Transcript Legionnaires Disease - Christina Riggall`s Portfolio

Christina Riggall, BS, RN, CNRN
SUNY Institute of Technology
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Legionella is a bacteria that first found in July 1976
during an American Legion Convention where it
caused the death of 34 delegates. At the time the
cause of illness was unknown.
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It wasn’t until January 1977 that the bacteria was
isolated and identified.
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Legionella is a common cause of communityacquired and nosocomial-acquired pneumonia.
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It is estimated that 25,000 people in the US
develop Legionnaires’ disease each year.
(Lane, Ferrari, & Dreher, ,2004 / NYS DOH, 2004)
 When
the organism is inhaled, it attaches to
the respiratory epithelial cells and the
alveolar macrophages.
 The
bacterium most often causes
pneumonia but can also cause flu-like
symptoms known as Pontiac fever. This
occurs 24-72 hours after exposure to the
bacteria.
 Legionnaires’ disease
occurs 2-14 days after
exposure to the bacteria.
(CDC, 2013 / Pedrot-Betot, Stout, & Yu, 2013)
 Legionella
is an aerobic,
gram-negative bacilli
 There
are over 50 species
of legionella, L.
pneumophila is the most
common, accounting for
80% of human infections.
Pedrot-Betot, Stout, & Yu, 2013
 Successful
diagnosis requires specialized
lab tests.
 Legionnaires’ disease accounts for 2-9%
of community acquired pneumonia
 The incidence has tripled from 2000-2009
in both the U.S. and U.K.
 Exposure
to bodies of water, especially
stagnant water.
 Man-made reservoirs cause the bacteria
to grow and proliferate.
 In warm temperatures (25-42°C) the
bacteria have increased growth
 Compost facilities or potting soil may
also be a reservoir for legionella.
 Chronic
lung disease/smoking
 Older age (>50)
 Transplant recipients
 Immunosuppressants
 Tumor necrosis factor- alpha inhibitor
 Immunosuppressed children
 Neonates
 Recent repairs/maintenance to domestic
plumbing.
 Recent travel
CDC, 2013
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Pneumonia
Fevers
Cough
Pleuritic chest pain
Headaches
Watery diarrhea
Neuro symptoms (seizure,
confusion, disorientation,
insomnia). (Domino, 2014)
Body aches, Flu-like
symptoms, malaise without
pneumonia is known as
Pontiac fever (CDC, 2013)
CDC, 2013/ Domino, 2014
 Legionnaires’ disease
(482.84)
 Pneumonia due to other gram neg.
bacteria (482.83)
 Pneumonia, unspecified organism (486)
Without pneumonia present:
 Flu
 Pontiac fever (also caused by Legionella)
 Ask
about travel that occurred 14 days
before onset of symptoms- 20% of
Legionnaires’ disease is thought to be
due to travel.
 The
majority of cases are sporadic and
outbreaks are rare. According to the NYS
Dept. of Health, only outbreaks of the
disease need to be investigated.
(NYS DOH, 2004)
 Legionella
can be found in cooling towers,
humidifiers, showers, hot tubs, ice machines,
faucets and sinks. Inhaling or swallowing
the bacteria is what causes the disease.
 It
can also be found in lakes and streams,
especially stagnant water.
 People
that have an increased risk
(immunocompromised) may need to avoid
situations where there is an increased risk of
legionellosis.
(Freije, 2013 & Lane, Ferrari, & Dreher, 2004)
 Urine
antigen testing (most common
method of detection)
 Culture of the organism
 Direct fluorescent antibody staining
 Serology (antibody titers)
 Both
urine antigen testing AND culture of
the organism are preferred by the CDC
for diagnosis.
(Lane, Ferrari, & Dreher, 2004)
PHARMACOLOGICAL
* Azithrhromycin or levaquintreatment of choice
NON-PHARMACOLOGICAL

Rest
Erythromycin- not favorable
Rifampin- in combination with
macrolide or flurquinolone if
pt is severely ill
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Deep breathing
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Symptomatic treatment
In an immunosuppressed pt:
Treatment with Levaquin or
Cipro for three weeks
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Oxygen
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Hydration
Antipyretics for fever
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Respiratory failure
Dehydration
Extrapulmonary disease
Disseminated intravascular coagulation
Multi orgal dysfunction
Coma
Death
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Follow up with a chest xray to ensure resolution.
