Medical Care

For Legionnaires disease (LD), a high level of suspicion and prompt initiation of adequate antimicrobial therapy are critical to improve clinical outcomes.^[33]In contrast, for Pontiac fever, treatment is symptomatic, and no antimicrobial therapy is recommended.

Therapy effective in patients with legionellosis should be considered for initial empirical treatment for severe community-acquired pneumonia (CAP) and for specific patients with nosocomial pneumonia. Support therapy in patients with shock and respiratory failure is administered as needed.

Situations suggesting Legionella disease
- Gram stains of respiratory samples revealing many polymorphonuclear leukocytes with few or no organisms
- Hyponatremia
- Pneumonia with prominent extrapulmonary manifestations (eg, diarrhea, confusion, other neurologic symptoms)
- Failure to respond to administration of beta-lactams, aminoglycoside antibiotics, or both
Antimicrobial therapy for Legionella disease
- Specific therapy includes antibiotics capable of achieving high intracellular concentrations (eg, macrolides, quinolones, ketolides, tetracyclines, rifampin). The reported rank order of in vitro and intracellular activity against L pneumophila is quinolones, then ketolides, and then macrolides^[34]. Beta-lactams and aminoglycosides have activity against Legionella species in vitro but are not clinically effective.
- No prospective randomized studies have been performed regarding antibiotic effectiveness in patients with Legionella disease. Recommendations are based on retrospective reviews and experimental (laboratory and animal) studies.
- Azithromycin is the drug of choice for children with suspected or confirmed Legionella disease.^[1]With rare exceptions, the initial course should be intravenously administered. After a good clinical response is observed, it can be switched to the oral route. In patients with severe disease or who appear to be unresponsive to monotherapy, the addition of rifampin is recommended.
- Certain fluoroquinolones (eg, levofloxacin, moxifloxacin) are effective and are recommended for adults with severe disease.^[35]Because macrolides may interfere with drugs metabolized by cytochrome P450 (CYP) 3A4 isoenzyme (eg, cyclosporine), the quinolones mentioned above are suitable alternatives to treat Legionnaires disease in patients taking cyclosporine or other CYP3A4 substrates. An older fluoroquinolone, ciprofloxacin, does inhibit CYP3A4. Although the US Food and Drug Administration (FDA) has not approved fluoroquinolones for persons younger than 18 years (because of concerns about arthropathy in studies of juvenile animals), they have been successfully used to treat children with Legionnaires disease^{[3, 36, 13]}and may be used in children in special circumstances.
- Other alternatives include doxycycline or trimethoprim (TMP) and sulfamethoxazole (SMZ).
- The recommended duration of therapy is 5-10 days if azithromycin is used. If other drugs are used, the duration should be 2-3 weeks. For patients with severe disease or immunocompromise, prolonged courses may be required.

Surgical Care

See the list below:

Surgical drainage of pulmonary or extrapulmonary disease may be necessary.

Consultations

See the list below:

Infectious disease specialist
Critical care specialist
Pulmonologist
Health-department officials: Confirmed cases of Legionnaires disease should be reported to local health-department officials. Legionellosis is a notifiable disease in the United States.

