Difference between revisions of "Legionella"

(EvaluationCunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.)
 
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==Background==
 
==Background==
 
*[[Gram negative]] aerobe
 
*[[Gram negative]] aerobe
*''L. pneumophila:'' associated with pneumonia and Pontiac Fever
+
*''L. pneumophila:'' associated with two distinct syndromes: pneumonia (legionnaires disease) and Pontiac Fever
*Increased incidence with hot, humid, weather and thundershowers;  outbreaks have been associated with cooling towers.
+
*Infection typically occurs via inhalation of aerosolized contaminated water or aspiration of contaminated water
 +
**Outbreaks often associated with cooling towers, hot tubs, medical equipment
 +
**Increased incidence with hot, humid, weather and thundershowers
 
*Most commonly found in patients age > 50 years, smokers, immunocompromised.<ref>Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.</ref>
 
*Most commonly found in patients age > 50 years, smokers, immunocompromised.<ref>Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.</ref>
 +
**However, likely underestimated in children<ref>Yu VL1, Lee TC. Neonatal legionellosis: the tip of the iceberg for pediatric hospital-acquired pneumonia? Pediatr Infect Dis J. 2010 Mar;29(3):282-4.</ref>
 +
 +
==Clinical Features==
 +
*Pontiac fever<ref>https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/legionellosis-legionnaires-disease-and-pontiac-fever</ref>
 +
**[[Fever]], mild [[flu-like]] illness
 +
**Absence of pneumonia
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*Legionnaires disease<ref>https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/legionellosis-legionnaires-disease-and-pontiac-fever</ref>
 +
**High mortality
 +
**Incubation 2-10d<ref>Eison, R. Legionella Pneumonia: When to Suspect, Diagnostic Considerations, and Treatment Strategies for Hospital-Based Clinicians. Curr Emerg Hosp Med Rep (2014) 2: 205.</ref>
 +
**[[Fever]], often high
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**[[Cough]]
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**[[Respiratory distress]]
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***Respiratory failure in ~10% of all cases<ref>https://pedemmorsels.com/legionellosis-in-children/</ref>
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**Relative [[bradycardia (relative to temperature)
 +
*Gastrointestinal symptoms (e.g. [[nausea/vomiting]], [[diarrhea]])
 +
*Neurologic symptoms
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**[[Headache]]
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**[[Tremor]]
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**[[Seizure]]
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**[[Guillain-barre]]
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**Chorea
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**Acute cerebellar [[ataxia]]
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Gastrointestinal symptoms
 +
Neurologic symptoms
 +
Can cause tremor, seizures, Guillain-Barre, and chorea.
 +
Has been linked to cases of Acute Cerebellar Ataxia. [Nigro, 1983]
 +
Respiratory failure occurs in ~10% of all cases.
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Evaluation<ref>Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.</ref>==
 
==Evaluation<ref>Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.</ref>==
[File:PMC5258191 cureus-0008-00000000937-i01.png|thumb|Severe case of Legionellosis on CXR]]
+
[[File:PMC5258191 cureus-0008-00000000937-i01.png|thumb|Severe case of Legionellosis on CXR]]
 +
*Sputum sample for culture
 +
*Urine legionella antigen
 
*Na: Low in CAP but mostly frequently associated with Legionella
 
*Na: Low in CAP but mostly frequently associated with Legionella
 
*AST/ALT: Mildly increased 2-5x normal
 
*AST/ALT: Mildly increased 2-5x normal
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==Management==
 
==Management==
 +
*Reportable disease, notify appropriate health department<ref>https://www.cdc.gov/legionella/downloads/case-report-form.pdf</ref>
 
*First line
 
*First line
 
**[[Azithromycin]]
 
**[[Azithromycin]]

Latest revision as of 16:19, 14 September 2019

Background

  • Gram negative aerobe
  • L. pneumophila: associated with two distinct syndromes: pneumonia (legionnaires disease) and Pontiac Fever
  • Infection typically occurs via inhalation of aerosolized contaminated water or aspiration of contaminated water
    • Outbreaks often associated with cooling towers, hot tubs, medical equipment
    • Increased incidence with hot, humid, weather and thundershowers
  • Most commonly found in patients age > 50 years, smokers, immunocompromised.[1]
    • However, likely underestimated in children[2]

Clinical Features

Gastrointestinal symptoms Neurologic symptoms Can cause tremor, seizures, Guillain-Barre, and chorea. Has been linked to cases of Acute Cerebellar Ataxia. [Nigro, 1983] Respiratory failure occurs in ~10% of all cases.

