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Controlling Legionella in Hospital Drinking Water: An Evidence-Based Review of Disinfection Methods

Published online by Cambridge University Press:  02 January 2015

Yusen E. Lin ,
Janet E. Stout  and
Victor L. Yu
Yusen E. Lin
Affiliation:
National Kaohsiung Normal University, Kaohsiung, Taiwan
Janet E. Stout
Affiliation:
Special Pathogens Laboratory, Pittsburgh, Pennsylvania University of Pittsburgh, Pittsburgh, Pennsylvania
Victor L. Yu*
Affiliation:
University of Pittsburgh, Pittsburgh, Pennsylvania
*
Special Pathogens Laboratory, 1401 Forbes Avenue, Suite 208, Pittsburgh, PA 15219 (vly@pitt.edu)
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Abstract

Hospital-acquired Legionnaires' disease is directly linked to the presence of Legionella in hospital drinking water. Disinfecting the drinking water system is an effective preventive measure. The efficacy of any disinfection measures should be validated in a stepwise fashion from laboratory assessment to a controlled multiple-hospital evaluation over a prolonged period of time. In this review, we evaluate systemic disinfection methods (copper-silver ionization, chlorine dioxide, monochloramine, ultraviolet light, and hyperchlorination), a focal disinfection method (point-of-use filtration), and short-term disinfection methods in outbreak situations (superheat-and-flush with or without hyperchlorination). The infection control practitioner should take the lead in selection of the disinfection system and the vendor. Formal appraisals by other hospitals with experience of the system under consideration is indicated. Routine performance of surveillance cultures of drinking water to detect Legionella and monitoring of disinfectant concentrations are necessary to ensure long-term efficacy.

Type
Review Article
Information
Infection Control & Hospital Epidemiology , Volume 32 , Issue 2 , February 2011 , pp. 166 - 173
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2011

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References

1. Tobin, JO, Swann, RA, Barflett, CL. Isolation of Legionella pneumophila from water systems: methods and preliminary results. Br Med J 1981;282:515–517.CrossRefGoogle ScholarPubMed
2. Stout, J, Yu, VL, Vickers, RM, Shonnard, J. Potable water supply as the hospital reservoir for Pittsburgh pneumonia agent. Lancet 1982;1:471–472.CrossRefGoogle Scholar
3. Best, M, Yu, VL, Stout, J, Goetz, A, Muder, RR, Taylor, F. Legi-onellaceae in the hospital water-supply: epidemiological link with disease and evaluation of a method for control of nosocomial legionnaires' disease and Pittsburgh pneumonia. Lancet 1983;2:307–310.Google Scholar
4. Muraca, PW, Yu, VL, Goetz, A. Disinfection of water distribution systems for Legionella: a review of application procedures and methodologies. Infect Control Hosp Epidemiol 1990;11:79–88.Google Scholar
5. Lin, YE, Vidic, RD, Stout, JE, Yu, VL. Legionella in water distribution systems. J Am Water Works Assoc 1998;90:112–121.Google Scholar
6. Lin, YS, Stout, JE, Yu, VL, Vidic, RD. Disinfection of water distribution systems for Legionella . Semin Respir Infect 1998;13:147–159.Google Scholar
7. Kusnetsov, J, Iivanainen, E, Elomaa, N, Zacheus, O, Martikainen, PJ. Copper and silver ions more effective against legionellae than against mycobacteria in a hospital warm water system. Water Res 2001;35:4217–4225.Google Scholar
8. Biurrun, A, Caballero, L, Pelaz, C, Leon, E, Gago, A. Treatment of a L. pneumophila-colonized water distribution system using copper-silver ionization and continuous chlorination. Infect Control Hosp Epidemiol 1999;20:426–428.Google Scholar
9. Lee, JV, Surman, SB, Kirby, A, Seddon, F. Eleven years of experience with novel strategies for Legionella control in a large teaching hospital. In: Marre, R, Kwaik, YA, Bartlett, C, eds. Legionella. Washington, DC: American Society for Microbiology, 2002:398–401.Google Scholar
