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BackgroundLegionnaires' disease is a respiratory illness often associated with hotels and travel. Spain is a major tourist destination and one of the European countries with most cases of Legionnaires' disease , both community- and travel-associated. However, the prevalence of Legionella in tourist facilities is unknown.AimThe present investigation aimed to survey the tourist facilities in the Balearic Islands, Spain, for Legionella prevalence.MethodsWe visited tourist facilities in the Balearic Islands in two different periods (2006-2010 and 2015-2018) and took water samples following national and international guidelines. Legionella was investigated by culture methods following international standards (ISO 11731:1998).ResultsWe evaluated 13,472 samples from 465 facilities. Bacteria of the Legionella genus were detected in 65.4% of the surveyed facilities. Contamination of the facilities was significantly higher during the second decade (54.5 vs 78.6%). The most frequent colonisers were L. pneumophila serogroup 2-14. We detected the pathogen in 15.9% and 6.9% of hot and cold water distribution systems samples, respectively. The Legionella contamination rate in cold water systems samples was higher when free chlorine levels were < 0.2 mg/L and at > 25 °C temperatures, while in the hot water systems samples, the contamination rate was higher at < 50 °C. Of the samples from hot tubs, 10.9% were contaminated.Conclusion Legionella prevalence in hotels in the Balearic Islands was high but the contamination rates depended on the installations. Corrective measures are still needed to improve Legionella control.

Sporadic Legionnaires' disease is frequently detected in commercial truck drivers. We report 2 sporadic cases of this disease in Barcelona, Spain, that occurred during December 2019 and September 2020. Laboratory findings were consistent with windshield wiper fluid without added screen wash as a possible source of infection for both cases.

Background: An explosive outbreak of Legionnaires' disease (LD) was identified on 11 December 2015 in Manzanares, Ciudad Real, Spain, and was declared closed by 03 February 2016. The number of declared cases was 593 with 277 confirmed cases so that it can be considered as one of the outbreaks with highest attack rate. This rate could be attributed to the ageing of the population, among others, in addition to various risk factors and habits, and the meteorological conditions (thermal inversion) maintained in this municipality at the time. The Public Health Services succeeded in breaking the bacterial transmission. Several facilities were early identified by microbiological analysis, including a cooling tower and a decorative fountain, as possible infectious sources. Rapid analytical techniques for rapid Legionella detection and the shutdown and preventative closure of positive installations have been considered key elements in the control of this outbreak., Results: Rapid microbiological analysis helped to the early identification of potential risk sources in a Legionnaires´ disease outbreak, reducing decision-making processes according to the actual needs of the intervention in public health and shortening the exposure of the population., Conclusions: Protocolized and immediate intervention in an outbreak is a crucial issue to reduce their effects on public health. For this, identification and control of the suspicious sources able to disseminate the bacteria and cause the illness is required. Rapid analytical techniques like immunomagnetic separation (IMS) method based on the whole bacterial cell detection are shown as excellent tools to investigate all the potential sources of risk.

Aim: To compare the discriminatory power of pulsed-field gel electrophoresis (PFGE) and sequence-based typing (SBT) in Legionella outbreaks for determining the infection source., Materials & Methods: Twenty-five investigations of Legionnaires' disease were analyzed by PFGE, SBT and Dresden monoclonal antibody., Results: The results suggested that monoclonal antibody could reduce the number of Legionella isolates to be characterized by molecular methods. The epidemiological concordance PFGE-SBT was 100%, while the molecular concordance was 64%. Adjusted Wallace index (AW) showed that PFGE has better discriminatory power than SBT (AWSBT→PFGE = 0.767; AWPFGE→SBT = 1). The discrepancies appeared mostly in sequence type (ST) 1, a worldwide distributed ST for which PFGE discriminated different profiles., Conclusion: SBT discriminatory power was not sufficient verifying the infection source, especially in worldwide distributed STs, which were classified into different PFGE patterns.

Legionella pneumophila is an accidental human pathogen associated with aerosol formation in water-related sources. High recombination rates make Legionella populations genetically diverse, and nearly 2,000 different sequence types (STs) have been described to date for this environmental pathogen. The spatial distribution of STs is extremely heterogeneous, with some variants being present worldwide and others being detected at only a local scale. Similarly, some STs have been associated with disease outbreaks, such as ST578 or ST23. Spain is among the European countries with the highest incidences of reported legionellosis cases, and specifically, Comunitat Valenciana (CV) is the second most affected area in the country. In this work, we aimed at studying the overall diversity of Legionella pneumophila populations found in the period from 1998 to 2013 in 79 localities encompassing 23 regions within CV. To do so, we performed sequence-based typing (SBT) on 1,088 L. pneumophila strains detected in the area from both environmental and clinical sources. A comparison with the genetic structuring detected in a global data set that included 20 European and 7 non-European countries was performed. Our results reveal a level of diversity in CV that can be considered representative of the diversity found in other countries worldwide., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Legionella pneumophila is a strictly environmental pathogen and the etiological agent of legionellosis. It is known that non-vertical processes have a major role in the short-term evolution of pathogens, but little is known about the relevance of these and other processes in environmental bacteria. We report the whole-genome sequencing of 69 L. pneumophila strains linked to recurrent outbreaks in a single location (Alcoy, Spain) over 11 years. We found some examples where the genome sequences of isolates of the same sequence type and outbreak did not cluster together and were more closely related to sequences from different outbreaks. Our analyses identify 16 recombination events responsible for almost 98% of the SNPs detected in the core genome and an apparent acceleration in the evolutionary rate. These results have profound implications for the understanding of microbial populations and for public health interventions in Legionella outbreak investigations.

