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Study objectives To prospectively assess the relative risk for phlebitis in a series of consecutive patients with pneumonia and to identify risk factors that predict an increased risk for phlebitis. Setting Internal medicine department of a tertiary teaching hospital. Patients Seven hundred sixty-six consecutive patients with acute pneumonia receiving IV therapy. Interventions Only the first catheter was taken into account. There were 308 short lines (a 51-mm, 18-gauge Teflon catheter); 307 midsized lines (a 28-cm, 16-gauge polyvinyl chloride catheter); and 151 long lines (71-cm, 14-gauge plain polyurethane catheter). Eighteen variables were prospectively evaluated in an open, nonrandomized study for their contribution to the occurrence of phlebitis. Results The overall phlebitis rate was 39%. Phlebitis developed in 53% of patients with short lines, in 41% of patients with midsized lines, and in 10% of patients with long lines, and these catheters remained in place an average (± SD) of 3.0 ± 2.4 days, 4.6 ± 3.4 days, and 7.8 ± 6.6 days, respectively. The variables that influenced the development of phlebitis, as determined by multivariate analysis, were the following: type of catheter; blood hemoglobin levels; and IV therapy with either corticosteroids or erythromycin. Conclusions According to our data, when the use of a catheter is expected to be required for ≤ 36 h, a short line can be used. If a longer duration is expected, a longer line is warranted. Ours is the first study in which the relationship between blood hemoglobin levels and phlebitis has been reported. Because the use of intravascular devices is increasingly common, a more complete knowledge of the factors that influence their acceptance has become essential.

The concentrations of Legionella pneumophila in cooling towers may vary considerably over short periods of time, producing significant fluctuations throughout the year. Despite genetic variability, in small geographical areas the same indistinguishable pulsed-field gel electrophoresis patterns may be shared among different cooling towers and persist over time.

Copper and silver ionization is a well-recognized disinfection method to control Legionella species in water distribution systems in hospitals. These systems may also serve as a potential indoor reservoir for fungi. The prevalence of fungi was significantly lower in ionized than in nonionized water samples from health care facilities. The clinical consequences of this finding require further investigation.

The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases.

Fluoroquinolones are the most active drugs against Legionella in intracellular and animal models, achieving high intracellular levels and low MICs. In patients with human immunodeficiency virus infection, Legionnaires' disease (LD) has a more severe clinical presentation and worse evolution, with a mortality rate of up to 20%. This chapter presents a case of a severely inmunosuppressed woman with LD in whom treatment failed with levofloxacin and who recovered after the addition of azithromycin. The intracellular location of the pathogen is relevant to the efficacy of the antibiotic. At present, new macrolides such as clarithromycin and azithromycin and fluoroquinolones are the most active drugs in the treatment of Legionella pneumonia. Even though the advances in rapid specific diagnosis and the greater efficacy of the new macrolides and quinolones have led to a better prognosis of Legionella pneumonia, mortality continues to be very high in immunosuppressed patients. Thus, randomized trials comparing the efficacy of combination therapies with new macrolides and quinolones versus monotherapy should be performed to evaluate their real impact in reducing morbidity and mortality of Legionella pneumonia with bad prognostic factors.

Fundamento y objetivo El choque termico es un metodo de desinfeccion frente a Legionella en circuitos de agua sanitaria. En enero de 1996 se produjo un brote de legionelosis nosocomial (LN) en el Hospital Germans Trias i Pujol. El objetivo de este estudio fue evaluar el impacto ambiental y clinico de un choque termico. Material y metodo Recogida diaria de muestras de agua de puntos centrales y de consumo 3 dias antes del choque termico y los 15 dias posteriores. Vigilancia clinica de LN durante 30 dias consecutivos tras el choque termico. Resultados Tras el choque termico, el inoculo de Legionella pneumophila en puntos centrales disminuyo, pero aumento a partir del dia 11 y alcanzo su valor maximo a los 15 dias. No se detecto L. pneumophila en puntos de consumo a los 4 dias. Sin embargo, a partir del dia 7, hubo recolonizacion, que alcanzo el 66% el dia 9. No se detectaron casos clinicos de LN durante el periodo de estudio. Conclusiones El choque termico es un metodo de desinfeccion, eficaz pero transitorio, que permite actuar de forma inmediata ante un brote de LN.

