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Clinical and Environmental Surveillance for the Prevention of Legionellosis

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A special issue of Microorganisms (ISSN 2076-2607). This special issue belongs to the section "Public Health Microbiology".

Deadline for manuscript submissions: closed (31 August 2023) | Viewed by 23426

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Dr. Maria Anna Coniglio

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Guest Editor

Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis, Department of Medical and Surgical Sciences and Advanced Technologies G.F. Ingrassia, University of Catania, Via Sofia 87, 95123 Catania, Italy
Interests: water systems; disinfection methods; emerging technologies; Legionnaires’ disease management; Legionnaires’ disease diagnosis; Legionnaires’ disease treatment
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Dr. Mohamed H Yassin

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Guest Editor

Department of Infection Control and Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Interests: infection
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Special Issue Information

Dear Colleagues,

The isolation and identification of Legionella from the environment is crucial for the management of environmental and clinical prevention, as well as for epidemiological purposes and for outbreak investigations. Early clinical diagnosis and the prompt initiation of appropriate antibiotics in all patients with community-acquired or hospital-acquired legionellosis are also crucial for the management of the disease. For these reasons, it is necessary to promote clinical and environmental surveillance programmes, and to improve the diagnostic techniques and set up preventive measures. Therefore, epidemiological data combined with microbiological and clinical information can contribute to identifying the source of infection and implementing control measures.

This Special Issue plans to give an overview of the most recent advances in the field of clinical and environmental surveillance of hospital and community-acquired legionellosis. This Special Issue is aimed at providing selected contributions on advances in the environmental surveillance, clinical diagnosis, and applications of innovative monitoring methods with regard to typing and sequencing technologies.

Potential topics include, but are not limited to:

Epidemiology management;
Clinical management;
Genomic epidemiology;
Remediation;
Controlled clinical trials for treatment;
Typing and sequencing technologies;
Diagnostic tests;
Differences in virulence.

Dr. Maria Anna Coniglio
Dr. Mohamed H Yassin
Guest Editors

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Keywords

water systems
disinfection methods
emerging technologies
Legionnaires’ disease management
Legionnaires’ disease diagnosis
Legionnaires’ disease treatment

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Published Papers (11 papers)

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Editorial

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3 pages, 158 KiB

Open AccessEditorial

Clinical and Environmental Surveillance for the Prevention of Legionellosis

by Maria Anna Coniglio and Mohamed H. Yassin

Microorganisms 2024, 12(5), 939; https://doi.org/10.3390/microorganisms12050939 - 6 May 2024

Cited by 1 | Viewed by 981

Abstract

Legionella is a Gram-negative bacterium whose natural hosts are aquatic protozoa, in which the microorganism replicates and is protected from adverse environmental conditions [...] Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

Research

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11 pages, 317 KiB

Open AccessArticle

The Presence of Legionella in Water Used for Car Washing: Implications for Public Health

by Pasqualina Laganà, Alessio Facciolà, Roberta Palermo, Osvalda De Giglio, Santi Antonino Delia and Maria Eufemia Gioffrè

Microorganisms 2023, 11(12), 2992; https://doi.org/10.3390/microorganisms11122992 - 15 Dec 2023

Viewed by 1397

Abstract

Although today all of the aspects of Legionella are better understood than in the past, in many countries the interest is still mainly focused on healthcare and tourism facilities. Other at-risk areas are less explored, such as those where workers are often in contact with water during their activities. In reality, any water system capable of producing aerosols can be considered a potential source of Legionella transmission, including car washes, where a large number of users work and flow through annually. From January to May 2022, 120 samples were carried out in 30 car washes located in Messina (Italy): 60 samples of water and 60 of aerosols. The aim of this investigation was to evaluate the risk of legionellosis in car washing workers exposed to potentially contaminated aerosols. To increase the probability of finding Legionella, the sample collections were organized on different days of the week. Of the total samples taken, 10 (8.3%) were positive for Legionella: seven (11.7%) water (range 100–1000 CFU) and three (5%) aerosol (range 10–150 CFU) samples. Detected serogroups were L. pneumophila sgr 1, 7, 10 and Legionella gormanii. Given the results obtained, preventative measures should be implemented in such facilities in order to protect the health of users and car wash operators. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