An outbreak of Legionnaires' disease with 113 confirmed cases was reported in the town of Mataró, Spain, in August 2002. In this study, we compared three different typing methods and characterized the clinical isolates by comparing them with other clinical isolates with the same ST from our own database to further characterize the outbreak. In the outbreak, a total of 16 clinical (nine patients) and 32 environmental (from four environmental sources) Legionella pneumophila isolates were analyzed by pulsed-field electrophoresis (PFGE), sequence-based typing (SBT), and monoclonal antibody typing (MAb). We compared the MAb and SBT profiles of the outbreak clinical isolates and other unrelated clinical isolates showing the same ST profile. We obtained seven different PFGE and SBT profiles and six MAb patterns from the outbreak isolates. PFGE and SBT showed 100% concordance during the outbreak. SBT proved to be highly discriminatory, particularly with the addition of the new neuA gene. One PFGE, SBT (ST-37), and Philadelphia profile was observed among the clinical isolates. Using PFGE, this ST37 Philadelphia profile was closely related to other unrelated clinical isolates. These findings suggest that the ST37 Philadelphia profile could be a virulence marker in our area. The combination of the three methodologies was useful to further characterize and obtain additional information on a very explosive outbreak. Despite the minor discrimination of PFGE versus SBT, the two genetic methods are recommended in outbreak investigations. Further studies are currently underway in this area to obtain more definitive conclusions.

Legionella pneumophila has been increasingly recognized as a cause of community-acquired pneumonia (CAP) and an important public health problem worldwide. We conducted the present study to assess trends in epidemiology, diagnosis, clinical features, treatment, and outcomes of sporadic community-acquired L. pneumophila pneumonia requiring hospitalization at a university hospital over a 15-year period (1995-2010). Among 3934 nonimmunosuppressed hospitalized patients with CAP, 214 (5.4%) had L. pneumophila pneumonia (16 cases were categorized as travel-associated pneumonia, and 21 were part of small clusters). Since the introduction of the urinary antigen test, the diagnosis of L. pneumophila using this method remained stable over the years (p = 0.42); however, diagnosis by means of seroconversion and culture decreased (p < 0.001 and p = 0.001, respectively). The median age of patients with L. pneumophila pneumonia was 58.2 years (SD 13.8), and 76.4% were male. At least 1 comorbid condition was present in 119 (55.6%) patients with L. pneumophila pneumonia, mainly chronic heart disease, diabetes mellitus, and chronic pulmonary disease. The frequency of older patients (aged >65 yr) and comorbidities among patients with L. pneumophila pneumonia increased over the years (p = 0.06 and p = 0.02, respectively). In addition, 100 (46.9%) patients were classified into high-risk classes according to the Pneumonia Severity Index (groups IV-V). Twenty-four (11.2%) patients with L. pneumophila pneumonia received inappropriate empirical antibiotic therapy at hospital admission. Compared with patients who received appropriate empirical antibiotic, patients who received inappropriate therapy more frequently had acute onset of illness (p = 0.004), pleuritic chest pain (p = 0.03), and pleural effusion (p = 0.05). The number of patients who received macrolides decreased over the study period (p < 0.001), whereas the number of patients who received levofloxacin increased (p < 0.001). No significant difference was found in the outcomes between patients who received erythromycin and clarithromycin. However, compared with macrolide use during hospital admission, levofloxacin therapy was associated with a trend toward a shorter time to reach clinical stability (median, 3 vs. 5 d; p = 0.09) and a shorter length of hospital stay (median, 7 vs. 10 d; p < 0.001). Regarding outcomes, 38 (17.8%) patients required intensive care unit (ICU) admission, and the inhospital case-fatality rate was 6.1% (13 of 214 patients). The frequency of ICU admission (p = 0.34) and the need for mechanical ventilation (p = 0.57) remained stable over the study period, but the inhospital case-fatality rate decreased (p = 0.04). In the logistic regression analysis, independent factors associated with severe disease (ICU admission and death) were current/former smoker (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.01-8.62), macrolide use (OR, 2.40; 95% CI, 1.03-5.56), initial inappropriate therapy (OR, 2.97; 95% CI, 1.01-8.74), and high-risk Pneumonia Severity Index classes (OR, 9.1; 95% CI, 3.52-23.4). In conclusion, L. pneumophila is a relatively frequent causative pathogen among hospitalized patients with CAP and is associated with high morbidity. The annual number of L. pneumophila cases remained stable over the study period. In recent years, there have been significant changes in diagnosis and treatment, and the inhospital case-fatality rate of L. pneumophila pneumonia has decreased.

Research is ongoing on eighteen cases of Legionellosis, including four deaths, identified among tourists and employees in a hotel in Calp, Spain. Cases occurred during a period of two months, indicating the possibility of a point-source transmission at the hotel. An environmental investigation identified several positive samples in the hotel, which as a precautionary measure, was closed until requested improvements were made. Surveillance measures currently remain active.

