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Nosocomial Neonatal Legionellosis Associated with Water in Infant Formula, Taiwan

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      Abstract

      We report 2 cases of neonatal Legionella infection associated with aspiration of contaminated water used in hospitals to make infant formula. The molecular profiles of Legionella strains isolated from samples from the infants and from water dispensers were indistinguishable. Our report highlights the need to consider nosocomial legionellosis among neonates who have respiratory symptoms.

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      Most cited references 14

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      Legionnaires' disease: description of an epidemic of pneumonia.

      An explosive, common-source outbreak of pneumonia caused by a previously unrecognized bacterium affected primarily persons attending an American Legion convention in Philadelphia in July, 1976. Twenty-nine of 182 cases were fatal. Spread of the bacterium appeared to be air borne. The source of the bacterium was not found, but epidemiologic analysis suggested that exposure may have occurred in the lobby of the headquarters hotel or in the area immediately surrounding the hotel. Person-to-person spread seemed not to have occurred. Many hotel employees appeared to be immune, suggesting that the agent may have been present in the vicinity, perhaps intermittently, for two or more years.
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        Nosocomial Legionnaires' disease: aspiration as a primary mode of disease acquisition.

        Nosocomial Legionnaires' disease remains a significant problem with many unresolved questions regarding transmission of legionella organisms to patients. We performed a case-control and environmental study to identify risk factors and modes of transmission of Legionella infection during an outbreak of nosocomial Legionnaires' disease in a military medical center. During the calendar year 1989, 14 cases of nosocomial Legionnaires' disease were identified by active surveillance following the discovery of 2 culture-proven cases among organ transplant recipients. Four control patients were matched to each case by age, sex, and date of admission. Cases and controls were compared with respect to past medical history and hospital exposure variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for matched variables. Environmental culturing of air and water supplies in and around the medical center was also performed. The case-control study revealed the following significant risk factors for the acquisition of nosocomial Legionnaires' disease: immunosuppressive therapy (OR = 32.7, CI = 4.5 to 302.6), nasogastric tube use (OR = 18.4, CI = 2.6 to 166.2), bedbathing (OR = 10.7, CI = 2.2 to 59.0), and antibiotic therapy (OR = 14.6, CI = 2.9 to 84.4). Shower use (OR = 0.1, CI = 0 to 0.4) appeared to be a negative risk factor. Water cultures revealed Legionella pneumophila serogroup 1, monoclonal antibody subtype Philadelphia (identical to all patient isolates) in the ground-water supply to the hospital, 1 hot-water tank, and 15% of 85 potable water sites tested. Air sampling of cooling towers, hospital air intakes, and medical air and oxygen supplies were negative for Legionella organisms. This study confirms the importance of potable water in transmitting nosocomial Legionnaires' disease and suggests that the organism gains access to the hospital via external water supplies. The risk factors identified in this case-control study provide evidence that Legionnaires' disease may act as a superinfection in a nosocomial setting and is likely acquired by aspiration, similar to other nosocomial pneumonias.
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          Hospital-acquired legionellosis: solutions for a preventable infection.

           M Sabria,  L Yu (2002)
          Hospital-acquired Legionnaires' disease has been reported from many hospitals since the first outbreak in 1976. Although cooling towers were linked to the cases of Legionnaires' disease in the years after its discovery, potable water has been the environmental source for almost all reported hospital outbreaks. Microaspiration is the major mode of transmission in hospital-acquired Legionnaires' disease; showering is not a mode of transmission. Since the clinical manifestations are non-specific, and specialised laboratory testing is required, hospital-acquired legionellosis is easily underdiagnosed. Discovery of a single case of hospital-acquired Legionnaires' disease is an important sentinel of additional undiscovered cases. Routine environmental culture of the hospital water supply for legionella has proven to be an important strategy in prevention. Documentation of legionella colonisation in the water supply would increase physician index of suspicion for Legionnaires' disease and the necessity for in-house legionella test methods would be obvious. Legionella is a common commensal of large-building water supplies. Preventive maintenance is commonly recommended; unfortunately, this measure is ineffective in minimising legionella colonisation of building water supplies. Copper-silver ionisation systems have emerged as the most successful long-term disinfection method for hospital water disinfection systems. There is a need for public-health agencies to educate the public and media that discovery of cases identifies those hospitals as providers of superior care, and that such hospitals are not negligent.
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            Author and article information

            Affiliations
            Centers for Disease Control, Taipei, Taiwan (S.-H. Wei, L.-R. Tseng, M.-T. Liu, H.-H. Wu, M.-C. Lin, C.-F. Ko, P.-H. Kao, T.-L. Kuo, C.-S. Chiang);
            Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan (S.-H. Wei, P. Chou);
            China Medical University Hospital, Taichung, Taiwan (H.-C. Lin, J.-H. Wang, H.-Y. Lin, K.-P. Hwang, Y.-L. Hsu);
            School of Medicine, Chung Shan Medical University and Hospital, Taichung (J.-N. Sheu); Jen-Ai Hospital, Taichung (F.-C. Liu);
            National Taipei University of Nursing and Health Sciences, Taipei (C.-S. Chiang)
            Author notes
            Address for correspondence: Chuen-Sheue Chiang, Centers for Disease Control, No. 161, Kun-Yang Street, Taipei, Taiwan; email: cschiang10@ 123456cdc.gov.tw
            Journal
            Emerg Infect Dis
            Emerging Infect. Dis
            EID
            Emerging Infectious Diseases
            Centers for Disease Control and Prevention
            1080-6040
            1080-6059
            November 2014
            : 20
            : 11
            : 1921-1924
            25340315
            4214307
            14-0542
            10.3201/eid2011.140542
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