#Legionella #pneumonia: increased #risk after #COVID19 #lockdown? #Italy, May to June 2020 (Euro Surveill., abstract)

[Source: Eurosurveillance, full page: (LINK). Abstract, edited.]

Legionella pneumonia: increased risk after COVID-19 lockdown? Italy, May to June 2020

Claudia Palazzolo1 , Gaetano Maffongelli1 , Alessandra D’Abramo1 , Luciana Lepore1 , Andrea Mariano1 , Antonella Vulcano1 , Tommaso Ascoli Bartoli1 , Nazario Bevilacqua1 , Maria Letizia Giancola1 , Enrico Di Rosa2 , Emanuele Nicastri1

Affiliations: 1 National Institute for Infectious Diseases ‘Lazzaro Spallanzani’ IRCCS, Rome, Italy; 2 Local Health Office, ASL Roma 1, Rome, Italy

Correspondence:  Gaetano Maffongelli

Citation style for this article: Palazzolo Claudia , Maffongelli Gaetano , D’Abramo Alessandra , Lepore Luciana , Mariano Andrea , Vulcano Antonella , Bartoli Tommaso Ascoli , Bevilacqua Nazario , Giancola Maria Letizia , Di Rosa Enrico , Nicastri Emanuele . Legionella pneumonia: increased risk after COVID-19 lockdown? Italy, May to June 2020. Euro Surveill. 2020;25(30):pii=2001372. https://doi.org/10.2807/1560-7917.ES.2020.25.30.2001372

Received: 13 Jul 2020;   Accepted: 27 Jul 2020



We report a case of Legionella pneumonia in a dishwasher of a restaurant in Rome, Italy, just after the end of the lockdown that was in place to control the SARS-CoV-2 epidemic. The case highlights the importance of strict monitoring of water and air systems immediately before reopening business or public sector buildings, and the need to consider Legionella infections among the differential diagnosis of respiratory infections after lockdown due to the ongoing COVID-19 pandemic.

©  This work is licensed under a Creative Commons Attribution 4.0 International License.

Keywords: SARS-CoV-2; COVID-19; Legionellosis; Italy.


#SARS-CoV-2 and #Legionella #Coinfection in a Person Returning from a Nile #Cruise (J Travel Med., abstract)

[Source: Journal of Travel Medicine, full page: (LINK). Abstract, edited.]

SARS-CoV-2 and Legionella Co-infection in a Person Returning from a Nile Cruise

Takeshi Arashiro, MD, Satoshi Nakamura, MD, Takahiro Asami, MD, Hatsuko Mikuni, MD, Emiyu Fujiwara, MD, So Sakamoto, MD, Ryotaro Miura, MD, Yosuke Shionoya, MD, Ryoichi Honda, MD, Keiichi Furukawa, MD, Akira Nakamura, MD, Haruhisa Saito, MD

Journal of Travel Medicine, taaa053, https://doi.org/10.1093/jtm/taaa053

Published: 17 April 2020



We report a case of severe acute respiratory syndrome coronavirus 2 and Legionella co- infection manifesting as pneumonia with gastrointestinal symptoms. The case highlights  the importance of differential diagnosis during the COVID-19 pandemic, so we do not  miss the opportunity to diagnose other treatable causes of disease with similar  symptoms.

coronavirus, COVID-19, severe acute respiratory syndrome coronavirus  2, pandemic, Legionella pneumophila, Legionnaires’ disease, respiratory infections, pneumonia, PCR, cruise ship, travel-related illness, viruses, global health, Japan, Egypt

Issue Section:  Clinical Pearls

This content is only available as a PDF.

Keywords: SARS-CoV-2; COVID-19; Legionellosis.


#Legionella pneumophila as Cause of Severe Community-Acquired #Pneumonia, #China (Emerg Infect Dis., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), Emerging Infectious Diseases Journal, full page: (LINK). Abstract, edited.]

Volume 26, Number 1—January 2020 / Research Letter

Legionella pneumophila as Cause of Severe Community-Acquired Pneumonia, China

Huahua Yi, Jie Fang, Jingwen Huang, Bing Liu, Jieming Qu, and Min Zhou

Author affiliations: Ruijin Hospital, Shanghai, China



We report a case of community-acquired pneumonia in a patient in China. We verified Legionella pneumophila infection through next-generation sequencing of blood, sputum, and pleural effusion samples. Our results show the usefulness of next-generation sequencing and of testing different samples early in the course of illness to identify this bacterium.

Keywords: Legionellosis; China; Pneumonia.


