Legionellosis and water safety

Water within healthcare plumbing systems can promote microbial growth, including multidrug-resistant organisms (MDROs). Water can be the source of healthcare-associated infections (HAIs). Water management programs in healthcare facilities are important to protect vulnerable patients from infections.

Water management programs should include:

  • A multidisciplinary team of facility managers, infection preventionists, clinicians, and administrators who meets regularly to review water management programs.
  • Make sure you meet all quality standards for water entering healthcare facilities (upstream). Work with the water utility to be notified of any water system disruptions that can affect water quality in your facility. Develop plans to mitigate upstream water quality issues.
  • Premise plumbing should be designed and maintained to minimize growth and spread of waterborne pathogens in water (midstream). Map the design of the facility’s water system, identify responses to plumbing with stagnant water, regularly monitor water quality, and identify and respond to any renovations that affect the facility’s plumbing.
  • Implement strategies to minimize patient exposure to waterborne pathogens that can grow in biofilms in sinks, drains, toilets. Splashing from these water sources can disrupt the biofilm and spread these pathogens. Clean and disinfect surfaces in the splash zones near drains, avoid placing patient care or personal items in the splash zone, avoid preparing medication next to a sink, install barriers to prevent splashing from sink to nearby surfaces, offset sink faucet from the drain to prevent splashing of biofilms, do not discard patient waste down sinks, and minimize discarding nutritional products or drinks down sinks or toilets (downstream).

Legionellosis includes 2 diseases: a dangerous type of pneumonia called Legionnaires’ disease and Pontiac Fever (a less severe form of the disease). Both are caused by a waterborne bacteria called Legionella. Humans are typically exposed to these bacteria through contaminated water droplets that contain Legionella from man-made water distribution systems. Common exposure sources are large building cooling towers, swamp coolers, hot tubs, showers/baths, sinks, vaporizers, and humidifiers. In general, people do not spread Legionnaires’ disease to other people. Properly managed potable water for use in residential and commercial locations are the best measures to prevent exposure. Using manufacturer-recommended water sources for respiratory devices such as CPAPs will also minimize risk of exposure to this organism.

Information for healthcare providers

Legionelloses are the collective group of diseases caused Legionella, primarily by Legionella pneumophila serogroup I. They are transmitted primarily via aerosolized water droplets containing the bacteria. Legionella is not usually transmitted person-to-person. Legionnaires’ disease can be very dangerous as it has a mortality rate of 1 in 10. Risk factors for disease include:

  • Age > 50
  • Smoking (current or history of)
  • Chronic lung disease
  • Immunocompromised
  • Systemic malignancies
  • Underlying illness such as diabetes, renal failure, or hepatic failure
  • Recent travel with an overnight stay outside of the home
  • Recent care at a healthcare facility
  • Exposure to hot tubs

Diagnoses can be made with culture from samples of the lower respiratory tract, urinary antigen tests, PCR, fluorescent assays, and radiography. Treatment of Legionelloses can vary greatly case by case. It is recommended to consider whether the exposure was community or healthcare associated and follow the appropriate IDSA-ATS guidelines IDSA-ATS guidelines for treatment of community-acquired pneumonia and the most recent IDSA-ATS guidelines for treatment of hospital-acquired pneumonia.