Objectives: To analyze the spatial pattern of legionellosis in Spain for men and women during the period 2003-2007 and to identify spatial clustering of risk., Methods: We identified the spatial pattern of the distribution of legionellosis rates based on calculation of rates by municipality through the direct method. Smoothing of these rates was performed by the Empirical Bayes method for studying the spatial pattern of disease for both sexes. We used Morańs index to analyze spatial autocorrelation rates globally. To calculate local rates, the Local Moran's Index [known as local indicators of spatial association (LISA)], was used to analyze the clusters of municipalities with the highest risk., Results: After smoothing the risk, the highest rates (over 50 per 100,000 inhabitants) were grouped in the eastern Mediterranean coastal areas and the north of the mainland, as well as in the Mediterranean islands. Moran's index smoothed rates were 0.15 for men and 0.23 for women. The spatial clusters of statistically significant higher rates calculated by the LISA index were distributed in the north and east for both sexes., Conclusions: These methods of spatial analysis allow patterns of disease distribution to be identified. All the methods used yielded similar results. These techniques are a complementary tool for epidemiological surveillance of infectious diseases., (Copyright © 2010 SESPAS. Published by Elsevier Espana. All rights reserved.)

An outbreak of Legionnaires' disease affected 12 customers of a supermarket in a town in Catalonia, Spain, between August and November 2006. An epidemiological and environmental investigation was undertaken. Preliminary investigation showed that all patients had visited the same supermarket in this town where a mist machine was found in the fish section. Water samples were collected from the machine and from the supermarket's water distribution system when high-risk samples were excluded. Environmental samples from the mist machine and clinical samples from two patients tested positive for L. pneumophila serogroup 1 and had the same molecular pattern. The PFGE pattern detected in the clinical and mist-machine isolates had never previously been identified in Catalonia prior to the outbreak and has not been identified since. Four days after turning off the machine, new cases ceased appearing. Molecular study supports the hypothesis that the mist machine from the fish section of the supermarket was the source of infection. We believe it is essential to include exposure to mist machines in any legionellosis epidemiological survey.

From 1999 through 2005 in Alcoi, Spain, incidence of legionellosis was continually high. Over the next 4 years, incidence was lower, but an increase in July 2009 led health authorities to declare an epidemic outbreak. A molecular epidemiology investigation showed that the allelic profiles for all Legionella pneumophila samples from the 2009 outbreak patients were the same, thus pointing to a common genetic origin for their infections, and that they were identical to that of the organism that had caused the previous outbreaks. Spatial-temporal and sequence-based typing analyses indicated a milling machine used in street asphalt repaving and its water tank as the most likely sources. As opposed to other machines used for street cleaning, the responsible milling machine used water from a natural spring. When the operation of this machine was prohibited and cleaning measures were adopted, infections ceased.

Objectives: To describe the characteristics of community outbreaks of legionellosis in Catalonia, Spain from 1990 to 2004, to compare two time periods (1990-1996 and 1997-2004), and to assess the influence of outbreak characteristics on the case fatality rate (CFR)., Methods: This is a descriptive analysis of the outbreaks detected by epidemiological surveillance units in Catalonia. Variables potentially related to the CFR were analyzed by logistic regression., Results: Of the 118 outbreaks involving 690 patients (overall CFR 4.5%), the urinary antigen test (UAT) was used for first case diagnosis in 80.5%. The origin of the outbreak was identified as a cooling tower in 35.6%, as a water distribution system in a public building in 14.4%, and a water distribution system at other sites in 7.6%. Statistically significant differences were found in the CFR (12.2% vs. 3.9%; p=0.018) and detection of the first case by UAT (0.0% vs. 87.2%; p<0.001) between the two time periods investigated. Logistic regression showed an increase in the CFR according to outbreak size (adjusted odds ratio (aOR) 1.18; 95% confidence interval (CI) 1.05-1.33) that was significantly lower in the second period (aOR 0.09; 95% CI 0.04-0.20)., Conclusions: Since the UAT was introduced, early diagnosis and treatment has helped to improve the outcomes and CFR of cases involved in outbreaks of legionellosis.

We report the investigation of a community-acquired outbreak of Legionnaires' disease. An epidemiological, environmental, and meteorological investigation was undertaken. Fifty-five cases were reported in October and November 2005. The exposure occurred in a large area, with 12 cases (21.8%) located between 1,800 and 3,400 metres from the source. Water sample cultures showed that Legionella pneumophila serogroup 1 (Lp-1) was present in five cooling towers in two industrial locations in Gurb (plants A and B). Two Lp-1 strains were recovered from plants A and B, but only Lp-1 strains from plant A showed a pulsed-field gel electrophoresis (PFGE) profile identical to those obtained from three of the cases. Inspection of the cooling towers in plant A revealed inadequate maintenance. Weather conditions in October 2005, with mostly high temperatures and high humidity, together with the flat terrain could have been favouring factors. This study showed a community outbreak from a cooling tower as a common source in a large area. Climate and terrain could explain the dissemination of contaminated aerosols.

We identified 14 cases of Legionnaires' disease occurring in 2946 solid organ transplant recipients from 1985 to 2007. Most cases were sporadic and community acquired. The recent introduction of the urinary antigen test has accelerated diagnosis and allows prompt institution of adequate therapy. The overall mortality rate in our series was 14.3%.

Objectives: Despite a recent decrease, bacterial pneumonia (BP) is still the most common admission diagnosis in HIV patients. We analyse BP incidence, characteristics and prevention measures., Methods: Observational study of all patients hospitalized for BP in a tertiary hospital in Barcelona, Spain, from January 2000 to December 2005. Demographic and HIV-related data, BP risk factors, characteristics of BP and outcomes are analysed., Results: One hundred and eighty-six BP episodes in 161 patients were included; patients were mainly male (73.7%) and intravenous drug users (73.7%). A decrease in BP incidence was seen during the study period, especially in vaccinated patients. The most commonly isolated microorganism was Streptococcus pneumoniae (31.7%), followed by Legionella pneumophila (5.9%). Legionella pneumophila was more likely in patients with undetectable viral load, higher CD4 cell counts or prior vaccination. Highly active antiretroviral therapy, cotrimoxazole prophylaxis and pneumococcal vaccination did not have a significant influence on bacteraemia rate, in-hospital complications or BP mortality. High Pneumonia Severity Index (PSI) predicted mortality accurately [relative risk 15.2, 95% confidence interval 3.2-71.7; P=0.001]. Mortality was 9.1%, but was significantly higher in patients with CD4 counts under 200 cells/microL (P=0.022)., Conclusions: A decline in BP incidence was seen during the study period. Combining CD4 cell count and PSI score could become a good strategy in deciding which patients have to be hospitalized.