10. Chen, YS, Lin, YE, Liu, YC, et al. Efficacy of point-of-entry copper-silver ionisation system in eradicating Legionella pneumophila in a tropical tertiary care hospital: implications for hospitals contaminated with Legionella in both hot and cold water. J Hosp Infect 2008;68:152–158.CrossRefGoogle Scholar
11. Thompson, RB, File, TM, Plouffe, J, Stephens, C, Richs, R. Use of Tarn-Pure to eradicate Legionella pneumophila from a hospital hot water system. In: Program and abstracts of the General Meeting of the American Society for Microbiology; 1990; Anaheim, CA. Abstract L18.Google Scholar
12. Liu, Z, Stout, JE, Tedesco, L, et al. Controlled evaluation of copper-silver ionization in eradicating Legionella pneumophila from a hospital water distribution system. J Infect Dis 1994;169:919–922.Google Scholar
13. Liu, Z, Stout, JE, Boldin, M, Rugh, J, Diven, WF, Yu, VL. Intermittent use of copper-silver ionization for Legionella control in water distribution systems: a potential option in buildings housing individuals at low risk of infection. Clin Infect Dis 1998;26:138–140.Google Scholar
14. Stout, JE, Brennen, C, Muder, RR. Legionnaires' disease in a newly constructed long-term care facility. J Am Geriatr Soc 2000;48:1589–1592.Google Scholar
15. Lin, YE, Vidic, RD, Stout, JE, Yu, VL. Legionnaires' disease in an apartment building: disinfection methods and recommendations. In: Program and abstracts of the 1st World Water Congress of the International Water Association; July 3-7, 2000; Paris, France.Google Scholar
16. Mietzner, S, Schwille, RC, Farley, A, et al. Efficacy of thermal treatment and copper-silver ionization for controlling Legionella pneumophila in high-volume hot water plumbing systems in hospitals. Am f Infect Control 1997;25:452–457.Google Scholar
17. Colville, A, Crowley, J, Dearden, D, Slack, RC, Lee, JPV. Outbreak of Legionnaires' disease at a University Hospital, Nottingham: epidemiology, microbiology, and control. Epidemiol Infect 1993;10:105–116.Google Scholar
18. Cachafeiro, SP, Naveira, IM, Garcia, IG. Is copper-silver ionisation safe and effective in controlling Legionella? . J Hosp Infect 2007;67:209–216.CrossRefGoogle ScholarPubMed
19. Modol, J, Sabria, M, Reynaga, E, et al. Hospital-acquired legionnaires disease in a university hospital: impact of the copper-silver ionization system. Clin Infect Dis 2007;44:263–265.CrossRefGoogle Scholar
20. Stout, JE, Yu, VL. Experiences of the first 16 hospitals using copper-silver ionization for Legionella control: implications for the evaluation of other disinfection modalities. Infect Control Hosp Epidemiol 2003;24:563–568.Google Scholar
21. Maki, DG, Stolz, S, Marx, JA. A decade of total prevention of endemic nosocomial legionellosis by continuous silver-copper ionization of hospital water. In: Program and abstracts of the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC); Sept 17-20, 2007; Chicago, IL.Google Scholar
22. Fiore, AE, Butler, JC, Emori, TG, Gaynes, RP. A survey of methods used to detect nosocomial legionellosis among participants in the National Nosocomial Infections Surveillance System. Infect Control Hosp Epidemiol 1999;20:412–416.Google Scholar
23. Yang, G. Experimental studies on inactivating Legionella by mon-ochloramine, chlorine dioxide and DBNPA as disinfection alternatives in a pilot water plumbing system. Master's Thesis, University of Pittsburgh, 2000.Google Scholar
24. Centers for Disease Control and Prevention. Transmission of nosocomial legionnaires disease. JAMA 1997;277:1927–1928.Google Scholar
25. Rohr, U, Senger, M, Selenka, F, Turley, R, Wilhelm, M. Four years of experience with silver-copper ionization for control of Legionella in a German university hospital hot water plumbing system. Clin Infect Dis 1999;29:1507–1511.Google Scholar