10 pages, 2345 KiB

Open AccessArticle

Contamination of Hotel Water Distribution Systems by Legionella Species: Environmental Surveillance in Campania Region, South Italy

by Valeria Di Onofrio, Mariangela Pagano, Marco Santulli, Annamaria Rossi, Renato Liguori, Mirella Di Dio and Giorgio Liguori

Microorganisms 2023, 11(7), 1840; https://doi.org/10.3390/microorganisms11071840 - 20 Jul 2023

Cited by 1 | Viewed by 1793

Abstract

The COVID-19 pandemic period was marked by the absence or reduced circulation of some infectious diseases. Legionellosis may have been affected by the prevention measures adopted to counter COVID-19. Legionellosis is a form of pneumonia interstitial that is normally transmitted via aerosol-containing bacteria (genus Legionella), that could be present in contaminated water sources and is often associated with travel and with staying in hotels. In this work, the data of the environmental surveys carried out by ARPA Campania in accommodation facilities since 2019 were analyzed for a better understanding of the dispersion patterns of L. pneumophila associated with the environment and to evaluate the variation of the data during the pandemic period. The aim was to provide a better understanding of Legionella at different geographic scales and to define a predictive epidemiological method. Results: In 2019, the Legionella genus contaminated 37.7% of all tourist facilities evaluated. In 2020, the Legionella genus contaminated 44.4% of all tourist facilities evaluated. In 2021, the Legionella genus contaminated 54.2% of all tourist facilities evaluated. Conclusions: Legionella pneumophila was the most prevalent species in our community, serogroup 1 was the most frequently isolated and the most implicated risk factor of contamination was the temperature of water in circulation. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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15 pages, 1377 KiB

Open AccessArticle

Water Safety Plan, Monochloramine Disinfection and Extensive Environmental Sampling Effectively Control Legionella and Other Waterborne Pathogens in Nosocomial Settings: The Ten-Year Experience of an Italian Hospital

by Claudio Farina, Eleonora Cacciabue, Franca Averara, Nadia Ferri, Francesca Vailati, Gabriele Del Castillo, Antonello Serafini, Beatrice Fermi, Nicola Doniselli and Fabio Pezzoli

Microorganisms 2023, 11(7), 1794; https://doi.org/10.3390/microorganisms11071794 - 13 Jul 2023

Cited by 1 | Viewed by 1832

Abstract

Legionella contamination control is crucial in healthcare settings where patients suffer an increased risk of disease and fatal outcome. To ensure an effective management of this health hazard, the accurate application of a hospital-specific Water Safety Plan (WSP), the choice of a suitable water disinfection system and an extensive monitoring program are required. Here, the ten-year experience of an Italian hospital is reported: since its commissioning, Legionellosis risk management has been entrusted to a multi-disciplinary Working Group, applying the principles of the World Health Organization’s WSP. The disinfection strategy to prevent Legionella and other waterborne pathogens relies on the treatment of domestic hot water with a system ensuring the in situ production and dosage of monochloramine. An average of 250 samples/year were collected and analyzed to allow an accurate assessment of the microbiological status of water network. With the aim of increasing the monitoring sensitivity, in addition to the standard culture method, an optimized MALDI-ToF MS-based strategy was applied, allowing the identification of Legionella species and other relevant opportunistic pathogens. Data collected so far confirmed the effectiveness of this multidisciplinary approach: the fraction of positive samples never overcame 1% on a yearly basis and Legionnaires’ Disease cases never occurred. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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16 pages, 2546 KiB

Open AccessArticle

Legionellosis-Associated Hospitalization in Spain from 2002 to 2021

by Enrique Gea-Izquierdo, Ruth Gil-Prieto, Valentín Hernández-Barrera, Gil Rodríguez-Caravaca and Ángel Gil-de-Miguel