An outbreak of Legionnaire's disease was detected in Pamplona, Spain, on 1 June 2006. Patients with pneumonia were tested to detect Legionella pneumophila antigen in urine (Binax Now; Binax Inc., Scarborough, ME, USA), and all 146 confirmed cases were interviewed. The outbreak was related to district 2 (22 012 inhabitants), where 45% of the cases lived and 50% had visited; 5% lived in neighbouring districts. The highest incidence was found in the resident population of district 2 (3/1000 inhabitants), section 2 (14/1000). All 31 cooling towers of district 2 were analysed. L. pneumophila antigen (Binax Now) was detected in four towers, which were closed on 2 June. Only the strain isolated in a tower situated in section 2 of district 2 matched all five clinical isolates, as assessed by mAb and two genotyping methods, AFLP and PFGE. Eight days after closing the towers, new cases ceased appearing. Early detection and rapid coordinated medical and environmental actions permitted immediate control of the outbreak and probably contributed to the null case fatality.

Background: Cases of legionellosis sometimes arise in the form of aggregations which are difficult to interpret. This study provides an analysis of these groupings having arisen one summer in Castellon., Methods: Microbiological, clinical and epidemiological field methods were employed., Results: Within a few days, there were five (5) cases of legionella pneumonia in workers related to various ceramic industries within an area where a large number of these plants are located. Two constituted a minor outbreak. By means of molecular biology techniques performed on the strains, the common origins of three of the cases were ruled out., Conclusions: It is debated whether this episode of an outbreak having arisen within the context of a broader-ranging cluster of cases of a multi-focal origin was a chance event or whether it was the manifestation of a risk related to this industrial activity which might repeat itself.

Objective: Description of an outbreak of legionnaires' disease originating in one of the cooling towers of a hospital., Patients and Methods: This study included patients with confirmed pneumonia caused by Legionella pneumophila serogroup 1 and related to the Vallcarca neighborhood of Barcelona (Spain) in August 2004. Exposure was determined by a standardized questionnaire. An environmental investigation was carried out to identify the source of the outbreak. A descriptive analysis including incidence rates estimation was performed, as well as molecular study to document the genetic identity among human and environmental strains., Results: Thirty-three cases of L. pneumophila pneumonia were detected. Median age was 68 years and 70% of the affected patients were men. Incidence rate among residents in less than 200 meters of the source and older than 65 was 888.9 cases/100,000 inhabitants. Lethality rate was 6%. Four seasonal cooling towers that were not registered with the authorities were identified in a health care center. L. pneumophila was isolated from all four and at least one colony in each tower had the same genetic profile as the strains isolated from patients., Conclusions: An association was demonstrated between a community outbreak of legionellosis and unregistered seasonal cooling towers located in a hospital. All risk facilities should be registered and inspected to ensure that they fulfill current legislation requirements.

For several years, over 50% of the cases of travel-associated Legionnaires' disease (TALD) reported to the European Working Group for Legionella Infections (EWGLINET) have been among travellers to France, Italy, and Spain. We describe clusters of TALD cases reported in these countries during a four-year period. We analysed data from EWGLINET and from the individual countries. In all three countries, upon notification of a cluster, local health authorities are alerted by the national collaborator and immediately begin an environmental investigation at the accommodation site, which includes risk assessments and analysis of water samples. From July 1, 2002 to June 30, 2006, 2,101 accommodation sites were associated with TALD cases and reported by EWGLINET to Italian, Spanish and French collaborators. Of these, 252 sites (12%) were associated with clusters: 13.8% (96/697) in Italy, 13.2% (81/615) in Spain and 9.5% (75/789) in France. Overall, 641 cases were reported. Hotels, camping sites and ships and other sites represented respectively 83%, 10% and 7% of the total accommodation sites, with similar proportions in the three countries. In 99% of the sites, samples were collected; 62% of them were found to be positive for Legionella. The findings of this study highlight that disinfection and long-term preventive measures were correctly implemented by the large majority of sites. However, additional efforts must be made to further reduce the percentage of re-offending sites so as to reduce the number of accommodations that are contaminated by Legionella.

This report describes an outbreak of Legionnaires' disease in severely immunosuppressed patients hospitalised at a cancer centre. Universal urine antigen testing and early levofloxacin therapy appeared to lower case fatality rates in comparison with previous reports concerning this high-risk population. This diagnostic and therapeutic strategy should be considered when facing a nosocomial outbreak of Legionnaires' disease in immunosuppressed hosts.

