Skip to main content
NCBI home page
CMAJ : Canadian Medical Association Journal logoLink to CMAJ : Canadian Medical Association Journal
. 1989 May 1;140(9):1047–1053.

Epidemic of nosocomial Legionnaires' disease in renal transplant recipients: a case-control and environmental study.

N M Le Saux 1, L Sekla 1, J McLeod 1, S Parker 1, D Rush 1, J R Jeffery 1, R C Brunham 1
PMCID: PMC1268977  PMID: 2650836

Abstract

An outbreak of Legionella pneumophila pneumonia occurred in 6 of 49 new renal transplant recipients over the course of 13 months. We compared infected patients (cases) and uninfected patients (controls) with respect to potential risk factors. Corticosteroid use, need for hemodialysis and number of days of hemodialysis were significantly greater among the cases. Logistic regression analysis identified corticosteroid dosage and number of days of hemodialysis as independent risk factors. Lymphopenia and monocytopenia were correlated with the amount of corticosteroid administered and occurred to a greater degree in the cases. All clinical isolates were of L. pneumophila serogroup 1, subtype Philadelphia 1, which was also cultured from a recovery room sink outside the operating room where the transplants were done. Other areas of the hospital were colonized with other, heterogeneous strains of L. pneumophila. The organism was not eliminated from the hospital water supply despite shock chlorination and superheating of water tanks. The epidemic ended when new transplant recipients routinely received prophylactic trimethoprim-sulfamethoxazole (160-800 mg given orally once daily) while in hospital after transplantation. Corticosteroid-induced monocytopenia and lymphopenia and the complement activation and monocyte depletion effects of hemodialysis may combine to increase susceptibility to Legionnaires' disease.