Comparison of #WGS of #Legionella pneumophila in #Tap #Water and in #Clinical Strains, #Flint, #Michigan, #USA, 2016 (Emerg Infect Dis., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), Emerging Infectious Diseases Journal, full page: (LINK). Abstract, edited.]

Volume 25, Number 11—November 2019 / Research

Comparison of Whole-Genome Sequences of Legionella pneumophila in Tap Water and in Clinical Strains, Flint, Michigan, USA, 2016

Emily Garner, Connor L. Brown, David Otto Schwake, William J. Rhoads, Gustavo Arango-Argoty, Liqing Zhang, Guillaume Jospin, David A. Coil, Jonathan A. Eisen, Marc A. Edwards, and Amy Pruden

Author affiliations: West Virginia University, Morgantown, West Virginia, USA (E. Garner); Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA (E. Garner, C.L. Brown, W.J. Rhoads, G. Arango-Argoty, L. Zhang, M.A. Edwards, A. Pruden); Methodist University, Fayetteville, North Carolina, USA (D.O. Schwake); University of California at Davis, Davis, California, USA (G. Jospin, D.A. Coil, J.A. Eisen)



During the water crisis in Flint, Michigan, USA (2014–2015), 2 outbreaks of Legionnaires’ disease occurred in Genesee County, Michigan. We compared whole-genome sequences of 10 clinical Legionella pneumophila isolates submitted to a laboratory in Genesee County during the second outbreak with 103 water isolates collected the following year. We documented a genetically diverse range of L. pneumophila strains across clinical and water isolates. Isolates belonging to 1 clade (3 clinical isolates, 3 water isolates from a Flint hospital, 1 water isolate from a Flint residence, and the reference Paris strain) had a high degree of similarity (2–1,062 single-nucleotide polymorphisms), all L. pneumophila sequence type 1, serogroup 1. Serogroup 6 isolates belonging to sequence type 2518 were widespread in Flint hospital water samples but bore no resemblance to available clinical isolates. L. pneumophila strains in Flint tap water after the outbreaks were diverse and similar to some disease-causing strains.

Keywords: Legionellosis; USA; Michigan.


#Antibiotic #resistance and #azithromycin resistance mechanism of #Legionella pneumophila serogroup 1 in #China (Antimicrob Agents Chemother., abstract)

[Source: Antimicrobial Agents and Chemotherapy, full page: (LINK). Abstract, edited.]

Antibiotic resistance and azithromycin resistance mechanism of Legionella pneumophila serogroup 1 in China

Xueyang Jia, Hongyu Ren, Xudong Nie, Yinan Li, Jianguo Li, Tian Qin

DOI: 10.1128/AAC.00768-19



Legionnaires’ disease, caused by Legionella pneumophila (Lp), was primarily treated with antibiotics. However, few reports have been published on antibiotic-resistant Legionella in China. Our aim was to determine the azithromycin resistance mechanism of Lp serogroup 1 in China. The sensitivities of 149 Lp1 strains, isolated from clinical cases or environmental water in China from 2005 to 2012, to five antibiotics including erythromycin, azithromycin, levofloxacin, moxifloxacin and rifampicin were evaluated. The mechanisms of the resistance of Lp1 to azithromycin were studied. The expression levels of efflux pump gene lpeAB and the minimum inhibitory concentration (MIC) of azithromycin-resistant strains in the presence and absence of the efflux pump inhibitor carbonyl cyanide-chlorophenylhydrazone (CCCP) were detected. All 149 strains were sensitive to erythromycin, levofloxacin, moxifloxacin and rifampicin, among which 25 strains exhibited azithromycin resistance. These 25 strains, including strains sequence type 1 (ST1), ST144, ST150, ST154 and ST629, were screened. The expression of lpeAB was responsible for the reduced azithromycin susceptibility in all these 25 strains. The phenotype of 25 strains with virulence were linked by evaluating the intracellular growth ability in mouse macrophage J774 cells. 60 % of 25 strains were more virulent than the reference strain ATCC 33152. The results in our study provide data support for the further study of antibiotic sensitivity of Lp strains in China.

Copyright © 2019 American Society for Microbiology. All Rights Reserved.

Keywords: Antibiotics; Drugs Resistance; Legionella pneumophila; Azithromycin.