Differential Diagnosis

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Evaluation[7]

Severe case of Legionellosis on CXR
  • Sputum sample for culture
  • Urine legionella antigen
  • Na: Low in CAP but mostly frequently associated with Legionella
  • AST/ALT: Mildly increased 2-5x normal
  • Phosphate: Decreased
  • CK: Increased
  • CRP: > 35
  • Ferritin: Increased >2x normal

Management

Antibiotic Sensitivities[10]

Category Antibiotic Sensitivity
Penicillins Penicillin G R
Penicillin V R
Anti-Staphylocccal Penicillins Methicillin R
Nafcillin/Oxacillin R
Cloxacillin/Diclox. R
Amino-Penicillins AMP/Amox R
Amox-Clav R
AMP-Sulb R
Anti-Pseudomonal Penicillins Ticarcillin R
Ticar-Clav R
Pip-Tazo R
Piperacillin R
Carbapenems Doripenem R
Ertapenem R
Imipenem R
Meropenem R
Aztreonam R
Fluroquinolones Ciprofloxacin S
Ofloxacin S
Pefloxacin S
Levofloxacin S
Moxifloxacin S
Gemifloxacin S
Gatifloxacin S
1st G Cephalo Cefazolin R
2nd G. Cephalo Cefotetan R
Cefoxitin R
Cefuroxime R
3rd/4th G. Cephalo Cefotaxime R
Cefizoxime R
CefTRIAXone R
Ceftaroline R
CefTAZidime R
Cefepime R
Oral 1st G. Cephalo Cefadroxil R
Cephalexin R
Oral 2nd G. Cephalo Cefaclor/Loracarbef R
Cefproxil R
Cefuroxime axetil R
Oral 3rd G. Cephalo Cefixime R
Ceftibuten R
Cefpodox/Cefdinir/Cefditoren R
Aminoglycosides Gentamicin X1
Tobramycin X1
Amikacin X1
Chloramphenicol X1
Clindamycin X1
Macrolides Erythromycin S
Azithromycin S
Clarithromycin S
Ketolide Telithromycin X2
Tetracyclines Doxycycline X2
Minocycline X2
Glycylcycline Tigecycline X2
Daptomycin R
Glyco/Lipoclycopeptides Vancomycin X1
Teicoplanin X1
Telavancin X1
Fusidic Acid I
Trimethoprim S
TMP-SMX S
Urinary Agents Nitrofurantoin X1
Fosfomycin X1
Other Rifampin X1
Metronidazole R
Quinupristin dalfoppristin X1
Linezolid X1
Colistimethate X1

Key

  • S susceptible/sensitive (usually)
  • I intermediate (variably susceptible/resistant)
  • R resistant (or not effective clinically)
  • S+ synergistic with cell wall antibiotics
  • U sensitive for UTI only (non systemic infection)
  • X1 no data
  • X2 active in vitro, but not used clinically
  • X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
  • X4 active in vitro, but not clinically effective for strep pneumonia

Table Overview

See Also

References

  1. Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.
  2. Yu VL1, Lee TC. Neonatal legionellosis: the tip of the iceberg for pediatric hospital-acquired pneumonia? Pediatr Infect Dis J. 2010 Mar;29(3):282-4.
  3. https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/legionellosis-legionnaires-disease-and-pontiac-fever
  4. https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/legionellosis-legionnaires-disease-and-pontiac-fever
  5. Eison, R. Legionella Pneumonia: When to Suspect, Diagnostic Considerations, and Treatment Strategies for Hospital-Based Clinicians. Curr Emerg Hosp Med Rep (2014) 2: 205.
  6. https://pedemmorsels.com/legionellosis-in-children/
  7. Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin N Am. 2010;24(1):73-105.
  8. https://www.cdc.gov/legionella/downloads/case-report-form.pdf
  9. Burke et Al. Legionnaires Disease Treatment & Management. Aug 18, 2014. http://emedicine.medscape.com/article/220163-treatment#d11
  10. Sanford Guide to Antimicrobial Therapy 2014