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Epidemiology and pathogenesis of Legionella infection

Authors
Victor L Yu, MD
Janet E Stout, PhD
Nieves Sopena Galindo, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Anna R Thorner, MD

INTRODUCTION

Since the organism was first identified in 1976 during an outbreak at an American Legion Convention in Philadelphia, Legionella has been recognized as a relatively common cause of both community-acquired [1,2] and hospital-acquired pneumonia [3,4]. Legionellosis refers to the two clinical syndromes caused by bacteria of the genus Legionella:

Legionnaires' disease is the more common syndrome of pneumonia caused by Legionella species.

Pontiac fever is an acute, febrile, self-limited illness, which has been linked to Legionella species [5].

The incidence of Legionnaires' disease depends upon the degree of water reservoir contamination, the intensity of patient exposure to that water, and the susceptibility of the host. Successful diagnosis requires specialized laboratory tests, which are not always available.

The microbiology, epidemiology, and pathogenesis of Legionella infection will be reviewed here. Clinical manifestations, diagnosis, and treatment of this entity are discussed separately. (See "Clinical manifestations and diagnosis of Legionella infection" and "Treatment and prevention of Legionella infection".)

            

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Literature review current through: Nov 2016. | This topic last updated: Thu Apr 07 00:00:00 GMT 2016.
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References
Top
  1. Marrie TJ, Peeling RW, Fine MJ, et al. Ambulatory patients with community-acquired pneumonia: the frequency of atypical agents and clinical course. Am J Med 1996; 101:508.
  2. Fang GD, Fine M, Orloff J, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore) 1990; 69:307.
  3. Sabria M, Yu VL. Hospital-acquired legionellosis: solutions for a preventable infection. Lancet Infect Dis 2002; 2:368.
  4. Kirby BD, Snyder KM, Meyer RD, Finegold SM. Legionnaires' disease: report of sixty-five nosocomially acquired cases of review of the literature. Medicine (Baltimore) 1980; 59:188.
  5. Castor ML, Wagstrom EA, Danila RN, et al. An outbreak of Pontiac fever with respiratory distress among workers performing high-pressure cleaning at a sugar-beet processing plant. J Infect Dis 2005; 191:1530.
  6. Benson RF, Fields BS. Classification of the genus Legionella. Semin Respir Infect 1998; 13:90.
  7. Euzèby JP. List of prokaryotic names with standing in nomenclature. http//www.bacterio.citr.fr (Accessed on June 11, 2008).
  8. Ricketts KD, Joseph CA, European Working Group for Legionella Infections. Legionnaires disease in Europe: 2005-2006. Euro Surveill 2007; 12:E7.
  9. Ginevra C, Duclos A, Vanhems P, et al. Host-related risk factors and clinical features of community-acquired legionnaires disease due to the Paris and Lorraine endemic strains, 1998-2007, France. Clin Infect Dis 2009; 49:184.
  10. Fang GD, Yu VL, Vickers RM. Disease due to the Legionellaceae (other than Legionella pneumophila). Historical, microbiological, clinical, and epidemiological review. Medicine (Baltimore) 1989; 68:116.
  11. Loeb M, Simor AE, Mandell L, et al. Two nursing home outbreaks of respiratory infection with Legionella sainthelensi. J Am Geriatr Soc 1999; 47:547.
  12. Whiley H, Bentham R. Legionella longbeachae and legionellosis. Emerg Infect Dis 2011; 17:579.
  13. Yu VL, Plouffe JF, Pastoris MC, et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey. J Infect Dis 2002; 186:127.
  14. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
  15. Marston BJ, Plouffe JF, File TM Jr, 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; 157:1709.
  16. von Baum H, Ewig S, Marre R, et al. Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia. Clin Infect Dis 2008; 46:1356.
  17. Cunha BA, Burillo A, Bouza E. Legionnaires' disease. Lancet 2016; 387:376.
  18. Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med 2015; 373:415.
  19. Yu VL, Stout JE. Community-acquired legionnaires disease: implications for underdiagnosis and laboratory testing. Clin Infect Dis 2008; 46:1365.
  20. Neil K, Berkelman R. Increasing incidence of legionellosis in the United States, 1990-2005: changing epidemiologic trends. Clin Infect Dis 2008; 47:591.