The burden of #Legionnaires’ disease in #NZ (#LegiNZ): a national #surveillance study (Lancet Infect Dis., abstract)

[Source: Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

The burden of Legionnaires’ disease in New Zealand (LegiNZ): a national surveillance study

Patricia C Priest, DPhil †, Sandy Slow, PhD †, Prof Stephen T Chambers, MD, Claire M Cameron, PhD, Michelle N Balm, FRCPA, Mark W Beale, FRACP, Timothy K Blackmore, PhD, Andrew D Burns, FRACP, Dragana Drinković, MD, Juliet A Elvy, FRCPath, Richard J Everts, FRACP, David A Hammer, FRCPA, Paul J Huggan, FRACP, Christopher J Mansell, FRCPA, Vicki M Raeder, DipMLT, Sally A Roberts, FRCPA, Murray C Robinson, DipMLT, Vani Sathyendran, FRCPA, Susan L Taylor, FRCPA, Alyssa W Thompson, DO, James E Ussher, PhD, Antje J van der Linden, FRCPA, Melanie J Williams, BMLSc, Roslyn G Podmore, BSc, Trevor P Anderson, MSc, Kevin Barratt, MSc, Joanne L Mitchell, PhD, David J Harte, MSc, Virginia T Hope, FAFPHM, Prof David R Murdoch, MD

Published: June 10, 2019 / DOI: https://doi.org/10.1016/S1473-3099(19)30113-6




Legionnaires’ disease is under-diagnosed because of inconsistent use of diagnostic tests and uncertainty about whom to test. We assessed the increase in case detection following large-scale introduction of routine PCR testing of respiratory specimens in New Zealand.


LegiNZ was a national surveillance study done over 1-year in which active case-finding was used to maximise the identification of cases of Legionnaires’ disease in hospitals. Respiratory specimens from patients of any age with pneumonia, who could provide an eligible lower respiratory specimen, admitted to one of 20 participating hospitals, covering a catchment area of 96% of New Zealand’s population, were routinely tested for legionella by PCR. Additional cases of Legionnaires’ disease in hospital were identified through mandatory notification.


Between May 21, 2015, and May 20, 2016, 5622 eligible specimens from 4862 patients were tested by PCR. From these, 197 cases of Legionnaires’ disease were detected. An additional 41 cases were identified from notification data, giving 238 cases requiring hospitalisation. The overall incidence of Legionnaires’ disease cases in hospital in the study area was 5·4 per 100 000 people per year, and Legionella longbeachae was the predominant cause, found in 150 (63%) of 238 cases.


The rate of notified disease during the study period was three-times the average over the preceding 3 years. Active case-finding through systematic PCR testing better clarified the regional epidemiology of Legionnaires’ disease and uncovered an otherwise hidden burden of disease. These data inform local Legionnaires’ disease testing strategies, allow targeted antibiotic therapy, and help identify outbreaks and effective prevention strategies. The same approach might have similar benefits if applied elsewhere in the world.


Health Research Council of New Zealand.

Keywords: Legionnaire’s diseases; New Zealand.


#Antibiotic susceptibility of #Legionella pneumophila strains isolated in #England and #Wales 2007–17 (J Antimicrob Chemother., abstract)

[Source: Journal of Antimicrobial Chemotherapy, full page: (LINK). Abstract, edited.]

Antibiotic susceptibility of Legionella pneumophilastrains isolated in England and Wales 2007–17

R E Wilson, R L R Hill, V J Chalker, M Mentasti, D Ready

Journal of Antimicrobial Chemotherapy, dky253, https://doi.org/10.1093/jac/dky253

Published: 24 July 2018




Antibiotic susceptibility of Legionella pneumophila is poorly understood, with treatment of Legionnaires’ disease often based on empirical choice. The aim of this study was to determine the antibiotic susceptibility of L. pneumophilastrains.


Antibiotic susceptibility of 92 L. pneumophila strains isolated in England and Wales between 2007 and 2017 was determined using a microbroth dilution methodology for each agent tested. MICs and MBCs were determined and compared with published intracellular concentrations of each agent tested.


The MIC range of erythromycin was 0.06–1 mg/L, the MIC range of rifampicin was 0.0001 mg/L, the MIC range of ciprofloxacin was 0.004–0.25 mg/L and the MIC range of levofloxacin and moxifloxacin was 0.03–0.25 mg/L. The MBC range of erythromycin was 1–32 mg/L, but the MBC range of ciprofloxacin was the same as the MIC range. For levofloxacin and moxifloxacin the MBC range was elevated by one dilution and two dilutions, respectively. Typically, intracellular bronchial secretion concentrations of erythromycin might be expected to reach a suitable level to exceed the MIC range; however, 91 of 92 (98.9%) isolates had an MBC below the expected intracellular concentrations, which indicated erythromycin may have variable efficacy. MIC and MBC values of ciprofloxacin, levofloxacin and moxifloxacin were below achievable intracellular levels within bronchial secretions. Comparison of the MIC/MBC correlation showed very little clustering for erythromycin, but strong clustering for levofloxacin and to a lesser extent ciprofloxacin.


