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Home | Articles | Respiratory | Legionnaires Disease

Legionnaires Disease

Last updated 3rd December 2020

Last updated on 13th August 2013 by Calum Murray

Importance

  1. Unique cause of CAP owing to mode of spread and importance of identifying source so as to prevent further cases

Aetiology

  1. Infection acquired by inhaling water mist containing legionella bacteria
  2. Common sources are water tanks, showers, hot tubs, whirlpool baths, humidifiers
  3. Older adults, smokers and people with poor immune sytems are particularly susceptible
  4. Infection occurs 2-14 days after exposure
  5. Person to person transmission has never been shown

Clinical Clues to Diagnosis in a Patient With Pneumonia

  1. Onset with headache, muscle pain, rigor and fever 40C or higher
  2. Presence of gastro-intestinal symptoms especially diarrhoea
  3. Confusion and stupor common
  4. Relative bradycardia often found in elderly patients
  5. Serum Na<120 occurs more frequently than in other pneumonias
  6. Abnormal LFTs

Diagnosis

  1. Urinary antigen test detects L. pneumophila sero group 1. This accounts for 90% cases in community and is nearly always positive by day 7
  2. Sputum culture/respiratory secretions should also be sent even in proven cases and after antibiotics have been started
  3. Direct PCR of sputum is another rapid diagnostic test – usually available by 48 hours
  4. Paired serology of retrospective value only but can be positive even in patients who are negative for the urinary antigen
  5. CXR findings are non specific – can range from lobar pneumonia to diffuse interstitial infiltrates

Treatment

  1. Treat as for Community Acquired Pneumonia – Click to View Section on Community Acquired Pneumonia
  2. Low/Moderately severe pneumonia – Levofloxacin 500mg bd orally
  3. Severe pneumonia – Levofloxacin 500mg bd IV/oral . For first few days this should be given with Clarythromicin 500mg bd orally or Rifampicin 300-600mg bd orally
  4. Duration of treatment – 7 days for low/moderate severity, 10-14 days for severe pneumonia

Outcome

  1. Most patients feel quite well within 3 to 5 days if treated promptly
  2. Mortality 5-30% depending on age and immunocompetence
  3. Complete resolution of CXR changes occurs over one to many months
  4. Second episodes rare, therefore infection must confer immunity

Determining Source of Infection

  1. As soon as diagnosis of Legionella pneumophila has been made, clinician should liaise with microbiologist to confirm that Public Health have been informed
  2. Public Health are then responsible for investigating potential sources of infection

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