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Article
August 1986

Mode of Transmission of Legionella pneumophilaA Critical Review

Author Affiliations

From the Department of Medicine, Mercy Hospital, University of Pittsburgh, and Veterans Administration Medical Center, Pittsburgh.

Arch Intern Med. 1986;146(8):1607-1612. doi:10.1001/archinte.1986.00360200183030
Abstract

Since the discovery of Legionella pneumophila as the cause of an outbreak of pneumonic illness at the American Legion Convention in Philadelphia in 1976,1,2 it has become apparent that Legionnaires' disease is a relatively common form of pneumonia in both the community and nosocomial setting.3,4 Despite admirable success in defining the illness and isolating the causative microorganism, investigators from the Centers for Disease Control (CDC), Atlanta, were not able to definitely identify the mode of transmission in the 1976 Philadelphia outbreak. Although the ensuing years have witnessed considerable advances in microbiologic technique as well as the accumulation of a substantial body of data regarding the microbial ecology and epidemiology of the Legionellaceae, the exact mode of transmission has eluded definition. In this article, we will critically examine various theories of transmission of Legionnaires' disease and attempt to place them in perspective in order to define future directions for

References
1.
Fraser DW, Tsai T, Orenstein W, et al:  Legionnaires' disease: Description of an epidemic of pneumonia. N Engl J Med 1977;297:1183-1197.Article
2.
McDade J, Shepard C, Fraser D, et al:  Legionnaires' disease: Isolation of a bacterium and demonstration of its role in other respiratory disease. N Engl J Med 1977;297:1197-1203.Article
3.
Muder RR, Yu VL, McClure J, et al:  Nosocomial Legionnaires' disease uncovered in a prospective pneumonia study: Implications for underdiagnosis. JAMA 1983;249:3184-3192.Article
4.
MacFarlane JT, Finch RG, Ward MJ, et al:  Hospital study of adult community-acquired pneumonia. Lancet 1982;2:255-258.Article
5.
Glick TH, Gregg MB, Berman B, et al:  Pontiac fever: An epidemic of unknown etiology in a health department. Clinical and epidemiologic aspects. Am J Epidemiol 1978;149-160.
6.
Fraser DW, Deubner DC, Hill DL, et al:  Nonpneumonic short-incubation period legionellosis (Pontiac fever) in men who cleaned a steam turbine condenser. Science 1979;205:691-692.Article
7.
Kaufmann A, McDade J, Patton C, et al:  Pontiac fever: Isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am J Epidemiol 1981;114:337-347.
8.
Rowbotham T:  Pontiac fever explained? Lancet 1980;2:969.Article
9.
Dondero TJ, Rendtorff RC, Mallison GF, et al:  An outbreak of Legionnaires' disease associated with a contaminated air-conditioning cooling tower. N Engl J Med 1980;302:365-370.Article
10.
Yu VL, Zuravleff JJ, Elder E, et al:  Pittsburgh pneumonia agent may be a common cause of nosocomial pneumonia—seroepidemiologic evidence. Ann Intern Med 1982;97:724-725.Article
11.
Lode H, Brothe R, Schafer H, et al:  Prospective one-year study of Legionnaires' disease in a German university hospital , in Thornsberry C, Balows A, Feely JC, et al (eds): Legionella, in the Proceedings of the Second International Symposium . Washington, DC, American Society for Microbiology, 1984, pp 220-221.
12.
Joly J, Winn W:  Correlation of subtypes of Legionella pneumophila defined by monoclonal antibodies with epidemiological classification of cases and environmental sources. J Infect Dis 1984;150:667-671.Article
13.
Nolte FS, Conlin C, Roisin A, et al:  Plasmids as epidemiological markers in nosocomial Legionnaires' disease. J Infect Dis 1984;149:251-256.Article
14.
Haley CE, Cohen ML, Halter J, et al:  Nosocomial Legionnaires' disease: A continuing common-source epidemic at Wadsworth Medical Center. Ann Intern Med 1979;583-586.
15.
Shands K, Ho J, Meyer R, et al:  Potable water as a source of Legionnaires' disease. JAMA 1985;253:1412-1416.Article
16.