Background Hospital-acquired pneumonia (HAP) is one of the leading nosocomial infections and is associated with high morbidity and mortality. Numerous studies on HAP have been performed in intensive care units (ICUs), whereas very few have focused on patients in general wards. This study examined the incidence of, risk factors for, and outcomes of HAP outside the ICU. Methods An incident case-control study was conducted in a 600-bed hospital between January 2006 and April 2008. Each case of HAP was randomly matched with 2 paired controls. Data on risk factors, patient characteristics, and outcomes were collected. Results The study group comprised 119 patients with HAP and 238 controls. The incidence of HAP outside the ICU was 2.45 cases per 1,000 discharges. Multivariate analysis identified malnutrition, chronic renal failure, anemia, depression of consciousness, Charlson comorbidity index ≥3, previous hospitalization, and thoracic surgery as significant risk factors for HAP. Complications occurred in 57.1% patients. The mortality attributed to HAP was 27.7%. Conclusions HAP outside the ICU prevailed in patients with malnutrition, chronic renal failure, anemia, depression of consciousness, comorbidity, recent hospitalization, and thoracic surgery. HAP in general wards carries an elevated morbidity and mortality and is associated with increased length of hospital stay and increased rate of discharge to a skilled nursing facility.

Fundamento y objetivo: La neumonia por Legionella es poco frecuente en pacientes infectados por el virus de la inmunodeficiencia humana (VIH), en los que, sin embargo, adquiere especial gravedad. Se analizan las caracteristicas clinicas y la situacion inmunitaria de los enfermos infectados por el VIH con legionelosis. Pacientes y metodo: Se revisaron las historias clinicas de los pacientes infectados por el VIH y diagnosticados de legionelosis desde 1983 hasta diciembre de 2003, y se comparo la incidencia de neumonia nosocomial por Legionella en pacientes infectados y no infectados por el VIH entre 1997 y 2000. Resultados: Se incluyo en el estudio a 18 enfermos, de los que el 72,2% fueron diagnosticados mediante deteccion del antigeno de Legionella pneumophila serogrupo 1 en orina. La incidencia de neumonia nosocomial por Legionella en pacientes infectados y no infectados por el VIH fue de 0,3 y 0,25/1.000 ingresos/ano, respectivamente (p = 0,42). El 83,3% de los pacientes recibieron tratamiento antibiotico adecuado a su llegada al servicio de urgencias. La mediana del recuento de linfocitos CD4+ fue de 340,5/µl, el 53,8% tuvo una carga viral indetectable y un 64,7% tomaba farmacos antirretrovirales. Un 72,2% eran fumadores, el 38,8% tenia cancer y el 16,7% recibia quimioterapia. El 93,8% presento tos; el 75%, dificultad respiratoria; el 62,5%, algun sintoma extrarrespiratorio; el 76,5%, incremento de la aspartatoaminotransferasa; el 50%, incremento de la creatincinasa, y el 56,3%, hiponatremia. El 50% presento infiltrados pulmonares bilaterales; el 83,3%, insuficiencia respiratoria, y el 22,2% fallecio. Conclusiones: A pesar de que la legionelosis no es mas frecuente en pacientes infectados por el VIH, la gravedad clinica en este contexto hace pensar que podria tratarse de una infeccion oportunista.

Subtyping isolates may be useful for epidemiological studies of methicillin-resistant-Staphylococcus aureus (MRSA) outbreaks. Among subtyping methods, DNA-based techniques have been applied very effectively for this purpose. An outbreak of MRSA infections took place in one hospital in Barcelona early during 1991. From the beginning of the outbreak to December 92, 70 MRSA isolates from different patients and sources were collected. All strains were evaluated by restriction endonuclease analysis of plasmid DNA (REAP) and macrorestriction endonuclease analysis of genomic DNA using Sma I and pulsed-field-gel-electrophoresis (PFGE). Plasmid screening and REAP using Hind III demonstrated two plasmid subtypes: subtype A showing a large plasmid, and subtype B showing the same large plasmid plus a smaller one. Subtypes A and B corresponded to the more recent and older isolates, respectively, suggesting the loss of the small plasmid during the epidemic. PFGE using Sma I displayed two closely related profiles (PFGE subtype A and A'; CS = 0.90). These subtypes were different from those subtypes exhibited from 4 methicillin-susceptible-Staphylococcus aureus (MSSA) isolates from the same hospital and from 2 epidemiologically unrelated MRSA isolates. Almost all isolates showing PFGE subtype A preceded those isolates showing PFGE subtype A'. This fact and the similarity between both subtypes suggested minor chromosomal DNA rearrangement during the outbreak from a unique strain. While PFGE using Sma I is a useful tool in evaluation of clonal dissemination, our data suggest epidemic or local outbreaks may need several methods to best delineate the source and spread of MRSA strains. The reproducibility and discriminatory power of REAP makes it a useful adjunct in this context.