This paper reports the investigation of a community-acquired outbreak of Legionnaires' disease in the municipalities of Vic and Gurb (Central Region of Catalonia, Spain). There were 55 cases reported in October and November 2005. An epidemiological and environmental investigation was undertaken. Thirty-five case patients (64%) lived in Vic or Gurb, while 36% had visited or worked in Vic or Gurb during the 10 days before onset of symptoms, but no commonly frequented building could be identified. Water probes for culture were obtained from 30 cooling towers. In five cooling towers of two industrial settings in Gurb (plants A and B), Legionella pneumophila (Lp) serogroup 1 was present. Two Lp-1 strains were recovered from cooling towers in plants A and B. The Lp-1 strain from plant A showed a PGFE profile identical with those obtained from three patients. The exposure to Legionella pneumophila apparently occurred in a large area, since 43 of the 55 cases lived, visited or worked within a distance of 1,800 m from plant A, and six cases in a distance between 2,500 and 3,400 m. The inspections of cooling towers in plant A revealed inadequate disinfectant doses of biocide, non-existent maintenance records on weekends and wrong sample points for routine microbial check-ups. Weather conditions in October 2005 template temperature and high humidity (wind conditions are unappreciable) could have been favourable factors in this outbreak together with the flat terrain of Gurb and Vic area, explaining the extensive horizontal airborne dissemination of contaminated aerosols. The outbreak could have been prevented by proper and correct maintenance of the cooling tower at plant A.

Objectives: To compare the risk factors, clinical and laboratory features, and outcome of community-acquired pneumonia (CAP) caused by Legionella pneumophila in elderly (aged > or =65) and younger patients., Design: Prospective enrollment of subjects with retrospective data analysis., Setting: A 630-bed tertiary center in Badalona (Barcelona), Spain., Participants: A total of 158 patients diagnosed with CAP caused by L. pneumophila from 1994 to 2004: 104 younger than 65 and 54 aged 65 and older., Measurements: Epidemiological, clinical, laboratory, and radiological data and the outcome of the two groups were compared using univariate and multivariate analysis., Results: Underlying diseases, such as chronic pulmonary diseases, diabetes mellitus, neuromuscular diseases, and heart failure; risk of aspiration; and therapy with corticosteroids were significantly more frequent in patients aged 65 and older. Patients younger than 65 were more likely to be male and have toxic habits (cigarette smoking, alcoholism) and human immunodeficiency virus infection than older patients. Fever, nonrespiratory symptoms (diarrhea and headache), and some laboratory abnormalities (hyponatremia (serum sodium concentration <130 mmol/L) and high aspartate aminotransferase and creatinine kinase levels) were significantly less frequent in patients aged 65 and older than in younger patients. No significant differences were observed between the two groups in the frequency of higher-severity risk classes and intensive care unit admission or in outcome (complications and mortality)., Conclusion: Elderly patients with CAP caused by L. pneumophila had a higher frequency of underlying comorbidities and presented less frequently with fever and classical nonrespiratory symptoms and laboratory abnormalities of Legionnaires' disease than younger patients, although greater severity of illness at onset and higher mortality were not significantly different between the two age groups.

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2) <7.98 KPa (60 mmHg) were also more frequent in sporadic cases, while headache prevailed in outbreak cases. Sporadic cases had a greater delay in treatment, were more severe and had a worse outcome than epidemic cases. Multivariate analysis showed significant differences in sex, chronic lung disease, HIV infection and headache. The clinical and outcome differences between the two groups may be explained by the detection of milder forms of legionnaires' disease, the earlier treatment and the lower severity of underlying disease in the outbreak cases.

We evaluated the effectiveness and safety of rifampicin addition to clarithromycin in the treatment of Legionnaires' disease. An observational cohort study was conducted on patients assigned to a Legionnaires' disease outbreak. Of 32 patients with confirmed Legionella pneumonia, 11 received clarithromycin monotherapy and 21 received combination therapy of clarithromycin with rifampicin. Both groups had similar baseline characteristics and all patients were cured. Patients who received rifampicin had a 50% longer length of stay (P=0.035) and a trend towards higher bilirubin levels (P=0.053). Length of stay was directly correlated with the duration of rifampicin treatment (P=0.001). Combination therapy of clarithromycin and rifampicin had no additional benefit compared with clarithromycin monotherapy and could prolong the length of stay owing to possible negative drug interactions that could also affect other antibiotics.

Legionella pneumophila has been recognized as an important cause of community- and hospital-acquired pneumonia. This study evaluates the interrelationship between that patients group with Legionnaires disease (LD) and the possible factors that may predispose hosts to acquire this infection. Likewise, we search for preliminary biochemical and immunologic evidences that could help physicians to differentiate between LD and other pneumonias. We analyzed biochemical parameters and immunoglobulin levels in 61 LD patients and a control group (n = 30) who were non-Legionella pneumonia diagnosed. We observed statistically significant differences in LD patients versus control group in serum sodium, albumin, gamma-band, IgG levels, (P < .01) and for total proteins, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) (P < .05). Our study shows a trend between the presence of LD and immunoglobulin deficiencies in the group studied. Deficit in IgG or IgG plus IgM, during the exposure period, may predispose individuals to suffer legionellosis (P < .05). Overall, hypoalbuminemia, hyponatremia, and high AST and LDH levels can represent a useful prognostic marker in patients with severe pulmonary infection suspected to be legionellosis.

Much data has been gathered by the EWGLINET scheme on the distribution of cases of travel-associated Legionnaires' disease (TALD) by country of infection, but less analysis has been carried out on the distribution of these cases within countries. Travel-associated cases with onset in 2002 linked to France, Italy, Spain and Turkey were mapped. Rates of Legionnaires' disease per 100,000 tourists were calculated for internal and foreign visitors for the regions of each country, and mapped. Rates of 1.5 cases/100,000 and 2 cases/100,000 tourists were classified as 'high' and 'very high' respectively. Cases of TALD were concentrated in certain regions, but when rates were calculated using tourist data, the results were relatively constant throughout each country. Rates were higher among foreign visitors than internal visitors; three of the countries had at least one region with 'high' rates, whilst Turkey additionally had three regions with 'very high' rates.

