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During the COVID-19 pandemic, the incidence of many droplet-transmitted infections decreased due to increased mask-wearing and social distancing. Contrastingly, there has been concern that COVID-19 countermeasures, such as lockdowns, may increase legionellosis incidence via water stagnation. During the pandemic in Japan, four state of emergency declarations were imposed between 2020 and 2021, which makes it particularly suitable to test this hypothesis.We use country-level surveillance data from the National Institute of Infectious Diseases to track the relative incidence of legionellosis compared to invasive pneumococcal disease (IPD) during the COVID-19 pandemic in Japan, with a focus on the periods just after state of emergency declarations were lifted.The absolute number of legionellosis and IPD cases decreased in 2020 and 2021 compared to previous years. The average relative incidence of legionellosis as well as the variance of the relative incidence significantly increased during the pandemic compared to previous years. There were no increases in the relative incidence of legionellosis during the periods immediately following emergency declaration liftings, but the relative incidence did increase considerably during the first two states of emergency.COVID-19 countermeasures appear more effective at decreasing the incidence of human-to-human transmitted infections, such as IPD, compared to environmentally-transmitted infections, such as legionellosis. Though no evidence was found to suggest that legionellosis cases increased after state of emergency declarations, public health efforts should continue to emphasize the importance of routine sanitation and water system maintenance to prevent water stagnation and Legionella spp. contamination.

This study examined 184 legionellosis outbreaks in the United States reported to the Centers for Disease Control and Prevention's Waterborne Disease and Outbreak Surveillance System, from 2001 to 2017. Drinking water characteristics examined include source water type, disinfectant type, exposure setting, geographical distribution by U.S. Census Divisions, and the public water system size (population served). This study found that most of the reported drinking water-associated legionellosis outbreaks occurred in eastern United States, including 35% in the South Atlantic, 32% in the Middle Atlantic, and 16% in the East North Central Census Divisions were linked with building water systems in healthcare and hotel settings; and were associated with buildings receiving drinking water from public water systems serving >10,000 people. Targeted evaluations and interventions may be useful to further determine the combination of factors, such as disinfectant residual type and drinking water system size that may lead to legionellosis outbreaks.

Incidence of Legionnaires' disease is increasing, particularly in the Mid-Atlantic states in the United States; since 2015, New Jersey has documented ≈250-350 legionellosis cases per year. We used SaTScan software to develop a semiautomated surveillance tool for prospectively detecting legionellosis clusters in New Jersey. We varied temporal window size and baseline period to evaluate optimal parameter selections. The surveillance system detected 3 community clusters of Legionnaires' disease that were subsequently investigated. Other, smaller clusters were detected, but standard epidemiologic data did not identify common sources or new cases. The semiautomated processing is straightforward and replicable in other jurisdictions, likely by persons with even basic programming skills.

Urinary antigen tests (UATs) have been used for the early detection of legionellosis and have demonstrated moderate sensitivity and high specificity. However, the most recent systematic review and meta-analysis published in 2009 evaluated the accuracy of UATs; since then, UAT accuracy may have changed owing to advances and developments in UAT technology and epidemiological changes in the frequency of Legionella species that cause legionellosis. Therefore, this systematic review and meta-analysis aimed to update the accuracy of UATs for legionellosis among patients with suspected pneumonia.Overall, 1326 studies were screened, 21 of which fulfilled the eligibility criteria for quality assessment and meta-analysis. Data from 5772 patients, including 1368 (23.7%) with the target condition (i.e., suspected legionellosis), were included in the analysis. The overall quality of the included studies, which was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, was unclear.The calculated pooled sensitivity and specificity were 0.79 (95% confidence interval [CI], 0.71-0.85) and 1.00 (95% CI, 0.99-1.00), respectively. Subpopulation analysis revealed that the accuracy of UATs for sensitivity and specificity for Legionella pneumophilia serogroup 1 was 0.86 (95% CI, 0.78-0.91) and 1.00 (95% CI, 0.99-1.00), respectively.This study demonstrated that the sensitivity and specificity of UATs were moderate and high, respectively, which is comparable to the results reported in 2009. Therefore, UATs may be a useful method for the early detection of legionellosis caused by Legionella pneumophila serogroup 1.The review protocol was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000041080).

Background Patients admitted to intensive care units are frequently exposed to pathogenic microorganisms present in their environment. Exposure to these microbes may lead to the development of hospital-acquired infections that complicate the illness and may be fatal. Amoeba-associated microorganisms (AAMs) are frequently isolated from hospital water networks and are reported to be associated to cases of community and hospital-acquired pneumonia. Methodology/Principal Findings We used a multiplexed immunofluorescence assay to test for the presence of antibodies against AAMs in sera of intensive care unit (ICU) pneumonia patients and compared to patients at the admission to the ICU (controls). Our results show that some AAMs may be more frequently detected in patients who had hospital-acquired pneumonia than in controls, whereas other AAMs are ubiquitously detected. However, ICU patients seem to exhibit increasing immune response to AAMs when the ICU stay is prolonged. Moreover, concomitant antibodies responses against seven different microorganisms (5 Rhizobiales, Balneatrix alpica, and Mimivirus) were observed in the serum of patients that had a prolonged ICU stay. Conclusions/Significance Our work partially confirms the results of previous studies, which show that ICU patients would be exposed to water amoeba-associated microorganisms, and provides information about the magnitude of AAM infection in ICU patients, especially patients that have a prolonged ICU stay. However, the incidence of this exposure on the development of pneumonia remains to assess.

Background This study aimed to investigate the occurrence of Legionella species in the respiratory samples of patients with pneumonia symptoms from Ahvaz, Iran by culture and the real-time PCR of 23S-5S rRNA gene spacer region. Methods and results A total of 123 clinical respiratory samples including 63 pleural aspirates, 57 bronchoalveolar lavage (BAL), and 3 sputum were collected from 65 males and 58 females with pneumonia symptoms. All samples were cultured on the Modified Wadowsky-Yee (MWY) agar. The Legionella species was identified by routine bacteriological tests. The presence of the 16S-23S rRNA spacer region gene was investigated by real-time PCR. The Legionella species were differentiated by sequencing of 16S-23S rRNA gene. A total of 2 (1.6%) BAL specimens were positive for Legionella species by culture method. No Legionella spp. were identified in pleural aspirates and sputum samples by the culture method. Using real-time PCR, 9 (7.3%) samples including 6 BAL, 1 sputum, and 2 pleural aspirates were positive for legionella species. These species were detected in 3 (5.2%) females and 6 males (9.2%). The results of sequencing showed that eight species were L. pneumophila while one was L. cherrii. Also, the 2 isolates that were identified by culture method, were confirmed as L. pneumophila by sequencing. Conclusions The results showed that using the real-time PCR has a more efficacy for detecting of Legionella species in respiratory samples. Also, L. pneumophila was the most prevalent species circulating in the southwest region of Iran. So, periodic monitoring programs is recommended to prevent epidemics due to this bacterium.