  21. Health Protection Agency. National increase in cases of legionnaires' disease. 3 August 2007 http://www.hpa.org.uk/hpr/archives/2007/news2007/news3107.htm (Accessed on October 18, 2011).
  22. Centers for Disease Control and Prevention (CDC). Legionellosis --- United States, 2000-2009. MMWR Morb Mortal Wkly Rep 2011; 60:1083.
  23. Fisman DN, Lim S, Wellenius GA, et al. It's not the heat, it's the humidity: wet weather increases legionellosis risk in the greater Philadelphia metropolitan area. J Infect Dis 2005; 192:2066.
  24. Ricketts KD, Charlett A, Gelb D, et al. Weather patterns and Legionnaires' disease: a meteorological study. Epidemiol Infect 2009; 137:1003.
  25. Stout J, Yu VL, Vickers RM, et al. Ubiquitousness of Legionella pneumophila in the water supply of a hospital with endemic Legionnaires' disease. N Engl J Med 1982; 306:466.
  26. Sax H, Dharan S, Pittet D. Legionnaires' disease in a renal transplant recipient: nosocomial or home-grown? Transplantation 2002; 74:890.
  27. Lin YS, Stout JE, Yu VL, Vidic RD. Disinfection of water distribution systems for Legionella. Semin Respir Infect 1998; 13:147.
  28. Lawrence C, Reyrolle M, Dubrou S, et al. Single clonal origin of a high proportion of Legionella pneumophila serogroup 1 isolates from patients and the environment in the area of Paris, France, over a 10-year period. J Clin Microbiol 1999; 37:2652.
  29. Squier CL, Stout JE, Krsytofiak S, et al. A proactive approach to prevention of health care-acquired Legionnaires' disease: the Allegheny County (Pittsburgh) experience. Am J Infect Control 2005; 33:360.
  30. Sabrià M, Mòdol JM, Garcia-Nuñez M, et al. Environmental cultures and hospital-acquired Legionnaires' disease: a 5-year prospective study in 20 hospitals in Catalonia, Spain. Infect Control Hosp Epidemiol 2004; 25:1072.
  31. Sopena N, Sabrià M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest 2005; 127:213.
  32. Seenivasan MH, Yu VL, Muder RR. Legionnaires' disease in long-term care facilities: overview and proposed solutions. J Am Geriatr Soc 2005; 53:875.
  33. Stout JE, Brennen C, Muder RR. Legionnaires' disease in a newly constructed long-term care facility. J Am Geriatr Soc 2000; 48:1589.
  34. Cristino S, Legnani PP, Leoni E. Plan for the control of Legionella infections in long-term care facilities: role of environmental monitoring. Int J Hyg Environ Health 2012; 215:279.
  35. Trop Skaza A, Beskovnik L, Storman A, et al. Epidemiological investigation of a legionellosis outbreak in a Slovenian nursing home, August 2010. Scand J Infect Dis 2012; 44:263.
  36. Phares CR, Russell E, Thigpen MC, et al. Legionnaires' disease among residents of a long-term care facility: the sentinel event in a community outbreak. Am J Infect Control 2007; 35:319.
  37. Benin AL, Benson RF, Besser RE. Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis. Clin Infect Dis 2002; 35:1039.
  38. Centers for Disease Control and Prevention (CDC). Legionnaires disease associated with potable water in a hotel--Ocean City, Maryland, October 2003-February 2004. MMWR Morb Mortal Wkly Rep 2005; 54:165.
  39. Yu VL. Legionella surveillance: political and social implications--a little knowledge is a dangerous thing. J Infect Dis 2002; 185:259.
  40. Joseph CA, Yadav R, Ricketts KD, European Working Group for Legionella Infections. Travel-associated Legionnaires disease in Europe in 2007. Euro Surveill 2009; 14.
  41. Rowbotham TJ. Legionellosis associated with ships: 1977 to 1997. Commun Dis Public Health 1998; 1:146.
  42. Centers for Disease Control and Prevention (CDC). Surveillance for travel-associated legionnaires disease--United States, 2005-2006. MMWR Morb Mortal Wkly Rep 2007; 56:1261.
  43. Pedro-Botet ML, Stout JE, Yu VL. Legionnaires' disease contracted from patient homes: the coming of the third plague? Eur J Clin Microbiol Infect Dis 2002; 21:699.
  44. Stout JE, Yu VL, Muraca P, et al. Potable water as a cause of sporadic cases of community-acquired legionnaires' disease. N Engl J Med 1992; 326:151.
  45. Lück PC, Schneider T, Wagner J, et al. Community-acquired Legionnaires' disease caused by Legionella pneumophila serogroup 10 linked to the private home. J Med Microbiol 2008; 57:240.
