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Environmental Cultures and Hospital-Acquired Legionnaires' Disease: A 5-Year Prospective Study in 20 Hospitals in Catalonia, Spain

  • Miquel Sabrià (a1), Josep M. Mòdol (a1), Marian Garcia-Nuñez (a1), Esteban Reynaga (a1), Maria L. Pedro-Botet (a1), Nieves Sopena (a1) and C. Rey-Joly (a1)...



To determine whether environmental cultures for Legionella increase the index of suspicion for legionnaires' disease (LD).


Five-year prospective study.


Twenty hospitals in Catalonia, Spain.


From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested for Legionella, Cases of hospital-acquired LD and availability of an “in-house” Legionella test in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing.


Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and used Legionella tests including Legionella urinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals, Legionella tests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) used Legionella urinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD.


The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using the Legionella urinary antigen test in their laboratories.


Corresponding author

Unitat de Malalties Infeccioses, Hospital Germans Trias i Pujol, Ctra del Canyet s/n, 08916 Badalona, Barcelona, Spain


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1.Fraser, DW, Tsai, T, Orenstein, W, et al.Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med 1977;297:11891197.
2.McDade, JE, Shepard, CC, Fraser, DW, Tsai, TR, Redus, MA, Dowdle, WR. Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N Engl J Med 1977;297:11971203.
3.Sabria, M, Yu, VL. Hospital-acquired legionellosis: solutions for a preventable infection. Lancet Infect Dis 2002;2:368373.
4.Yu, VL. Nosocomial legionellosis. Curr Opin Infect Dis 2000;13:385388.
5.Kohler, JR, Maiwald, M, Luck, PC, Helbig, JH, Hingst, V, Sonntag, HG. Detecting legionellosis by unselected culture of respiratory tract secretions and developing links to hospital water strains. J Hosp Infect 1999;41:301311.
6.Kool, JL, Fiore, AE, Kioski, CM, et al.More than 10 years of unrecognized nosocomial transmission of legionnaires' disease among transplant patients. Infect Control Hosp Epidemiol 1998;19:898904.
7.Lepine, L, Jernigan, DB, Butler, JC, 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.
8.Joseph, CA, Watson, JM, Harrison, TG, Bartlett, CL. Nosocomial Legionnaires' disease in England and Wales, 1980-1992. Epidemiol Infect 1994;112:329345.
9.Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR 1997;46:3134.
10.Allegheny County Health Department. Approaches to Prevention and Control of Legionella Infection in Allegheny County Health Care Facilities, ed. 2. Pittsburgh, PA: Allegheny County Health Department;1997.
11.State of Maryland, Department of Health and Mental Hygiene. Report of the Maryland Scientific Working Group to Study Legionella in Water Systems in Health Care Institutions. Baltimore, MD: Department of Health and Mental Hygiene; 2000. Available at
12.Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities. MMWR 2003;52(RR-10):142.
13.Sabria, M, Garcia-Nuñez, M, Pedro-Botet, ML, et al.Presence and chromosomal subtyping of Legionella species in potable water systems in 20 hospitals of Catalonia, Spain. Infect Control Hosp Epidemiol 2001;11:673676.
14.Chow, JW, Yu, VL. Legionella: a major opportunistic pathogen in transplant recipients. Semin Respir Infect 1998;13:132139.
15.Carratala, J, Gudiol, F, Pallares, R, et al.Risk factors for nosocomial Legionella pneumophila pneumonia. Am J Respir Crit Care Med 1994;149:625629.
16.Patterson, WJ, Hay, J, Seal, DV, McLuckie, JC. Colonisation of transplant unit water supplies with Legionella and protozoa: precautions required to reduce the risk of legionellosis. J Hosp Infect 1997;37:717.
17.Alary, M, Joly, JR. Factors contributing to the contamination of hospital water distribution systems. J Infect Dis 1992;165:565569.
18.Vickers, RM, Yu, VL, Hanna, SS, et al.Determinants of Legionella pneumophila contamination of water distribution systems: 15-hospital prospective study. Infect Control 1987;8:357363.
19.Marrie, TJ, Green, T, Burbridge, S. Legionellaceae in the potable water of Nova Scotia hospital and Halifax residences. Epidemiol Infect 1994;112:143150.
20.Yu, V. Resolving the controversy on environmental cultures for Legionella: a modest proposal. Infect Control Hosp Epidemiol 1998;19:893897.
21.Joly, J, Alary, M. Occurrence of nosocomial legionnaires' disease in hospitals with contaminated potable water supply. In: Barbaree, JD, Breiman, RF, Dufour, AP, eds. Current Status and Emerging Perspectives. Washington, DC: American Society of Microbiology; 1994:39.
22.Muder, RR, Yu, VL, McClure, J, Kominos, S. Nosocomial legionnaires' disease uncovered in a prospective pneumonia study: implications for underdiagnosis. JAMA 1983;249:31843188.
23.Yu, VL, Beam, TR, Lumish, RM, et al.Routine culturing for Legionella in the hospital environment may be a good idea: a three-hospital prospective study. Am J Med Sci 1987;294:9799.
24.Goetz, AM, Stout, JE, Jacobs, SL, et al.Nosocomial legionnaires' disease discovered in community hospitals following cultures of the water system: seek and ye shall find. Am J Infect Control 1998;26:611.
25.Domlnguez, JA, Gali, N, Pedroso, P, et al.Comparison of the Binax Legionella urinary antigen enzyme immunoassay (EIA) with the Biotest Legionella urinary antigen EIA for detection of Legionella antigen in both concentrated and nonconcentrated urine samples. J Clin Microbiol 1998;36:27182722.
26.Murdoch, DR. Diagnosis of Legionella infection. Clin Infect Dis 2003;36:6469.
27.Knirsch, CA, Jakob, K, Schoonmaker, D, et al.An outbreak of Legionella micdadei pneumonia in transplant patients: evaluation, molecular epidemiology, and control. Am J Med 2000;108:290295.
28.Lin, YE, Stout, JE, Yu, VL, Vidic, RD. Disinfection of water distribution systems for Legionella. Semin Respir Infect 1998;13:147149.

Environmental Cultures and Hospital-Acquired Legionnaires' Disease: A 5-Year Prospective Study in 20 Hospitals in Catalonia, Spain

  • Miquel Sabrià (a1), Josep M. Mòdol (a1), Marian Garcia-Nuñez (a1), Esteban Reynaga (a1), Maria L. Pedro-Botet (a1), Nieves Sopena (a1) and C. Rey-Joly (a1)...


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