Factores pronósticos en adultos hospitalizados por neumonía causada por Legionella pneumophila / Prognostic factors in adult patients hospitalized for pneumonia caused by Legionella pneumophila

Introduction: Legionellosis is a multisystem bacterial disease, which causes pneumonia with high mortality in patients with comorbidity and admitted in intensive care units (ICU). Objective: Determine predictors of mortality or ICU admission. Methods: Retrospective follow-up of patients diagnosed with Legionella pneumophila pneumonia in Complexo Hospitalario Universitario de A Coruña. Period 2000-2013 (n = 240). Analysis of multivariate logistic regression was performed. Results: Mean age was 57.2 ± 15.4 years old, 88.3% were male. Average score of comorbidity (Charlson score) was 2.3 ± 2.3. There was a clear seasonal variation. Predominant symptoms were fever (92.5%), dry cough (38.1%) and dyspnea (33.9%). Creatinine clearance was lower than 60 mL/min/1.73 m² in 29.7% and sodium < 135 mEq/l in 58.3%. Admission to ICU rate was 16.3% and 10.8% needs mechanical ventilation. Inhospital mortality rate was 4.6%, rising to 23.1% in patients admitted to ICU. Variables associated to predict ICU admission were age (OR = 0.96), liver disease (OR = 7.13), dyspnea (OR = 4.33), delirium (OR = 5.86) and high levels of lactatedehydrogenase (OR = 1.002). Variables associated with inhospital mortality were Charlson index (OR = 1.70), mechanical ventilation (OR = 31.44) and high levels of lactatedehydrogenase (OR = 1.002). Discussion: Younger patients with liver disease, dyspnea and confusion are more likely to be admitted to ICU. Comorbidity, mechanical ventilation and elevated LDH levels are associated with higher mortality rate.

Introducción: La legionelosis es una enfermedad bacteriana multisistémica, causante de neumonías con mortalidad elevada en pacientes con comorbilidad e ingresos en Unidad de Cuidados Intensivos (UCI). Objetivo: Determinar factores pronósticos de mortalidad o ingreso en UCI. Material y Métodos: Estudio de seguimiento retrospectivo de pacientes diagnosticados de neumonía por Legionella pneumophila en Complexo Hospitalario Universitario de A Coruña (España). Período 2000-2013 (n = 240), con análisis de regresión logística multivariada. Resultados: La edad media fue 57,2 ± 15,4 años, 88,3% fueron hombres. La puntuación media de comorbilidad (score Charlson) fue 2,3 ± 2,3. Existe clara estacionalidad. La clínica predominante fue fiebre (92,5%), tos seca (38,1%) y disnea (33,9%). El 29,7% presentó aclaramiento de creatinina < 60 mL/min/1,73 m² y el 58,3% sodio < 135 mEq/l. Un 16,3% ingresó en UCI, precisando ventilación mecánica invasiva el 10,8%. La mortalidad global fue 4,6% y de 23,1% en ingresados en UCI. Variables asociadas para predecir ingreso en UCI fueron menor edad (OR = 0,96), hepatopatía (OR = 7,13), disnea (OR = 4,33), síndrome confusional (OR = 5,86) y lactato deshidrogenasa elevada (OR = 1,002). Las variables asociadas a mortalidad intrahospitalaria fueron índice de Charlson (OR = 1,70), ventilación mecánica invasiva (OR = 31,44) y cifras elevadas de lactato deshidrogenasa (OR = 1,002). Discusión: Pacientes jóvenes, con hepatopatía, disnea o confusión tienen más probabilidad de ingresar en UCI. Comorbilidad, ventilación mecánica y lactato deshidrogenasa elevada se asocian a mortalidad.