A community outbreak of Legionella pneumonia in the district of Cerdanyola, Mataró (Catalonia, Spain) was investigated in an epidemiological, environmental and molecular study. Each patient was interviewed to ascertain personal risk-factors and the clinical and epidemiological data. Isolates of Legionella from patients and water samples were subtyped by pulsed-field gel electrophoresis. Between 7 August and 25 August 2002, 113 cases of Legionella pneumonia fulfilling the outbreak case definition criteria were reported, with 84 (74%) cases being located within a 500-m radius of the suspected cooling tower source. In this area, the relative risk of being infected was 54.6 (95% CI 25.3-118.1) compared with individuals living far from the cooling tower. Considering the population residing in the Cerdanyola district (28,256 inhabitants) as a reference population, the attack rate for the outbreak was 399.9 cases/100,000 inhabitants, and the case fatality rate was 1.8%. A single DNA subtype was observed among the ten clinical isolates, and one of the subtypes from the cooling tower matched exactly with the clinical subtype. Nine days after closing the cooling tower, new cases of pneumonia caused by Legionella ceased to appear. The epidemiological features of the outbreak, and the microbiological and molecular investigations, implicated the cooling tower as the source of infection.

Background and Objective: To describe an outbreak of Legionella pneumophila serogroup 1 in Mataró, Catalunya, Spain, in August 2002. The source of the microorganism was a cooling tower., Patients and Method: Prospective and observational study with analysis of epidemiological, clinical, and microbiological data., Results: 151 patients were affected (62% male), with a mean age of 58.4 years old. Seven patients were classified as Pontiac Fever and 144 suffered from pneumonia. The diagnosis of pneumonia was confirmed in 79% of cases, was considered suspicious in 14% and probable in 7%. Forty per cent of patients were smokers and 53.5% had comorbidities, mainly diabetes mellitus (22%). Chief symptoms were fever (97%), chills and muscular pain (63% respectively), headache (54%) and cough (53%). Pulmonary condensation was the more frequent radiological feature (71%). Normal pulmonary exploration was observed in 38%. Forty-three per cent of cases were severely ill, and 16% of patients belonged to Fine's IV and V class. Antigenuria was the most important test for diagnosis, which confirmed 76% of cases. Legionella spp. was obtained in respiratory secretions of 10 patients. Molecular analysis confirmed clonality between respiratory microorganisms and that obtained in the cooling tower., Conclusion: The outbreak involved an important number of subjects in a short period of time. Antigenuria was the most useful test. However, the isolation of L. pneumophila from patients permitted the prompt identification of microorganism's source in a cooling tower. The low mortality observed probably relates to a rapid diagnosis and its target treatment.

Objective: To determine whether environmental cultures for Legionella increase the index of suspicion for legionnaires' disease (LD)., Design: Five-year prospective study., Setting: Twenty hospitals in Catalonia, Spain., Methods: From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested for Legionella. Cases of hospital-acquired LD and availability of an "in-house" Legionella test in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing., Results: Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and used Legionella tests including Legionella urinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals, Legionella tests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) used Legionella urinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD., Conclusions: The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using the Legionella urinary antigen test in their laboratories.

Objective: To describe the health resources used in patients hospitalized with Legionella pneumonia during an outbreak of Legionnaire's disease in Alcoy (Spain), and to compare them with those used in other forms of pneumonia., Methods and Results: Using a clinical protocol, 177 Legionella pneumonia patients were compared with 180 patients hospitalized for other types of pneumonia. Data on therapy and the resources used were collected. The most common antibiotic treatment in both groups was clarithromycin, but intensive care and mechanical ventilation requirements were greater in Legionella pneumonia. Home-based hospital care was successfully used in 15.6% of patients with Legionella pneumonia and in 11.3% of those with other types of pneumonia. Home oxygen therapy after discharge was less frequent in the Legionella pneumonia group (7.8%) than in the group with non-Legionella pneumonia (16.7%)., Conclusions: Notable results were the greater requirement for mechanical ventilation in Legionella pneumonia and the good results obtained by home-based hospital care within current health care management.

Objective: Clinical and microbiological descriptive analysis of the outbreak of community legionnaire's disease recorded in the Barcelona's Barcelonesa neighborhood in November 2000., Patients and Methods: Retrospective review of the epidemiological and clinical manifestations, as well as the evolution of the cases of Legionella pneumophila pneumonia associated with the outbreak and cared of in the Hospital del Mar., Results: The 48 patients evaluated, all of them with confirmed diagnoses, represent 89% of the cases communicated. Seventy-five percent of patients showed some underlying disease, 54% had some criterion for severity, and mortality was 4%. In 81% of cases the detection of the antigen of Legionella pneumophila in urine was the diagnostic method., Conclusions: The detection in urine of the Legionella pneumophila antigen makes possible the early diagnosis of legionnaire's disease, particularly in epidemic outbreaks, which that facilitates the fast establishment of the adequate treatment and contributes to the reduction in mortality even in patients of high risk.

Epidemiological surveillance and control of travel associated cases of legionnaires' disease are necessary tasks for public health and collaboration between countries is necessary to do this. Within the framework of the European Surveillance Scheme for Travel Associated Legionnaires' Disease (EWGLINET), European Guidelines for Control and Prevention of Travel Associated Legionnaires' Disease have been produced . This has established the reporting and response criteria when cases or clusters appear. In this paper the analysis of the information corresponding to the 46 reported clusters related to Spain is presented. Data corresponds to the period January 2001 to July 2003.

