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Association of Legionnaires Disease with Construction: Contamination of Potable Water?

Published online by Cambridge University Press:  02 January 2015

Leonard A. Mermel*
Departments of Medicine, Providence, Rhode island Infection Control, Providence, Rhode island Pathology, Providence, Rhode island Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode island
Stephen L. Josephson
Pathology, Providence, Rhode island Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode island
Jane Dempsey
Infection Control, Providence, Rhode island
Stephen Parenteau
Infection Control, Providence, Rhode island
Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903



To describe two cases of nosocomial legionellosis and discuss the epidemiology of this infection.


Potable water was collected from multiple sites. Patient and environmental isolates were characterized by the Legionella slide agglutination test and monoclonal antibody subtyping. Concordance among isolates was confirmed by pulsed-field gel electrophoresis (PFGE).


A 713-bed university-affiliated hospital.


There was widespread contamination of potable water with Legionella pneumophila during a period of major construction; cooling towers were without growth of Legionella. One patient's isolate was the same by PFGE as the environmental isolate collected from the water faucet in his room. Control measures included superheating water used in all patient care areas to 75°C for 72 hours and flushing superheated water through faucets and showers; cleaning shower heads with a sonicator washer; and raising the hot water storage tank temperature from 43°C to 52°C. After these interventions, repeat environmental cultures over the next 6 months were without growth of Legionella, and no further cases of nosocomial legionnaires' disease were documented. An association between legionnaires' disease and construction is postulated. Heightened surveillance and preventive measures may be warranted during periods of excavation on hospital grounds or when potable water supplies are otherwise shut down and later repressurized.

Original Articles
Copyright © The Society for Healthcare Epidemiology of America 1995