Use of the MIC/MBC linkage analysis seems an appropriate way forward for antimicrobial susceptibility testing and supports current guidance recommending levofloxacin for the treatment of Legionnaires’ disease.

Topic: antibiotics – rifampin – erythromycin – genetic linkage analysis – ciprofloxacin – bodily secretions – legionella pneumophila – legionnaires’ disease – country of wales – levofloxacin – moxifloxacin – antimicrobial susceptibility – antimicrobial susceptibility test – dilution technique – dilute (action) – malnutrition-inflammation-cachexia syndrome


© The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com.

This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Keywords: Antibiotics; Drugs Resistance; Legionalla pneumophila; England; Wales; rifampin; erythromycin; ciprofloxacin; levofloxacin; moxifloxacin.


#Clinical #management of respiratory syndrome in patients hospitalized for suspected #MERS-CoV #infection in the #Paris area from 2013 to 2016 (BMC Infect Dis., abstract)

[Source: US National Library of Medicine, full page: (LINK). Abstract, edited.]

BMC Infect Dis. 2018 Jul 16;18(1):331. doi: 10.1186/s12879-018-3223-5.

Clinical management of respiratory syndrome in patients hospitalized for suspected Middle East respiratory syndrome coronavirus infection in the Paris area from 2013 to 2016.

Bleibtreu A1,2,3,4, Jaureguiberry S5, Houhou N6, Boutolleau D7, Guillot H5, Vallois D8, Lucet JC9,10,11, Robert J12,13, Mourvillier B10,11,14, Delemazure J15, Jaspard M5, Lescure FX8,10,11, Rioux C8, Caumes E5, Yazdanapanah Y8,10,11.

Author information: 1 APHP, Hôpital Bichat Claude Bernard, Service des Maladies Infectieuses et Tropicales, Paris Diderot University, Paris, France. alexandre.bleibtreu@aphp.fr. 2 APHP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Service des Maladies Infectieuses et Tropicales, Paris, France. alexandre.bleibtreu@aphp.fr. 3 INSERM, IAME, UMR 1137, Paris, France. alexandre.bleibtreu@aphp.fr. 4 Univ Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, Paris, France. alexandre.bleibtreu@aphp.fr. 5 APHP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Service des Maladies Infectieuses et Tropicales, Paris, France. 6 Virology Department, APHP-Bichat-Claude Bernard Hospital, Paris, France. 7 AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Service de Virologie, et Sorbonne Universités, UPMC Univ Paris 06, CR7, CIMI, INSERM U1135, Paris, France. 8 APHP, Hôpital Bichat Claude Bernard, Service des Maladies Infectieuses et Tropicales, Paris Diderot University, Paris, France. 9 APHP, Infection control unit, Bichat Claude Bernard hospital, Paris Diderot University, Paris, France. 10 INSERM, IAME, UMR 1137, Paris, France. 11 Univ Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, Paris, France. 12 AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Bactériologie-Hygiène Hospitalière, Paris, France. 13 Faculté de Médecine P. & M. Curie Paris-6 – Site Pitié, Centre d’Immunologie et des Maladies Infectieuses (CIMI) – E13, Paris, France. 14 APHP- Hôpital Bichat Claude Bernard, Service de Réanimation médicale et Infectieuse, Paris, France. 15 Service de pneumologie et réanimation Département R3S, AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, unité de Soin de Réadaptation Post Réanimation (SRPR), Paris, France.




Patients with suspected Middle East respiratory syndrome coronavirus (MERS-CoV) infection should be hospitalized in isolation wards to avoid transmission. This suspicion can also lead to medical confusion and inappropriate management of acute respiratory syndrome due to causes other than MERS-CoV.


We studied the characteristics and outcome of patients hospitalized for suspected MERS-CoV infection in the isolation wards of two referral infectious disease departments in the Paris area between January 2013 and December 2016.


Of 93 adult patients (49 male (52.6%), median age 63.4 years) hospitalized, 82 out of 93 adult patients had returned from Saudi Arabia, and 74 of them were pilgrims (Hajj). Chest X-ray findings were abnormal in 72 (77%) patients. The 93 patients were negative for MERS-CoV RT-PCR, and 70 (75.2%) patients had documented infection, 47 (50.5%) viral, 22 (23.6%) bacterial and one Plasmodium falciparum malaria. Microbiological analysis identified Rhinovirus (27.9%), Influenza virus (26.8%), Legionella pneumophila (7.5%), Streptococcus pneumoniae (7.5%), and non-MERS-coronavirus (6.4%). Antibiotics were initiated in 81 (87%) cases, with two antibiotics in 63 patients (67.7%). The median duration of hospitalization and isolation was 3 days (1-33) and 24 h (8-92), respectively. Time of isolation decreased over time (P < 0.01). Two patients (2%) died.