Microorganisms 2023, 11(7), 1693; https://doi.org/10.3390/microorganisms11071693 - 29 Jun 2023

Cited by 1 | Viewed by 1682

Abstract

Legionellosis is a respiratory disease of bacterial and environmental origin that usually presents two distinct clinical entities, “Legionnaires’ disease” (LD) and “Pontiac fever”. LD is an important cause of hospital-acquired pneumonia (HAP). The objective of this study is to describe the epidemiology of legionellosis-associated hospitalization (L-AH) in Spain from 2002 to 2021 and the burden of hospitalization due to legionellosis. Discharge reports from the Minimum Basic Data Set (MBDS) were used to retrospectively analyze hospital discharge data with a diagnosis of legionellosis, based on the ICD-9-CM and ICD-10-CM diagnosis codes, from 2002 to 2021. 21,300 L-AH occurred throughout the year during 2002–2021. The incidence of hospitalization associated per 100,000 inhabitants by month showed a similar trend for the 2002–2011, 2012–2021, and 2002–2021 periods. In Spain, during 2002–2021, the hospitalization rate (HR) in the autonomous communities ranged from 4.57 (2002–2011) to 0.24 (2012–2021) cases per 100,000 inhabitants. The HR of legionellosis in Spain has substantially increased across the 2002–2021 period, and the estimate is consistent with available European data. It is considered that in-depth epidemiological surveillance studies of legionellosis and improvements in the prevention and control of the disease are required in Spain. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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13 pages, 959 KiB

Open AccessArticle

Legionella pneumophila Risk from Air–Water Cooling Units Regarding Pipe Material and Type of Water

by Enrique Gea-Izquierdo, Ángel Gil-de-Miguel and Gil Rodríguez-Caravaca

Microorganisms 2023, 11(3), 638; https://doi.org/10.3390/microorganisms11030638 - 2 Mar 2023

Cited by 1 | Viewed by 1662

Abstract

Legionellosis is a respiratory disease related to environmental health. There have been manifold studies of pipe materials, risk installations and legionellosis without considering the type of transferred water. The objective of this study was to determine the potential development of the causative agent Legionella pneumophila regarding air–water cooling units, legislative compliance, pipe material and type of water. Forty-four hotel units in Andalusia (Spain) were analysed with respect to compliance with Spanish health legislation for the prevention of legionellosis. The chi-square test was used to explain the relationship between material–water and legislative compliance, and a biplot of the first two factors was generated. Multiple correspondence analysis (MCA) was performed on the type of equipment, legislative compliance, pipe material and type of water, and graphs of cases were constructed by adding confidence ellipses by categories of the variables. Pipe material–type of water (p value = 0.29; p < 0.05) and legislative compliance were not associated (p value = 0.15; p < 0.05). Iron, stainless steel, and recycled and well water contributed the most to the biplot. MCA showed a global pattern in which lead, iron and polyethylene were well represented. Confidence ellipses around categories indicated significant differences among categories. Compliance with Spanish health legislation regarding the prevention and control of legionellosis linked to pipe material and type of water was not observed. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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18 pages, 2569 KiB

Open AccessArticle

Comparative Genomics of Legionella pneumophila Isolates from the West Bank and Germany Support Molecular Epidemiology of Legionnaires’ Disease

by Ashraf R. Zayed, Dina M. Bitar, Michael Steinert, Christian Lück, Cathrin Spröer, Ingrid Brettar, Manfred G. Höfle and Boyke Bunk

Microorganisms 2023, 11(2), 449; https://doi.org/10.3390/microorganisms11020449 - 10 Feb 2023