The primary aim of this study was to evaluate associated factors, clinical features and prognosis of healthcare-related infective endocarditis cases compared with community-acquired and intravenous drug user-related episodes. Changes in the distribution of healthcare-related infective endocarditis were also analysed over time in our setting.A prospective, observational, comparative study was performed. We included all the cases of infective endocarditis from January 2003 to June 2010, which were then classified into 2 groups: group 1: community-acquired and intravenous drug user origin, and group 2: nosocomial and non-nosocomial healthcare-related cases. The episodes were classified into 2 periods: period I: January/2003-June/2006 and period II: July/2006-June 2010. Univariate and multivariate analyses were performed.A total of 212 cases were included (group 1: 138, group 2: 74). The variables of age (risk ratio 1.026; 95%CI, 1.003 to 1.049), Charlson index (risk radio 1.242; 95%CI, 1.067 to 1.445), and previous heart surgery (risk ratio 2.522; 95%CI, 1.353 to 4.701) were independently associated with healthcare-related infective endocarditis on multivariate analysis. A non-significant increase was observed in healthcare-related cases of infective endocarditis in period II (40/104; 38.4% vs. 34/108; 31.4%).The recent increase in healthcare-related infective endocarditis seems to be associated with the use of invasive procedures in elderly patients with prosthetic cardiac valve, and those with a greater number of underlying diseases, especially patients with chronic renal failure on haemodialysis.

Fundamento El uso del tratamiento antirretroviral de gran actividad (TARGA) (highly active antiretroviral therapy) ha conducido probablemente a la reduccion de las infecciones hematogenas en pacientes infectados por el virus de la inmunodeficiencia humana (VIH). Pacientes y metodo Se han estudiado todas las infecciones hematogenas, incluidas micobacteriemias y fungemias, ocurridas en pacientes infectados por el VIH y se han estratificado en dos periodos ( I: 1995-1996, y II: 1997-1998) para evaluar los cambios atribuibles al TARGA. Resultados Se atendieron 226 episodios (incidencia: 38,8 en el periodo I y 15,3 en el periodo II; p Conclusiones La infeccion hematogena en pacientes infectados por el VIH ha disminuido de forma significativa tras el uso generalizado del TARGA.

SUMMARYThe cytopathogenicity of 22Legionella pneumophilaisolates from 17 hospitals was determined by assessing the dose of bacteria necessary to produce 50% cytopathic effect (CPED50) in U937 human-derived macrophages. All isolates were able to infect and grow in macrophage-like cells (range log10CPED50: 2·67–6·73 c.f.u./ml). Five groups were established and related to the serogroup, the number of PFGE patterns coexisting in the same hospital water distribution system, and the possible reporting of hospital-acquired Legionnaires' disease cases.L. pneumophilaserogroup 1 isolates had the highest cytopathogenicity (P=0·003). Moreover, a trend to more cytopathogenic groups (groups 1–3) in hospitals with more than one PFGE pattern ofL. pneumophilain the water distribution system (60%vs. 17%) and in hospitals reporting cases of hospital-acquired Legionnaires' disease (36·3%vs. 16·6%) was observed. We conclude that the cytopathogenicty of environmentalL. pneumophilashould be taken into account in evaluating the risk of a contaminated water reservoir in a hospital and hospital acquisition of Legionnaires' disease.

The molecular epidemiology of clinical and environmental Legionella species isolates was studied in seven hospitals from 1989 to 2006. The number of environmental pulsed field gel electrophoresis (PFGE) patterns ranged from one to nine according to the hospital. Genomic PFGE pattern persistence was observed in 71% of the hospitals, even after 17 years in some hospitals, and the relationship between environmental and clinical isolates was established. The isolates associated with hospital-acquired Legionnaires' disease corresponded to the persistent environmental PFGE patterns of Legionella pneumophila in potable water supplies.