The management of patients with possible MERS-CoV infection requires medical facilities with trained personnel, and rapid access to virological results. Empirical treatment with neuraminidase inhibitors and an association of antibiotics effective against S. pneumoniae and L. pneumophila are the cornerstones of the management of patients hospitalized for suspected MERS-CoV infection.

KEYWORDS: Isolation ward; Legionella; Middle East respiratory syndrome coronavirus (MERS-CoV); Pilgrims; Respiratory tract infection; Saudi Arabia

PMID: 30012113 DOI: 10.1186/s12879-018-3223-5

Keywords: MERS-CoV; Quarantine Measures; France.


#Tigecycline as a Second-Line Agent for #Legionnaires’ Disease in Severely Ill Patients (Open Forum Infect Dis., abstract)

[Source: Open Forum Infectious Diseases, full page: (LINK). Abstract, edited.]

Tigecycline as a Second-Line Agent for Legionnaires’ Disease in Severely Ill Patients

Deepika Slawek, Diana Altshuler, Yanina Dubrovskaya, Eddie Louie

Open Forum Infectious Diseases, Volume 4, Issue 4, 1 October 2017, ofx184,  DOI: https://doi.org/10.1093/ofid/ofx184

Published: 07 October 2017 – Received: 18 May 2017 – Accepted: 30 August 2017

Citation: Deepika Slawek, Diana Altshuler, Yanina Dubrovskaya, Eddie Louie; Tigecycline as a Second-Line Agent for Legionnaires’ Disease in Severely Ill Patients, Open Forum Infectious Diseases, Volume 4, Issue 4, 1 October 2017, ofx184, https://doi.org/10.1093/ofid/ofx184

© 2017 Oxford University Press



Treatment of Legionnaires’ disease in severely ill or immunosuppressed patients presents a clinical challenge. Tigecycline (TG) achieves high concentrations intracellularly and has been shown to be effective against L. pneumophila in animal and cell models. We report our experience using TG as second-line therapy. Clinical response was seen in most patients after switching to TG alone or as a combination therapy.

Issue Section: Brief Report

Keywords: Tigecycline; Legionellosis.


#Legionnaires’ Disease #Outbreak Caused by Endemic Strain of #Legionella pneumophila, #NY, New York, #USA, 2015 (Emerg Infect Dis., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), Emerging Infectious Diseases Journal, full page: (LINK). Abstract, edited.]

Volume 23, Number 11—November 2017 / Research

Legionnaires’ Disease Outbreak Caused by Endemic Strain of Legionella pneumophila, New York, New York, USA, 2015

Pascal Lapierre  , Elizabeth Nazarian, Yan Zhu, Danielle Wroblewski, Amy Saylors, Teresa Passaretti, Scott Hughes, Anthony Tran, Ying Lin, John Kornblum, Shatavia S. Morrison, Jeffrey W. Mercante, Robert Fitzhenry, Don Weiss, Brian H. Raphael, Jay K. Varma, Howard A. Zucker, Jennifer L. Rakeman, and Kimberlee A. Musser

Author affiliations: Wadsworth Center, Albany, New York, USA (P. Lapierre, E. Nazarian, Y. Zhu, D. Wroblewski, A. Saylors, T. Passaretti, H.A. Zucker, K.A. Musser); New York City Department of Health and Mental Hygiene, New York, New York, USA (S. Hughes, A. Tran, Y. Lin, J. Kornblum, R. Fitzhenry, D. Weiss, J.K. Varma, J.L. Rakeman); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (S.S. Morrison, J.W. Mercante, B.H. Raphael)



During the summer of 2015, New York, New York, USA, had one of the largest and deadliest outbreaks of Legionnaires’ disease in the history of the United States. A total of 138 cases and 16 deaths were linked to a single cooling tower in the South Bronx. Analysis of environmental samples and clinical isolates showed that sporadic cases of legionellosis before, during, and after the outbreak could be traced to a slowly evolving, single-ancestor strain. Detection of an ostensibly virulent Legionella strain endemic to the Bronx community suggests potential risk for future cases of legionellosis in the area. The genetic homogeneity of the Legionella population in this area might complicate investigations and interpretations of future outbreaks of Legionnaires’ disease.

Keywords: Legionellosis; USA; NYC.