Application of three uniplex polymerase chain reaction assays for the detection of atypical bacteria in asthmatic patients in Kuwait

Respiratory infections are known to exacerbate wheezing in many asthmatic patients. We aimed to use molecular methods for the fast detection of Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila in respiratory specimens from asthmatic patients in Kuwait. We used uniplex PCR assays to detect the three atypical bacteria in clinical specimens from 235 asthmatic and non-asthmatic patients in Kuwait. A regression analysis was used to identify the risk factors related to the bacterial type. Group comparisons for similarity were conducted and correlation coefficients were calculated using SPSS statistical software. The detection limits using uniplex PCR for C. pneumoniae, L. pneumophila and M. pneumoniae were approximately 1 pg, 2.4 fg and 12 pg of DNA, respectively. M. pneumoniae PCR positivity was more common in asthmatic patients [15%] than in non-asthmatic subjects [9%] [P < 0.05]. A marked difference was observed between patients with acute asthma exacerbation [11%] and patients with chronic [stable] asthma [7%] among Kuwaiti patients; these percentages were 16% for non-Kuwaiti acute asthma patients and 14% for non-Kuwaiti chronic asthma patients [P < 0.201]. There was a weak positive correlation between asthma severity and PCR positivity for M. pneumoniae. The PCR results for C. pneumoniae and L. pneumoniae were found to be statistically insignificant. The results of this study suggest that infection with M. pneumoniae may be related to the exacerbation of asthma symptoms and could possibly be a factor that induces wheezing

Comparison of Sputum and Nasopharyngeal Swab Specimens for Molecular Diagnosis of Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila

BACKGROUND: Differentiation of atypical pathogens is important for community-acquired pneumonia (CAP). In this study, we compared sputum and nasopharyngeal swabs (NPS) for use in detection of Mycoplasma pneumoniae (MP), Chlamydophila pneumoniae (CP), and Legionella pneumophila (LP), using Seeplex PneumoBacter ACE Detection Assay (PneumoBacter; Seegene). METHODS: Sputum and NPS specimens were collected from patients in 15 hospitals. DNA was extracted from sputum using QIAamp DNA Stool Mini Kit (Qiagen) and from NPS using easyMAG (bioMerieux). Both types of specimens were evaluated by multiplex PCR using PneumoBacter. To determine the diagnostic performance of this assay, sputum samples were also tested using BD ProbeTec ET Atypical Pneumonia Assay (APA; Becton Dickinson). RESULTS: Among 217 sputum and NPS, 20 (9.2%), 2 (0.9%), and 0 sputum were positive for MP, LP, and CP, respectively, whereas 8 (3.7%) NPS were positive for MP. The sputum APA test yielded 186, 206, and 204 interpretable results for MP, LP, and CP, respectively. Of these, 21 (11.3%) were positive for MP, 2 (1.0%) were positive for LP, and 0 samples were positive for CP. Compared to APA, the sensitivity and specificity of the sputum assay for MP were 95.2% and 100.0%, respectively, whereas for the NPS assay, these were 38.1% and 93.9%. Sputum testing was more sensitive than NPS testing (P=0.002). For LP and CP diagnosis, PneumoBacter and APA tests agreed 100%. CONCLUSIONS: Specimen type is crucial and sputum is preferred over NPS for simultaneous detection of MP, LP, and CP using multiplex PCR in CAP.

Sero diagnosis of Legionella infection in community acquired pneumonia.

Background & objectives: Legionella pneumophila has been increasingly recognized as an emerging pathogen responsible for community acquired pneumonia (CAP) worldwide. In India, the actual burden is not known. The present study was thus undertaken to see the presence of Legionella infection in patients with community acquired pneumonia admitted in a tertiary care centre in north India. Methods: Both children and adults (n=113) with symptoms of pneumonia were included in the study. Clinical samples (blood, urine, nasopharyngeal aspirates, bronchoalveolar lavage, sputum, etc.) were collected and subjected to culture and other tests. Enzyme linked immunosorbent assay (ELISA) was done by commercial kits for all the three classes of immunoglobulins (IgG, IgM & IgA). Urinary antigen was also detected using commercial kits. Culture was performed on 51 respiratory tract fluid samples. Serum samples of 44 healthy controls were also screened for the presence of anti-legionella antibodies (IgG, IgM & IgA). Results: Thirty one of the 113 cases (27.43%) were serologically positive. Anti-legionella IgG, IgM and IgA antibodies were positive in 7.96, 15.92 and 11.50 per cent patients respectively. In controls, seropositivity was 9.09 (4/44). IgA was positive in 3 and IgM, IgG combined in one. Antigenuria detection by Microwell ELISA kit showed 17.69 per cent positivity. Four antigenuria positive patients were also serologically positive; of these two patients were positive for IgM, hence considered as confirmed cases of Legionella infection. None of the sample was culture positive. Interpretation & conclusions: Combination of serology and antigenuria detection may be a valuable tool for the diagnosis of Legionella infection in absence of culture positivity. In order to evaluate the actual burden of Legionella in community acquired pneumonia, further studies with larger samples need to be done.