Garbe P, David B, Weisfeld J, et al:  Nosocomial Legionnaires' disease: Epidemiological demonstration of cooling towers as a source. JAMA 1985;254:521-524.Article
17.
Cordes L, Fraser D, Skaliy P, et al:  Legionnaires' disease outbreak at an Atlanta country club: Evidence for spread from an evaporative condensor. Am J Epidemiol 1980;11:425-431.
18.
Conwill D, Werner SB, Dritz S, et al:  Legionellosis—the 1980 San Francisco outbreak. Am Rev Respir Dis 1982;126:666-669.
19.
Band JD, LaVenture M, David JP, et al:  Epidemic Legionnaires' disease: Airborne transmission down a chimney. JAMA 1981;245:2404-2407.Article
20.
Klaucke D, Vogt R, LaRue D, et al:  Legionnaires' disease: The epidemiology of two outbreaks in Burlington, Vt. Am J Epidemiol 1984;119: 382-391.
21.
Girod J, Reichman R, Winn W, et al:  Pneumonic and nonpneumonic forms of legionellosis. Arch Intern Med 1982;142:545-547.Article
22.
Politi B, Fraser D, Mallison G, et al:  A major focus of Legionnaires' disease in Bloomington, Ind. Ann Intern Med 1979;90:587-591.Article
23.
Broome CV, Fraser DW:  Epidemiological aspects of legionellosis. Epidemiol Rev 1979;1:1-16.
24.
Fisher-Hoch SP, Tobin JO'H, Nelson AM, et al:  Investigation and control of an outbreak of Legionnaires' disease in a district general hospital. Lancet 1981;1:932-936.Article
25.
Tobin JO'H, Beare J, Dunnill M, et al:  Legionnaires' disease in a transplant unit: Isolation of the causative agent from shower baths. Lancet 1980;2:118-121.Article
26.
Cordes LG, Wiesenthal AM, Gorman GW, et al:  Isolation of Legionella pneumophila from hospital showerheads. Ann Intern Med 1981;94:195-197.Article
27.
Woo AH, Yu VL, Goetz A:  Potential in-hospital mode of transmission for Legionella pneumophila: Demonstration experiments for dissemination by showers. Am J Med , in press.
28.
Dennis P, Wright AE, Rutter D, et al:  Legionella pneumophila in aerosols from shower baths. J Hyg 1984;93:349-353.Article
29.
Bollin G, Plouffe J, Para M, et al:  Aerosols containing Legionella pneumophila generated by shower heads and hot water faucets. Appl Environ Microbiol 1985;1128-1131.
30.
Rosmini F, Castellani-Pastoris M, Mazzotti MG, et al:  Febrile illness in successive cohorts of tourists at a hotel on the Italian adriatic coast: Evidence for a persistent focus of Legionella infection. Am J Epidemiol 1984;119:124-134.
31.
Bartlett CLR, Swann R, Casal J, et al:  Recurrent Legionnaires' disease from a hotel water system , in Thornsberry C, Balows A, Feely JC, et al (eds): Legionella, in the Proceedings of the Second International Symposium , Washington, DC, American Society for Microbiology, 1984, pp 237-239.
32.
Helms CM, Massanari R, Zeiter S, et al:  Legionnaires' disease associated with a hospital water system: A cluster of 24 nosocomial cases. Ann Intern Med 1983;99:172-178.Article
33.
Zuravleff J, Yu VL, Shonnard J, et al:  Legionella pneumophila contamination of a hospital humidifier: Demonstration of aerosol transmission and subsequent subclinical infection in exposed guinea pigs. Am Rev Respir Dis 1983;128:657-661.
34.
Arnow P, Chou T, Weil D, et al:  Nosocomial Legionnaires' disease caused by aerosolized tap water from respiratory devices. J Infect Dis 1982;146:460-467.Article
35.
Sharrar R, Friedman H, Miller W, et al:  Summertime pneumonias in Philadelphia in 1976. Ann Intern Med 1979;90:557-580.Article
36.
Markowitz L, Tompkins L, Wilkinson H, et al:  Transmission of nosocomial Legionnaires' disease in heart transplant patients. Program and Abstracts of the 24th Interscientific Conference on Antimicrobial Agents and Chemotherapy 1984 , abstracted. Washington, DC, American Society for Microbiology, p 170.
37.
Rodgers FG, Greaves PW, MacRae AD, et al:  Electron microscope evidence of flagella and pili on Legionella pneumophila. J Clin Pathol 1980;33:1184-1188.Article
38.
Stout J, Best M, Yu VL, et al:  Symbiosis of Legionella pneumophila and Tatlockia micdadei with human respiratory flora. J Appl Bacteriol , in press.
39.
Yu VL, Kroboth FJ, Shonnard J, et al:  Legionnaires' disease: New clinical perspective from a prospective pneumonia study. Am J Med 1982;73:357-361.Article
