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More than 10 Years of Unrecognized Nosocomial Transmission of Legionnaires' Disease Among Transplant Patients

Published online by Cambridge University Press:  02 January 2015

Jacob L. Kool*
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Anthony E. Fiore
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Clare M. Kioski
Affiliation:
Arizona Department of Health Services, Phoenix, Arizona
Ellen W. Brown
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Robert F. Benson
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Janet M. Pruckler
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Constance Glasby
Affiliation:
University Medical Center, Tucson, Arizona
Jay C. Butler
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Gary D. Cage
Affiliation:
Arizona Department of Health Services, Phoenix, Arizona
Joseph C. Carpenter
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Richard M. Mandel
Affiliation:
University Medical Center, Tucson, Arizona
Bob England
Affiliation:
Arizona Department of Health Services, Phoenix, Arizona
Robert F. Breiman
Affiliation:
National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
*
County of Los Angeles Department of Health Services, Acute Communicable Disease Control, 313 N Figueroa St, Rm 212, Los Angeles, CA 90012

Abstract

Objective:

To investigate a cluster of cases of legionnaires' disease among patients at a hospital.

Setting:

A university hospital that is a regional transplant center.

Design:

Retrospective review of microbiology and serology data from the hospital laboratories and prospective surveillance via the radiology department; a case-control study and environmental sampling within the hospital and from nearby cooling towers.

Results:

Diagnosis of seven cases of legionnaires' disease in the first 9 months of 1996 led to recognition of a nosocomial outbreak that may have begun as early as 1979. Review of charts from 1987 through September 1996 identified 25 culture-confirmed cases of nosocomial or possibly nosocomial legionnaires' disease, including 18 in bone marrow and heart transplant patients. Twelve patients (48%) died. During the first 9 months of 1996, the attack rate was 6% among cardiac and bone marrow transplant patients. For cases that occurred before 1996, intubation was associated with increased risk for disease. High-dose corticosteroid medication was strongly associated with the risk for disease, but other immunosuppressive therapy or cancer chemotherapy was not. Several species and serogroups of Legionella were isolated from numerous sites in the hospital's potable water system. Six of seven available clinical isolates were identical and were indistinguishable from environmental isolates by pulsed-field gel electrophoresis. Initial infection control measures failed to interrupt nosocomial acquisition of infection. After extensive modifications to the water system, closely monitored repeated hyperchlorinations, and reduction of patient exposures to aerosols, transmission was interrupted. No cases have been identified since September 1996.

Conclusions:

Legionella can colonize hospital potable water systems for long periods of time, resulting in an ongoing risk for patients, especially those who are immunocompromised. In this hospital, nosocomial transmission possibly occurred for more than 17 years and was interrupted in 1996, after a sudden increase in incidence led to its recognition. Hospitals specializing in the care of immunocompromised patients (eg, transplant centers) should prioritize surveillance for cases of legionnaires' disease. Aggressive control measures can interrupt transmission of this disease successfully.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1998