In August 2021, a legionellosis outbreak involving 7 persons occurred within a 500-meter radius in the Montérégie region of Québec, Canada. Near real-time modeling of wind direction along with epidemiologic and environmental investigations identified the possible source. Modeling wind direction could help identify likely Legionella pneumophila sources during legionellosis outbreaks.

Legionellosis is a neglected disease due to the absence of well-defined clinical symptoms and difficulties in isolating the causal organism. Legionella spp. is known to colonize the lumen of respiratory therapy equipment(RTE) and evade conventional detection by entering the viable but non-culturable state. Monitoring these surfaces for Legionella pneumophila in addition to routine monitoring of water could aid in decreasing incidences of hospital-acquired infections by this pathogen. In this study swabs of different respiratory therapy equipment were tested for the presence of Legionella by conventional culture-based methods versus molecular detection of culture-independent template by polymerase chain reaction (PCR). Genetic diversity of the genes amplified were studied using bioinformatic tools. The dotA genes were genetically diverse indicating no clonality. This communication highlights that the persistence of virulence genes like dotA on abiotic surfaces can result in the mobilization of these genes to other species and give rise to virulent forms especially in a healthcare setting.

SUMMARY Background Since 2000, the National Health System has adopted international guidelines for assessing Legionella spp. in hospital water systems. The control of water contamination by Legionella spp. is still a matter of research concerning the most effective method in preventing nosocomial infections. Aim To compare three different decontamination methods by monitoring colony-forming unit count and number of hospital-acquired legionellosis cases. A secondary objective was to evaluate the long-term effects of the preventive measures on the water pipes. Methods A protocol was developed for the selection of high-risk sampling sites and for the testing of three disinfection methods over the course of 19 years: hyperchlorination and thermal shock (period A, 2000–2005); copper–silver ionization (period B, 2006–2010); and integration of pre-filtering, filtering, pipe-protecting products, and remote control with chlorine dioxide (ClO2) (period C, 2011–2018). Findings The use of shock disinfection and hyperchlorination led to a decrease in contamination level immediately after the procedure, but then it rose again to the previous level in two months. Both copper–silver ionization and ClO2 disinfection showed a stable and durable decrease in contamination level. Throughout these three phases, six cases of Legionella spp. occurred during period A, six cases during period B, and three cases during period C. With regard to the damage of water pipes, effective copper–silver levels caused corrosion and calcification in water pipes. Conclusion Both copper–silver ionization and ClO2 properly controlled Legionella spp. contamination. ClO2 significantly reduced the number of positive sites (P

Objective of the work was to conduct an extended study of Legionella strains isolated from epidemiologically significant environmental objects during the preparation and conduct of mass events in the territory of the Russian Federation in 2013-2014 . Materials and methods . Studied were 53 strains of Legionella pneumophila, isolated from epidemiologically significant objects during the preparation and conduct of a number of mass events (ME): XXVII World Summer Universiade, XXII Olympic Winter Games and XI Paralympic Winter Games, Sochi; Summer Health Promotion Campaign in 2014, Republic of Crimea; IV Caspian Summit, Astrakhan, 2014. Strains were analyzed using multilocus sequencing, time-of-flight mass spectrometry (MALDI-ToF-MS) and atomic force microscopy. Legionella strains were typed by multilocus sequencing in accordance with the algorithm of the European Legionellosis Research Group “Sequence-Based Typing protocol for epidemiological typing of L. pneumophila ". Results and discussion . Strains of L. pneumophila , legionellosis agent, were isolated in the territory of the Republic of Crimea, Moscow, Kazan, Sochi, Astrakhan and characterized. According to the results of slide agglutination, 17 L. pneumophila strains were assigned to 1 serogroup , 37 - to 2-14 serogroups. Based on the data obtained by multilocus sequencing, in accordance with the algorithm of the European Working Group on Legionellosis Surveillance, allelic profiles of all the studied L. pneumophila strains were identified; their belonging to 7 sequence types was established. Using the method of time-of-flight mass spectrometry, legionella strains were characterized, their protein profiles were studied, and a database was formed. Using the method of scanning probe microscopy, information was obtained on the morphology of the cells of 18 legionella strains and the features of their surface structures. Using the methods of multilocus sequencing, time-of-flight mass spectrometry, and atomic force microscopy, molecular-genetic, proteomic, and morphometric features of Legionellosis pathogen strains that circulate in epidemiologically significant sites in the Russian Federation were determined.

Legionella is considered one of the most important causes of potentially preventable morbid-ity and mortality. These microorganisms are ubiquitous, but incomplete information is available on the geographic distribution of Legionella species in our region.For the mentioned reasons, in this work the distribution of Legionella spp. in non-hospital facilities of the urban area of Pesaro-Urbino (Central Italy), including public fountains, residential build-ings, public and private offices and retirement homes, was investigated.A total of 298 water samples were collected from the different facilities and subjected to standard Legionella isolation and identification protocols.As reported, 17.8% of the collected water samples resulted positive for Legionella spp. (28.6% from retirement homes, 21.3% from residential buildings, 15.3% from private and public offices). The highest per-centage of positive samples (14.4%) was found in hot water from retirements homes (58.8%) and residential buildings (31.8%); the most frequent isolated serogroups were L. pneumophila 2-14 (71.7%).This work is the first describing the distribution of Legionella spp. in non-hospital facilities in the province of Pesaro-Urbino, and highlights a condition of potential risk for susceptible categories. From our data, we can point that a regular and constant control to prevent microbiological risk from legionellosis, particularly in facilities housing the elderly, is recommended.