We compared the epidemiological data, clinical features and mortality of community-acquired pneumonia (CAP) by Streptococcus pneumoniae and Legionella in HIV-infected patients and determined discriminative features. An observational, comparative study was performed (January 1994 to December 2004) in 15 HIV patients with CAP by Legionella and 46 by S. pneumoniae. No significant differences were observed in delay until initiation of appropriate antibiotic therapy. Smoking, cancer and chemotherapy were more frequent in patients with Legionella pneumonia (p=0.03, p=0.00009 and p=0.01). Patients with Legionella pneumonia had a higher mean CD4 count (p=0.04), undetectable viral load (p=0.01) and received highly active antiretroviral therapy more frequently (p=0.004). AIDS was more frequent in patients with S. pneumoniae pneumonia (p=0.03). Legionella pneumonia was more severe (p=0.007). Extrarespiratory symptoms, hyponatraemia and increased creatine phosphokinase were more frequent in Legionella pneumonia (p=0.02, p=0.002 and p=0.006). Respiratory failure, need for ventilation and bilateral chest X-ray involvement were of note in the Legionella group (p=0.003, p=0.002 and p=0.002). Mortality tended to be higher in the Legionella group (6.7 vs 2.2%). In conclusion, CAP by Legionella has a higher morbimortality than CAP by S. pneumoniae in HIV-infected patients. Detailed analysis of CAP presentation features allows suspicion of Legionnaires' disease in this subset.

To determine the prevalence of and risk factors for methicillin-resistantStaphylococcus aureus(MRSA) carriage at the time of admission to our hospital, we screened the medical records of 1,128 patients for demographic and clinical data. The antimicrobial resistance pattern and genotype of MRSA isolates were studied. The prevalence of MRSA carriage at hospital admission was 1.4%. Older patients and patients previously admitted to healthcare centers were the most likely to have MRSA carriage at admission.

To compare the risk factors, clinical and laboratory features, and outcome of community-acquired pneumonia (CAP) caused by Legionella pneumophila in elderly (agedor =65) and younger patients.Prospective enrollment of subjects with retrospective data analysis.A 630-bed tertiary center in Badalona (Barcelona), Spain.A total of 158 patients diagnosed with CAP caused by L. pneumophila from 1994 to 2004: 104 younger than 65 and 54 aged 65 and older.Epidemiological, clinical, laboratory, and radiological data and the outcome of the two groups were compared using univariate and multivariate analysis.Underlying diseases, such as chronic pulmonary diseases, diabetes mellitus, neuromuscular diseases, and heart failure; risk of aspiration; and therapy with corticosteroids were significantly more frequent in patients aged 65 and older. Patients younger than 65 were more likely to be male and have toxic habits (cigarette smoking, alcoholism) and human immunodeficiency virus infection than older patients. Fever, nonrespiratory symptoms (diarrhea and headache), and some laboratory abnormalities (hyponatremia (serum sodium concentration130 mmol/L) and high aspartate aminotransferase and creatinine kinase levels) were significantly less frequent in patients aged 65 and older than in younger patients. No significant differences were observed between the two groups in the frequency of higher-severity risk classes and intensive care unit admission or in outcome (complications and mortality).Elderly patients with CAP caused by L. pneumophila had a higher frequency of underlying comorbidities and presented less frequently with fever and classical nonrespiratory symptoms and laboratory abnormalities of Legionnaires' disease than younger patients, although greater severity of illness at onset and higher mortality were not significantly different between the two age groups.

