious Diseases, 43(8), 609-615. doi:10.3109/00365548.2011.570785
Kolditz, M., Halank, M., & Höffken, G. (2006). Monotherapy versus combination therapy in
patients hospitalized with community-acquired pneumonia. Treatments In Respiratory
Medicine, 5(6), 371-383.
Lane, G., Ferrari, A., & Dreher, H. (2004). Clinical practice. Legionnaire's disease: a current
update. MEDSURG Nursing, 13(6), 409-414.
Legionella.org. (2012). Legionnaires' disease: What is it? Retrieved from
http://legionella.org/about-the-disease/what-is-legionnaires-disease/
Lettinga, K.D., Verbon, A., Nieuwkerk, P.T., Jonkers, R.E., Gersons, B.P., Prins, J.M. &
Speelman, P. (2002). Health-related quality of life and posttraumatic stress disorder
among survivors of an outbreak of Legionnaires' disease. Clinical Infectious Disease.
35(11-7). Retrieved from http://cid.oxfordjournals.org/content/35/1/11.long#cited-by
New York State Department of Health. (2004). Legionellosis (Legionnaires’ Disease). Retrieved
from http://www.health.ny.gov/diseases/communicable/legionellosis/docs/fact_sheet.pdf
15
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Occupational Safety & Health Administration. (2013). Legionnaires' Disease. Retrieved from
https://www.osha.gov/dts/osta/otm/legionnaires/disease_rec.html
Orsini, J., Yunen, J., Lalane, N., & Izarnotegui, W. (2010). Legionnaires' disease: do not forget
the fluoroquinolones or macrolides. Internet Journal Of Emergency & Intensive Care
Medicine, 12(1).
Pedrot-Betot, M.L., Stout, S.E. & Yu, V.L. (2013). Epidemiology and pathogenesis of
Legionella infection. Retrieved from www.uptodate.com/contents/epidemiologyand=pathogenesis-of-legionella-infection.
Sadashivaiah, J., & Carr, B. (2009). Severe community-acquired pneumonia. Continuing
Education In Anaesthesia, Critical Care & Pain, 9(3), 87-91.
doi:10.1093/bjaceaccp/mkp014
Silk, B. J., Foltz, J. L., Ngamsnga, K., Brown, E., Muñoz, M., Hampton, L. M., & ... Hicks, L. A.
(2013). Legionnaires' disease case-finding algorithm, attack rates, and risk factors during
a residential outbreak among older adults: an environmental and cohort study. BMC
Infectious Diseases, 13(1), 1-8. doi:10.1186/1471-2334-13-291
Sopena, N., Pedro-Botet, M., Sabriá, M., García-Parés, D., Reynaga, E., & García-Nuñez, M.
(2004). Comparative study of community-acquired pneumonia caused by Streptococcus
pneumoniae, Legionella pneumophila or Chlamydia pneumoniae. Scandinavian Journal
Of Infectious Diseases, 36(5), 330-334.
von Baum, H., Bommer, M., Forke, A., Holz, J., Frenz, P., & Wellinghausen, N. (2010). Is
domestic tap water a risk for infections in neutropenic patients?. Infection, 38(3), 181186. doi:10.1007/s15010-010-0005-4
16
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Yu, V., Greenberg, R., Zadeikis, N., Stout, J., Khashab, M., Olson, W., & Tennenberg, A.
(2004). Levofloxacin efficacy in the treatment of community-acquired legionellosis.
Chest, 125(6), 2135-2139.
Wingfield, T., Rowell, S., Peel, A., Puli, D., Guleri, A., & Sharma, R. (2013). Legionella
pneumonia cases over a five-year period: a descriptive, retrospective study of outcomes
in a UK district hospital. Clinical Medicine, 13(2), 152-159.
17
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
Appendix
#
Studies
1
Beauté, J.,
Zucs, P., &
de Jong, B.
(2012)
LD and
travel
N=607
European
travelers
2
Euser, S.,
Pelgrim,
M., & den
Boer, J.
(2010)
Was a hot
tub
associated
with LD in
these
cases?
N=4
3
GarciaVidal, C.,
Labori, M.,
Viasus, D.,
Simonetti,
A., GarciaSomoza, D.
et al.
(2013)
Jespersen,
S., Søgaard,
O. S.,
Schønheyd
er, H. C.,
Fine, M. J.,
&
Østergaard,
L. (2010).
LD &
rainfall
Johansson,
N., Kalin,
M., &
Hedlund, J.
(2011).
4
5
Focus
Subje
cts
Population
Age
Methods
Findings
Not
reported
Risk per nights
spent in different
countries- looking
for trends & higher
risk areas
Greece and Italy
had higher rates
of LD per night
spent there
comparend to
Spain, France,
UK &
Netherlands
Four cases of
LD/Pontiac
Fever that
arose from the
same home.
52-83
years old
After cases were
confirmed, samples
were taken from
the hose, showers,
hot tub.
Legionella was
found in the hose
and hot tub
samples. It is
believed that all
four people had
contact with the
hot tub and is
therefore the
source of
infection.
N=439
3
Nonimmunocompr
omised pts that
came in with
community
acquired
pneumonia
(CAP)
Not
reported
Over 16 years 4393
cases of CAP were
hospitalized that
met criteria- the
causative agent
found & then
correlated with
rainfall
Legionella
caused 5.3%
(231) of these
cases- this was
correlated with
rainfall &
showed statistical
significance.