Isolation of legionella from BAL samples of legionella pneumonia patients, by PCR and Culture methods

Among the members of legionellaceae, Legionella Pneumophila is involved in 95% of cases of severe pneumonia. Isolation of the causative agent from bronchoalveolar lavage [BAL] fluid specimen is a delicate process and also time-consuming. Moreover, it has been shown that some Legionella strains may be viable but cannot be cultured. The aim of this study was comparison of culture and PCR for detection of Legionella Pneumophila from bronchoalveolar lavage [BAL] fluid specimens. In this study, 70 BAL fluid specimens were collected from patients suspected to Legionnaires' disease. These samples were cultured on selective buffered charcoal-yeast extract agar [BCYE] and then tested with specific L. Pneumophila primers for mip gene. Among 70 BAL samples, three [4.2%] were positive with culture and six [8.4%] of specimens were positive by PCR. The three culture positive samples were all positive after specific DNA amplification. Among 63 culture-negative samples, 3 were positive after amplification. The clinical features of the patients were in accordance with legionellosis. The accurate diagnosis of Legionella Pneumophila has an important implication for the treatment of infection. Analysis of the results showed that PCR is faster and more sensitive for isolation and identification of L. pneumophila to apply on BAL fluid specimens than culture. Therefore, specific Legionella PCR can be a good option for isolation and identification of Legionella Pneumophila from bronchoalveolar lavage [BAL] fluid specimens in patient of severe pneumonia

Legionnaires' disease: a rare entity in Puerto Rico?

Legionnaires' disease is a severe, often fatal pneumonia, caused by Legionella pneumophila. Its incidence is reported about 6. In Puerto Rico, there is no data available of the prevalence of Legionnaires' disease. A case of Legionnaires' is presented as well as data to support that the prevalence in our Island is higher than the reported elsewhere.

First isolation of Legionella pneumophila in Sri Lanka.

OBJECTIVES: To determine the presence of legionellae and species composition of the genus Legionella in Sri Lankan hotel cooling towers, and to determine the previous exposure of hotel workers to Legionella pneumophila. DESIGN: Collection of water samples from 16 cooling towers of air conditioning plants from 7 representative hotels, and blood samples from hotel workers. SETTING: Department of Bacteriology, Medical Research Institute, Colombo 8. RESULTS: Water samples from 4 (57.4%) hotels selected were positive for legionellae. Five (38.4%) selected cooling towers yielded legionellae with viable counts ranging from 1 to 5 colony forming units (CFU)/ml. 93.7% of the isolates were Legionella pneumophila. Only one hotel worker had significant antibody levels denoting past infection to Legionella pneumophila. CONCLUSION: Legionella does occur in the Sri Lankan hotel environment and Legionella pneumophila appears to be the most common species.

Pneumonia due to unusual organisms in children.

Generally antimicrobials for treatment of pneumonia are chosen to target the usual bacterial etiological agents. Such regimens are unable to cure patients of pneumonia caused by 'unusual organisms' mycoplasma, chlamydia, Pneumocystis carinii and Legionella pneumophilus). Thus, there is a need to anticipate their presence in appropriate cases and to plan the initial antimicrobial therapy accordingly. Studies in Europe as well as India have shown that such infections form a fairly substantial percentage of community acquired pneumonia in children. Mycoplasma pneumoniae and Chlamydia pneumoniae are common in school age children while Chlamydia trachomatis occurs in early infancy. Pneumocystis carinii is an important pathogen in immunocompromised children. Routine laboratory tests and radiological features are not specific enough to give accurate diagnosis of these infections for which one has to depend on sophisticated culture techniques, immunological tests for the antigens or antibodies and polymerase chain reaction. Mycoplasma, chlamydia and legionella infections respond to macrolide antibiotics and for pneumocystis infections, trimethoprim-sulfamethaxozole or pentamidine is the drug of choice. Overall prognosis with appropriate treatment is good except for P. carinii infection in immunocompromised host which carries a high mortality and recurrence rate.