RESUMO: A Legionella pneumophila (LP) é considerada em muitos estudos como uma das três causas mais comuns de pneumonia adquirida na comunidade (2,4) e a segunda causa em termos de gravidade.O principal objectivo do presente estudo realizado no Hospital da Universidade Autónoma de Barcelona, foi comparar os diferentes aspectos clínicos, biológicos e radiológicos da Pneumonia a Legionella pneumophilla e das outras Pneumonias adquiridas oa comunidade (PAC), de modo a auxiliar o diagnóstico precoce da pneumonia a LP.Foi realizado um estudo prospectivo de 392 doentes com PAC. Procedeu-se à análise comparativa dos aspectos epidemiológicos (hospitalizações ou viagens recentes, residência próximo de escavações ou trabalhos de constrção, contacto com animais, aves), demográficos (idade e sexo), clinicos (febre, tosse, expectoração, toracalgia, dispneia, cefaleias, confusão mental, dor aboominal, náuseas, vómitos, diarreia, artromialgias, dias de evolução, antibioterapia prévia, patologiaassociada), analiticos (leucocitose, natrémia­Na, creatina Kinase-CK, aspartato aminotransferase­AST) e radiológicos. Estes aspectos foram estudados em 48 doentes com PAC por LP e 125 doentes com PAC de outra etiologia (68 por Streptococcus pneumoniae, 41 por Clamydia pneumoniae, 5 por Mycoplasma pneumoniae, 4 por Coxiella burnetii, 3 por Pseudomonas aeruginosa, 2 por Haemophilus injluenzae e 2 por Nocardia).A análise unifactorial mostrou que a PAC por LP foi mais frequente hos doentes de meia idade, do sexo masculino, em saúde aparente, mas com hábitos alcoó1icos acentuados, relativamente aos doentes com PAC de outra etioçogia. Também a auseocia de resposta aos fármacos beta-lactamicos prévios, cefaleias, diarreia, hiponatrémia grave e a elevação dos níveis de creatina Kinase sérica (CK) foram mais frequentes na PAC por LP, enquanto que a tosse, expectoração e a toracalgia., foram mais frequeotes na pneumonia bacteriana de outra etiologia. Contudo, a análise multifactorial sómente confirmou estas diferenças relativamente à ausência de doença subjacente, diarreia e elevação dos niveis de CK. Concluiu-se que a anàlise detalbada do modo de apresentação da. PAC perrnite suspeitar a doença dos Legionários numa. unidade de emergência medica. O inicio de antibioterapia, incluindo urn macrólido e as técnicas que permitem urn diagnóstico rápido (isolamento no sangue, secreções brônquicas, urina) são mandatórias de modo a reduzir a morbilidade e mortalidade da doença. COMENTÁRIO: A Pneumonia a Legionella pneumophila é uma das pneumonias adquiridas na. comunidade mais frequentes(1,2,4,5,9), constituindo o terceiro agente etiológico a seguir ao Pneumococo e Mycoplasma. Esta pneumonia adquire por vezes formas graves, com morbilidade e mortalidade elevadas (1,3).Têm sido realizados diversos trabalhos prospectivos e retrospectivos (1,2,3,4,6,8), com o intuito de conhecer quais as principais caracteristicas epidemio1ógicas, clinicas e laboratoriais que permitem distinguir a pneumonia a LP das outras pneumonias da comunidade, de modo a obter um diagnóstico de presunção e uma terapêutica adequada tão precoces quanto possível.A transmissão ocorre por via aérea, habitualmente através da inalação de vaporcs que contêm o microrganismo. Apesar de oeste estudo não se ter encontrado um predominio sazonal, vários trabalhos o apontarn. embora variável de ano para ano(1,6).A pneumonia a LP como foi observado no presente trabalho, predomina em docntcs do sexo masculino (1), de meia-idade. Relativamcntc aos tactores de risco para infecção, o alcoolismo e hábitos tabagicos foram mais rrcquentes na pneumonia a LP (1), enquanto que nas pneumonias de outra etiologia predominararn os doentes com patologias associadas ou imunodeprimidos.Relativamente às manifestacções clínicas, a tosse, expectoração e toracalgia são mais frequentes nas pneumonias de outra etiologia, enquanto que as cefaleias, confusão mental e a diarreia predominam na pneumonia a LP, em que é frequente o envolvimento multissistémico (rim. figado e sistema nervoso) (1,9,10).Nos doentes com PAC a LP, os valores de hiponatrémia (37 U/L) e dos níveis de CK (>232 U/L) foram significativamente superiores aos obtidos nas PAC de outra etiologia, embora apenas nos valores de Natrémia e creatina Kinase as diferenças tenham sido estatisticamente significativas. Outros trabalhos têm rcferido que a encefalopatia, a hiponatrémia, a hematuria microscópica, as anomalias da função renal e hepática surgem com mais frequência na pneumonia a LP que noutras pneumonias (1).Não se encontraram diferenças radiológicas significativas em ambos os grupos de pneumonias adquiridas na comunidade (8), tal como verificado noutros trabalhos (1).Pode concluir-se que perante urn doente com urn quadro clinico sugestivo de Pneumonia grave adquirida na comunidade, há algumas características clínicas e laboratoriais que permitem urn diagnóstico de presunção de pneumonia a Legione/la pneumophila, sendo mandatório nestes casos (7) o inicio de terapêutica empírica com urn macrólido.Convém ser-se criterioso, permanecendo contudo dificil a decisão terapêutica dos doentes com pneumonia adquirida na comunidade. Se por urn lado se corre o risco de não tratar adequada e precocemente uma PAC aLP que pode ter uma cvolução grave, por outro lado, o uso sistematico de determinado grupo de farmacos sem indicação para tal, conduz ao perigo de aumcnto da resistencia antibiótica, como se tern verificado na última decada relativamente à eritrornicina (11). Palavras-chave: lnfecçõcs adquiridas na comunidade, Legionella pneumophila, Pneumonia, Bacteriana, Key-words: Community-acquired infections, Legionella pneumophila, Pncumonia, Bacterial