Exposure models are useful tools for relating environmental monitoring data to expected health outcomes. The objective of this study was to (1) compare two Legionella shower exposure models, and (2) develop a risk calculator tool for relating environmental monitoring data to estimated Legionella infection risks and Legionnaires' Disease (LD) illness risks. Legionella infection risks for a single shower event were compared using two shower Legionella exposure models. These models varied in their description of partitioning of Legionella in aerosols and aerosol deposition in the lung, where Model 1 had larger and fewer aerosol ranges than Model 2. Model 2 described conventional vs. water efficient showers separately, while Model 1 described exposure for an unspecified shower type (did not describe it as conventional or water efficient). A Monte Carlo approach was used to account for variability and uncertainty in these aerosolization and deposition parameters, Legionella concentrations, and the dose-response parameter. Methods for relating infection risks to illness risks accounting for demographic differences were used to inform the risk calculator web application ("app"). Model 2 consistently estimated higher infection risks than Model 1 for the same Legionella concentration in water and estimated deposited doses with less variability. For a 7.8-min shower with a Legionella concentration of 0.1 CFU/mL, the average infection risks estimated using Model 2 were 4.8 × 10

The notification rate of legionellosis in Switzerland and other European countries has markedly increased over the last 20 years. Here, we investigated the Swiss notification data on legionellosis from 2000 to 2020 in regards of overall time trend, content and data quality. We further explored the impact of the COVID-19 pandemic on the reported case numbers using an interrupted time series approach. Between 2000 and 2020, 5980 cases were included in our analysis. The annual crude notification rate for legionellosis cases increased from 1.1/100,000 population (CI: 0.9-1.4) in 2000 to 5.6/100,000 population (CI: 5.1-6.1) in 2020. In recent years, the summer peaks have been more pronounced and some shifted earlier in the year. The highest notification rate was recorded in 2018 with 6.7/100,000 population (CI: 6.2-7.3). The hospitalisation rate for notified cases remained high across all study years (89.9%), while the case fatality rate slightly decreased (from 7.7% to 3.6%). COVID-19 containment measures, such as travel restrictions and/or related behavioural changes, are associated with a temporary decline in cases of 35%. Overall, the quality of the notification data was good. Clinical data were more susceptible to interferences than data from laboratory reporting, which could be observed most clearly in the decline of clinical reports by 4.3 percentage points in 2020. As the case classification for Legionnaires' disease includes pneumonia symptoms, this decline could lead to an underestimation of Legionnaires' disease cases, yet the continuous reporting though the diagnostic laboratories suggested a robust surveillance system for legionellosis in Switzerland.

The increase in legionellosis incidence in the general population in recent years calls for a better characterization of the sources of infection, such as showering. Water-efficient shower systems that use water-atomizing technology have been shown to emit slightly more inhalable particles in the range of bacterial sizes than the traditional systems; however, the actual rate of bacterial emission remains poorly documented. The aim of this study was to assess the aerosolisation rate of the opportunistic water pathogen

Based on the data from a French outbreak of legionellosis, a probabilistic approach was developed to analyze and assess the potential role of several suspected sources of contamination. Potential dates of exposure of all cases were determined using back-calculation, using two probability distribution functions to model incubation period. A probabilistic analysis and risk assessment were then used to determine the most probable sources of contamination for each wave of the outbreak. The risk assessment was based on parameters representing emission and dispersion of Legionella: level and duration of emission; aerosol dispersion capacity; and probability of potential exposure for each patient. Four types of facilities containing the Legionella epidemic strain were analyzed: cooling towers, aerated wastewater basins, high pressure water cleaners, and car wash stations. The results highlighted the potential role of an aerated wastewater basin in the outbreak in addition to cooling towers. The role of high-pressure water cleaners and car wash stations appeared to be non-significant. This study also reveals the lack of knowledge on facility parameters that can be useful for microbial risk assessments. This type of probabilistic analysis can be used to quantitatively assess the risk for various facilities in order to manage a legionellosis outbreak.

Bacterial culture remains the gold standard for the diagnosis of legionellosis. However, past reports indicate that most physicians use the urinary antigen test (UAT) alone. Combining it with other tests is important, especially in patients with negative UAT results. The aim of this study was to investigate the current situation of legionellosis diagnostics and clarify the issues that need to be addressed.Between March 1, 2021 and April 30, 2021, a questionnaire survey was conducted in an anonymous manner among physicians working in Japan. Questionnaires were generated on a website and asked questions in a multiple-choice format.Valid responses were received from 309 physicians during the study period. Most (92.9%) physicians reported using UAT as the initial test for patients suspected of having legionellosis, and10% reported using other tests (e.g., culture, nucleic acid amplification test [NAAT], Gimenez staining, and serum antibody titer measurement [ATM]). When the initial test result was negative, 63% of physicians reported not conducting additional tests. Even when they chose to run additional tests, at most 27.8%, 23.6%, 12.3%, and 10.4% of all physicians used NAAT, culture, Gimenez staining, and serum ATM, respectively. The major reasons for not using tests other than UAT were "unavailability in the medical facility," "long turn-around time," and "difficult to collect sputum."The present survey revealed that most physicians in Japan used UAT alone for diagnosing legionellosis. Eliminating barriers to creating a reasonable environment and edification of physicians are needed to improve the current situation.

Legionnaires' disease (LD) (

Most cases of legionellosis in Norway are acquired outside the country. This was a domestic case from an unusual source.A man in his thirties was admitted with pneumonia early in the summer. He developed respiratory failure before recovering. Cultures from his lower airways grew Legionella pneumophila serogroup 1. Samples from his home and workplace did not identify Legionella. On further questioning it was discovered that the patient regularly sat beside an outdoor fountain during his breaks from work. Samples from the fountain identified high numbers of L. pneumophila serogroup 1, sequence type 256. Full genome sequencing showed that isolates from the patient and fountain were identical. The fountain used recirculated water with small amounts of chlorine. High outdoor temperatures in Oslo may have facilitated growth of Legionella in the fountain.To our knowledge, this is the first published case of Legionella transmission from an outdoor fountain.

Legionella longbeachae has been frequently identified in composted plant material and can cause Legionnaires' disease (LD). We wanted to determine how frequently L. longbeachae DNA was present on gardeners' gloves, and how long L. longbeachae could persist on inoculated gloves and masks. Volunteers completed a survey of gardening practices and their gardening gloves were tested for L. longbeachae DNA by qPCR. The persistence of viable L. longbeachae was assessed by timed subcultures after inoculation of gardening gloves and masks. Gloves but not masks were used regularly. L. longbeachae was detected on 11 (14%; 95% CI 8-24%) gloves. Viable organisms were recovered from 25-50% of inoculated cotton, leather and PU coated gloves but not rubber gloves after 8 hours incubation. There was a difference in dose response curve slopes by glove material (p = 0.001) and time to 50% sterility (p = 0.036). There were differences in persistence of L. longbeachae between mask types from analysis of the slopes and 50% sterility on the decay curves (p = 0.042, p < 0.001 respectively). Gardening gloves and masks may act as a vector for transmission of L. longbeachae during gardening. Washing gardening gloves and prompt disposal of masks could reduce risk of LD.