Medication

[Guideline] American Academy of Pediatrics. Legionella pneumophila infections. Pickering LK, Baker CJ, Kimberlin DW, Long SS. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. 461-62.
Cunha BA, Burillo A, Bouza E. Legionnaires' disease. Lancet. 2016 Jan 23. 387 (10016):376-85. [QxMD MEDLINE Link].
Gonzalez AG, Martin JM. Legionella pneumophila serogroup 1 pneumonia recurrence postbone marrow transplantation. Pediatr Infect Dis J. October 2007. 26:961-963.
Greenberg D, Chiou CC, Famigilleti R, Lee TC, Yu VL. Problem pathogens: paediatric legionellosis--implications for improved diagnosis. Lancet Infect Dis. 2006 Aug. 6(8):529-35. [QxMD MEDLINE Link].
Luttichau HR, Vinther C, Uldum SA, et al. An outbreak of Pontiac fever among children following use of a whirlpool. Clin Infect Dis. 1998 Jun. 26(6):1374-8. [QxMD MEDLINE Link].
Campins M, Ferrer A, Callis L, et al. Nosocomial Legionnaire's disease in a children's hospital. Pediatr Infect Dis J. 2000 Mar. 19(3):228-34. [QxMD MEDLINE Link].
Johansson PJ, Andersson K, Wiebe T, Schalen C, Bernander S. Nosocomial transmission of Legionella pneumophila to a child from a hospital's cold-water supply. Scand J Infect Dis. 2006. 38(11-12):1023-7. [QxMD MEDLINE Link].
Franzin L, Scolfaro C, Cabodi D, et al. Legionella pneumophila pneumonia in a newborn after water birth: a new mode of transmission [case report]. Clin Infect Dis. 2001 Nov 1. 33(9):e103-4. [QxMD MEDLINE Link].
Thoni A, Zech N, Moroder L, Ploner F. [Water contamination and infection rate after water births]. Gynakol Geburtshilfliche Rundsch. 2007. 47(1):33-8. [QxMD MEDLINE Link].
Stone BJ, Abu Kwaik Y. Expression of multiple pili by Legionella pneumophila: identification and characterization of a type IV pilin gene and its role in adherence to mammalian and protozoan cells. Infect Immun. 1998 Apr. 66(4):1768-75. [QxMD MEDLINE Link].
Rubin LG. Legionella species. Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 4th ed. Philadelphia, PA: Churchill Livingstone; 2012. 922-925.
Myers C, Corbelli R, Schrenzel J, Gervaix A. Multiple pulmonary abscesses caused by Legionella pneumophila infection in an infant with croup. Pediatr Infect Dis J. 2006 Aug. 25(8):753-4. [QxMD MEDLINE Link].
Heine S, Fuchs A, von Muller L, Krenn T, Nemat S, Graf N. Legionellosis must be kept in mind in case of pneumonia with lung abscesses in children receiving therapeutic steroids. Infection. 2011 Oct. 39(5):481-4. [QxMD MEDLINE Link].
Monforte R, Marco F, Estruch R, Campo E. Multiple organ involvement by Legionella pneumophila in a fatal case of Legionnaires' disease. J Infect Dis. 1989 Apr. 159(4):809. [QxMD MEDLINE Link].
American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005. 171:388-416.
Scola BL, Maltezou H. Legionella and Q fever community acquired pneumonia in children. Paediatr Respir Rev. 2004. 5 Suppl A:S171-7. [QxMD MEDLINE Link].
Wolf J, Daley AJ. Microbiological aspects of bacterial lower respiratory tract illness in children: atypical pathogens. Paediatr Respir Rev. 2007 Sep. 8(3):212-9, quiz 219-20. [QxMD MEDLINE Link].
Carlson NC, Kuskie MR, Dobyns EL, et al. Legionellosis in children: an expanding spectrum. Pediatr Infect Dis J. 1990 Feb. 9(2):133-7. [QxMD MEDLINE Link].
Soda EA, Barskey AE, Shah PP, Schrag S, Whitney CG, Arduino MJ, et al. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Jun 9. 66 (22):584-589. [QxMD MEDLINE Link].
Farnham A, Alleyne L, Cimini D, Balter S. Legionnaires' disease incidence and risk factors, New York, New York, USA, 2002-2011. Emerg Infect Dis. 2014 Nov. 20(11):1795-1802. [QxMD MEDLINE Link]. [Full Text].
Swift D. Occupation, Socioeconomic Status Tied to Legionellosis Risk. Medscape Medical News. Available at http://www.medscape.com/viewarticle/833883. Accessed: May 7, 2015.