Full text

PDF
1047

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Arnow P. M., Chou T., Weil D., Shapiro E. N., Kretzschmar C. Nosocomial Legionnaires' disease caused by aerosolized tap water from respiratory devices. J Infect Dis. 1982 Oct;146(4):460–467. doi: 10.1093/infdis/146.4.460. [DOI] [PubMed] [Google Scholar]
  2. Baskerville A., Conlan J. W., Ashworth L. A., Dowsett A. B. Pulmonary damage caused by a protease from Legionella pneumophila. Br J Exp Pathol. 1986 Aug;67(4):527–536. [PMC free article] [PubMed] [Google Scholar]
  3. Bock B. V., Kirby B. D., Edelstein P. H., George W. L., Snyder K. M., Owens M. L., Hatayama C. M., Haley C. E., Lewis R. P., Meyer R. D. Legionnaires' disease in renal-transplant recipients. Lancet. 1978 Feb 25;1(8061):410–413. doi: 10.1016/s0140-6736(78)91202-3. [DOI] [PubMed] [Google Scholar]
  4. Bridge J. A., Edelstein P. H. Oropharyngeal colonization with Legionella pneumophila. J Clin Microbiol. 1983 Nov;18(5):1108–1112. doi: 10.1128/jcm.18.5.1108-1112.1983. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Brindle R. J., Stannett P. J., Tobin J. O. Legionella pneumophila: monoclonal antibody typing of clinical and environmental isolates. Epidemiol Infect. 1987 Oct;99(2):235–239. doi: 10.1017/s0950268800067698. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Craddock P. R., Fehr J., Brigham K. L., Kronenberg R. S., Jacob H. S. Complement and leukocyte-mediated pulmonary dysfunction in hemodialysis. N Engl J Med. 1977 Apr 7;296(14):769–774. doi: 10.1056/NEJM197704072961401. [DOI] [PubMed] [Google Scholar]
  7. Cupps T. R., Fauci A. S. Corticosteroid-mediated immunoregulation in man. Immunol Rev. 1982;65:133–155. doi: 10.1111/j.1600-065x.1982.tb00431.x. [DOI] [PubMed] [Google Scholar]
  8. Dournon E., Bibb W. F., Rajagopalan P., Desplaces N., McKinney R. M. Monoclonal antibody reactivity as a virulence marker for Legionella pneumophila serogroup 1 strains. J Infect Dis. 1988 Mar;157(3):496–501. doi: 10.1093/infdis/157.3.496. [DOI] [PubMed] [Google Scholar]
  9. Dowling J. N., Pasculle A. W., Frola F. N., Zaphyr M. K., Yee R. B. Infections caused by Legionella micdadei and Legionella pneumophila among renal transplant recipients. J Infect Dis. 1984 May;149(5):703–713. doi: 10.1093/infdis/149.5.703. [DOI] [PubMed] [Google Scholar]
  10. Dreyfus L. A., Iglewski B. H. Purification and characterization of an extracellular protease of Legionella pneumophila. Infect Immun. 1986 Mar;51(3):736–743. doi: 10.1128/iai.51.3.736-743.1986. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Edelstein P. H., Nakahama C., Tobin J. O., Calarco K., Beer K. B., Joly J. R., Selander R. K. Paleoepidemiologic investigation of Legionnaires disease at Wadsworth Veterans Administration Hospital by using three typing methods for comparison of legionellae from clinical and environmental sources. J Clin Microbiol. 1986 Jun;23(6):1121–1126. doi: 10.1128/jcm.23.6.1121-1126.1986. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. England A. C., 3rd, Fraser D. W., Plikaytis B. D., Tsai T. F., Storch G., Broome C. V. Sporadic legionellosis in the United States: the first thousand cases. Ann Intern Med. 1981 Feb;94(2):164–170. doi: 10.7326/0003-4819-94-2-164. [DOI] [PubMed] [Google Scholar]
  13. Fauci A. S., Dale D. C. The effect of in vivo hydrocortisone on subpopulations of human lymphocytes. J Clin Invest. 1974 Jan;53(1):240–246. doi: 10.1172/JCI107544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Fraser D. W., Tsai T. R., Orenstein W., Parkin W. E., Beecham H. J., Sharrar R. G., Harris J., Mallison G. F., Martin S. M., McDade J. E. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med. 1977 Dec 1;297(22):1189–1197. doi: 10.1056/NEJM197712012972201. [DOI] [PubMed] [Google Scholar]
  15. Gombert M. E., Josephson A., Goldstein E. J., Smith P. R., Butt K. M. Cavitary Legionnaires' pneumonia: nosocomial infection in renal transplant recipients. Am J Surg. 1984 Mar;147(3):402–405. doi: 10.1016/0002-9610(84)90177-6. [DOI] [PubMed] [Google Scholar]
  16. Guiguet M., Pierre J., Brun P., Berthelot G., Gottot S., Gibert C., Valleron A. J. Epidemiological survey of a major outbreak of nosocomial legionellosis. Int J Epidemiol. 1987 Sep;16(3):466–471. doi: 10.1093/ije/16.3.466. [DOI] [PubMed] [Google Scholar]