Legionellosis caused by Legionella longbeachae is diagnosed mainly by PCR. We report a case of L. longbeachae infection in mainland China, which was diagnosed by metagenomic next-generation sequencing, in a man who developed an epileptic seizure after using moxifloxacin. Metagenomic next-generation sequencing may be a useful tool to detect Legionella spp.

Clinical observation of the patient with legionella pneumonia which developed in the setting of hairy-cell leukosis, required use of extracorporeal membrane oxygenation for controlling life-threatening hypoxia is presented. Active diagnostic approach for identification of the etiologic agent (Legionella pneumophila, Acinetobacter baumannii) that caused pneumonia, allowed to choose an optimum set of antibacterial agents and medicines for specific therapy of hemoblastosis (BRAFV600E mutation and use of Zelboraf). After correction of respiratory insufficiency and discontinue the patient from ECMO, we could reach hematologic remission and transfer the patient to the Institute of Hematology for further treatment.

Due to poor diagnostics and increased co-infections, HIV-associated Legionella infections are underreported. We aimed to retrospectively determine the frequency of Legionella infections in bronchoalveolar lavage (BAL) from HIV-associated pneumonia patients hospitalized in Medellin, Colombia, between February 2007 and April 2014. Although culture was negative, 17 BAL (36%) were positive for Legionella by quantitative polymerase chain reaction, most of which were in the Mycobacterium tuberculosis or Pneumocystis jirovecii co-infected patients, and included L. anisa (n = 6), L. bozemanae (n = 4), L. pneumophila (n = 3), and L. micdadei (n = 2). All L. bozemanae and L. micdadei associated with Pneumocystis, while all L. pneumophila associated with M. tuberculosis. Legionella probable cases had more complications and higher mortality rates (P = 0.02) and were rarely administered empirical anti-Legionella therapy while in hospital. Clinicians should be aware of the possible presence of Legionella in HIV and M. tuberculosis or P. jirovecii co-infected patients.

Latar belakang: Pneumonia akibat bakteri Legionella masih menjadi masalah di berbagai tempat di dunia; menjadi penyebab 2-15 % dari pneumonia yang perlu di rawat di Rumah Sakit. Kasus legionellosis di Indonesia dilaporkan terjadi di Bali pada tahun 1996 dan di Tangerang tahun 1999. Keberadaan Legionella di fasilitas Pelayanan Kesehatan berpotensi sebagai penyebab infeksi nosokomial. Bakteri Legionella hidup di lingkungan perairan hangat dan lembab, juga ditemukan diberbagai sumber air seperti, sumber air sistem pendingin ruangan, kolam renang, tempat penampungan air di rumah sakit, perkantoran, hotel, dan perumahan sehingga turut berkontribusi dalam terjadinya community acquired dan pneumonia nosokomial. Metode: Penelitian ini merupakan penelitian deskriptif yang bertujuan untuk penapisan keberadaan Legionella pneumophila diberbagai sumber dan penampungan air di Rumah Sakit (RS) di Jakarta dengan menggunakan medium Legionella Charcoal Yeast Extract (CYE) dan dengan berbagai suplemen. Tujuh belas sampel air yang berasal dari berbagai sumber air di dua RS yang berlokasi diJakarta Utara dan Barat telah diteliti. Hasil: Dua puluh satu koloni yang ditemukan memiliki karakterisitik L. pneumophila dari semua varian medium, namun pada tes agglutinasi latex tidak memberikan reaksi positif. Kesimpulan: L. pneumophila tidak ditemukan diberbagai sumber air dari dua RS ini. Penggunaan metode yang lebih sensitif dan spesifik perlu dilakukan untuk memastikan ditemukannya L. pneumophila. Kata kunci: Legionellosis, Legionella pneumophila, medium BCYE Abstract Background: Pneumonia due to Legionella bacteria is still a problem in various places in the world, causes 2 15% of pneumonia that need hospitalization. In Indonesia, legionellosis cases have been reported in Bali in 1996 and Tangerang in 1999. The existence of Legionella in healthcare facilities is potential to cause nosocomial infections. Legionella bacteria live in warm and humid waters, and are also commonly found in various water sources, such as water cooling systems, swimming pools, water reservoirs in hospitals, offices, hotels and housing. These bacteria contribute to the occurrence of community-acquired and nosocomial pneumonia. Methods: This study was a descriptive research, and aimed to screen water sources and reservoirs in the hospitals in Jakarta for the existence of Legionella pneumophilla using Legionella Charcoal Yeast Extract (CYE) medium with various supplements. A total of 17 water samples from 2 hospitals located in West and North Jakarta have been examined. Results: The results showed a total of 21 colonies with characteristics as of L. pneumophila were obtained from those water samples, however, none showed positive results in the latex agglutination test. Conclusion: L. pneumophila was not found thus far in the water sources in these two hospitals. A more sensitive and specific approaches might be used to enable the findings of L. pneumophila. Keywords: Legionellosis, Legionella pneumophila, BCYE medium

A case of bilateral polysegmental destructive legionella pneumonia with the formation of multiple lung abscesses in an immunocompetent boy aged 15 years is presented. The child had symptoms of intoxication with febrile fever, myalgia, unproductive cough, respiratory failure, dull percussion sound and weakening of breathing on both sides in the lower sections. A computed tomography of the chest revealed multiple bilateral multifocal foci of pulmonary tissue with destruction. The diagnosis of legionella pneumonia was made on the basis of detection of IgM antibodies to L. pneumophila with an increase in titer in the dynamics and exclusion of other causes of lung damage. Levofloxacin turned out to be an effective antibacterial drug. It is necessary to take into account the ability of microorganisms of the genus Legionella to cause multiple abscess formation of lung tissue.

Inflammasome activation is an innate host defense mechanism initiated upon sensing pathogens or danger in the cytosol. Both autophagy and cell death are cell autonomous processes important in development, as well as in host defense against intracellular bacteria. Inflammasome, autophagy, and cell death pathways can be activated by pathogens, pathogen-associated molecular patterns (PAMPs), cell stress, and host-derived damage-associated molecular patterns (DAMPs). Phagocytosis and toll-like receptor (TLR) signaling induce reactive oxygen species (ROS), type I IFN, NFκB activation of proinflammatory cytokines, and the mitogen-activated protein kinase cascade. ROS and IFNγare also prominent inducers of autophagy. Pathogens, PAMPs, and DAMPs activate TLRs and intracellular inflammasomes, inducing apoptotic and inflammatory caspases in a context-dependent manner to promote various forms of cell death to eliminate pathogens. Common downstream signaling molecules of inflammasomes, autophagy, and cell death pathways interact to initiate appropriate measures against pathogens and determine host survival as well as pathological consequences of infection. The integration of inflammasome activation, autophagy, and cell death is central to pathogen clearance. Various pathogens produce virulence factors to control inflammasomes, subvert autophagy, and modulate host cell death in order to evade host defense. This review highlights the interaction of inflammasomes, autophagy, and host cell death pathways in counteractingBurkholderia pseudomallei, the causative agent of melioidosis. Contrasting evasion strategies used byB.pseudomallei,Mycobacterium tuberculosis, andLegionella pneumophilato avoid and dampen these innate immune responses will be discussed.