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References

1. Marston, BJ, Plouffe, JF, File, TM, Hackman, BA, Salstrom, SJ, Lipman, HB, et al. Incidence of community-acquired pneumonia requiring hospital-ization: population-based active surveillance in Ohio. Arch Intern Med 1997;157:17091717.CrossRefGoogle Scholar
2. Marston, BJ, Lipman, BH, Breiman, RF. Surveillance for legionnaires' disease: risk factors for morbidity and mortality. Arch Intern Med 1994;154:24172422.CrossRefGoogle ScholarPubMed
3. Matulonis, U, Rosenfeld, CS, Shadduck, RK. Prevention of Legionella infections in a bone marrow transplant unit: multifaceted approach to decontamination of a water system. Infect Control Hosp Epidemiol 1993;14:571575.CrossRefGoogle Scholar
4. Prodinger, WM, Bonatti, H, Allerberger, F, Wewalka, G, Harrison, TG, Aichberger, C, et al. Legionella pneumophila in transplant recipients: a cluster of cases of eight years duration. J Hosp Infect 1994;26:191202.CrossRefGoogle ScholarPubMed
5. Singh, N, Gayowski, T, Wagener, M, Marino, IR, Yu, VL. Pulmonary infections in liver transplant recipients receiving tacrolimus. Transplantation 1996;61:396401.CrossRefGoogle ScholarPubMed
6. Harrington, RD, Woolfrey, A, Bowden, R, McDowell, MG, Hackman, RC. Legionellosis in a bone marrow transplant center. Bone Marrow Transplant 1996;18:361368.Google Scholar
7. Kugler, JW, Armitage, JO, Helms, CM, Klassen, LW, Goeken, NE, Ahmann, GB, et al. Nosocomial legionnaires' disease: occurrence in recipients of bone marrow transplants. Am J Med 1983;74:281288.CrossRefGoogle ScholarPubMed
8. Harbarth, S, Pittet, D, Romand, J. Fatal concomitant nosocomial legionnaires' disease and cytomegalovirus pneumonitis after cardiac transplantation. Intensive Care Med 1996;22:11331134.CrossRefGoogle ScholarPubMed
9. Breiman, RF, Fields, BS, Sanden, G, Volmer, L, Meier, A, Spika, J. An outbreak of legionnaires' disease associated with shower use: possible role of amoebae. JAMA 1990;263:29242926.CrossRefGoogle Scholar
10. Centers for Disease Control and Prevention. Sustained transmission of nosocomial legionnaires' disease—Arizona and Ohio. MMWR 1997;46:416421.Google Scholar
11. Heimberger, T, Birkhead, G, Bornstein, D, Same, K, Morse, D. Control of nosocomial legionnaires' disease through hot water flushing and supplemental chlorination of potable water. J Infect Dis 1991;163:143.CrossRefGoogle ScholarPubMed
12. Tobin, JO, Beare, J, Dunnill, MS, Fisher-Hoch, S, French, M, Mitchell, RG, et al. Legionnaires' disease in a transplant unit: isolation of the causative agent from shower baths. Lancet 1980;2:118121.CrossRefGoogle Scholar
13. Hanrahan, JP, Morse, DL, Scharf, VB, Debbie, JG, Schmid, GP, McKinney, RM, et al. A community hospital outbreak of legionellosis. Am J Epidemiol 1987;125:639649.CrossRefGoogle ScholarPubMed
14. Mermel, LA, Josephson, SL, Giorgio, CH, Dempsey, J, Parenteau, S. Association of legionnaires' disease with construction: contamination of potable water? Infect Control Hosp Epidemiol 1995;16:7681.CrossRefGoogle ScholarPubMed
15. Colville, A, Crowley, J, Dearden, D, Slack, RCB, Lee, JV. Outbreak of legionnaires' disease at University Hospital, Nottingham. Epidemiology, microbiology and control. Epidemiol Infect 1993;110:105116.CrossRefGoogle ScholarPubMed
16. Helms, CM, Massanari, RM, Wenzel, RP, Pfaller, MA, et al. Legionnaires' disease associated with a hospital water system. JAMA 1988;259:24232427.CrossRefGoogle ScholarPubMed
17. Best, M, Yu, VL, Stout, J, Goetz, A, Muder, RR, Taylor, F. Legionellaceae in the hospital water supply. Lancet 1983;2(8345):307310.CrossRefGoogle ScholarPubMed
18. Dondero, TJ, Rendtorff, RC, Mallison, GF, Weeks, RM, Levy, JS, Wong, EW, et al. An outbreak of legionnaires' disease associated with a contaminated air-conditioning cooling tower. N Engl J Med 1980;302:365370.CrossRefGoogle ScholarPubMed
19. Klaucke, DN, Vogt, RL, Larue, D, Witherell, LE, Orciari, LA, Spitalny, KC, et al. Legionnaires' disease: the epidemiology of two outbreaks in Burlington, Vermont. Am J Epidemiol 1984;119:382391.CrossRefGoogle ScholarPubMed
20. Garbe, PL, Davis, BJ, Weisfeld, JS, Markowitz, L, Miner, P, Garrity, F, et al. Nosocomial legionnaires' disease: epidemiologic demonstration of cooling towers as a source. JAMA 1985;254:521524.CrossRefGoogle ScholarPubMed
21. Mastro, TD, Fields, BS, Breiman, RF, Campbell, J, Plikaytis, BD, Spika, JS. Nosocomial legionnaires' disease and use of medication nebulizers. J Infect Dis 1991;163:667671.CrossRefGoogle ScholarPubMed
22. Arrow, PM, Chou, T, Weil, D, Shapiro, EN, Kretzschmar, C. Nosocomial legionnaires' disease caused by aerosolized tap water from respiratory devices. J Infect Dis 1982;146:460467.Google Scholar
23. Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR 1997;46(RR-1):28-34, 54-57, 7479.Google Scholar
24. Joly, JR, McKinley, RM, Tobin, JO, Bibb, WF, Watkins, ID, Ramsey, D. Development of a standardized subgrouping scheme for Legionella pneumophila serogroup 1 using monoclonal antibodies. J Clin Microbiol 1986;23:768771.CrossRefGoogle ScholarPubMed
25. Breiman, RF, Cozen, W, Fields, BS, Mastro, TD, Carr, SJ, Spika, JS, et al. Role of air sampling in investigation of an outbreak of legionnaires' disease associated with exposure to aerosols from an evaporative condenser. J Infect Dis 1990;161:12571261.CrossRefGoogle ScholarPubMed
26. Copeland, J, Wieden, M, Feinberg, W, Salomon, N, Hager, D, Galgiani, J. Legionnaires' disease following cardiac transplantation. Chest 1981;79:669671.CrossRefGoogle ScholarPubMed
27. Fuller, J, Levinson, MM, Kline, JR, Copeland, J. Legionnaires' disease after heart transplantation. Ann Thorac Surg 1985;39:308311.CrossRefGoogle ScholarPubMed
28. Edelstein, PH. Legionnaires' disease. Clin Infect Dis 1993;16:741749.CrossRefGoogle ScholarPubMed