Superheat-and-flush is one of the methods of disinfection used against Legionella in hospital water distribution systems. An outbreak of nosocomial legionellosis (NL) was detected in the hospital Germans Trias i Pujol in January 1996. The aim of this study was to evaluate the impact of this disinfection technique at an environmental and clinical level.Water samples were collected daily from central and tap water points 3 days prior to 15 days after superheating and flushing. Clinical surveillance of NL was performed 30 consecutive days following disinfection.After superheat-and-flush, the inoculum of Legionella pneumophila decreased in the central points but increased after day 11, achieving maximum values at 15 days. On the other hand, L. pneumophila was not detected in tap water points after 4 days but recolonization was observed after day 7, achieving 66% at day 9. No clinical cases of NL were detected during the study period.Superheat-and-flush is an effective albeit transitory method of rapid disinfection in outbreaks of NL.

Hospital-acquired pneumonia is one of the main causes of nosocomial infection. Although its incidence is higher in intubated patients, around half of all cases occur outside the intensive care unit (ICU). However, few studies have been performed in this setting and consequently most data come from hospitalized series that include patients undergoing mechanical ventilation. The epidemiological differences between intubated patients and non-ICU patients suggest that the etiology and therapeutic approach differ between these two groups. The present article reviews the epidemiology, diagnosis, treatment and prevention of nosocomial pneumonia in general wards.

We evaluated the impact of the copper-silver ionization system in a hospital where hyperendemic nosocomial legionellosis and was present and all previous disinfection measures had failed. After implementation of the copper-silver ionization system, environmental colonization with Legionella species decreased significantly, and the incidence of nosocomial legionellosis decreased dramatically, from 2.45 to 0.18 cases per 1000 patient discharges.

We evaluated a commercially available radioimmunoassay technique for detecting the soluble antigen of Legionella pneumophila serogroup 1 using concentrated and nonconcentrated urine. Concentration was achieved by selective ultrafiltration. The sensitivity of the technique was 60.9% for nonconcentrated urine and 80.4% for concentrated samples, with 100% specificity in both cases.

Legionella infections are not frequent in HIV-infected patients, although clinical manifestations and outcome are particularly severe in this subset. This manuscript analyzes the clinical features and immunological situation of HIV-infected patients with Legionnaires' disease (LD).The clinical files of HIV-infected patients diagnosed with LD from 1983 to December 2003 were reviewed. The incidence of hospital-acquired Legionella pneumonia (HALP) from 1997-2000 in HIV-infected patients was compared with that of non infected patients.Eighteen patients were included. 72.2% were diagnosed by the Legionella urinary antigen assay. The incidence of HALP in HIV-infected and non infected patients was 0.3 and 0.25/1000 admissions/year, respectively (p = 0.42). 83.3% received appropriate antibiotic treatment at the Emergency department. The mean lymphocyte CD4 count was 348.1/microl, 53.8% had an undetectable viral load and 64.7% were on antiretroviral therapy. 72.2% were smokers, 38.8% had cancer and 16.7% were on chemotherapy. 93.8% had cough, 75% dyspnea, 62.5% extrarespiratory symptoms, 76.5% increased AST, 50% increased CK and 56.3% hyponatremia. Moreover, 50% developed bilateral pulmonary infiltrates, 83.3% respiratory failure and 22.2% died.Although LD is not more frequent in HIV-infected than in non infected patients, its clinical severity suggests that it is an opportunistic infection.

