Treatment and prevention of Legionella infection
- Victor L Yu, MD
Victor L Yu, MD
- Professor of Medicine
- University of Pittsburgh Medical Center
- Nieves Sopena Galindo, MD
Nieves Sopena Galindo, MD
- Assistant Professor of Medicine
- Universitat Autònoma de Barcelona
The mortality of community-acquired Legionnaires' disease ranges from 16 to 30 percent if untreated or treated with inactive antibiotics; the mortality for nosocomial Legionnaires' disease can approach 50 percent given the underlying illness of the patient . With the advent of improved diagnostic methods leading to earlier diagnosis and more potent therapies, mortality has been reduced to less than 10 percent in patients with community-acquired legionellosis [2-5].
The treatment of Legionella infection will be reviewed here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of this entity are discussed separately. (See "Epidemiology and pathogenesis of Legionella infection" and "Clinical manifestations and diagnosis of Legionella infection".)
In vitro susceptibility results are not readily interpretable for Legionella since methods have not been standardized. Conventional in vitro susceptibility methods in broth and agar have proven unreliable. For example, the charcoal in buffered charcoal yeast extract agar used for Legionella isolation binds antibiotics, and, thus, activity of these antibiotics against the organism is falsely minimized. Also, many commercially available antibiotics, which have excellent in vitro activity against Legionella by conventional testing (eg, beta-lactam agents and aminoglycosides), have proven to be relatively ineffective in patients with Legionnaires' disease.
The intracellular location of the pathogen is relevant to the efficacy of the antibiotic. Antibiotics capable of achieving intracellular concentrations higher than the minimum inhibitory concentration are more effective clinically than antibiotics with poor intracellular penetration . Antibiotics with intracellular penetration include the macrolides, quinolones, tetracyclines, and rifampin.
The empiric finding that tetracycline and erythromycin appeared to be more effective than beta-lactam agents and aminoglycosides in early outbreaks of Legionnaires' disease was consistent with in vitro results in intracellular [7-11] and animal models of Legionnaires' disease [12-14]. Determination of the susceptibility of Legionella spp to antimicrobial agents is now based upon such intracellular and animal models of Legionella infection [6,15].
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- Stout JE, Yu VL. Experiences of the first 16 hospitals using copper-silver ionization for Legionella control: implications for the evaluation of other disinfection modalities. Infect Control Hosp Epidemiol 2003; 24:563.
- Lin YE, Stout JE, Yu VL. Controlling Legionella in hospital drinking water: an evidence-based review of disinfection methods. Infect Control Hosp Epidemiol 2011; 32:166.
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- SUSCEPTIBILITY TESTING
- SELECTION OF ANTIMICROBIAL AGENTS
- Quinolones versus macrolides
- Monotherapy versus combination therapy
- Oral versus parenteral and duration of therapy
- Empiric therapy for community-acquired pneumonia
- Nosocomial pneumonia
- Transplant recipients
- Endocarditis and extrapulmonary legionellosis
- HIV infection
- Pontiac fever
- Approach to therapy
- Nosocomial disease
- - Disinfection of the water supply
- Community-acquired disease
- SUMMARY AND RECOMMENDATIONS