INTRODUCTION. Bacteria Legionella sp. found in water distribution systems, especially warm, transferred to water spray devices for aerators and showers in the form of aerosols infected with them become a threat to the human inhaler. OBJECTIVE. Assessment of colonization of the water supply network with Legionella bacteria in teaching and education facilities in Małopolska in 2016 year. MATERIAL AND METHODS. The results of water samples taken from plumbing installations were analyzed in teaching and education facilities by employees of the State Sanitary Inspection of the Lesser Poland Voivodeship. RESULTS. The results of 366 testing hot water samples in 111 teaching and education centers in Małopolska have shown that in 123 testing samples (33,6%) in 48 centers (43,2%) the water sample was colonized with Legionella sp. and the water quality did not meet the requirements of the current ordinance of the Minister of Health. CONCLUSIONS. It is justified to periodically monitor the presence of Legionella sp. in water supply installations in teaching and education centers and taking action to reduce the colonization of these bacteria.

OBJECTIVE. The aim of this study is to assess the epidemiological situation of legionellosis in Poland in 2017 in comparison with previous years. MATERIAL AND METHODS. The analysis is based on national surveillance data published in the annual bulletin: “Infectious diseases and poisonings in Poland in 2017” and bulletins from previous years along with data from legionellosis case reports collected and sent to the Department of Epidemiology of Infectious Diseases and Surveillance NIPH – NIH by Sanitary and Epidemiological Stations. RESULTS. In Poland, both cases of Legionnaires’ disease (an acute form of infection with pneumonia) and Pontiac fever (a mild, influenza-like form of infection) are routinely reported to the surveillance system. In 2017, a total of 39 cases of legionellosis were registered, including 38 cases of Legionnaires’ disease and 1 case of Pontiac fever; the annual incidence rate 0.102 (per 100,000 population) has increased by almost 50 percent since previous year (0.070) and is almost three times higher than the median incidence (0.036) for 2011-2015. The infections were reported in fourteen voivodeships; only one voivodeship (Świętokrzyskie) did not register any case in last years. The incidence in men (0.129 per 100,000) was higher compared to women (0.076); the highest incidence (0.323) was noted in men aged 50-59. All reported cases were sporadic and were hospitalised. The Sanitary Inspection reported nine fatal cases – 6 women and 3 men. Thirty three cases were autochthonous including four cases linked with contaminated water systems in health-care settings. Six cases were associated with travels abroad (to Egypt, Albania, Italy and Crete). SUMMARY AND CONCLUSIONS. Although in recent years number of reported cases continues to rise, the incidence of legionellosis in Poland remains one of the lowest in the entire EU. Also draws attention variation of incidence between provinces and a high mortality among reported cases. Our data suggest significant under-diagnosis of legionellosis. A priority remains to improve early diagnosis of Legionnaires’ disease in health care settings.

Bacterial pneumonia caused by the inhalation of aerosols contaminated with Legionella spp. is also known as Legionnaires' disease. In this study, we report a case of pneumonia caused by Legionella pneumophila sg.1 in a 58-year-old man who visited a sea water-filled whirlpool within a hotel and spa complex. The patient's Legionella urine antigen test was positive for L. pneumophila sg.1. During the field study, samples were taken from both the outdoor and indoor sea water-filled pools. Samples from the whirlpool were culture positive for L. pneumophila sg.1. Typing results indicated sea water isolate belonged to Sequence type ST82 and Allentown/France MAb subgroup. In vitro experiments showed that L. pneumophila strains are able to survive within sea water up to 7 days, and survival time is prolonged with sea water dilution. Also, our results indicate that L. pneumophila Allentown strain was the most resistant to adverse conditions in sea water with the highest values of DT50 (420 min) and DT90 (1,396 min). The possible source of infection was adding potable water for filling up the whirlpool. The survival of the L. pneumophila in additionally conditioned sea water should be considered in a further study. HIGHLIGHTS Sea water in spa resorts may act as an environmental reservoir for Legionella spp.; Sea and brackish water are suitable media for the survival of the Legionella pneumophila.; In vitro experiments show that most Legionella spp. can survive in sea water up to 7 days.; L. pneumophila Allentown strain shows better survival ability in seawater compared to other strains.; The possible source of infection was filling up the whirlpool with potable water.

LegionellaDB is the first database on Legionella outbreaks; it is based on a metadata analysis of peer-reviewed manuscripts from PubMed and SCOPUS. LegionellaDB is dynamic and extensible, allowing users to search for specific outbreaks, suggest additional information to be included after curation, visualize statistical representations on specific outbreaks, and download selected data. The database is maintained online.

Background: Legionnaires' disease (LD) is a potentially fatal pneumonia predominantly caused by infection due to Legionella pneumophila although more than 50 other Legionella species are described. Water systems contaminated with Legionella spp. are the implicated sources of Legionnaires' disease. In this study, we aimed to assess Legionella contamination in the water sources of a tertiary care hospital and to determine the virulence properties and molecular characteristics of L. pneumophila environmental isolates.Methods: During May 2015 through August 2018, a total of 201 hospital water samples were tested for L. pneumophila by standardized culture procedures; environmental isolates were examined for the presence of two virulence genes: Legionella vir homolog (lvh) and repeats in structural toxin (rtxA) by PCR. The genotyping of isolates was performed by sequence-based typing (SBT) according to the protocol of the European Study Group for Legionella Infections (ESGLI).Results:L. pneumophila was isolated from 38/201 (18.9%) water samples; among the 46 isolates, the lvh locus was present in 45 (97.8%), the rtxA locus was found in 45 (97.8%), and both loci were found in 44 (95.7%) isolates. A total of 23 sequence types (STs) were identified among the 44 isolates (index of discrimination [IOD] of 0.929), and 11/23 (47.8%) STs were new to the ESGLI database.Conclusions: The study results showed genetic diversity in L. pneumophila isolates from the hospital environment along with a high percentage of pathogenicity loci. Besides, certain STs may have an increased ability to cause legionellosis, thus requires specific infection control and prevention strategies whenever identified.