The objective of this study was to compare epidemiological data and clinical presentation of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae, Legionella pneumophila or Chlamydia pneumoniae. From May 1994 to February 1996, 157 patients with S. pneumoniae (n = 68), L. pneumophila (n = 48) and C. pneumoniae (n = 41) pneumonia with definitive diagnosis, were prospectively studied. The following comparisons showed differences at a level of at least p0.05. Patients with S. pneumoniae pneumonia had more frequently underlying diseases (HIV infection and neoplasm) and those with C. pneumoniae pneumonia were older and had a higher frequency of chronic obstructive pulmonary disease (COPD), while L. pneumophila pneumonia prevailed in patients without comorbidity, but with alcohol intake. Presentation with cough and expectoration were significantly more frequent in patients with S. pneumoniae or C. pneumoniae pneumonia, while headache, diarrhoea and no response to betalactam antibiotics prevailed in L. pneumophila pneumonia. However, duration of symptomsor = 7 d was more frequent in C. pneumoniae pneumonia. Patients with CAP caused by L. pneumophila presented hyponatraemia and an increase in CK more frequently, while AST elevation prevailed in L. pneumophila and C. pneumoniae pneumonia. In conclusion, some risk factors and clinical characteristics of patients with CAP may help to broaden empirical therapy against atypical pathogens until rapid diagnostic tests are available.

Inhalation of contaminated aerosols is considered the most common route ofLegionellatransmission. The aim of this study was to determine whether contact with water contaminated byLegionellawas related to oropharyngeal colonization in immunosuppressed patients. Eighty-five oropharyngeal swabs (April 1996 to June 1996) were seeded on selective and nonselective buffered charcoal-yeast extract media.Legionellawas not isolated.

Objective:To investigate the presence and clonal distribution ofLegionellaspecies in the water supply of 20 hospitals in Catalonia, Spain.Setting:20 hospitals in Catalonia, an area of 32,000 km2, located in northeast Spain.Methods:Environmental cultures of 186 points of potable water supply and 10 cooling towers were performed for the presence ofLegionellaspecies. Following filtration and acid treatment, the samples were seeded in selective MWY (modified Wadowsky Yee)-buffered charcoal yeast extract-a agar. All isolates obtained were characterized microbiologically and genotyped bySfilpulsed-field gel electrophoresis (PFGE).Results:73 of 196 water samples, representing 17 of the 20 hospitals included in the study, were positive forLegionella pneumophila(serogroups 1, 2-14, or both). The degree of contamination ranged from 200 to 74,250 colony-forming units/L. Twenty-five chromosomal DNA subtypes were detected by PFGE. A single DNA subtype was identified in 10 hospitals, 2 DNA subtypes were observed in 6 hospitals, and 1 hospital exhibited 3 different DNA subtypes. Each hospital had its ownLegionellaDNA subtype, which was not shared with any other hospitals.Conclusions:Legionellawas present in the water of most of the hospitals studied; each such hospital had a unique, dominant chromosomal DNA subtype. The verification of several genomic DNA restriction profiles in such a small geographic area demonstrates the great genetic diversity ofLegionellain the aquatic environment.

The aim of this study was to prospectively analyze the bacterial etiology of community-acquired pneumonia in adults in Spain. From May 1994 to February 1996, 392 episodes of CAP diagnosed in the emergency department of a 600-bed university hospital were studied. An etiological diagnosis based on noninvasive microbiological investigations was achieved in 228 cases (58%); 173 of these diagnoses were definitive and 55 probable. Streptococcus pneumoniae, which caused 23.9% of the episodes, was the predominant pathogen observed, followed by Chlamydia pneumoniae (13.5%) and Legionella pneumophila (12.5%). Other less frequent pathogens found were Haemophilus influenzae (2.3%), Pseudomonas aeruginosa (1.5%), Mycoplasma pneumoniae (1.3%), Coxiella burnetii (1%), Moraxella catarrhalis (2 cases), Nocardia spp. (2 cases), and Staphylococcus aureus (2 cases). Streptococcus pneumoniae was significantly more frequent in patients with underlying disease and/or age > or =60 years (28% vs. 13%, P = 0.002), while Legionella pneumophila was more frequent in patients below 60 years of age and without underlying disease (20% vs. 9%, P = 0.006). Likewise, Streptococcus pneumoniae and Legionella pneumophila were the most frequent etiologies in patients requiring admission to the intensive care unit, occurring in 29% and 26.3% of the patients, respectively. In addition to Streptococcus pneumoniae, other microorganisms such as Chlamydia pneumoniae and Legionella spp. should be seriously considered in adults with community-acquired pneumonia when initiating empiric treatment or ordering rapid diagnostic tests.