40.
Stout J, Yu VL, Vickers RM, et al:  Ubiquitousness of Legionella pneumophila in the water supply of a hospital with endemic Legionnaires' disease. N Engl J Med 1982;306:466-468.Article
41.
Best M, Yu VL, Stout J, et al:  Legionellaceae in the hospital water supply: Epidemiological link with disease and evaluation of a method of control of nosocomial Legionnaires' disease and Pittsburgh pneumonia. Lancet 1983;2:307-310.Article
42.
Yu VL, Stout J, Zuravleff JJ: Aspiration of contaminated water may be a mode of transmission for Legionella pneumophila. Program and Abstracts of 21st Interscientific Conference on Antimicrobial Agents and Chemotherapy 1985, Chicago, Nov 4-6,1985, p 297.
43.
Stout JE, Yu VL, Muraca P:  Isolation of Legionella pneumophila from the cold water of hospital ice machines: Implications for origin and transmission of the organism. Infect Control 1984;6:141-146.
44.
Johnson JT, Yu VL, Best M, et al:  Nosocomial legionellosis uncovered in surgical patients with head and neck cancer: Implications for epidemiologic reservoir and mode of transmission. Lancet 1985;2: 298-300.Article
45.
Bridge JA, Edelstein PH:  Oropharyngeal colonization with Legionella pneumophila. J Clin Microbiol 1983;18:1108-1112.
46.
Saravolatz L, Pohlod D, Helzer K, et al:  Legionella infections in renal transplant recipients , in Thornsberry C, Balows A, Feely JC, et al (eds): Legionella, in the Proceedings of the Second International Symposium , Washington, DC, American Society for Microbiology, 1984, pp 231-233.
47.
Zanen-Lim OG, van den Broek N, Rietra P, et al:  Comparison of strains of Legionella pneumophila serogroup 1 isolated in four Amsterdam hospitals from patients and hot water supplies. J Infect Dis 1984;150: 508-512.Article
48.
White H, Felton W, Sun CN:  Extrapulmonary histopathologic manifestations of Legionnaires' disease. Arch Pathol Lab Med 1980;104:287-289.
49.
Dorman S, Hardin N, Winn W:  Pyelonephritis associated with Legionella pneumophila, serogroup 4. Ann Intern Med 1980;93:835-836.Article
50.
Rihs JD, Yu VL, Zuravleff JJ, et al:  Isolation of Legionella pneumophila from blood using the BACTEC: A prospective study yielding positive results. J Clin Microbiol 1985;22:422-424.
51.
Kirby BD, Snyder K, Meyer R, et al:  Legionnaires' disease: Report of 65 nosocomially acquired cases and a review of the literature. Medicine 1980;59:188-205.Article
52.
Tsai TF, Finn DR, Pilikaytis B, et al:  Clinical features of the epidemic in Philadelphia. Ann Intern Med 1979;90:509-517.Article
53.
Helms C, Viner J, Sturm R, et al:  Comparative features of pneumococcal, mycoplasmal, and Legionnaires' disease pneumonias. Ann Intern Med 1979;90:543-547.Article
54.
Katz S, Matus J:  Febrile illness produced in guinea pigs by oral inoculation of Legionella pneumophila , in Thornsberry C, Balows A, Feely JC, et al (eds): Legionella, in the Proceedings of the Second International Symposium . Washington, DC, American Society for Microbiology, 1984, pp 124-126.
55.
Plouffe J, Kelly K, Bolin G: Oral ingestion of Legionella pneumophila. Annual meeting of the American Society for Microbiology, Chicago, March 4-6, 1985, B201 (abstract).
56.
Dournon E, Bure A, Kenney J, et al:  Legionella pneumophila peritonitis. Lancet 1982;1:1363.Article
57.
Harris L:  Legionnaires' disease associated with massive precardial effusion. Arch Intern Med 1981;141:385.Article
58.
Spano C, Menozzi M:  Legionnaires' disease on Palermo and possible involvement of Legionella pneumophila in cases of pericardial effusion. Infection 1982;10:103-104.Article
59.
McCabe RE, Baldwin J, McGregor C, et al:  Prosthetic valve endocarditis caused by Legionella pneumophila. Ann Intern Med 1984;100:525-527.Article
60.
Brabender W, Hinthorn D, Asher M, et al:  Legionella pneumophila wound infection. JAMA 1983;250:3091-3092.Article
61.
Evans AS:  Causation and disease: The Henle-Koch postulates revisited. Yale J Biol Med 1976;49:175-195
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