La neumonía atípica por Legionella pneumophila: informe del segundo caso en México / Atypical pneumonia caused by Legionella pneumophila: second case report in Mexico

En 1977 se informó de 34 muertes por neumonía en 221 asistentes a la Convención de la Legión Americana en Filadelfia. El agente causal fue identificado y llamado Legionella pneumophila. La legionellosis es una enfermedad de distribución mundial, pero en México sólo hay un caso informado, posiblemente por no considerarse en el diagnóstico diferencial de las neumonías adquiridas en la comunidad. Informamos el caso de una paciente previamente sana en la que se diagnosticó una neumonía secundaria a Legionella pneumophila

Pneumonia por "legionella pneumophila" e síndrome da angústia respiratória do adulto: relato de um caso / Legionnair's disease and adult respiratory distress syndrome: a case report

Os autores apresentam caso de paciente, previamente hígido, que apresentou pneumonia por legionella pneumophila, confirmada por reaçäo sorológica, com evoluçäo para síndrome da angústia respiratória do adulto (SARA). Os autores abordam as principais características dessa infecçäo

Legionnaires'disease in the renal transplant unit of Hospital das Clinicas FMUSP: during a five year period (1988-1993)

Embora varios trabalhos tem mostrado a presenca de Legionella pneumophila associado a pneumopatias infecciosas em transplantados renais, tal associacao nao fora antes realizado de maneira sistematica no Brasil. Os autores julgaram oportuno a determinacao da incidencia por comprovacao sorologica da Legionella pneumophila sorogrupo 1 em transplantados renais num periodo de 5 anos. Para tanto amostras de soros de 70 pacientes com pneumopatia infecciosa internados na UTR do HC-FMUSP, colhidos na fase aguda e convalescente da infeccao, foram submetidas a reacao de imunofluorescencia indireta para pesquisa de anticorpos anti-Legionella pneumophila sorogrupo 1....

Diagnóstico de neumonía por legionella pneumophila mediante inmunofluorescencia directa del lavado broncoalveolar / Diagnosis of legionella pneumophila pneumonia through direct immunofluorescence in bronchoalveolar lavage fluid

Investigamos retrospectivamente la presencia de Legionella pneumonophila mediante la técnica de inmunofluorescencia directa (IFD) para detección de antígenos polivalentes (Organon Teknika) en 50 muestras almacenadas de lavado broncoalveolar (LBA). La IFD fue realizada ignorando los datos clínicos de los pacientes, 64 porciento de los cuales habían tenido una neumonía, de acuerdo a criterios clínicos, radiológicos y microbiológicos. La IFD fue positiva en dos muestras. El primero fue un varon de 44 años, con un cuadro clínico de neumonía adquirida en la comunidad, tratada por tres días con penicilina sódica sin resultados. El estudio corriente de LBA no fue diagnóstico. Se trató con roxitromicina, con buena respuesta clínica y radiográfica. El segundo corresponde a un varón de 45 años, con rechazo agudo de transplante renal que desarrolló una neumonía fulminante que lo llevó a la muerte, pese a un tratamiento antimicrobiano de amplio espectro, que incluía eritromicina. Concluímos que en nuestro medio existen neumonías graves por L. pneumophila que pueden ser detectadas mediante IFD de LBA, método que es altamente específico

Five cases of nosocomial and community-acquired Legionnaires' disease in São Paulo, Brazil

Legionella sp has been emerging over the last decade as an important cause of pneumonia both hospital and community-acquired. Following an outbreak in a Renal-Transplant Unit stocked serum was tested for antibodies against Legionella pneumophila serogroup 1, and 5 cases of Legionnaires' Disease were reviewed. Two of the cases were nosocomial and three cases were community-acquired. Clinical and laboratorial aspects were similar to those expected for other causes of pneumonia, however jaundice was encountered in two cases. This study suggests that the real incidence of pneumonia caused by Legionella sp is being underestimated and the authors emphasize the importance of considering Legionnaires' Disease when empirically treating community-acquired pneumonia.