Background: Legionnaires' disease (LD) is a potentially fatal pneumonia predominantly caused by infection due to Legionella pneumophila although more than 50 other Legionella species are described. Water systems contaminated with Legionella spp. are the implicated sources of Legionnaires' disease. In this study, we aimed to assess Legionella contamination in the water sources of a tertiary care hospital and to determine the virulence properties and molecular characteristics of L. pneumophila environmental isolates. Methods: During May 2015 through August 2018, a total of 201 hospital water samples were tested for L. pneumophila by standardized culture procedures; environmental isolates were examined for the presence of two virulence genes: Legionella vir homolog (lvh) and repeats in structural toxin (rtxA) by PCR. The genotyping of isolates was performed by sequence-based typing (SBT) according to the protocol of the European Study Group for Legionella Infections (ESGLI). Results: L. pneumophila was isolated from 38/201 (18.9%) water samples; among the 46 isolates, the lvh locus was present in 45 (97.8%), the rtxA locus was found in 45 (97.8%), and both loci were found in 44 (95.7%) isolates. A total of 23 sequence types (STs) were identified among the 44 isolates (index of discrimination [IOD] of 0.929), and 11/23 (47.8%) STs were new to the ESGLI database. Conclusions: The study results showed genetic diversity in L. pneumophila isolates from the hospital environment along with a high percentage of pathogenicity loci. Besides, certain STs may have an increased ability to cause legionellosis, thus requires specific infection control and prevention strategies whenever identified.

Sit Bath Systems (SBSs) are the most common hygiene method for patients who are not self-sufficient. Therefore, the water quality of SBSs in the nosocomial environment plays a fundamental role in controlling infections for both patients and health-care workers. A long-term study on Legionella and Pseudomonas aeruginosa (P. aeruginosa) contamination was performed in SBSs (n = 20) of six Health Care Facilities (HCFs). A total of 254 water samples were analyzed following ISO procedures. The samples were positive for P. aeruginosa (46.85%) and Legionella (53.54%), respectively, both over the directive limits. Legionella isolates were identified as: Legionella pneumophila (L. pneumophila) serogroups 1, 3, and 6 and Legionella non-pneumophila species (L. anisa, L. londiniensis, L. rubrilucens, and L. nagelii). Moreover, the contamination found was studied with respect to median temperature measured (42 °C), from which two groups (A and B) could be distinguished. P. aeruginosa was found in both groups (100% of SBSs), while a higher percentage of Legionella positive samples was found in group A (75% of SBSs), compared to group B (50% of SBSs), showing how Legionella control could be carried out by using temperatures above 42 °C. An analysis of SBS water pipelines, maintenance, and disinfection treatments indicates SBSs as a new source of infection risk for both patients and health-care workers.

Legionella is a ubiquitous pathogen yet the global occurrence of legionellosis is poorly understood. To address this deficit, this paper summarises the available evidence on the seroprevalence of Legionella antibodies and explores factors that may influence seroprevalence estimates. Through a systematic review, a total of 3979 studies were identified with seroprevalence results published after 1 January 1990. We tabulated findings by World Health Organization (WHO) region, location, study period and design, composition of study population(s) for all ages in terms of exposure, sex, detection methods, IFA titre, Legionella species measured, and present seroprevalence point estimates and 95% confidence intervals. Sampled populations were classified according to income, WHO region, gender, age, occupation and publication date. We conducted a meta-analysis on these subgroups using Comprehensive Meta-Analysis 3.0 software. Heterogeneity across studies was evaluated by the Q test in conjunction with I2 statistics. Publication bias was evaluated via funnel plot and Egger’s test. Fifty-seven studies met our inclusion criteria, giving an overall estimate of seroprevalence for Legionella of 13.7% (95% CI 11.3–16.5), but with substantial heterogeneity across studies.

And so, formed the basis for the song Legionnaires’ disease (LD) composed by the legendry musician Bob Dylan shortly after this mysterious illness dramatically entered the clinical and epidemiological scene in July 1976 at an American hotel. Now more than forty years have passed since Legionella pneumophila, the causative agent of LD, was formally identified in 1977. Once the publicity associated with the outbreak subsided, there was the challenge to science and health professionals of what was an extremely complex and intriguing health concern. In the United States, the outbreak investigation that eventually solved the mystery had taken an array of surprising twists and turns. Globally, it revealed the strengths and weakness of countries’ health systems in response to the outbreak from an unknown agent. Extensive international coverage of the outbreak also marked a turning point in journalism’s efforts to hold officials accountable for their response to epidemics that had the potential to threaten the lives of hundreds of people. In 1979, New Zealand became an active participant in the international efforts towards increasing the understanding of infection caused by Legionella species and set up a centralized laboratory diagnostic service. By 1980 LD had become a notifiable disease making New Zealand one of the first countries globally to do so. This historical narrative in the decade or so from its recognition, provides a unique insight into how the One Health paradigm was instrumental in New Zealand’s early response to LD in tandem with control strategies. The findings show that from 1979 the distribution of the Legionella species in New Zealand did not follow patterns observed in studies carried out globally.

Background Spa pools (SPs) pose risks of Legionella infection for users and bystanders. Methods We searched the National Enhanced Legionella Surveillance System for reported SP-associated legionellosis incidents in England between 2002 and 2018 involving at least two cases. Results For seven legionellosis SP-associated incidents, six were in commercial settings such as hotels. The median number of cases per outbreak was four (range 2–115). Conclusion SP-associated legionellosis incidents were mainly located in commercial settings with a wider range of cases than those recognised in previous publications, reinforcing the need for effective environmental controls for SPs in a range of settings.

Objective: The feasibility of the decontamination procedure for Legionella pneumophila of water systems in healthcare facilities varies by water purification and disinfection methods in each country. We evaluated the efficacy of feasible decontamination strategies in Japan. Methods: This study was conducted at Tokyo Medical University Hospital (1015 beds) between 2015 and 2018. Samples from the water system and cooling tower were cultured periodically. Hyper-chlorination of cool tap water (>0.2 ppm), increases in the temperature of hot water (>55 °C), and flushing were used as decontamination strategies. The case of healthcare-associated legionellosis was surveyed. Environmental and clinical isolates were genotyped. Results: 1439 environmental samples were collected; 19 (1.3%) samples tested positive for L. pneumophila from water faucets of patient rooms, toilets, waste rooms, and water sourced from wells. Genotyping of 12 isolates confirmed that the same strains were present in eight environmental isolates and two isolates from patients over three years. Although the environmental contamination of the water system was persistent, the number of positive locations of hospital environments gradually decreased; eight in 2015, four in 2016, three in 2017, and four in 2018, respectively. Conclusions: Monitoring contamination, hyper-chlorination, controlling temperature, and flushing were effective as a Legionella decontamination strategy. Keywords: Tap water, Legionellosis, Legionnaires’ disease, Infection control, Disinfectant, Decontamination

