Abstract

Legionella pneumophilais a pathogen that causes severe pneumonia in humans;

L. pneumophilaserogroup1 accounts for at least 90% of infections. This is not
linked to an environmental predominance of Legionellapneumophila 1, but may
be due to a greater virulence of the strain. L. pneumophilasg 5 has also
beenreported, albeit less frequently, to be a cause of the disease. We report a
case of L. pneumophilasg 5occurring in a large hospital in southern Italy (Apulia
region), where both L. pneumophilasg 1 and sg 5 weredetected in the water
supply; the nosocomial origin was demonstrated by molecular subtyping (PFGE).
Anenvironmental investigation, performed immediately after diagnosis of the case
of legionellosis, identified alow L. pneumophila sg 5contamination level. Our
experience highlights that in hospital, risk assessment, inorder to institute control
measures for Legionella,should be carried out not only in response to a case of
thedisease and/or in risk wards only, as described in the Italian Guidelines, but
periodically in every ward. Thepresent study confirms that, although in the
community L. pneumophilasg 1 is the most frequent strainisolated in both
outbreaks and isolated cases, in hospital other serogroups and species may
often causeinfection because of the high susceptibility of the hosts.Key words:
Legionella spp, legionellosis, bacteriological diagnosis, epidemiology

ITALIAN JOURNAL OF PUBLIC HEALTHIntroduction Legionella

pneumophilais a pathogen thatcauses severe pneumonia in humans. It isfrequently found
in water distribution systemsand has been repeatedly associated with bothhospital and
community-acquired infections,especially in immunocompromised
patients.L.pneumophilaserogroup (sg) 1 accounts for atleast 90% of infections [1],
followed by serogroup6 [2].L. pneumophilasg 5 has also been reported,albeit less
frequently, as a cause of disease [3-12].The high frequency of L. pneumophila1
isolationfrom clinical samples is not linked to anenvironmental predominance but may be
due to ahigher virulence of the strain or a more efficientintracellular growth [13, 14]. It
must, however, benoted that a precise etiological diagnosis is biasedby the difficulty of
isolating the germ when thepatient has already received antibiotics that maskthe identity
of the pathogen [15, 16]. ForLegionellapneumoniae this problem iscompounded by the
patient’s difficulty inbringing up sputum and by, in general, limitedlaboratory experience
in actually isolatingLegionellafrom clinical specimens [17, 18]We report a case of L.
pneumophilasg 5occurring in a large hospital in southern Italy(Apulia region), where both
L. pneumophilasg 1and sg 5 were detected in the water supply; thenosocomial origin of
the strains was demonstratedby molecular subtyping.

DiscussionLegionellais a widely distributed microorganismin man-made environments

and multiple speciesand serogroups can co-exist in the same watersupply.L. pneumophila
sg 1 is a frequent cause ofpneumonia, whereas confirmed cases of L.pneumophilasg 5 are
rare.Definitivedocumentation of the infectious agent can only beobtained by culture of the
microorganism fromclinical specimens. In the present case L.pneumophilasg 5 was
isolated from the sputum ofapatient at a hospital where nosocomialLegionellainfections
had not been previouslydetected.The urinary antigen test was positive, butthis test detects
specific Legionellaantigen andrecognizes all L. pneumophilaserogroups with arelatively
wide spectrum of cross-reactivity, as wellas other Legionellaspecies [6, 21, 22]. For
thisreason, taking into account only the positiveurinary antigen, it was not possible to
identify thespecific species and serogroup of Legionellathathad caused the disease.
Antibody titres against aITALIAN JOURNAL OF PUBLIC
HEALTH72LOng papersIJPH - Year 5, Volume 4, Number 1, 2007
ITALIAN JOURNAL OF PUBLIC HEALTHcommercially available
polyvalent antigen showedseroconversion of L. pneumophila sg 1 to 6. Noseroconversion
was seen using antigens preparedwith L.pneumophilasg 1 Philadelphia, whereasthere was
strong evidence of antibodies to L.pneumophilasg 5 in the patient’s serum sampleswhen
tested against the clinical isolate. Moreover,the similarity between the PFGE clinical
patternand some of the environmental strains of L.pneumophilasg 5 demonstrated that the
infectionwas indeed due to L. pneumophila sg 5.The PFGEalso showed that the L.
pneumophilasg 5 strainsisolated from the two hospital wards had differentgenomic
patterns, and that the infection wasacquired in the General Medical Ward (Figure 1).The
data reported herein underlines the necessityto confirm the diagnosis of a suspected
Legionellapneumonia by bacteriological culture. This willavoid an erroneous etiological
diagnosis, facilitatethe detection of the source of the infection, andcontribute to a better
understanding of theincidence of L. pneumophilasg non-1infections.Inthe present study,
the environmentalinvestigation carried out immediately followingthe case of
Legionnaires’ disease identified a lowL.pneumophilasg 5 contamination level. In fact,as
recently demonstrated by other authors [23],even if the environmental contamination
level islow it is possible to observe cases of disease.Thishighlights the fact that, in our
opinion, riskassessment in order to institute control measuresfor Legionellashould be
carried out in hospitalsnot only in response to a case of disease and/oronly in risk wards,
as reported in the ItalianGuidelines, but periodically in every ward, inorder to prevent the
disease [18].Our experience underlines that although L.pneumophilasg 1 is considered the
mostpathogenic serogroup,L. pneumophilasg 5 canbe responsible for the disease if both
L.pneumophilasg 1 and sg 5 are present in theenvironment. In accordance with other
studies[24, 10], although in the community L.pneumophilasg 1 is the most frequent
strainisolated in both outbreaks and isolated cases, inhospitals other serogroups and
species may oftencause isolated cases or outbreaks of infectionbecause of the high
susceptibility of the hosts