Legionnaires Disease Treatment & Management

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

Medical Care

  • A delay in treatment significantly increases the risk of mortality. Therefore, include empiric anti-Legionella therapy in the regimen for severe CAP and in specific cases of nosocomial pneumonia.
  • Although Legionella pneumonia can present as a mild illness, most patients require hospitalization with parenteral antibiotics.
  • Historically, erythromycin was used for L pneumophila infection, but doxycycline, azithromycin, macrolides, and quinolones are more active against legionnaires disease (LD) than erythromycin.
  • Fluoroquinolones and azithromycin have greater in vitro activity and better intracellular penetration than erythromycin. In addition, animal studies of L pneumophila infection have shown these agents to have superior activity.
  • The fluoroquinolones doxycycline, tigecycline, and azithromycin are preferred because of their activity and pharmacokinetic properties (eg, better bioavailability, better penetration into macrophages, longer half-life).
  • For severe disease, a fluoroquinolone is recommended. Severe disease is defined by respiratory failure, bilateral pneumonia, rapidly worsening pulmonary infiltrates, or the presence of at least 2 of the following 3 characteristics:
    • Blood urea nitrogen greater than or equal to 30 mg/dL
    • Diastolic blood pressure lower than 60 mm Hg
    • Respiratory rate greater than 30/min
  • With doxycycline or fluoroquinolones, rifampin does not need to be added in severely ill patients.
  • Most healthy hosts exhibit clinical response to treatment within 3-5 days.
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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.

References

  1. Nguyen TM, Ilef D, Jarraud S, Rouil L, Campese C, Che D. A community-wide outbreak of legionnaires disease linked to industrial cooling towers--how far can contaminated aerosols spread?. J Infect Dis. Jan 1 2006;193(1):102-11. [Medline].

  2. Woo AH, Goetz A, Yu VL. Transmission of Legionella by respiratory equipment and aerosol generating devices. Chest. Nov 1992;102(5):1586-90. [Medline].

  3. Cristino S, Legnani PP, Leoni E. Plan for the control of Legionella infections in long-term care facilities: Role of environmental monitoring. Int J Hyg Environ Health. Sep 16 2011;[Medline].

  4. Lin YE, Stout JE, Yu VL. Controlling Legionella in hospital drinking water: an evidence-based review of disinfection methods. Infect Control Hosp Epidemiol. Feb 2011;32(2):166-73. [Medline].

  5. Legionellosis --- United States, 2000-2009. MMWR Morb Mortal Wkly Rep. Aug 19 2011;60(32):1083-6. [Medline].

  6. Cunha BA. Hypophosphatemia: diagnostic significance in Legionnaires' disease. Am J Med. Jul 2006;119(7):e5-6. [Medline].

  7. Kashuba AD, Ballow CH. Legionella urinary antigen testing: potential impact on diagnosis and antibiotic therapy. Diagn Microbiol Infect Dis. Mar 1996;24(3):129-39. [Medline].

  8. Tan MJ, Tan JS, Hamor RH, File TM Jr, Breiman RF. The radiologic manifestations of Legionnaire's disease. The Ohio Community-Based Pneumonia Incidence Study Group. Chest. Feb 2000;117(2):398-403. [Medline].

  9. Amodeo MR, Murdoch DR, Pithie AD. Legionnaires' disease caused by Legionella longbeachae and Legionella pneumophila: comparison of clinical features, host-related risk factors, and outcomes. Clin Microbiol Infect. Sep 2010;16(9):1405-7. [Medline].

  10. Amsden GW. Treatment of Legionnaires' disease. Drugs. 2005;65(5):605-14. [Medline].

  11. Baltch AL, Bopp LH, Smith RP, Michelsen PB, Ritz WJ. Antibacterial activities of gemifloxacin, levofloxacin, gatifloxacin, moxifloxacin and erythromycin against intracellular Legionella pneumophila and Legionella micdadei in human monocytes. J Antimicrob Chemother. Jul 2005;56(1):104-9. [Medline].

  12. Barrabeig I, Rovira A, Garcia M, Oliva JM, Vilamala A, Ferrer MD, et al. Outbreak of Legionnaires' disease associated with a supermarket mist machine. Epidemiol Infect. Dec 2010;138(12):1823-8. [Medline].