Legionelose associada a pneumopatias em São Paulo. Estudo da comprovação etiológica por isolamento e sorologia (1) / Legionellosis associated with pneumopathies in São Paulo. Study of the etiologic confirmation by isolation and serology

The role of Legionella sp as an important pathogen, although reported in many countries, had not been well documented in Brazil. The main objective of the present study is to detect this organism or it's immunological response in patients with pulmonary infections in the city of São Paulo. For this purpose, specific laboratory methodology was introduced to cultivate the agent and demonstrate specific antibodies by serology. Patients from two University centers in São Paulo were studied: 100 from the Hospital Universitario, University of São Paulo with general pulmonary infections and 100 from Hospital das Clínicas, Faculdade de Medicina, University of São Paulo. The latter were selected to exclude pulmonary infections of other bacterial aetiology, and 30 of these were selected from the Renal Transplant Unit. Clinical specimens for cultures included sputum tracheal secretion, pleural, fluid, bronchial washing or lung tissue biopsy. Isolation of Legionella sp was attempted in BCYE medium with and without antibiotics, presumptive diagnosis by biochemical methods and identification through direct immunofluorescence staining and slide agglutination test. Direct evidence of the organism in tissue was attempted by direct immunofluorescence staining. Specific antibodies for Legionella pneumophila serogroup 1 were tested by the indirect immunofluorescence assay. Serology was also carried out in specimens from human contacts with Legionnaires' Disease. Legionella pneumophila serogroup 1 was isolated from two patients, demonstrating the presence of the pathogen in this country. Serology was able to establish present or past infection with the agent in 16 of the 100 patients from Hospital das Clínicas and in only one from Hospital Universitário. In patients considered as high risk groups from Hospital das Clínicas with renal transplantation, serology for present or past Legionellosis was positive in 33 and in 8.5 for community acquired infections. Serology in specimens from Medical personnel in contact with patients of Legionnaires' disease was positive for past infection in one single subject, confirming information already published that direct transmission from person to person is unusual. The introduction of specific methods for laboratorial evidence of Legionella sp infections at the Hospital das Clínicas-Faculdade de Medicina USP community has permitted diagnosis in able time to allow use of specific anti-microbial therapy, with good results.

Insuficiência respiratória aguda secundária a pneumonia por Legionella: relato de um caso / Acute pulmonary insufficiency secondary to Legionella pneumonia: a case report

Os autores descrevem o caso de um jovem policial da Polícia Militar, com 24 anos de idade e previamente gozando de um excelente estado de saúde, que se apresentou com um quadro clínico de broncopneumonia adquirida na comunidade, seguindo-se de uma evoluçäo rápida para a insuficiência respiratória aguda, com necessidade precoce de prótese respiratória e admissäo em Centro de Tratamento Intensivo. Com base no quadro clínico grave de insuficiência respiratória aguda, secundária à infecçäo pulmonar adquirida na comunidade e na história epidemiológica, foi feita a hipótese diagnóstica de pneumonia por Legionella, e iniciado o tratamento específico com sulfametoxazol e trimetoprin, com 800 e 160 mg por dia, respectivamente. Com a confirmaçäo de legionelose pulmonar, pela avaliaçäo de anticorpo por imunofluorescência indireta (IFA), alcançando um título de 1:4000, foi associada ao esquema antibioterápico inicial a eritromicina na dose de 4 g por dia. Assim, o paciente gradativamente desmamou do respirador, recebeu alta da terapia intensiva para a enfermaria, e no 15§ dia de tratamento com a eritromicina teve alta hopitalar, indo para a residência, se sentindo bem e em franca melhora clínica, a ser acompanhada no ambulatório de clínica médica.

Doença dos legionários / Legionnaries' disease

Os autores descrevem um caso de pneumonia por Legionella pneumophilia que evoluiu com insuficiência respiratória aguda grave e óbito. A legionelose foi reconhecida como uma entidade nosológica em 1976, durante um surto epidêmico nos EUA. As facilidades diagnósticas vêm modificando o antigo conceito de que se tratava de doença incomum. A constataçäo de que esta pneumonia - de morbidade e mortalidade elevadas - É freqüente obriga a um redimensionamento de sua importância, na prática médica diária.