Type 1 secretion systems (T1SSs) are broadly distributed among bacteria and translocate effectors with diverse function across the bacterial cell membrane. Legionella pneumophila, the species most commonly associated with Legionellosis, encodes a T1SS at the lssXYZABD locus which is responsible for the secretion of the virulence factor RtxA. Many investigations have failed to detect lssD, the gene encoding the membrane fusion protein of the RtxA T1SS, in non-pneumophila Legionella, which has led to the assumption that this system is a virulence factor exclusively possessed by L. pneumophila. Here we discovered RtxA and its associated T1SS in a novel Legionella taurinensis strain, leading us to question whether this system may be more widespread than previously thought. Through a bioinformatic analysis of publicly available data, we classified and determined the distribution of four T1SSs including the RtxA T1SS and four novel T1SSs among diverse Legionella spp. The ABC transporter of the novel Legionella T1SS Legionella repeat protein secretion system shares structural similarity to those of diverse T1SS families, including the alkaline protease T1SS in Pseudomonas aeruginosa. The Legionella bacteriocin (1-3) secretion systems T1SSs are novel putative bacteriocin transporting T1SSs as their ABC transporters include C-39 peptidase domains in their N-terminal regions, with LB2SS and LB3SS likely constituting a nitrile hydratase leader peptide transport T1SSs. The LB1SS is more closely related to the colicin V T1SS in Escherichia coli. Of 45 Legionella spp. whole genomes examined, 19 (42%) were determined to possess lssB and lssD homologs. Of these 19, only 7 (37%) are known pathogens. There was no difference in the proportions of disease associated and non-disease associated species that possessed the RtxA T1SS (p = 0.4), contrary to the current consensus regarding the RtxA T1SS. These results draw into question the nature of RtxA and its T1SS as a singular virulence factor. Future studies should investigate mechanistic explanations for the association of RtxA with virulence.

Objectives Due to recent safety concerns regarding fluoroquinolones and the potential medical and economic benefits, we investigated the efficacy of a single intravenous dose of azithromycin 1.5 g for treatment of pulmonary legionellosis. Methods Using a nationwide legionellosis registry for preselection, 74 patients admitted form 2000-2018 at a tertiary care hospital due to pneumonia caused by Legionella pneumophila were retrospectively included in this study. Results Conventional regimes consisting of fluoroquinolones (n=20), macrolides (n=30) or combinations of both (n=24) and a single intravenous dose of azithromycin (n=12) have been demonstrated to be equally effective. Single-dose azithromycin treatment was well tolerated, resulted in a shorter hospital stay (p=0.0464) and a shorter antibiotic treatment duration (p=0.0004) allowing earlier discharge. Conclusion A single intravenous dose of azithromycin might be a valuable treatment alternative for patients with legionellosis.

Pneumonia is a disease with great relevance in public health, as a leading individual cause of infant mortality worldwide. Legionellosis is a respiratory disease with a bacterial origin and two different clinical forms.To determine pneumonia and legionellosis mortality in Spain.Time series study of pneumonia and legionellosis in Spain in two periods, from 1997 to 2001 and from 2011 to 2015. Mortality was calculated according to disease and sex, number of deaths and rates per 100,000 inhabitants.Pneumonia mortality in the first period shows a relatively stable and similar tendency according to sex, preferably affecting males. In the second period, pneumonia mortality increased significantly in recent years. Although pneumonia mortality in Spain decreased in both sexes in some age groups (especially5 years), it remained relatively stable in patients aged75 years. Deaths due to legionellosis were relevant in 1997, 1998 and 2000 and increased in the last period.A higher mortality due to pneumonia along the years was identified. Strategies to reduce the incidence and improve the diagnosis of pneumonia, especially in children and older people elderly, are encouraged.

BackgroundIn Norway, Legionnaires’ disease is reportable upon clinical suspicion to public health authorities and mandatorily notifiable through the Norwegian surveillance system for communicable diseases (MSIS) for both clinicians and laboratories. In the summer of 2017, several European countries reported high notification rates for Legionnaires’ disease, which was not observed in Norway. We evaluated MSIS to assess if it meets its objectives of detecting cases and trends in incidence of Legionnaires’ disease.MethodsWe retrieved MSIS data from 2008 to 2017 and calculated timeliness as days from sampling to notification, and internal completeness for key variables as the proportion of observations with a value. Where possible, we assessed internal validity on the presence of a plausible value. To estimate external completeness and validity we linked MSIS with hospital reimbursement claims in the Norwegian Patient Registry. To assess acceptability and representativeness, we surveyed doctors in 39 hospitals on their units’ diagnostic and notification procedures, and their use of MSIS.ResultsThere were 438 notified cases. Internal completeness and internal validity were high for key variables (≥95%). The median delay from sampling to notification was 4 days.There were 73 patients in MSIS only, 70 in the Norwegian Patient Registry only, and 351 in both registers. The external completeness of MSIS was 83% (95% CI 80–86%). For external validity, the positive predictive value of MSIS was 83% (95% CI 79–86%).Forty-seven respondents from 28 hospitals described testing procedures. These were inconsistent: 29 (62%) reported no systematic application of criteria for requesting legionella testing. Eighteen (38%) reported testing all patients with suspected pneumonia and a travel history. Thirty-one (66%) found the notification criteria clear.ConclusionsOur results suggest that the surveillance in MSIS can detect incidence changes for Legionnaires’ disease over time, by place and person, but likely does not detect every case diagnosed in Norway.We recommend wider investigation of diagnostic procedures in order to improve representativeness and awareness of MSIS notification criteria among clinicians in order to improve acceptability of the surveillance. We also recommend a more comprehensive assessment of whether patients only registered in the Norwegian Patient Registry were true Legionnaires’ disease cases.

The present review summarizes new knowledge about Legionella epidemiology, clinical characteristics, community-associated and hospital-based outbreaks, molecular typing and molecular epidemiology, prevention, and detection in environmental and clinical specimens.The incidence of Legionnaire's disease is rising and the mortality rate remains high, particularly for immunocompromised patients. Extracorporeal membrane oxygenation may help support patients with severe respiratory failure. Fluoroquinolones and macrolides appear to be equally efficacious for treating Legionnaires' disease. Whole genome sequencing is an important tool for determining the source for Legionella infections and for understanding routes of transmission and mechanisms by which new pathogenic clones emerge. Real-time quantitative polymerase chain reaction testing of respiratory specimens may improve our ability to diagnose Legionnaire's disease. The frequency of viable but nonculturable organisms is quite high in some water systems but their role in causing clinical disease has not been defined.Legionellosis remains an important public health threat. To prevent these infections, staff of municipalities and large buildings must implement effective water system management programs that reduce Legionella growth and transmission and all Medicare-certified healthcare facilities must have water management policies. In addition, we need better methods for detecting Legionella in water systems and in clinical specimens to improve prevention strategies and clinical diagnosis.

