Legionnaires Disease

Legionnaires DiseaseChristina Riggall, BS, RN, CNRNSUNY Institute of Technology

Definition of ProblemLegionella is a bacteria that first found in July 1976 during an American Legion Convention where it caused the death of 34 delegates. At the time the cause of illness was unknown.

It wasnt until January 1977 that the bacteria was isolated and identified.

Legionella is a common cause of community-acquired and nosocomial-acquired pneumonia.

It is estimated that 25,000 people in the US develop Legionnaires disease each year.

(Lane, Ferrari, & Dreher, ,2004 / NYS DOH, 2004)PathophysiologyWhen the organism is inhaled, it attaches to the respiratory epithelial cells and the alveolar macrophages.

The bacterium most often causes pneumonia but can also cause flu-like symptoms known as Pontiac fever. This occurs 24-72 hours after exposure to the bacteria.

Legionnaires disease occurs 2-14 days after exposure to the bacteria. (CDC, 2013 / Pedrot-Betot, Stout, & Yu, 2013)EtiologyLegionella is an aerobic, gram-negative bacilli

There are over 50 species of legionella, L. pneumophila is the most common, accounting for 80% of human infections.

Pedrot-Betot, Stout, & Yu, 2013IncidenceSuccessful diagnosis requires specialized lab tests.Legionnaires disease accounts for 2-9% of community acquired pneumoniaThe incidence has tripled from 2000-2009 in both the U.S. and U.K.

Screening & Environmental Risk FactorsExposure to bodies of water, especially stagnant water.Man-made reservoirs cause the bacteria to grow and proliferate.In warm temperatures (25-42C) the bacteria have increased growthCompost facilities or potting soil may also be a reservoir for legionella. Risk Factors continuedChronic lung disease/smokingOlder age (>50)Transplant recipientsImmunosuppressants Tumor necrosis factor- alpha inhibitorImmunosuppressed childrenNeonatesRecent repairs/maintenance to domestic plumbing. Recent travelCDC, 2013Clinical FindingsPneumoniaFeversCoughPleuritic chest painHeadachesWatery diarrheaNeuro symptoms (seizure, confusion, disorientation, insomnia). (Domino, 2014)

Body aches, Flu-like symptoms, malaise without pneumonia is known as Pontiac fever (CDC, 2013)

CDC, 2013/ Domino, 2014Differential DiagnosesLegionnaires disease (482.84)Pneumonia due to other gram neg. bacteria (482.83)Pneumonia, unspecified organism (486)

Without pneumonia present:FluPontiac fever (also caused by Legionella)

Societal ConsiderationsAsk about travel that occurred 14 days before onset of symptoms- 20% of Legionnaires disease is thought to be due to travel.

The majority of cases are sporadic and outbreaks are rare. According to the NYS Dept. of Health, only outbreaks of the disease need to be investigated. (NYS DOH, 2004)Environmental ConsiderationsLegionella can be found in cooling towers, humidifiers, showers, hot tubs, ice machines, faucets and sinks. Inhaling or swallowing the bacteria is what causes the disease.

It can also be found in lakes and streams, especially stagnant water.

People that have an increased risk (immunocompromised) may need to avoid situations where there is an increased risk of legionellosis.

(Freije, 2013 & Lane, Ferrari, & Dreher, 2004)Laboratory TestsUrine antigen testing (most common method of detection)Culture of the organismDirect fluorescent antibody stainingSerology (antibody titers)

Both urine antigen testing AND culture of the organism are preferred by the CDC for diagnosis.

(Lane, Ferrari, & Dreher, 2004)Management/Treatment GuidelinesPharmacologicalNon-pharmacological* Azithrhromycin or levaquin- treatment of choice

Erythromycin- not favorable Rifampin- in combination with macrolide or flurquinolone if pt is severely ill

In an immunosuppressed pt:Treatment with Levaquin or Cipro for three weeks

Antipyretics for feverRest

Deep breathing

Symptomatic treatment

Oxygen

Hydration

Complications & Follow UpRespiratory failureDehydrationExtrapulmonary disease Disseminated intravascular coagulationMulti orgal dysfunctionComaDeath

Follow up with a chest xray to ensure resolution.Respiratory status, hydration and electrolyte status should be assessed.Domino, 2014Counseling/EducationHot water tank temperature should be above 140F.The temperature at the faucet should be above 122F.Avoid conditions that allow water to stagnate.Tub baths may have less aerosolized bacteria then shower.

Consultation/ReferralMay need to collaborate with local public health officials to assess environmental risks, especially in areas such as apartment complexes. Silk, et al., 2013Literature ReviewSome highlights from the literature review were that Legionella is actually a fairly common cause of pneumonia, however it is very under-reported.

There were difference in the first line treatment between literature. The 5-Minute Clinical Consult recommends levaquin as first line treatment but states that azithromycin may also be used as first line. In the article by Lane, Ferrari and Dreher, azithromycin is listed as first line.

The Engineers Notebook discusses how new piping systems are not resistant to Legionella, some of the older systems are actually less prone to legionella growth due to less surface area in the piping.

Multiple Choice QuestionsTrue or False: Legionella can be identified using routine bacteriologic media? TrueFalse

Who is at most risk to develop Legionnaires disease?65 year old transplant recipient14 year old swimming in a lake90 year old living in an apartment complex

The preferred treatment for Legionnaires is ________.ErythomycinRifampinAzithromycin

Multiple Choice Questions Continued4. True or False: The CDC recommends urine antigen testing only for the diagnosis of Legionnaires disease?TrueFalse

5. Who should be tested for Legionnaires?In a person that has travelled in the last 2 weeks.Severe pneumoniaA pt that has failed antibiotic therapyAll of the above

6. NYS will most likely investigate cases of Legionella infection when:Someone is diagnosed with the conditionA patient dies from the diseaseAn outbreak is suspected

Multiple Choice Questions Continued7. True or False: Legionnaires Disease should be reported to the Department of Health.TrueFalse

8. Complications of Legionnaires disease include:FeversRespiratory failureDeathAll of the above9. True or false: Legionella infection can be transmitted person to person.TrueFalse

10. Domestic water heaters should be kept at temperatures:Below 140 degrees FAbove 140 degrees F

Answersb. False- Specialized media like buffered charcoal yeast extract must be used.a. Transplant recipients are at a high risk for LD due to anti-rejection medications.c. Azithromycinb. False- Both culture and urine antigen testing is recommended by the CDC.d. All of the abovec. When an outbreak is suspecteda. Trued. All of the aboveb. Falsea. Above 140 degrees F (60 degrees C)

ReferencesCenters 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.

Freije, M.R. (2012). Legionella: Dont assume. Engineers Notebook: ASHRAA Journal, 54 (10), 100-101.

Lane, G., Ferrari, A., & Dreher, H. (2004). Clinical practice. Legionnaire's disease: a current update. MEDSURG Nursing, 13(6), 409-414.

New York State Department of Health. (2004). Legionellosis (Legionnaires Disease). Retrieved from http://www.health.ny.gov/diseases/communicable/legionellosis/docs/fact_sheet.pdf

Pedrot-Betot, M.L., Stout, S.E. & Yu, V.L. (2013). Epidemiology and pathogenesis of Legionella infection. Retrieved from www.uptodate.com/contents/epidemiology-and=pathogenesis-of-legionella-infection.

Silk, B. J., Foltz, J. L., Ngamsnga, K., Brown, E., Muoz, 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.