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1.Fraser, DW, Tsai, TR, Orenstein, W, et al.Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med 1977;297:11891197.Google Scholar
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 diseases. N Engl J Med 1977; 297:11971203.Google Scholar
3.Muder, RR, Yu, VL, Fang, G-D.Community-acquired Legionnaires' disease. Semin Respir Infect 1989;4:3239.Google Scholar
4.Korvick, JA, Yu, VL, Fang, G-D. Legionella species as hospital-acquired respiratory pathogens. Semin Respir Infect 1987;2:3447.Google Scholar
5.Doebbeling, BN, Wenzel, RP. The epidemiology of Legionella pneumophila infections. Semin Respir Infect 1987;2:206221.Google Scholar
6.Müder, RR, Yu, VL. Woo, AH. Mode of transmission of Legionella pneumophila. Arch Intern Med 1986;146:16071612.Google Scholar
7.US Department of Health and Human Services. Procedures for the Recovery of Legionella from the Environment. Atlanta, GA: Centers for Disease Control and Prevention; 1992;113.Google Scholar
8.Struelens, MT. Maes, N. Deplano, A. Bornstein, N. Grimont F Comparison of methods for subtyping Legionella pneumophila. In: Barbaree, JM. Breiman, RF, Dufour, AP, eds. Legionella: Current Status and Emerging Perspectives. Washington, DC: American Society for Microbiology; 1993:183186.Google Scholar
9.Maslow, JN, Slutsky, A, Arbeit, RD. The application of pulsed-field gel electrophoresis to molecular biology. In: Persing, DH, Smith, TFTenover, FC. White, TS. eds. Diagnostic Molecular Microbiology Principles and Applications. Washington, DC: American Society for Microbiology; 1993:563572.Google Scholar
10.Helms, CM, Massanari, RM, Zeitler, R, et al.Legionnaires' disease associated with a hospital water system: cluster of 24 nosocomial cases. Ann Intern Med 1983;99:172178.Google Scholar
11.Garbe, PL, Davis, BJ, Weisfeld, JS, et al.Nosocomial Legionnaires' disease. Epidemiologic demonstration of cooling towers as a source. JAMA 1985;254:521524.Google Scholar
12.Bartlett, CLR. Potable water as reservoir and means of transmission. In: Thornsberry, C, Balows, A, Feeley, JC, Jakubowski, W, eds. Legionella. Proceedings of the 2nd International Symposium. Washington, DC: American Society for Microbiology; 1984:210215.Google Scholar
13.Struelens, MJ, Maes, N, Rost, F, et al.Genotypic and phenotypic methods for the investigation of a nosocomial Legionella pneumophila outbreak and efficacy of control measures. J Infect Dis 1992;166;2230.Google Scholar
14.Marrie, TJ, Haldane, D, MacDonald, S, et al.Control of endemic nosocomial Legionnaires' disease by using sterile potable water for high risk patients. Epidemiol Infect 1991;107:591605.Google Scholar
15.Venezia, RA, Agresta, MD, Vigna, PA, Hanley, EM, Urquhart, K, Schoonmaker, D. Legionellosis in an intensive care unit from a potable hot water system. Am J Infect Control 1993;21:102. Abstract.Google Scholar
16.Meenhorst, PL, Reingold, AL. Groothuis, DG, et al.Water-related nosocomial pneumonia caused by Legionella pneumophila sero-groups 1 and lO. Infect Dis 1985:152:356364.Google Scholar
17.Meigh, RE, Makin, TScott, MH, Hart, CA. Legionella pneumophila serogroup 12 pneumonia in a renal transplant recipient: case report and environmentalobservations. J Hosp Infect 1989;13:315319.Google Scholar
18.LeSaux, NM, Sekla, L, McLeod, J, et al.Epidemie of nosocomial Legionnaires' disease in renal transplant recipients: a case-control and environmental study. Can Med Assoc J 1989;140:10471053.Google Scholar
19.Ott, M, Bender, L, Marre, R, Hacker, J. Pulsed field electrophoresis of genomic restriction fragments for the detection of nosocomial Legionella pneumophila in hospital water supplies. I Clin Microbiol 1991;29:813-815.Google Scholar
20.Schoonmaker, DJ, Kondracki, SF. Investigation of nosocomial legionellosis using restriction enzyme analysis by pulsed-field gel electrophoresis. In: Barbaree, JM, Breiman, REDufour, AP, eds. Legionella. Current Status and Emerging Perspectives. Washington, DC: American Society for Microbiology; 1993:189194.Google Scholar
21.Parry, MEStampleman, L, Hutchinson, JH, Folta, D, Steinberg, MG, Krasnogor, W. Waterborne Legionella bozemanii and nosocomial pneumonia in immunosuppressed patients. Ann Intern Med 1985;103:205210.Google Scholar
22.Meenhorst, PL, Reingold, AL, Gorman, GW, et al.Legionella pneumonia in guinea pigs exposed to aerosols of concentrated potable water from a hospital with nosocomial Legionnaires' disease. J hfect Dis 1983;147:129132.Google Scholar