The objective of this study was to compare epidemiological data and clinical presentation of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae, Legionella pneumophila or Chlamydia pneumoniae. From May 1994 to February 1996, 157 patients with S. pneumoniae (n = 68), L. pneumophila (n = 48) and C. pneumoniae (n = 41) pneumonia with definitive diagnosis, were prospectively studied. The following comparisons showed differences at a level of at least p < 0.05. Patients with S. pneumoniae pneumonia had more frequently underlying diseases (HIV infection and neoplasm) and those with C. pneumoniae pneumonia were older and had a higher frequency of chronic obstructive pulmonary disease (COPD), while L. pneumophila pneumonia prevailed in patients without comorbidity, but with alcohol intake. Presentation with cough and expectoration were significantly more frequent in patients with S. pneumoniae or C. pneumoniae pneumonia, while headache, diarrhoea and no response to betalactam antibiotics prevailed in L. pneumophila pneumonia. However, duration of symptoms > or = 7 d was more frequent in C. pneumoniae pneumonia. Patients with CAP caused by L. pneumophila presented hyponatraemia and an increase in CK more frequently, while AST elevation prevailed in L. pneumophila and C. pneumoniae pneumonia. In conclusion, some risk factors and clinical characteristics of patients with CAP may help to broaden empirical therapy against atypical pathogens until rapid diagnostic tests are available.

Introduction: Legionella pneumophila is the causal agent of 5% to 12% of sporadic community-acquired pneumonia cases, though rates are changing with the use of new diagnostic methods., Methods: This is a retrospective study of all patients admitted to our hospital with community-acquired pneumonia due to Legionella pneumophila between 1997 and 2001. Diagnostic criteria included either a positive Legionella serogroup 1 urinary antigen test or seroconversion and a chest radiograph consistent with pneumonia., Results: A total of 97 patients were studied. Ninety cases (92.8%) were community-acquired and 7 (7.2%) were associated with travelling. In 82 cases (84.5%) the presentation was sporadic. Seventy-five patients were smokers (77.3%). The most common symptoms were fever in 91 patients (93.8%) and cough in 67 (68.1%). In five patients (5.2%) creatine phosphokinase concentrations were over 5 times their baseline values (in two over 100 times); four of these patients presented acute renal failure. Seroconversion was observed in 23/42 patients (54.8%). There were no statistically significant differences between the administration of erythromycin or clarithromycin in monotherapy, or in combination with rifampin. Nineteen patients (19.6%) presented acute renal failure and mechanical ventilation was necessary in 22 (22.7%). Twelve patients died (12.5%). Independent prognostic factors associated with death included respiratory rate > 30 breaths/min, urea > 60 mg/dL and PaO2 < 60 mmHg. A significant linear association was found between severity scale scores and the presence of complications or mortality., Conclusion: The Legionella urinary antigen test permits early diagnosis and treatment of this disease. The severity scale is an indicator of complications or death.

An explosive outbreak of Legionnaires' disease occurred in Murcia, Spain, in July 2001. More than 800 suspected cases were reported; 449 these cases were confirmed, which made this the world's largest outbreak of the disease reported to date. Dates of onset for confirmed cases ranged from June 26 to July 19, with a case-fatality rate of 1%. The epidemic curve and geographic pattern from the 600 competed epidemiologic questionnaires indicated an outdoor point-source exposure in the northern part of the city. A case-control study matching 85 patients living outside the city of Murcia with two controls each was undertaken to identify to outbreak source; the epidemiologic investigation implicated the cooling towers at a city hospital. An environmental isolate from these towers with an identical molecular pattern as the clinical isolates was subsequently identified and supported that epidemiologic conclusion.

The European Surveillance Scheme for Travel Associated Legionnaires' Disease (EWGLINET) was notified of 360 cases in 2000 and 481 cases in 2001, the highest number reported since 1987. This increase reflects enhanced surveillance activities, especially in the Netherlands, France and Italy, mainly through urinary antigen detection test (78% of cases in 2001). The median delay in reporting to the scheme fell to under 30 days, at the cost of some loss of information on the outcomes of illness. In 2000, 28 clusters were detected compared to 72 in 2001, most of this rise resulting from a change in the definition of clusters. In 2000 and 2001, 55 and 140 environmental investigations were reported respectively.

The aim of this study was to identify the clinical features of Legionnaires' disease, sudden outbreaks of which demand a quick and flexible clinical approach, particularly with regard to diagnosis and therapy. A prospective and comparative study based on a clinical protocol was performed during an outbreak of Legionnaires' disease in Alcoy, Spain. The outbreak was environmental in origin, linked to cooling towers. Data about epidemiological and clinical features, blood chemistry values, radiological and microbiological findings, and characteristics related to the clinical course of Legionnaires' disease were obtained for 357 patients admitted to hospital with community-acquired pneumonia (177 with Legionella pneumonia). Patients with Legionnaires' disease were younger (mean age, 65.3+/-16.5 years) and more likely to be smokers compared with patients with other types of pneumonia (28.8% vs. 11.1%; P<0.01). Moreover, they had not been admitted to any hospital because of pneumonia in the previous year. Patients with Legionnaires' disease had higher fever, more severe headache, and less expectoration as well as lower sodium blood levels (mean, 132.6+/-4.8 mmol/l vs. 135.7 mmol/l; P<0.01). Radiological studies also showed that fewer patients with Legionnaires' disease had pleural effusion (9% vs. 19.4% of those with non- Legionella pneumonia). The presence of headache, high fever, hyponatremia, scanty or null expectoration, and current cigarette smoking provides physicians with important clues for a high suspicion of Legionella pneumonia before the results of confirmatory laboratory tests are available.

