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Hospital Characteristics Associated With Colonization of Water Systems by Legionella and Risk of Nosocomial Legionnaires' Disease: A Cohort Study of 15 Hospitals

Published online by Cambridge University Press:  02 January 2015

Jacob L. Kool
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia National Center for Infectious Diseases; Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
David Bergmire-Sweat
Affiliation:
Infectious Disease Epidemiology and Surveillance Division, Texas Department of Health, Austin, Texas
Jay C. Butler
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Ellen W. Brown
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Deborah J. Peabody
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia Epidemiology Elective Program, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Daniel S. Massi
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia Epidemiology Elective Program, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Joseph C. Carpenter
Affiliation:
Hospital Infections Program, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Janet M. Pruckler
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Robert F. Benson
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Barry S. Fields
Affiliation:
Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia

Abstract

Objective:

To investigate an increase in reports of legionnaires' disease by multiple hospitals in San Antonio, Texas, and to study risk factors for nosocomial transmission of legionnaires' disease and determinants for Legionella colonization of hospital hot-water systems.

Setting:

The 16 largest hospitals in the cities of San Antonio, Temple, and Austin, Texas.

Design:

Review of laboratory databases to identify patients with legionnaires' disease in the 3 years prior to the investigation and to determine the number of diagnostic tests for Legionella performed; measurement of hot-water temperature and chlorine concentration and culture of potable water for Legionella. Exact univariate calculations, Poisson regression, and linear regression were used to determine factors associated with water-system colonization and transmission of Legionella.

Results:

Twelve cases of nosocomial legionnaires' disease were identified; eight of these occurred in 1996. The rise in cases occurred shortly after physicians started requesting Legionella urinary antigen tests. Hospitals that frequently used Legionella urinary antigen tests tended to detect more cases of legionnaires' disease. Legionella was isolated from the water systems of 11 of 12 hospitals in San Antonio; the 12th had just experienced an outbreak of legionnaires' disease and had implemented control measures. Nosocomial legionellosis cases probably occurred in 5 hospitals. The number of nosocomial legionnaires' disease cases in each hospital correlated better with the proportion of water-system sites that tested positive for Legionella (P=.07) than with the concentration of Legionella bacteria in water samples (P=.23). Hospitals in municipalities where the water treatment plant used monochloramine as a residual disinfectant (n=4) and the hospital that had implemented control measures were Legionella-free. The hot-water systems of all other hospitals (n=11) were colonized with Legionella. These were all supplied with municipal drinking water that contained free chlorine as a residual disinfectant. In these contaminated hospitals, the proportion of sites testing positive was inversely correlated with free residual chlorine concentration (P=.01). In all hospitals, hot-water temperatures were too low to inhibit Legionella growth.

Conclusions:

The increase in reporting of nosocomial legionnaires' disease was attributable to increased use of urinary antigen tests; prior cases may have gone unrecognized. Risk of legionnaires' disease in hospital patients was better predicted by the proportion of water-system sites testing positive for Legionella than by the measured concentration of Legionella bacteria. Use of monochloramine by municipalities for residual drinking water disinfection may help prevent legionnaires' disease.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1999