26. Lin, YS, Vidic, RD, Stout, JE, Yu, VL. Negative effect of high pH on biocidal efficacy of copper and silver ions in controlling Legionella pneumophila . Appl Environ Miaobiol 2002;68:2711–2715.Google Scholar
27. Bowler, WA, Bresnahan, J, Bradfish, AA, eds. “Vitriolic” solution to the problem of Legionella contamination of a hospital water system. In: Program and abstracts of the 9th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 18-20, 1999; San Francisco, CA.Google Scholar
28. Mathys, W, Hohmann, CP, Junge-Mathys, E. Efficacy of copper-silver ionization in controlling Legionella in a hospital hot water distribution system: a German experience. In: Marre, R, Kwaik, YA, Bartlett, C, eds. Legionella. Washington, DC: American Society for Microbiology; 2002:419–424.Google Scholar
29. Lin, YE. Ionization failure not due to resistance. Clin Infect Dis 2000;31:1315–1317.Google Scholar
30. Blanc, DS, Carrara, P, Zanetti, G, Francioli, P. Water disinfection with ozone, copper and silver ions, and temperature increase to control Legionella: seven years of experience in a university teaching hospital. J Hosp Infect 2005;60:69–72.Google Scholar
31. Lin, YE, Vidic, RD. Possible phosphate interference with copper-silver ionization for Legionella control. J Hosp Infect 2006;62:119.Google Scholar
32. Mietzner, M, Hangard, A, Stout, JE, et al. Reduced susceptibility of Legionella pneumophila to the antimicrobial effects of copper and silver ions. 45th Interscience Conference on Antimicrobial Agents and Chemotherapy December 16-19; Washington, DC.Google Scholar
33. Sidari, FP, Stout, JE, Vanbriesen, JM, et al. Keeping Legionelb out of water systems. J Am Water Worh Assoc 2004;96:111–119.Google Scholar
34. Zhang, Z, McCann, C, Stout, JE, et al. Safety and efficacy of chlorine dioxide for Legionella control in a hospital water system. Infect Control Hosp Epidemiol 2007;28:1009–1012.Google Scholar
35. Hosein, IK, Hill, DW, Tan, TY, et al. Point-of-care controls for nosocomial legionellosis combined with chlorine dioxide potable water decontamination: a two-year survey at a Welsh teaching hospital. J Hosp Infect 2005;61:100–6.Google Scholar
36. Makin, T. Control of Legionella in domestic water systems and potential energy savings resulting from the control of legionellae with chlorine dioxide. In: Program and abstracts of the 15th IFHE Congress; 1998; Edinburgh, Scotland.Google Scholar
37. Ricci, ML, Dell'Eva, I, Scaturro, M, et al. A four-year experience of a chlorine dioxide treatment for the control of Legionella in a hospital water system. ISTISAN Congressi 2005;05:18.Google Scholar
38. Hood, J, Cheape, G, Mead, A, Curran, E. Six years' experience with chlorine dioxide in control of Legionella pneumophila in potable water supply of Glasgow Royal Infirmary. Am J Infect Control 2000;28:86.Google Scholar
39. Srinivasan, A, Bova, G, Ross, T, et al. A 17-month evaluation of a chlorine dioxide water treatment system to control Legionella species in a hospital water supply. Infect Control Hosp Epidemiol 2003;24:575–579.CrossRefGoogle Scholar
40. Doleans, A, Aureli, H, Reyrolle, M, et al. Clinical and environmental distributions of Legionella strains in France are different. / Clin Microbiol 2004;42:458–460.CrossRefGoogle ScholarPubMed
41. Stout, JE, Muder, RR, Mietzner, S, et al. Role of environmental surveillance in determining the risk of hospital-acquired legionellosis: a national surveillance study with clinical correlations. Infect Control Hosp Epidemiol 2007;28:818–824.Google Scholar
42. Bova, G, Sharpe, P, Keane, T. Evaluation of chlorine dioxide in potable water systems for Legionella control in an acute care hospital environment. In: Proceedings of the International Water Conference Official Proceedings. Pittsburgh, PA; Engineering Society of Western Pennsylvania, 2004.Google Scholar