Predictors
of mortality
in pt's dx
with LD
N=332
Both CAP and
hospital
acquired
legionella was
included.
>15 y/o
30 & 90 day case
fatalities were
identified
Hospital acquired
LD had a higher
mortality rate
than CAP.
Prospective
study to
determine
if patient's
with resp.
virus were
more likely
to get
community
acquired
N=184
Patients with
CAP admitted
to the hospital
Mean age
63.1
Nasopharyngel
swabs, sputum and
blood cultures were
done to assess for
CAP related
bacteria. Urine was
taken for
legionella testing
and blood was
taken to test for
1% of the
patients that were
tested (3 pts)were positive for
Legionella. No
specific findings
were found to
link viral
infections to LD.
However as the
18
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
pneumonia
viruses
patient aged it
seemed they may
be at risk for
more combined
viral/bacterial
infections.
Combination
therapy lead to a
lower mortality
rate in patients
with severe
pneumonia.
6
Kolditz,
M., Halank,
M., &
Höffken, G.
(2006)
Review of
lit and
clinical
trials for
combo vs
monothera
py
antibiotic
tx
N/A
Patient's
admitted to the
hospital with
severe
community
acquired
pneumonia
N/A
A review of
retrospective
studies and
prospective
randomized studies
based on combo vs
monotherapy in tx
of CAP and CAP
associated with LD
7
Lane, G.,
Ferrari, A.,
& Dreher,
H. (2004)
Water
taken from
8
apartments
was
cultured for
legionella
Total
N=171
Legion
ella +
N=10
Elderly living
in elderapartments
66-72
Attack rate was
calculated, 8
residents and 2
visitors were + for
LD, cultures were
taken from water.
Consider the
implementation
of a Legionella
prevention plan
in elderlyhousing facilities
8
Lettinga, et.
al, 2002
A followup study
was
conducted
to assess
for residual
effects
from a LD
outbreak
N=122
Survivors of a
Legionella
outbreak
25-87
(median
66)
122 patients
answered
questionnaires 2, 6
& 17 months after
antibiotic
completion to
assess for any
residual symptoms
9
Sopena, N.,
PedroBotet, M.,
Sabriá, M.,
GarcíaParés, D.,
Reynaga,
E., &
GarcíaNuñez, M.
(2004).
Comparativ
e study of
risk factors,
presentatio
n and
outcomes
of CAP
with
different
bacteria
N=157
Hospitalized
pts diagnosed
with CAP, due
to
S.pneumoniae,
L.
pneumophilia
& C.
pneumoniae
>50
Demographics, risk
factors, clinical
manifestations,
outcomes and
antibiotic therapy
were all studied to
see if the variables
related to the
causative
organism.
17 months after
resolution of LD,
75% of patients
reported fatigue,
66% of pts
reported
neurologic sxs
(headache,
dizziness, loss of
memory or
concentration),
63% reported
neuromuscular
symptoms
(paresthesias,
muscle pain,
weakness).
Hyponatremia,
elevated CK, and
elevated AST
rates were higher
in pt's with
Legionella
pneumophila.
Resp. sxs were
higher in those
with S.
pneumoniae and
C. pneumonia
19
LEGIONNAIRES' DISEASE WRITTEN PROTOCOL
10
von Baum,
H.,
Bommer,
M., Forke,
A., Holz, J.,
Frenz, P.,
&
Wellinghau
sen, N.
(2010).
11
Wingfield,
T., Rowell,
S., Peel, A.,
Puli, D.,
Guleri, A.,
& Sharma,
R. (2013).
12
Yu, V.,
Greenberg,
R.,
Zadeikis,
N., Stout,
J.,
Khashab,
M., Olson,
W., &
Tennenberg
, A. (2004).
Prospective
study to
find out if
patients
with
neutropenia
are at risk
for
infections
from tap
water.
Descriptive
retrospectiv
e study of
outcomes
N=65
Patient's
discharged
from hosp.
with dx of
neutropenia
18-76
Water samples
were obtained from
the tap and shower
of 65 houses of
patients with
neutropenia
N=26
Hospitalized
patients
41-87
Co-morbidities,
clinical findings,
relevant history
were all reviewed.
Randomize
d
controlled
study to
test
different
dosages
and tx
courses of
CAP
N=75
that
were +
for LD
Treatment was
of 1,997
patients- 75
patients were +
for legionella.
Wide
range- not
specified
except
that over
70% of
subjects
were less
than 65.
Patient's were split
into different
groups, some
received 500mg po
daily, some 750mg
po daily. The
duration of
treatment also
varied depending
on the group.
Responses were
assessed 2-14 days
after stopping the
drug.
than in L.
pneumophilia. L
pnemophilia had
higher rates of
neuro and GI
symptoms.
Six households
(9.2%) were
positive for
Legionella
however none of
the patients
ended up with
Legionella
infections. The
risk appears to
remain low.
Outcomes: 6
deaths which
were in the older
population.
Those who did
not receive the
correct
antibiotics had
longer length of
stay.
Levaquin was
found to be very
effective against
Legionella in
over 90% of
patients. The
study
recommended
high-dose, short
course therapy
(ie. 750mg daily
x5 days to
prevent
resistance) but
stated that more
research needed
to be done due to
population age
that was studied.