  46. Verhoef LP, Yzerman EP, Bruin JP, Den Boer JW. Domestic exposure to legionellae for Dutch Legionnaires' disease patients. Arch Environ Health 2004; 59:597.
  47. Stout JE, Yu VL, Yee YC, et al. Legionella pneumophila in residential water supplies: environmental surveillance with clinical assessment for Legionnaires' disease. Epidemiol Infect 1992; 109:49.
  48. Greenberg D, Chiou CC, Famigilleti R, et al. Problem pathogens: paediatric legionellosis--implications for improved diagnosis. Lancet Infect Dis 2006; 6:529.
  49. Franzin L, Scolfaro C, Cabodi D, et al. Legionella pneumophila pneumonia in a newborn after water birth: a new mode of transmission. Clin Infect Dis 2001; 33:e103.
  50. Skogberg K, Nuorti JP, Saxen H, et al. A newborn with domestically acquired legionnaires disease confirmed by molecular typing. Clin Infect Dis 2002; 35:e82.
  51. Fritschel E, Sanyal K, Threadgill H, Cervantes D. Fatal legionellosis after water birth, Texas, USA, 2014. Emerg Infect Dis 2015; 21:130.
  52. Yiallouros PK, Papadouri T, Karaoli C, et al. First outbreak of nosocomial Legionella infection in term neonates caused by a cold mist ultrasonic humidifier. Clin Infect Dis 2013; 57:48.
  53. Yu VL, Greenberg RN, Zadeikis N, et al. Levofloxacin efficacy in the treatment of community-acquired legionellosis. Chest 2004; 125:2135.
  54. Greig JE, Carnie JA, Tallis GF, et al. An outbreak of Legionnaires' disease at the Melbourne Aquarium, April 2000: investigation and case-control studies. Med J Aust 2004; 180:566.
  55. Den Boer JW, Nijhof J, Friesema I. Risk factors for sporadic community-acquired Legionnaires' disease. A 3-year national case-control study. Public Health 2006; 120:566.
  56. Singh N, Stout JE, Yu VL. Prevention of Legionnaires' disease in transplant recipients: recommendations for a standardized approach. Transpl Infect Dis 2004; 6:58.
  57. Gudiol C, Garcia-Vidal C, Fernández-Sabé N, et al. Clinical features and outcomes of Legionnaires' disease in solid organ transplant recipients. Transpl Infect Dis 2009; 11:78.
  58. Sandkovsky U, Sandkovsky G, Suh J, et al. Legionella pneumonia and HIV: case reports and review of the literature. AIDS Patient Care STDS 2008; 22:473.
  59. Jacobson KL, Miceli MH, Tarrand JJ, Kontoyiannis DP. Legionella pneumonia in cancer patients. Medicine (Baltimore) 2008; 87:152.
  60. Aringer M, Houssiau F, Gordon C, et al. Adverse events and efficacy of TNF-alpha blockade with infliximab in patients with systemic lupus erythematosus: long-term follow-up of 13 patients. Rheumatology (Oxford) 2009; 48:1451.
  61. Jinno S, Pulido S, Pien BC. First reported United States case of Legionella pneumophila serogroup 1 pneumonia in a patient receiving anti-tumor necrosis factor-alpha therapy. Hawaii Med J 2009; 68:109.
  62. Beigel F, Jürgens M, Filik L, et al. Severe Legionella pneumophila pneumonia following infliximab therapy in a patient with Crohn's disease. Inflamm Bowel Dis 2009; 15:1240.
  63. Vinter H, Nielsen HI. [Legionella pneumonia in patients treated with infliximab]. Ugeskr Laeger 2009; 171:247.
  64. FDA Drug Safety Communication: drug labels for the tumor necrosis factor-alpha (TNFα) blockers now include warnings about infection with Legionella and Listeria bacteria. http://www.fda.gov/Drugs/DrugSafety/ucm270849.htm (Accessed on September 07, 2011).
  65. Bodro M, Carratalà J, Paterson DL. Legionellosis and biologic therapies. Respir Med 2014; 108:1223.
  66. Casati S, Gioria-Martinoni A, Gaia V. Commercial potting soils as an alternative infection source of Legionella pneumophila and other Legionella species in Switzerland. Clin Microbiol Infect 2009; 15:571.
  67. Velonakis EN, Kiousi IM, Koutis C, et al. First isolation of Legionella species, including L. pneumophila serogroup 1, in Greek potting soils: possible importance for public health. Clin Microbiol Infect 2010; 16:763.
  68. Casati S, Conza L, Bruin J, Gaia V. Compost facilities as a reservoir of Legionella pneumophila and other Legionella species. Clin Microbiol Infect 2010; 16:945.
  69. Breiman RF. Modes of transmission in epidemic and nonepidemic Legionella infection: Directions for further study. In: : Current Status and Emerging Perspectives, Barbaree JM, Breiman RF, Dufour AP (Eds), American Society for Microbiology, Washington, DC 1993. p.30.