Cited by 2 | Viewed by 3013

Abstract

Legionella pneumophila is an environmental bacterium and clinical pathogen that causes many life-threating outbreaks of an atypical pneumonia called Legionnaires’ disease (LD). Studies of this pathogen have focused mainly on Europe and the United States. A shortage in L. pneumophila data is clearly observed for developing countries. To reduce this knowledge gap, L. pneumophila isolates were studied in two widely different geographical areas, i.e., the West Bank and Germany. For this study, we sequenced and compared the whole genome of 38 clinical and environmental isolates of L. pneumophila covering different MLVA-8(12) genotypes in the two areas. Sequencing was conducted using the Illumina HiSeq 2500 platform. In addition, two isolates (A194 and H3) were sequenced using a Pacific Biosciences (PacBio) RSII platform to generate complete reference genomes from each of the geographical areas. Genome sequences from 55 L. pneumophila strains, including 17 reference strains, were aligned with the genome sequence of the closest strain (L. pneumophila strain Alcoy). A whole genome phylogeny based on single nucleotide polymorphisms (SNPs) was created using the ParSNP software v 1.0. The reference genomes obtained for isolates A194 and H3 consisted of circular chromosomes of 3,467,904 bp and 3,691,263 bp, respectively. An average of 36,418 SNPs (min. 8569, max. 70,708 SNPs) against our reference strain L. pneumophila str. Alcoy, and 2367 core-genes were identified among the fifty-five strains. An analysis of the genomic population structure by SNP comparison divided the fifty-five L. pneumophila strains into six branches. Individual isolates in sub-lineages in these branches differed by less than 120 SNPs if they had the same MLVA genotype and were isolated from the same location. A bioinformatics analysis identified the genomic islands (GIs) for horizontal gene transfer and mobile genetic elements, demonstrating that L. pneumophila showed high genome plasticity. Four L. pneumophila isolates (H3, A29, A129 and L10-091) contained well-defined plasmids. On average, only about half of the plasmid genes could be matched to proteins in databases. In silico phage findings suggested that 43 strains contained at least one phage. However, none of them were found to be complete. BLASTp analysis of proteins from the type IV secretion Dot/Icm system showed those proteins highly conserved, with less than 25% structural differences in the new L. pneumophila isolates. Overall, we demonstrated that whole genome sequencing provides a molecular surveillance tool for L. pneumophila at the highest conceivable discriminatory level, i.e., two to eight SNPs were observed for isolates from the same location but several years apart. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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12 pages, 2619 KiB

Open AccessArticle

Legionnaires’ Disease in China Caused by Legionella pneumophila Corby

by Pei-Xing Xu, Hong-Yu Ren, Ran Li, Xiao-Jing Jin, Zhan-Cheng Gao and Tian Qin

Microorganisms 2023, 11(1), 204; https://doi.org/10.3390/microorganisms11010204 - 13 Jan 2023

Viewed by 2988

Abstract

Legionella pneumophila is an intracellular pathogen causing pneumonia in humans. In February 2022, Legionnaires’ disease caused by L. pneumophila strain Corby in a patient with lung adenocarcinoma was identified for the first time in China. This paper includes the case report and phenotypic and genomic analysis of the Corby (ICDC) strain. Its biological characteristics were evaluated by antibiotic sensitivity testing and cytology experiments, and genomic analysis was performed to understand its genetic evolution. The patient’s clinical manifestations included cough, fever, pulmonary infiltration, and significantly decreased activity endurance. After empirical antimicrobial therapy, infection indicators decreased. The Corby (ICDC) strain was susceptible to nine antibiotics and exhibited strong intracellular proliferation ability. A phylogenetic tree showed that the Corby (ICDC) strain was closely related to the Corby strain, but under the pressure of a complex environment, its genome had undergone more rearrangement and inversion. The type IF CRISPR-Cas system was identified in its genome, and spacer analysis indicated that it had been invaded by several foreign plasmids, bacteria, and viruses during evolution. Legionnaires’ disease caused by L. pneumophila strain Corby may be ignored in China, and it is urgent to improve long-term monitoring and investigation of aquatic environments and patients with respiratory infections to prevent a large-scale outbreak of Legionnaires’ disease. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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11 pages, 725 KiB

Open AccessArticle

Inaccuracies of the ISO 11731 Method for Environmental Validation of Legionella in Building Water Systems: Opportunities to Improve Sensitivity and Detect Viable but Non-Culturable Legionella

by Leah P. Wickenberg, Katherine E. Fisher, Melissa F. Cain and William F. McCoy

Microorganisms 2023, 11(1), 94; https://doi.org/10.3390/microorganisms11010094 - 30 Dec 2022