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References

1. Marston, BJ, Plouffe, JF, File, TM Jr, Hackman, BA, Salstrom, SJ, Lipman, HB, et al. Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch Intern Med 1997;157:17091718.CrossRefGoogle ScholarPubMed
2. Marston, BJ, Lipman, HB, Breiman, RF. Surveillance for legionnaires' disease. Risk factors for morbidity and mortality. Arch Intern Med 1994;154:24172422.CrossRefGoogle Scholar
3. 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
4. Marrie, TJ, Haldane, D, MacDonald, S, Clarke, K, Fanning, C, Le Fort-Jost, S, et al. Control of endemie nosocomial legionnaires' disease by using sterile potable water for high risk patients. Epidemiol Infect 1991;107:591605.CrossRefGoogle Scholar
5. O'Mahony, MC, Stanwell-Smith, RE, Tillett, HE, Harper, D, Hutchison, JG, Farrell, ID, et al. The Stafford outbreak of legionnaires' disease. Epidemiol Infect 1990;104:361380.CrossRefGoogle Scholar
6. Ruf, B, Schurmann, D, Horbach, I, Seidel, K, Pohle, HD. Nosocomial Legionella pneumonia: demonstration of potable water as the source of infection. Epidemiol Infect 1988;101:647654.CrossRefGoogle ScholarPubMed
7. Centers for Disease Control and Prevention. Sustained transmission of nosocomial Legionnaires disease—Arizona and Ohio. MMWR 1997;46:416421.Google ScholarPubMed
8. Alary, M, Joly, JR. Factors contributing to the contamination of hospital water distribution systems by legionellae. Dis 1992;165:565569.Google ScholarPubMed
9. Breiman, RF, Fields, BS, Sanden, GN, Volmer, L, Meier, A, Spika, JS. Association of shower use with legionnaires' disease. Possible role of amoebae. JAMA 1990;263:29242926.CrossRefGoogle ScholarPubMed
10. Blatt, SP, Parkinson, MD, Pace, E, Hoffman, P, Dolan, D, Lauderdale, P, et al. Nosocomial legionnaires' disease: aspiration as a primary mode of disease acquisition. Am J Med 1993;95:1622.CrossRefGoogle ScholarPubMed
11. Edelstein, PH. Legionnaires' disease. Clin Infect Dis 1993;16:741747.CrossRefGoogle ScholarPubMed
12. Lepine, LA, Jernigan, DB, Butler, JC, Pruckler, JM, Benson, RF, Kim, G, et al. A recurrent outbreak of nosocomial legionnaires' disease detected by urinary antigen testing: evidence for long-term colonization of a hospital plumbing system. Infect Control Hosp Epidemiol 1998;19:905910.CrossRefGoogle ScholarPubMed
13. Helms, CM, Renner, ED, Viner, JP, Hierholzer, WJ Jr, Wintermeyer, LA, Johnson, W. Indirect immunofluorescence antibodies to Legionella pneumophila: frequency in a rural community. J Clin Microbiol 1980;12:326328.Google Scholar
14. Kirmeyer, GJ, Foust, GW, Pierson, GL, Simmler, JJ, LeChevalier, MW. Optimizing Chloramine Treatment. Denver, CO: American Water Works Research Foundation; 1993.Google Scholar
15. Kool, JL, Carpenter, JC, Fields, BS. Effect of monochloramine disinfection of municipal drinking water on risk of nosocomial legionnaires' disease. Lancet 1999;353:272277.CrossRefGoogle ScholarPubMed
16. Vickers, RM, Yu, VL, Hanna, SS, Muraca, P, Diven, W, Carmen, N, et al. Determinants of Legionella pneumophila contamination of water distribution systems: 15-hospital prospective study. Infect Control 1987;8:357363.CrossRefGoogle ScholarPubMed
17. Kool, JL, Fiore, AE, Kioski, CM, Brown, EW, Benson, RF, Pruckler, JM, et al. More than 10 years of unrecognized nosocomial transmission of legionnaires' disease among transplant patients. Infect Control Hosp Epidemiol 1998;19:898904.CrossRefGoogle Scholar
18. Health Facility Licensure and Certification Division. Hospital Licensing Standards, Amended Through March 1, 1994. Austin, TX: Texas Department of Health; 1994:81.Google Scholar
19. Katcher, ML. Scald burns from hot tap water. JAMA 1981;246:12191222.CrossRefGoogle ScholarPubMed
20. Best, M, Yu, VL, Stout, J, Goetz, A, Muder, RR, Taylor, F. Legionellaceae 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;2:307310.Google Scholar
21. Bezanson, GS, Joly, J, Burbridge, SM, Kuehn, RD, Haldane, DJM, Marrie, TJ. Phenotypic and genotypic variability of Legionella pneumophila populating potable waters and patients of a tertiary-care hospital over a five-year period. In: Barbaree, JM, Breiman, RF, Dufour, AP, eds. Legionella: Current Status and Emerging Perspectives. Washington, DC: American Society for Microbiology; 1993:275278.Google Scholar
22. Boulanger, CA, Edelstein, PH. Precision and accuracy of recovery of Legionella pneumophila from seeded tap water by filtration and centrifugation. Appl Environ Microbiol 1995;61:18051809.Google Scholar
23. Allegheny County Health Department. Approaches to Prevention and Control of Legionella Infection in Allegheny County Health Care Facilities. Pittsburgh, PA: Allegheny County Health Department; 1997.Google Scholar
24. Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR 1997;46(RR-1):179.Google ScholarPubMed

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