  70. Woo AH, Goetz A, Yu VL. Transmission of Legionella by respiratory equipment and aerosol generating devices. Chest 1992; 102:1586.
  71. Mahoney FJ, Hoge CW, Farley TA, et al. Communitywide outbreak of Legionnaires' disease associated with a grocery store mist machine. J Infect Dis 1992; 165:736.
  72. Den Boer JW, Yzerman EP, Schellekens J, et al. A large outbreak of Legionnaires' disease at a flower show, the Netherlands, 1999. Emerg Infect Dis 2002; 8:37.
  73. Yu VL. Cooling towers and legionellosis: a conundrum with proposed solutions. Int J Hyg Environ Health 2008; 211:229.
  74. Sanchez I, Garcia-Nuñez M, Ragull S, et al. Genotypic variability and persistence of Legionella pneumophila PFGE patterns in 34 cooling towers from two different areas. Environ Microbiol 2008; 10:395.
  75. Kubota M, Tomii K, Tachikawa R, et al. [Legionella longbeachae pneumonia infection from home garden soil]. Nihon Kokyuki Gakkai Zasshi 2007; 45:698.
  76. den Boer JW, Yzerman EP, Jansen R, et al. Legionnaires' disease and gardening. Clin Microbiol Infect 2007; 13:88.
  77. O'Connor BA, Carman J, Eckert K, et al. Does using potting mix make you sick? Results from a Legionella longbeachae case-control study in South Australia. Epidemiol Infect 2007; 135:34.
  78. Venezia RA, Agresta MD, Hanley EM, et al. Nosocomial legionellosis associated with aspiration of nasogastric feedings diluted in tap water. Infect Control Hosp Epidemiol 1994; 15:529.
  79. Blatt SP, Parkinson MD, Pace E, et al. Nosocomial Legionnaires' disease: aspiration as a primary mode of disease acquisition. Am J Med 1993; 95:16.
  80. 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; 107:591.
  81. Jaresova M, Hlozanek I, Striz I, et al. Legionella detection in oropharyngeal aspirates of transplant patients prior to surgery. Eur J Clin Microbiol Infect Dis 2006; 25:63.
  82. Hicks LA, Rose CE Jr, Fields BS, et al. Increased rainfall is associated with increased risk for legionellosis. Epidemiol Infect 2007; 135:811.
  83. Stone BJ, Abu Kwaik Y. Expression of multiple pili by Legionella pneumophila: identification and characterization of a type IV pilin gene and its role in adherence to mammalian and protozoan cells. Infect Immun 1998; 66:1768.
  84. Payne NR, Horwitz MA. Phagocytosis of Legionella pneumophila is mediated by human monocyte complement receptors. J Exp Med 1987; 166:1377.
  85. Hoffman PS, Ripley M, Weeratna R. Cloning and nucleotide sequence of a gene (ompS) encoding the major outer membrane protein of Legionella pneumophila. J Bacteriol 1992; 174:914.
  86. Cianciotto NP, Eisenstein BI, Mody CH, Engleberg NC. A mutation in the mip gene results in an attenuation of Legionella pneumophila virulence. J Infect Dis 1990; 162:121.
  87. Horwitz MA. Toward an understanding of host and bacterial molecules mediating L. pneumophila pathogenesis. In: Legionella - Current Status and Emerging Perspectives, Barbaree JM, Breiman RF, Dufour AP (Eds), American Society of Microbiology, Washington, DC 1993. p.55.
  88. Vogel JP, Andrews HL, Wong SK, Isberg RR. Conjugative transfer by the virulence system of Legionella pneumophila. Science 1998; 279:873.
  89. Roy CR. Trafficking of the Legionella pneumophila phagosome. ASM News 1999; 65:416.
  90. Stout JE, Yu VL. Legionellosis. N Engl J Med 1997; 337:682.
  91. Baine WB, Rasheed JK, Mackel DC, et al. Exotoxin activity associated with the Legionnaires disease bacterium. J Clin Microbiol 1979; 9:453.
  92. Friedman RL, Iglewski BH, Miller RD. Identification of a cytotoxin produced by Legionella pneumophila. Infect Immun 1980; 29:271.
  93. Sonesson A, Jantzen E, Bryn K, et al. Chemical composition of a lipopolysaccharide from Legionella pneumophila. Arch Microbiol 1989; 153:72.
  94. Mintz CS, Schultz DR, Arnold PI, Johnson W. Legionella pneumophila lipopolysaccharide activates the classical complement pathway. Infect Immun 1992; 60:2769.
  95. Dournon E, Bibb WF, Rajagopalan P, et al. Monoclonal antibody reactivity as a virulence marker for Legionella pneumophila serogroup 1 strains. J Infect Dis 1988; 157:496.
  96. Yu VL. Legionella pneumophila (Legionnaires' Disease). In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 5th edition, Mandell GL, Bennett JE, Dolin R. (Eds), Churchill Livingstone, Philadelphia 2000. Vol 2, p.2424.