  17. Gump D. W., Frank R. O., Winn W. C., Jr, Foster R. S., Jr, Broome C. V., Cherry W. B. Legionnaires' disease in patients with associated serious disease. Ann Intern Med. 1979 Apr;90(4):538–542. doi: 10.7326/0003-4819-90-4-538. [DOI] [PubMed] [Google Scholar]
  18. Haley C. E., Cohen M. L., Halter J., Meyer R. D. Nosocomial Legionnaires' disease: a continuing common-source epidemic at Wadsworth Medical Center. Ann Intern Med. 1979 Apr;90(4):583–586. doi: 10.7326/0003-4819-90-4-583. [DOI] [PubMed] [Google Scholar]
  19. Helms C. M., Massanari R. M., Zeitler R., Streed S., Gilchrist M. J., Hall N., Hausler W. J., Jr, Sywassink J., Johnson W., Wintermeyer L. Legionnaires' disease associated with a hospital water system: a cluster of 24 nosocomial cases. Ann Intern Med. 1983 Aug;99(2):172–178. doi: 10.7326/0003-4819-99-2-172. [DOI] [PubMed] [Google Scholar]
  20. Johnston J. M., Latham R. H., Meier F. A., Green J. A., Boshard R., Mooney B. R., Edelstein P. H. Nosocomial outbreak of Legionnaires' disease: molecular epidemiology and disease control measures. Infect Control. 1987 Feb;8(2):53–58. doi: 10.1017/s0195941700067072. [DOI] [PubMed] [Google Scholar]
  21. Joly J. R., McKinney R. M., Tobin J. O., Bibb W. F., Watkins I. D., Ramsay D. Development of a standardized subgrouping scheme for Legionella pneumophila serogroup 1 using monoclonal antibodies. J Clin Microbiol. 1986 Apr;23(4):768–771. doi: 10.1128/jcm.23.4.768-771.1986. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Maher W. E., Plouffe J. F., Para M. F. Plasmid profiles of clinical and environmental isolates of Legionella pneumophila serogroup 1. J Clin Microbiol. 1983 Dec;18(6):1422–1423. doi: 10.1128/jcm.18.6.1422-1423.1983. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Marshall W., Foster R. S., Jr, Winn W. Legionnaires' disease in renal transplant patients. Am J Surg. 1981 Apr;141(4):423–429. doi: 10.1016/0002-9610(81)90134-3. [DOI] [PubMed] [Google Scholar]
  24. Nash T. W., Libby D. M., Horwitz M. A. Interaction between the legionnaires' disease bacterium (Legionella pneumophila) and human alveolar macrophages. Influence of antibody, lymphokines, and hydrocortisone. J Clin Invest. 1984 Sep;74(3):771–782. doi: 10.1172/JCI111493. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Nolte F. S., Conlin C. A., Roisin A. J., Redmond S. R. Plasmids as epidemiological markers in nosocomial Legionnaires' disease. J Infect Dis. 1984 Feb;149(2):251–256. doi: 10.1093/infdis/149.2.251. [DOI] [PubMed] [Google Scholar]
  26. Plouffe J. F., Para M. F., Bollin G. E. Sulfamethoxazole-trimethoprim treatment of guinea pigs infected with Legionella pneumophila. J Infect Dis. 1984 Nov;150(5):780–782. doi: 10.1093/infdis/150.5.780. [DOI] [PubMed] [Google Scholar]
  27. Rosenberg J. C., Lysz K. Suppression of human cytotoxic lymphocytes by methylprednisolone. An immunosuppressive mechanism of action of steroids. Transplantation. 1978 Mar;25(3):115–120. doi: 10.1097/00007890-197803000-00004. [DOI] [PubMed] [Google Scholar]
  28. Saravolatz L. D., Pohlod D. J., Quinn E. L. In vitro susceptibility of Legionella pneumophila, serogroups I-IV. J Infect Dis. 1979 Aug;140(2):251–251. doi: 10.1093/infdis/140.2.251. [DOI] [PubMed] [Google Scholar]
  29. Vereerstraeten P., Stolear J. C., Schoutens-Serruys E., Maes N., Thys J. P., Liesnard C., Rost F., Kinnaert P., Toussaint C. Erythromycin prophylaxis for Legionnaire's disease in immunosuppressed patients in a contaminated hospital environment. Transplantation. 1986 Jan;41(1):52–54. doi: 10.1097/00007890-198601000-00010. [DOI] [PubMed] [Google Scholar]
  30. Wadowsky R. M., Yee R. B. Glycine-containing selective medium for isolation of Legionellaceae from environmental specimens. Appl Environ Microbiol. 1981 Nov;42(5):768–772. doi: 10.1128/aem.42.5.768-772.1981. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Werb Z. Biochemical actions of glucocorticoids on macrophages in culture. Specific inhibition of elastase, collagenase, and plasminogen activator secretion and effects on other metabolic functions. J Exp Med. 1978 Jun 1;147(6):1695–1712. doi: 10.1084/jem.147.6.1695. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Wilczek H., Kallings I., Nyström B., Hoffner S. Nosocomial Legionnaires' disease following renal transplantation. Transplantation. 1987 Jun;43(6):847–851. [PubMed] [Google Scholar]

Articles from CMAJ: Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association

RESOURCES