43. Casini, B, Valentini, P, Baggiani, A, et al. Molecular epidemiology of Legionella pneumophila serogroup 1 isolates following long-term chlorine dioxide treatment in a university hospital water system. J Hosp Infect 2008;69:141–147.CrossRefGoogle Scholar
44. Zhang, Z, Stout, JE, Yu, VL, Vidic, R. Effect of pipe corrosion scales on chlorine dioxide consumption in drinking water distribution systems. Water Res 2008;42:129–136.CrossRefGoogle ScholarPubMed
45. USEPA. National primary drinking water rules: disinfectants-disinfection by-products. Final rule. Federal Register, 1998:63.Google Scholar
46. Condie, LW. Toxicological problems associated with chlorine dioxide. J Am Water Works Assoc 1986;78:73–78.Google Scholar
47. USEPA. Pesticide registration: clarification for ion-genarating equipment, 2007.Google Scholar
48. Gao, Y, McCall, EC, Stout, JE, Vidic, RD, Yu, VL. Monochloramine and chlorine dioxide as alternative disinfection methods for Legionella control. In: Program and abstracts of the Annual Meeting of the American Water Works Association; 2000; Denver, CO.Google Scholar
49. Donlan, R, Murga, R, Carpenter, J, Brown, E, Besser, R, Fields, BS. Monochloramine disinfection of biofilm-associated Legionella pneumophila in a potable water model system. In: Marre, R, Abu Kwail, Y, Bartlett, C, et al, eds. Legionella. Washington, DC: American Society for Microbiology;2002:406–410.Google Scholar
50. LeChevallier, MW, Cawthon, CD, Lee, RG. Factors promoting survival of bacteria in chlorinated water supplies. Appi Environ Microbiol 1988;54:649–654.CrossRefGoogle ScholarPubMed
51. 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;24:569–574.CrossRefGoogle ScholarPubMed
52. Kool, JL, Carpenter, JC, Fields, BS. Effect of monochloramine disinfection of municipal drinking water on risk of nosocomial Legionnaires' disease. Lancet 1999;353:272–277.CrossRefGoogle ScholarPubMed
53. Flannery, B, Gelling, LB, Vugia, DJ, et al. Reducing Legionella colonization in water systems with monochloramine. Emerg Infect Dis 2006;12:588–596.Google Scholar
54. Moore, MR, Pryor, M, Fields, B, Lucas, C, Phelan, M, Besser, RE. Introduction of monochloramine into a municipal water system: impact on colonization of buildings by Legionella spp. Appi Environ Microbiol 2006;72:378–383.Google Scholar
55. Pryor, M, Springthorpe, S, Riffard, S, et al. Investigation of opportunistic pathogens in municipal drinking water under different supply and treatment regimes. Water Sci Technol 2004;50:83–90.Google Scholar
56. Shelton, BG, Donegan, N, Flanders, WD, Kool, J, Pic-Aluas, L, Witherell, L. Efficacy of point of use monochloramine treatment to control Legionella in colonized building water system. In: Program and abstracts of the 5th International Conference on Legionella; September 26-29, 2000; Ulm, Germany.Google Scholar
57. Marchesi, I, Messi, P, Anacarso, I, et al. Control of Legionella colonization and effects on biofilm in a hospital water system treated with monochloramine. In: Program and abstracts of the Legionella Conference;2009; Paris, France.Google Scholar
58. Lin, YE, Yu, VL, Vidic, RD, States, SJ. Discussion of monochloramine and Legionnaires' disease. J Am Water Works Assoc 2000;92:88–90.Google Scholar
59. Garcia, MT, Baladran, B, Gil, V, et al. Persistence of chlorine-sensitive Legionella pneumophila in hyperchlorinated installations. J Appi Microbiol 2008;105:837–847.Google Scholar
60. Morris, RD, Audet, AM, Angelillo, IF, Chalmers, TC, Mosteller, F. Chlorination, chlorination by-products, and cancer: a metaanalysis. Am J Public Health 1992;82:955–963.Google Scholar
61. Campins, M, Ferrer, A, Callis, L, et al. Nosocomial Legionnaire's disease in a children's hospital. Pediatr Infect Dis 2000;19:228–234.Google Scholar
62. Sheffer, PJ, Stout, JE, Wagener, MM, Muder, RR. Efficacy of new point-of-use water filter for preventing exposure to Legionella and waterborne bacteria. Am J Infect Control 2005;33:S20–S25.Google Scholar