  13. Blázquez Garrido RM, Espinosa Parra FJ, Alemany Francés L, Ramos Guevara RM, Sánchez-Nieto JM, Segovia Hernández M. Antimicrobial chemotherapy for Legionnaires disease: levofloxacin versus macrolides. Clin Infect Dis. Mar 15 2005;40(6):800-6. [Medline].

  14. Campese C, Roche D, Clément C, Fierobe F, Jarraud S, de Waelle P, et al. Cluster of Legionnaires' disease associated with a public whirlpool spa, France, April-May 2010. Euro Surveill. Jul 1 2010;15(26):[Medline].

  15. Casati S, Conza L, Bruin J, Gaia V. Compost facilities as a reservoir of Legionella pneumophila and other Legionella species. Clin Microbiol Infect. Jul 2010;16(7):945-7. [Medline].

  16. Cunha BA. Antibiotic Essentials. 10th ed. Sudbury, MD: Jones & Bartlett; 2011.

  17. Cunha BA. Atypical pneumonias: current clinical concepts focusing on Legionnaires' disease. Curr Opin Pulm Med. May 2008;14(3):183-94. [Medline].

  18. Cunha BA. Antimicrobial Therapy of Legionnaire's Disease. In: Rakel RE, ed. Conn's Current Therapy. 53rd ed. Philadelphia, Pa: WB Saunders; 2001.

  19. Cunha BA. Highly elevated serum ferritin levels as a diagnostic marker for Legionella pneumonia. Clin Infect Dis. Jun 1 2008;46(11):1789-91. [Medline].

  20. Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. Mar 2010;24(1):73-105. [Medline].

  21. Cunha BA. Pneumonia Essentials. Sudbury, MA: Jones & Bartlett; 2011.

  22. Cunha BA. The atypical pneumonias: clinical diagnosis and importance. Clin Microbiol Infect. May 2006;12 Suppl 3:12-24. [Medline].

  23. Cunha BA, Mickail N, Syed U, Strollo S, Laguerre M. Rapid clinical diagnosis of Legionnaires' disease during the "herald wave" of the swine influenza (H1N1) pandemic: the Legionnaires' disease triad. Heart Lung. May-Jun 2010;39(3):249-59. [Medline].

  24. Cunha BA, Strollo S, Schoch P. Extremely elevated erythrocyte sedimentation rates (ESRs) in Legionnaires' disease. Eur J Clin Microbiol Infect Dis. Dec 2010;29(12):1567-9. [Medline].

  25. Cunha BA, Strollo S, Schoch P. Legionella pneumophila community-acquired pneumonia (CAP): incidence and intensity of microscopic hematuria. J Infect. Sep 2010;61(3):275-6. [Medline].

  26. Den Boer JW, Yzerman EP. Diagnosis of Legionella infection in Legionnaires' disease. Eur J Clin Microbiol Infect Dis. Dec 2004;23(12):871-8. [Medline].

  27. Dufresne SF, Locas MC, Duchesne A, Restieri C, Ismaïl J, Lefebvre B, et al. Sporadic Legionnaires' disease: the role of domestic electric hot-water tanks. Epidemiol Infect. Mar 14 2011;1-10. [Medline].

  28. Erdogan H, Erdogan A, Lakamdayali H, Yilmaz A, Arslan H. Travel-associated Legionnaires disease: clinical features of 17 cases and a review of the literature. Diagn Microbiol Infect Dis. Nov 2010;68(3):297-303. [Medline].

  29. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med. Dec 1 1977;297(22):1189-97. [Medline].

  30. Hart CA, Makin T. Legionella in hospitals: a review. J Hosp Infect. Jun 1991;18 Suppl A:481-9. [Medline].

  31. Kura F, Amemura-Maekawa J, Yagita K, Endo T, Ikeno M, Tsuji H. Outbreak of Legionnaires' disease on a cruise ship linked to spa-bath filter stones contaminated with Legionella pneumophila serogroup 5. Epidemiol Infect. Apr 2006;134(2):385-91. [Medline].

  32. Li Gobbi F, Benucci M, Del Rosso A. Pneumonitis caused by Legionella pneumoniae in a patient with rheumatoid arthritis treated with anti-TNF-alpha therapy (infliximab). J Clin Rheumatol. Apr 2005;11(2):119-20. [Medline].

