Legionnaires Disease Follow-up

  • Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD   more...
 
Updated: Nov 15, 2011
 

Further Inpatient Care

  • Patients with mild-to-moderate pneumonia are admitted to the hospital for parenteral antibiotics and supportive measures. Patients deemed to have a severe pneumonia may require ICU admission for closer monitoring. Quickly initiate empiric antibiotic treatment and obtain a diagnostic workup.
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Further Outpatient Care

  • In milder cases, patients can be treated in the outpatient setting with oral antibiotics.
  • For patients who are hospitalized and treated with intravenous antibiotics, start oral antibiotics while in the hospital and observe for continued response. Continue oral antibiotics on an outpatient basis for 14-21 days, depending on the severity of the presenting illness. Patients should receive close follow-up care to ensure complete resolution of their respiratory symptoms.
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Inpatient & Outpatient Medications

  • Patients should complete the full course of their antibiotics, whether the treatment is initiated in the outpatient setting or in the hospital.
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Deterrence/Prevention

  • Prevention and control of nosocomial legionellosis
    • Legionellae should be sought in hospitalized patients with an increased risk for infection and subsequent death.
    • If one definite case or 2 possible cases of nosocomial legionnaires disease (LD) occur among inpatients, initiate an investigation for a hospital source.
    • Routinely maintain cooling towers and use only sterile water for filling and rinsing of nebulization devices.
    • Improve the design and maintenance of cooling towers and plumbing systems.
  • Disinfection
    • Superheating water to 70-80°C, with flushing of distal sites
    • Installation of copper-silver ionization units, which produce metallic ions that disrupt the bacterial cell wall, thus resulting in lysis and cell death: This method provides sustained protection and is very effective at eradicating legionellae.
    • Use of ultraviolet light, which kills legionellae by damaging cellular DNA: This system is effective when disinfecting localized areas; however, because it provides no sustained protection, adjunctive treatments must be used.
    • Hyperchlorination of water is no longer recommended because legionellae are fairly chlorine resistant, and chlorine decomposes at higher water temperatures found in hot water systems being treated.
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Complications

  • Decreased pulmonary function
  • Abscess formation (in the lungs or at extrapulmonary sites)
  • Pulmonary fibrosis or scarring
  • Fulminant respiratory failure
  • Death
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Prognosis

  • Progressive respiratory failure is the most common cause of death in patients with Legionella pneumonia. The mortality rate depends on the comorbid conditions of the patient, as well as the choice and timeliness of antibiotics administration. The site of acquisition (eg, nosocomial, community-acquired) may also affect the outcome.
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Patient Education

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Contributor Information and Disclosures
Author

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Lynn E Sullivan  MD, MD, Assistant Professor of Medicine, Yale University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred A Lopez, MD  Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD  Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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Table. Modified Winthrop-University Hospital Infection Disease Division's Point System for Diagnosing Legionnaires Disease in Adults
Clinical Features Qualifying Conditions Point Score
Temperature >103°F*With relative bradycardia+5
HeadacheAcute onset+2
Mental confusion/lethargy*Not drug induced+4
Ear painAcute onset-3
Nonexudative pharyngitisAcute onset-3
HoarsenessAcute, not chronic-3
Sputum (purulent)Excluding chronic bronchitis-3
Hemoptysis*Mild/moderate-3
Chest pain (pleuritic)Rapidly progressive asymmetrical



infiltrates* (excluding severe influenza/severe acute respiratory syndrome)



-3
Loose stools/watery diarrhea*Not drug induced+3
Abdominal pain*With or without diarrhea+5
Renal failure*Acute, not chronic+3
Shock/hypotension*Not 2° to acute cardiac-5
/pulmonary causes+5
SplenomegalyExcluding non-CAP causes-5
Lack of response to beta lactamsAfter 72 h (excluding viral pneumonias)+5
Laboratory Features
Chest radiographRapidly progressive asymmetrical infiltrates*



(excluding severe influenza/SARS)



+3
↓ PO2 with ↑ A-a gradient (>35)*(Excluding severe influenza/SARS)-5
↓ Na+Acute onset+1
↓ PO4 =*Acute onset+5
↑ SGOT/SGPT (early mild/transient)*Acute onset+4
↑ Total bilirubinOtherwise unexplained+1
↑ LDH (>400 U/L)*Excluding HIV/PCP-5
↑ CPK/aldolaseOtherwise unexplained+4
↑ CRP (>30 mg/L)Acute onset+5
↑ Cold agglutinins (≥ 1:64)Acute onset-5
↑ CreatinineAcute onset+2
Microscopic hematuria*Excluding trauma, BPH, Foley catheter,



bladder/renal neoplasms



+2
Likelihood of Legionella infection
Total points>15 Legionella infection very likely
5-15 Legionella infection likely
< 5 Legionella infection unlikely
*Otherwise unexplained (acute and associated with pneumonia)
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