Respiratory status, hydration and electrolyte
status should be assessed.
Domino, 2014
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Hot water tank
temperature should be
above 140°F.
The temperature at the
faucet should be above
122°F.
Avoid conditions that
allow water to stagnate.
Tub baths may have less
aerosolized bacteria
then shower.
 May
need to collaborate with local public
health officials to assess environmental
risks, especially in areas such as
apartment complexes.
Silk, et al., 2013
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Some highlights from the literature review were that
Legionella is actually a fairly common cause of
pneumonia, however it is very under-reported.
There were difference in the first line treatment
between literature. The 5-Minute Clinical Consult
recommends levaquin as first line treatment but states
that azithromycin may also be used as first line. In the
article by Lane, Ferrari and Dreher, azithromycin is
listed as first line.
The Engineer’s Notebook discusses how new piping
systems are not resistant to Legionella, some of the
older systems are actually less prone to legionella
growth due to less surface area in the piping.
1.
True or False: Legionella can be identified using routine
bacteriologic media?
a.
b.
2.
Who is at most risk to develop Legionnaires’ disease?
a.
b.
c.
3.
True
False
65 year old transplant recipient
14 year old swimming in a lake
90 year old living in an apartment complex
The preferred treatment for Legionnaires’ is ________.
a.
b.
c.
Erythomycin
Rifampin
Azithromycin
4. True or False: The CDC recommends urine antigen
testing only for the diagnosis of Legionnaires disease?
a.
b.
True
False
5. Who should be tested for Legionnaires?
a.
b.
c.
d.
In a person that has travelled in the last 2 weeks.
Severe pneumonia
A pt that has failed antibiotic therapy
All of the above
6. NYS will most likely investigate cases of Legionella
infection when:
a.
b.
c.
Someone is diagnosed with the condition
A patient dies from the disease
An outbreak is suspected
7. True or False: Legionnaires Disease should be reported to
the Department of Health.
a.
b.
True
False
8. Complications of Legionnaires’ disease include:
a.
b.
c.
d.
Fevers
Respiratory failure
Death
All of the above
a.
b.
True
False
9. True or false: Legionella infection can be transmitted person
to person.
10. Domestic water heaters should be kept at temperatures:
a.
b.
Below 140 degrees F
Above 140 degrees F
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
b. False- Specialized media like buffered
charcoal yeast extract must be used.
a. Transplant recipients are at a high risk for LD
due to anti-rejection medications.
c. Azithromycin
b. False- Both culture and urine antigen testing
is recommended by the CDC.
d. All of the above
c. When an outbreak is suspected
a. True
d. All of the above
b. False
a. Above 140 degrees F (60 degrees C)
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Centers for Disease Control & Prevention. (2013). Legionnaires’ disease for clinicians. Retrieved from
http://www.cdc.gov/legionella/clinicians.html
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Domino, F. (2014). The 5-Minute Clinical Consult. (22nd ed.) Philadelphia: Lippincott Williams & Wilkins.
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Freije, M.R. (2012). Legionella: Don’t assume. Engineer’s Notebook: ASHRAA Journal, 54 (10), 100-101.
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Lane, G., Ferrari, A., & Dreher, H. (2004). Clinical practice. Legionnaire's disease: a current update.
MEDSURG Nursing, 13(6), 409-414.
New York State Department of Health. (2004). Legionellosis (Legionnaires’ Disease). Retrieved from
http://www.health.ny.gov/diseases/communicable/legionellosis/docs/fact_sheet.pdf
Pedrot-Betot, M.L., Stout, S.E. & Yu, V.L. (2013). Epidemiology and pathogenesis of Legionella infection.
Retrieved from www.uptodate.com/contents/epidemiology-and=pathogenesis-of-legionellainfection.
Silk, B. J., Foltz, J. L., Ngamsnga, K., Brown, E., Muñoz, M., Hampton, L. M., & ... Hicks, L. A. (2013).
Legionnaires' disease case-finding algorithm, attack rates, and risk factors during a residential
outbreak among older adults: an environmental and cohort study. BMC Infectious Diseases, 13(1), 18.