  33. Lieberman D, Porath A, Schlaeffer F, et al. Legionella species community-acquired pneumonia. A review of 56 hospitalized adult patients. Chest. May 1996;109(5):1243-9. [Medline].

  34. Lin YS, Yu VL. Underdiagnosis of hospital-acquired Legionnaires disease in Singapore. Am J Infect Control. Apr 2006;34(3):161-2. [Medline].

  35. McDade JE, Shepard CC, Fraser DW, Tsai TR, Redus MA, Dowdle WR. Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N Engl J Med. Dec 1 1977;297(22):1197-203. [Medline].

  36. Pedro-Botet L, Yu VL. Legionella: macrolides or quinolones?. Clin Microbiol Infect. May 2006;12 Suppl 3:25-30. [Medline].

  37. Plouffe JF, File TM Jr, Breiman RF, Hackman BA, Salstrom SJ, Marston BJ. Reevaluation of the definition of Legionnaires' disease: use of the urinary antigen assay. Community Based Pneumonia Incidence Study Group. Clin Infect Dis. May 1995;20(5):1286-91. [Medline].

  38. Pravinkumar SJ, Edwards G, Lindsay D, Redmond S, Stirling J, House R, et al. A cluster of Legionnaires' disease caused by Legionella longbeachae linked to potting compost in Scotland, 2008-2009. Euro Surveill. Feb 25 2010;15(8):19496. [Medline].

  39. Ricketts KD, Joseph CA. The distribution of travel-associated Legionnaires' disease within selected European countries, and a comparison with tourist patterns. Epidemiol Infect. Aug 2006;134(4):887-93. [Medline].

  40. Ricketts KD, McNaught B, Joseph CA. Travel-associated legionnaires' disease in Europe: 2004. Euro Surveill. 2006;11(4):107-10. [Medline].

  41. Rizzo C, Caporali MG, Rota MC. Pandemic influenza and pneumonia due to Legionella pneumophila: a frequently underestimated coinfection. Clin Infect Dis. Jul 1 2010;51(1):115. [Medline].

  42. Roig J, Domingo C, Morera J. Legionnaires' disease. Chest. Jun 1994;105(6):1817-25. [Medline].

  43. Sabrià M, Pedro-Botet ML, Gómez J, Roig J, Vilaseca B, Sopena N. Fluoroquinolones vs macrolides in the treatment of Legionnaires disease. Chest. Sep 2005;128(3):1401-5. [Medline].

  44. Sakamoto R, Ohno A, Nakahara T, Satomura K, Iwanaga S, Kouyama Y, et al. Legionella pneumophila in rainwater on roads. Emerg Infect Dis. Aug 2009;15(8):1295-7. [Medline]. [Full Text].

  45. Seenivasan MH, Yu VL, Muder RR. Legionnaires' disease in long-term care facilities: overview and proposed solutions. J Am Geriatr Soc. May 2005;53(5):875-80. [Medline].

  46. St Clair M, Crowley MJ, Sexton D. Legionella as a cause of hyperpyrexia. Clin Infect Dis. Aug 15 2009;49(4):646-7. [Medline].

  47. Stout JE, Yu VL. Legionellosis. N Engl J Med. Sep 4 1997;337(10):682-7. [Medline].

  48. Trop Skaza A, Beskovnik L, Storman A, Ursic S, Groboljsek B, Kese D. Outbreak of Legionnaires' disease in a nursing home, Slovenia, August 2010: preliminary report. Euro Surveill. Sep 30 2010;15(39):19672. [Medline].

  49. Winiecka-Krusnell J, Linder E. Free-living amoebae protecting Legionella in water: the tip of an iceberg?. Scand J Infect Dis. 1999;31(4):383-5. [Medline].

  50. Yu VL, Kroboth FJ, Shonnard J, Brown A, McDearman S, Magnussen M. Legionnaires' disease: new clinical perspective from a prospective pneumonia study. Am J Med. Sep 1982;73(3):357-61. [Medline].

  51. Yu VL, Stout JE. Legionella in an ice machine may be a sentinel for drinking water contamination. Infect Control Hosp Epidemiol. Mar 2010;31(3):317; author reply 318. [Medline].

 
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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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