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Nosocomial outbreak of legionellosis in a rehabilitation center. Demonstration of potable water as a source

Legionärskrankheit in einer Rehabilitationsklinik. Trinkwasser als Quelle eines nosokomialen Ausbruchs

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Summary

Ten patients from a rehabilitation center were admitted to hospital with serious respiratory infections within ten weeks. An outbreak of Legionnaire's disease was suspected based on the epidemic and atypical manifestation of pneumonia and could be proven microbiologically. Pulmonary and extrapulmonary complications included respiratory failure, lung abscess, transitory renal impairment in five patients and acute renal failure requiring dialysis in one, tetraparesis caused by peripheral neuropathy and acute psychosis. Three patients died despite immediate institution of therapy with erythromycin.Legionella pneumophila serogroup 1 subtype Pontiac was isolated from a bronchial lavage sample of one patient and from the water supply of the rehabilitation center. Monoclonal antibody subtyping and restriction endonuclease analysis were performed on both environmental and patient isolates. Potable water was identified as the source of the outbreak based on identical patterns on restriction endonuclease analysis. Despite thermic and chemical disinfection with chlorination (up to 15 ppm) in the rehabilitation clinic, an eleventh case of Legionnaire's disease was detected 11 months later.

Zusammenfassung

In einem Zeitraum von zehn Wochen wurden zehn Patienten von einer Rehabilitationsklinik mit meist schweren respiratorischen Infektionen übernommen. Aufgrund des epidemischen Auftretens und der atypischen Manifestation bestand der Verdacht auf eine durch Legionellen verusachte Kleinepidemie, was durch mikrobiologische Untersuchungen bestätigt werden konnte. Im Verlauf kam es zu pulmonalen Komplikationen wie respiratorischer Insuffizienz und Abszedierung. Extrapulmonale Manifestationen waren passagere Nierenfunktionsstörungen bei fünf und akutes dialysepflichtiges Nierenversagen bei einem Patienten, sowie die Entwicklung einer akuten Psychose und einer Tetraparese im Rahmen einer parainfektiösen Polyneuropathie. Trotz sofortiger Therapie mit Erythromycin verstarben drei Patienten. Als Erreger konnteLegionella pneumophila Serogruppe 1 aus der Bronchiallavage eines Patienten und dem Trinkwassernetz der Rehabilitationsklinik angezüchtet werden. Durch Subtypisierung mit monoklonalen Antikörpern und Analyse genomischer Fragmente mittels Restriktionsendonuklease konnte das Trinkwasser als Quelle des nosokominalen Ausbruchs identifiziert werden. Trotz thermischer und chemischer Desinfektion mit Chlor bis zu 15 ppm und aufwendigen Umbaumaßnahmen in der Rehabilitationsklinik kam es nach elf Monaten jedoch zu einem weiteren, elften Krankheitsfall.

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Authors and Affiliations

  1. Medizinische Klinik I, Klinikum Bayreuth, Preuschwitzerstr. 101, D-95440, Bayreuth

    R. Nechwatal,  A. Prull &  H. Lutz

  2. Institut für Medizinische Mikrobiologie und Hygiene der Universität, Franz-Josef-Strauß-Allee 11, D-93042, Regensburg

    W. Ehret

  3. Landesuntersuchungsamt für das Gesundheitswesen Nordbayern, Eggenreuther Weg 43, D-91058, Erlangen

    O. J. Klatte

  4. Medizinische Abteilung, Krankenhaus Hohe Warte, Hohe Warte 8, D-95445, Bayreuth, Germany

    H-J Zeissler

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  1. R. Nechwatal
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Nechwatal, R., Prull, A., Lutz, H. et al. Nosocomial outbreak of legionellosis in a rehabilitation center. Demonstration of potable water as a source. Infection 21, 235–240 (1993). https://doi.org/10.1007/BF01728897

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