Two cases of Legionnaires’ disease and 1 of Pontiac fever occurred among the crew of a merchant ship operating off the shores of Australia. PCR assays identified potential sources in the ship’s cabins. Modification of maritime regulations for Legionnaires’ disease prevention in commercial vessels is needed for nonpassenger merchant ships.

A large outbreak of Legionnaires’ disease occurred at a California state prison in August 2015. We conducted environmental and epidemiological investigations to identify the most likely source of exposure and characterise morbidity. Sixty-four inmates had probable Legionnaires’ disease; 14 had laboratory-confirmed legionellosis. Thirteen (17%) inmates were hospitalised; there were no deaths. Ill inmates were more likely to be ⩾65 years old (P < 0.01), have the chronic obstructive pulmonary disease (P < 0.01), diabetes mellitus (P = 0.02), hepatitis C infection (P < 0.01), or end-stage liver disease (P < 0.01). The case-patients were in ten housing units throughout the prison grounds. All either resided in or were near the central clinical building (for appointments or yard time) during their incubation periods. Legionella pneumophila serogroup 1 was cultured from three cooling towers on top of the central medical clinic (range, 880–1200 cfu/ml). An inadequate water management program, dense biofilm within the cooling towers, and high ambient temperatures preceding the outbreak created an ideal environment for Legionella sp. proliferation. All state prisons were directed to develop local operating procedures for maintaining their cooling towers and the state health department added a review of the maintenance plans to their environmental inspection protocol.

Increasing numbers of legionellosis outbreaks within the last years have shown that Legionella are a growing challenge for public health. Molecular biological detection methods capable of rapidly identifying viable Legionella are important for the control of engineered water systems. The current gold standard based on culture methods takes up to 10 days to show positive results. For this reason, a flow-based chemiluminescence (CL) DNA microarray was developed that is able to quantify viable and non-viable Legionella spp. as well as Legionella pneumophila in one hour. An isothermal heterogeneous asymmetric recombinase polymerase amplification (haRPA) was carried out on flow-based CL DNA microarrays. Detection limits of 87 genomic units (GU) µL-1 and 26GUµL-1 for Legionella spp. and Legionella pneumophila, respectively, were achieved. In this work, it was shown for the first time that the combination of a propidium monoazide (PMA) treatment with haRPA, the so-called viability haRPA, is able to identify viable Legionella on DNA microarrays. Different proportions of viable and non-viable Legionella, shown with the example of L. pneumophila, ranging in a total concentration between 101 to 105GUµL-1 were analyzed on the microarray analysis platform MCR 3. Recovery values for viable Legionella spp. were found between 81% and 133%. With the combination of these two methods, there is a chance to replace culture-based methods in the future for the monitoring of engineered water systems like condensation recooling plants.

Legionella has a global distribution, mainly in aquatic and man-made environments. Under the right conditions, this bacterium is a notorious human pathogen responsible for severe pulmonary illnesses. Legionellosis outbreaks are reported around the world, and exposure to water droplet aerosols containing Legionella pneumophila is usually the mechanism of its transmission. Even if L. pneumophila causes most outbreaks, Legionella longbeachae also accounts for some cases. Unlike most other Legionella strains, L. longbeachae is typically found in soil. Given the wide diversity and high concentration of microorganisms found in soil, isolating L. longbeachae by culture can be challenging. Because the chances of successfully isolating the strain are low, it is often not even attempted. This study reports the strategies used to successfully isolate L. longbeachae strain that was responsible of the two occupational legionellosis in Quebec. Fifteen random samples were collected from the soil of the metal recycling plant where the diagnosed workers were employed, covering 1.5% of the accessible surface of the plant. All samples were analyzed with both the quantitative polymerase chain reaction (qPCR) and culture methods. Four qPCR detection systems targeting Legionella spp, L. pneumophila, L. pneumophila serogroup 1, and L. longbeachae were used. Acid, heat, and acid/heat treatments were used for the culture method. For the qPCR method, all samples were positives for Legionella spp but only four were positives for L. longbeachae. For the culture method, only one isolate could be confirmed to be L. longbeachae. However, that strain proves to be the same one that caused the occupational legionellosis. Detecting the presence of L. longbeachae using the qPCR method made it possible to target the right samples to enable the cultivable strain of L. longbeachae to be isolated from the soil of the metal recycling plant. The complementarity of the two methods was established. This paper demonstrated the advantages of selecting the proper sampling and analytical strategies to achieve the isolation of the strain responsible for the infections. It also highlights for the first time in Quebec the potential occupational risks associated with L. longbeachae from soil and should motivate questioning soil exposures when all sources of water contamination have been eliminated from the causal analysis of legionellosis.

Invasive pulmonary Aspergillus infection during or after severe influenza infection in an immunocompromised patient or a previously healthy person has been reported in the literature [1-2]. In addition, coinfections of Staphylococcus aureus or Streptococcus pneumoniae with influenza are common, whereas simultaneous infections of legionellosis with aspergillosis are unusual in patients with influenza [2]. We herein report a diabetic patient who presented with a community-acquired pneumonia (CAP). The initial sputum culture yielded Aspergillus species and S. aureus, which were coinfected with influenza A, Pneumococcus and Legionella, with a deteriorated fatal course. A 63-year-old man with diabetes mellitus felt general malaise and cough with sputum for 3 days. He was admitted to the intensive care unit (ICU) of the hospital on June 20, 2015 due to pneumonia with respiratory failure. There was no fever, diarrhea, headache, or skin rash. He denied travel and contact history. On examination, a blood pressure of 80/60 mmHg was noticed. The breath sounds revealed bilateral fine rales. Laboratory data included WBC 15,700/μL; band, 18%; CRP, 91.9 mg/L; BUN, 50 mg/dL; creatinine, 2.38 mg/dL; blood sugar, 221 mg/dL and HbA1C, 9.1%. The initial chest x-ray (CXR) film showed mild infiltration in perihilar area of left lung on June 20 (Figures 1A). The result of urinary Legionella Ag test was negative. Empirical antibiotic therapy included piperacillin-tazobactam and levofloxacin.