63. Trautmann, M, Halder, S, Hoegel, J, Royer, H, Haller, M. Point-of-use water filtration reduces endemic Pseudomonas aeruginosa infections on a surgical intensive care unit. Am J Infect Control 2008;36:421–429.CrossRefGoogle ScholarPubMed
64. Ortolano, GA, McAlister, MB, Angelbeck, JA, et al. Hospital water point-of-use filtration: a complementary strategy to reduce the risk of nosocomial infection. Am J Infect Control 2005;33:S1–S19.Google Scholar
65. Eckmanns, T, Schwab, F, Posselt, H, Gastmeier, P, Ruden, H. UV light for elimination of Legionella . In: Marre, R, Abu Kwail, Y, Bartlett, C, et al, eds. Legionella. Washington, DC: American Society for Microbiology;2002:402–405.Google Scholar
66. Franzin, L, Cabodi, D, Fantino, C. Evaluation of the efficacy of ultraviolet irradiation for disinfection of hospital water contaminated by Legionella . J Hosp Infect 2002;51:269.Google Scholar
67. Matulonis, U, Rosenfeld, CS, Shadduck, RK. Prevention of Legionella infections in a bone marrow transplant unit: multifac-eted approach to decontamination of a water system. Infect Control Hosp Epidemiol 1993;14:571–575.Google Scholar
68. Triassi, M, Di Poppolo, A, Ribera d'Alcala, G, et al. Clinical and environmental distribution of Legionella pneumophila in a university hospital in Italy: efficacy of ultraviolet disinfection. J Hosp Infect 2006;62:494–501.Google Scholar
69. Franzin, L, Cabodi, D, Fantino, C. Evaluation of the efficacy of ultraviolet radiation for disinfection of hospital water contaminated by Legionella . J Hosp Infect 2002;51:269–274.Google Scholar
70. Hall, KK, Giannetta, ET, Getchell-White, SI, Durbin, LJ, Farr, BM. Ultraviolet light disinfection of hospital water for preventing nosocomial Legionella infection: a 13-year follow-up. Infect Control Hosp Epidemiol 2003;24:580–583.Google Scholar
71. Best, M, Goetz, A, Yu, VL. Heat eradication measures for control of nosocomial Legionnaires' disease: implementation, education, and cost analysis. Am J Infect Control 1984;12:26–30.Google Scholar
72. Chen, YS, Liu, YC, Lee, SS, et al. Abbreviated duration of su-perheat-and-flush and disinfection of taps for Legionella disinfection: lessons learned from failure. Am J Infect Control 2005;33:606–610.Google Scholar
73. Stout, JE. New Disinfection options for controlling Legionella in building water systems. In: Program and abstracts of the Association of Water Technologies 2009 Annual Convention and Exposition;2009; Hollywood, FL.Google Scholar
74. 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.Google Scholar
75. Report of the Maryland Scientific Working Group to Study Legionella in Water Systems in Healthcare Institutions. Baltimore, MD: State of Maryland Department of Health and Mental Hygiene, 2000.Google Scholar
76. Bartram, J, Chartier, Y, Lee, JV, Pond, K, Surman-Lee, S. Legionella and the prevention of legionellosis. Geneva, Switzerland: World Health Organization, 2007 contract no. WC 200.Google Scholar
77. Risa, KJ, Stout, JE, Muder, RR. Intermittent flushing of outlets improved control of Legionella colonization in a hospital hot water system treated by CU/Ag ionization. In: Program and abstracts of the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 12-16; Chicago, IL.Google Scholar
78. Shih, HY, Lin, YE. Efficacy of copper-silver ionization in controlling biofilm- and plankton-associated waterborne pathogens. Appi Environ Microbiol 2010;76:2032–2035.CrossRefGoogle ScholarPubMed
79. Huang, HI, Shih, HY, Lee, CM, Yang, TC, Lay, JJ, Lin, YE. In vitro efficacy of copper and silver ions in eradicating Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Acinetobacter baumannii: implications for on-site disinfection for hospital infection control. Water Res 2008;42:73–80.CrossRefGoogle ScholarPubMed