23.Yu, VL, Stout, J, Zuravleff, J, Brown, A. Aspiration of contaminated water may be a mode of transmission for Legionella pneumophila. In: Program and Abstracts of the 21st Interscience Conference on Antimicrobial Agents and Chemotherapy Washington, DC: American Society for Microbiology; 1981:297.Google Scholar
24.Dournan, E, Bure, A, Desplaces, N, Carette, MF, Mayaue, CH. Legionnaires' disease related to gastric lavage with tap water. Lancet 1982;i:797798.Google Scholar
25.Katz, SM, Matus, JP. Febrile illness produced in guinea pigs by oral inoculation of Legionella pneumophila. In: Thornsberry, C, Balows, A, Geeley, JC, Jakubowski, W, eds. Legionella. Proceedings of the 2nd International Svmvosium. Washington, DC: American Society for Microbiology; 1985:124127.Google Scholar
26.Plouffe, JFKelly, KA, Bollin, GE. Oral ingestion of Legionella pneumophila. In: Program and Abstracts of the 2lst Interscience Conference on Antimicrobial Agents and Chemotherapy, 1985. Washington, DC: American Society for Microbiology; 1985:297.Google Scholar
27.Johnson, JT, Best, MG, Goetz, A, et al.Nosocomial legionellosis in surgical patients with head-and-neck cancer: implications for epidemiological reservoir and mode of transmission. Lancet 1985;ii:298300.Google Scholar
28.Muder, RR, Stout, JE, Yee, YC. Isolation of Legionella pneumophila serogroup 5 from empyema following esophageal perforation. Source of the organism and mode of transmission. Chest 1992;102:16011603.Google Scholar
29.Blatt, SP: Parkinson, MD, Pace, E, et al.Nosocomial Legionnaires' disease: aspiration as a primary mode of disease acquisition. Am J Med 1993;95:1622.Google Scholar
30.Storch, G, Baine, WB, Fraser, DW, et al.Sporadic community-acquired Legionnaires' disease in the United States. Ann Intern Med 1979;90:596600.Google Scholar
31.Monforte, R, Cayla, J, Sala, MR, et al.Community outbreak of Legionnaires' disease in Barcelona. Lancet 1989:i:1011.Google Scholar
32.Redd, S, Lyn, FYC, Fields, BS, et al.A rural outbreak of Legionnaires' disease linked to visiting a retail store. Am J Public Health 1990;80:431434.Google Scholar
33.Thacker, SB, Bennett, JV, Tsai, TF, et al.An outbreak in 1965 of severe respiratory illness caused by the Legionnaires' disease bacterium. J Infect Dis 1978;138:512519.Google Scholar
34.Marks, JS, Tsai, TF, Martone, WJ, et al.Nosocomial Legionnaires' disease in Columbus, Ohio. Ann Intern Med 1979;90:565569.Google Scholar
35.Haley, CE, Cohen, ML, Halter, J, Meyer, RD. Nosocomial Legionnaires' disease: continuing common-source epidemic at Wadsworth Medical Center. Ann Intern Med 1979;90:583586.Google Scholar
36.Kirby, BD, Snyder, KM, Meyer, RD, Fineold, SM. Legionnaires' disease: report of sixty-five nosocomially acquired cases and review of the literature. Medicine 1980:59;188205.Google Scholar
37.Stolz, SM, Maki, DG. Endemie nosocomial legionellosis despite very low-level contamination of hospital water, identified by molecular subtyping by restriction enzyme digestion and pulsed-field electrophoresis. In: Program of the 2nd Annual Meeting of the Society for Hospital Epidemiology of America. West Deptford, NJ: The Society for Hospital Epidemiology of America: 1992:S42.Google Scholar
38.Morton, S, Bartlett, CLR, Bibby, LFHutchinson, DN, Dyer, JV, Dennis, PJ. Outbreak of Legionnaires' disease from a cooling water system in a power station. Br J Ind Med 1986;43:630635.Google Scholar
39.Shands, KN, Ho, JL, Meyer, RD, et al.Potable water as a source of Legionnaires' disease. JAMA 1985;253:14121416.Google Scholar
40.Fisher-Hoch, SP: Smith, MG, Colboume, JS. Legionella pneumophila in hospital hot water cylinders. Lancet 1982;i:1073.Google Scholar
41.Bartlett, CLR, Swann, RA, Casal, J, Canada-Royo, L, Taylor, AG. Recurrent Legionnaires disease from a hotel water system. In: Thornsberry, C, Balows, A, Feeley, JC, Jakubowski, W, eds. Legionella. Proceedings of the 2nd International Symposium. Washington, DC: American Society for Microbiology; 1984:217219.Google Scholar
42.Straus, WL, Plouffe, JFFile, TM, et al.Factors associated with transmission of Legionnaires' disease in the home. In: Program and Abstracts of the 34th Interscience Conference of Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology; 1994:J259.Google Scholar
43.Seu, P, Winston, DJ, Olthoff, KM, Bruckner, DA, Busuttil, RW. Legionnaires' disease in liver transplant recipients. Infect Dis ClinPrac 1993;2:109113.Google Scholar
44.Stout, JE, Yu, VL, Muraca, P. Isolation of legionella pneumophila from the cold water of hospital ice machines: implications for origin and transmission of the organism. Infect Control 1985;6:141146.Google Scholar