Dooling KL, Toews KA, Hicks LA, Garrison LE, Bachaus B, Zansky S, et al. Active Bacterial Core Surveillance for Legionellosis - United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2015 Oct 30. 64 (42):1190-3. [QxMD MEDLINE Link].
Barclay L. Legionellosis Incidence Increases; Better Diagnostics Needed. Medscape Medical News. Available at http://www.medscape.com/viewarticle/853488. October 30, 2015; Accessed: March 29, 2016.
Sopena N, Sabria-Leal M, Pedro-Botet ML, et al. Comparative study of the clinical presentation of Legionella pneumonia and other community-acquired pneumonias. Chest. 1998 May. 113(5):1195-200. [QxMD MEDLINE Link].
Qin X, Abe PM, Weissman SJ, Manning SC. Extrapulmonary legionella micdadei infection in a previously healthy child. Pediatr Infect Dis J. 2002 Dec. 21(12):1174-6. [QxMD MEDLINE Link].
Holmberg RE Jr, Pavia AT, Montgomery D, et al. Nosocomial Legionella pneumonia in the neonate. Pediatrics. 1993 Sep. 92(3):450-3. [QxMD MEDLINE Link].
Shachor-Meyouhas Y, Kassis I, Bamberger E, et al. Fatal hospital-acquired Legionella pneumonia in a neonate. Pediatr Infect Dis J. 2010 Mar. 29(3):280-1. [QxMD MEDLINE Link].
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. 2000 Feb. 117(2):398-403. [QxMD MEDLINE Link].
Hodina M, Hanquinet S, Cotting J, et al. Imaging of cavitary necrosis in complicated childhood pneumonia. Eur Radiol. 2002 Feb. 12(2):391-6. [QxMD MEDLINE Link].
Miller ML, Hayden R, Gaur A. Legionella bozemanii pulmonary abscess in a pediatric allogeneic stem cell transplant recipient. Pediatr Infect Dis J. 2007 Aug. 26(8):760-2. [QxMD MEDLINE Link].
Famiglietti RF, Bakerman PR, Saubolle MA, Rudinsky M. Cavitary legionellosis in two immunocompetent infants. Pediatrics. 1997 Jun. 99(6):899-903. [QxMD MEDLINE Link].
Gervaix A, Beghetti M, Rimensberger P, et al. Bullous emphysema after Legionella pneumonia in a two-year-old child. Pediatr Infect Dis J. 2000 Jan. 19(1):86-7. [QxMD MEDLINE Link].
Sasaki T, Matsumoto N, Nakao H, et al. An outbreak of Legionnaires' disease associated with a circulating bathwater system at a public bathhouse. I: a clinical analysis. J Infect Chemother. 2008 Apr. 14(2):117-22. [QxMD MEDLINE Link].
Stout JE, Sens K, Mietzner S, et al. Comparative activity of quinolones, macrolides and ketolides against Legionella species using in vitro broth dilution and intracellular susceptibility testing. Int J Antimicrob Agents. 2005 Apr. 25(4):302-7. [QxMD MEDLINE Link].
Blazquez Garrido RM, Espinosa Parra FJ, Alemany Frances L, et al. Antimicrobial chemotherapy for Legionnaires disease: levofloxacin versus macrolides. Clin Infect Dis. 2005 Mar 15. 40(6):800-6. [QxMD MEDLINE Link].
Watson AM, Boyce TG, Wylam ME. Legionella pneumonia: infection during immunosuppressive therapy for idiopathic pulmonary hemosiderosis. Pediatr Infect Dis J. 2004 Jan. 23(1):82-4. [QxMD MEDLINE Link].
Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care--associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar 26. 53(RR-3):1-36. [QxMD MEDLINE Link].
Yu VL, Lee TC. Neonatal legionellosis: the tip of the iceberg for pediatric hospital-acquired pneumonia?. Pediatr Infect Dis J. 2010 Mar. 29(3):282-4. [QxMD MEDLINE Link].
Singh N, Stout JE, Yu VL. Prevention of Legionnaires' disease in transplant recipients: recommendations for a standardized approach. Transpl Infect Dis. 2004 Jun. 6(2):58-62. [QxMD MEDLINE Link].
Rubin R. Why Are Legionnaires Disease Diagnoses Becoming More Common in the United States?. JAMA. 2018 May 1. 319 (17):1753-1754. [QxMD MEDLINE Link].
Yackley JK, Sweat D, Fill MA, Garman K, Dunn JR. Notes from the Field: Legionellosis Outbreak Associated with a Hotel Aquatics Facility - Tennessee, 2017. MMWR Morb Mortal Wkly Rep. 2018 Jan 19. 67 (2):77-78. [QxMD MEDLINE Link].