As part of a case-control study of community-acquired Legionnaires' disease, several factors related to residential water distribution systems and public drinking water systems were studied in the homes of 124 patients with community-acquired Legionnaire's disease and in the homes of 354 controls. The presence of water reservoirs and hot water tanks was studied in residential systems. Factors such as deficient chlorine levels, pipe repairs and other work, water flow interruptions, the use of alternative water sources, inadequate cleaning operations in public water reservoirs, and the position of the home within the public network (and whether this location constituted an endpoint) were studied in public water supply systems. Levels of legionellae in domestic water samples were also measured. Although the use of water reservoirs and hot water tanks promotes colonization by legionellae in residential systems, none of the variables studied seems to increase the incidence of community-acquired Legionnaires' disease.

Objective: To present the main results of the investigation of an outbreak of Legionnaire's disease that occurred in an inner city district of Barcelona between 15 October and 15 November 2000., Methods: Epidemiological surveys of patients and environmental investigations were initiated on the day the first five cases were notified. Water samples and smears from cooling tower trays were taken for microbiological analysis. Maps of the distribution of cases and possible contamination foci were elaborated. Incidences were calculated for each census tract., Results: A total of 54 patients related to the outbreak were identified, with a case fatality rate of 5.5%. Incidence rate in the area closest to the cooling tower (6.40/1000) was significantly higher than that of the rest of the neighbourhood (2.23/1.000, RR 2.87, 95%CI 1.37-6.12, P = 0.0035). Cultures positive for Legionella pneumophila serogroup 1, subtypes Pontiac, Philadelphia or Allentown, were obtained from eight patients. On the 39th day of the investigation it was found that the strain isolated in one of the cooling towers coincided with the serogroup, subtype and molecular profiles identified in clinical samples., Conclusions: Rapid coordination of clinicians, microbiologists, epidemiologists and environmentalists permitted the source of infection and the affected cases to be correlated within a few days.

Inhalation of contaminated aerosols is considered the most common route of Legionella transmission. The aim of this study was to determine whether contact with water contaminated by Legionella was related to oropharyngeal colonization in immunosuppressed patients. Eighty-five oropharyngeal swabs (April 1996 to June 1996) were seeded on selective and nonselective buffered charcoal-yeast extract media. Legionella was not isolated.

Background: The effectiveness of the different laboratory test methods to diagnose Legionella spp. in clinical specimens varies according to the epidemiological context. In this study, the usefulness of the laboratory methods used for an outbreak that occurred in the municipality of Alcoy (Alicante, Spain) are evaluated., Materials and Methods: 222 community-acquired cases of infection caused by Legionella pneumophila serogroup 1, subtype Pontiac-Knoxville, genotypes I and II were studied, that had been diagnosed by the Microbiology laboratory from January 1999 to December 2000, corresponding to patients residing in the municipality of Alcoy (Alicante). The methods used were direct antigen detection in respiratory specimens by immunoflurescence, direct antigen detection in urine, cultures and serology., Results: The detection of the antigen in urine diagnosed 201 cases (90,5%). Direct immunofluorescence provided a high number of false positives (n=24). A culture was essential to confirm the etiology of the outbreak (25 sputum) strains from 22 patients). Serology complemented the other methods and helped to retrospectively diagnose 21 patients (9%) when the other tests were not carried out or when they provided negative results., Conclusions: A rapid diagnosis is essential to evaluate the patients and to control epidemical outbreaks, and the detection of the urinary antigen is very useful, but should be complemented with other methods. The culture of the respiratory specimens and the subsequent typing of the strains means that the etiology can be established with certainty and this helps to determine the source(s) of the infection. Serology complemented the diagnosis in 9% of the cases.

Background: Only a few cases of nosocomial Legionella sp. infection have been reported in children. We report the clinical and epidemiologic data of five nosocomial legionellosis cases that occurred in the Pediatric Nephrology Service between August, 1994, and December, 1998, and the control measures adopted., Methods: The Hospital Materno-Infantil Vall d'Hebron, Barcelona, is a 407-bed tertiary care hospital. The pediatric kidney transplant unit has three isolated beds in the same ward within the Pediatric Nephrology Service. Diagnostic workup to establish Legionella pneumophila infection included culture, fluorescent antibody and serologic studies. Macrorestriction analysis of genomic DNA was used as epidemiologic markers of the isolated strains., Results: In May, 1996, a case of L. pneumophila serogroup 6 pneumonia was identified in a 19-year-old youth who had received a kidney transplant 16 days earlier. Retrospective and prospective analysis of legionellosis cases diagnosed at our center up to August, 1994, yielded four additional cases. Four patients had had a kidney transplant and were receiving immunosuppressive therapy, and the fifth had been diagnosed with systemic lupus erythematosus with renal involvement. L. pneumophila serogroup 6 was isolated in bronchial secretions in four cases; in the fifth patient the diagnosis was made by serology. L. pneumophila serogroup 6 was isolated from potable water of the hospital. Molecular epidemiologic methods revealed the identity of the environmental and clinical isolates. Showering was implicated as the most feasible means of exposure to contaminated water., Conclusions: Nosocomial legionellosis, albeit rare in children, should be considered in the differential diagnosis of pneumonias, particularly in immunosuppressed children, because the fatality rate may be high without early diagnosis and treatment.