Viewed by 2684

Abstract

Current environmental diagnostics for the detection of Legionella fail to detect viable but non-culturable Legionella, have sensitivity limitations and are time-consuming (10–14 days to results). The objective of this study was to compare Legionella detection results between the standard ISO 11731 and an innovative Legionella detection method that utilizes a hybrid methodology of traditional microbiology and molecular detection. In this study, four hundred and seventy-six (476) potable building water samples were analyzed with ISO 11731 and the novel method in parallel. Of the 476 total samples that were tested, a discrepancy of 21% was observed when comparing the ISO 11731 method to the novel method. Separating the samples based on hazard control methods yielded a 15.4% discrepancy for chlorinated systems (n = 284) and a 29% discrepancy for monochloraminated systems (n = 192). The data presented here conclusively show inaccuracies in environmental validation for building water systems based on results returned by the standard ISO 11731 method. This is especially evident in systems primarily disinfected with monochloramines. Overall, these data highlight the need for new and innovative methods to overcome the inaccuracies of the traditional ISO 11731 spread plates to prevent disease and injury caused by Legionella. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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12 pages, 2325 KiB

Open AccessArticle

Surveillance of Legionella pneumophila: Detection in Public Swimming Pool Environment

by Darija Vukić Lušić, Vanda Piškur, Arijana Cenov, Dijana Tomić Linšak, Dalibor Broznić, Marin Glad and Željko Linšak

Microorganisms 2022, 10(12), 2429; https://doi.org/10.3390/microorganisms10122429 - 8 Dec 2022

Viewed by 2072

Abstract

The bacterium Legionella pneumophila is a ubiquitous microorganism naturally present in water environments. The actual presence of this opportunistic premise plumbing pathogen in recreational swimming pools and hot tubs in the northwestern part of Croatia has not been investigated. This study aimed to analyze the presence of the opportunistic pathogen L. pneumophila in public swimming pool water in Primorje-Gorski Kotar County (N = 4587) over a four-year period (2018–2021). Additionally, the second aim was to investigate the connection between the presence of L. pneumophila and pool water physicochemical parameters using mathematical predictive models. The presence of L. pneumophila was detected in six pool samples. Five positive samples were found in the water of indoor hot tubs filled with fresh water, and one positive sample in an outdoor recreational saltwater pool. A predictive mathematical model showed the simultaneous influence of chemical parameters dominated by the temperature in saltwater and freshwater pools, as well as the significant influence of free residual chlorine and trihalomethanes. Our results pointed out that keeping all physicochemical parameters in perfect harmony is necessary to reach the best disinfection procedure and to avoid the optimum conditions for L. pneumophila occurrence. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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4 pages, 684 KiB

Open AccessBrief Report

Investigation of a Legionella pneumophila Outbreak at a Bath Facility in Japan Using Whole-Genome Sequencing of Isolates from Clinical and Environmental Samples

by Noriko Nakanishi, Shoko Komatsu, Shinobu Tanaka, Kengo Mukai and Ryohei Nomoto

Microorganisms 2023, 11(1), 28; https://doi.org/10.3390/microorganisms11010028 - 22 Dec 2022

Cited by 4 | Viewed by 1799

Abstract

Exposure to aerosols containing Legionella from artificially made water systems has been established as a primary cause of Legionnaires’ disease. In this study, we investigated an outbreak of L. pneumophila serogroup 1 sequence type 138 which occurred at a bath facility in 2022. The whole-genome sequencing of isolates revealed that the colonization of L. pneumophila at the bath facility had occurred before 2013, and the patients had been exposed to multiple genetic lineages of the strain. Our study demonstrates the importance of performing a careful comparative genetic analysis of clinical and environmental isolates from LD outbreaks in order to effectively investigate and prevent future LD outbreaks. Full article

(This article belongs to the Special Issue Clinical and Environmental Surveillance for the Prevention of Legionellosis)

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