The clinical course of legionella pneumonia in immunosuppressed patients is uncertain. This study was undertaken to determine the clinical evolution of legionellosis on the basis of the immune state and to establish the variables associated with death directly related to legionellosis. The study included 78 patients: 28 with chronic disease who had received immunosuppressive treatment (group 1), 24 with chronic disease without immunosuppressive treatment (group 2), and 26 controls. Inclusion criteria were the occurrence of nosocomially acquired pneumonia, Legionella pneumophila infection, and erythromycin therapy that was initiated within 72 hours following diagnosis. Respiratory and extrarespiratory complications were observed more frequently in groups 1 and 2. Bilateral radiological involvement was most frequent in group 1, and recurrence of legionella pneumonia was observed exclusively in group 1. None of these variables achieved statistical significance. The global mortality of the series was 11.5% (17.9%, 12.5%, and 3.8% in groups 1, 2, and 3, respectively). Variables statistically related to mortality were acute renal failure, shock, and need for mechanical ventilation. Although many of the variables analyzed lacked statistical significance, a trend was seen between complications and basal immunosuppression, as previously suggested.

tualmente sindromico. En consecuencia, la etiologia de la neumonia no se conoce bien fuera de las UCI, y asi, en el estudio de Barreiro et al10 solo se determino en el 21% de los casos. La mayoria de los datos disponibles en la bibliografia proceden de series hospitalarias que incluyen a pacientes criticos, donde tienen un gran protagonismo los bacilos gramnegativos4,5. Sin embargo, es probable que la flora orofaringea normal persista mas en el enfermo no ventilado que en el sometido a ventilacion mecanica, y que el papel de determinados microorganismos como Streptococcus pneumoniae sea mayor12. Por otro lado, es dificil conocer la prevalencia de algunos microorganismos como Legionella, hongos, bacterias anaerobias y virus, debido a que no se investigan de forma rutinaria en muchos centros11,13. En el estudio de Barreiro et al10, las etiologias mas frecuentes fueron S. pneumoniae en la neumonia precoz y enterobacterias y Pseudomonas aeruginosa en la neumonia de inicio tardio. S. pneumoniae siempre deberia tenerse en cuenta en la neumonia nosocomial, incluyendo la de inicio tardio, como senala otro estudio que utilizo la deteccion de antigeno en orina de forma sistematica9. Ademas, la demostracion de una amplia colonizacion de las aguas de la mayoria de los hospitales por Legionella spp. y la disponibilidad de tecnicas mas sensibles hacen pensar que este microorganismo pueda ser una causa endemica y relativamente frecuente de neumonia nosocomial en el enfermo no ventilado9,14. Atendiendo a las peculiaridades de la neumonia nosocomial fuera de la UCI resulta necesario un protocolo diagnostico y terapeutico especifico15. Siempre que sea posible, el diagnostico microbiologico, permitira adecuar el tratamiento antibiotico y mejorar el pronostico de los pacientes, especialmente en aquellos mas graves o inmunodeprimidos. Se realizaran hemocultivos en todos los casos y una toracocentesis cuando exista un derrame pleural importante, a pesar de su baja rentabilidad. El cultivo de esputo o del aspirado traqueal tiene poca sensibilidad y una baja especificidad debido a la contaminacion con la flora orofaringea y a la colonizacion por bacilos gramnegativos de un porcentaje elevado de los pacientes hospitalizados y tratados con antibioticos. La tincion de Gram nos da una idea de la calidad del esputo, de forma que muchos laboratorios solo cultivan las muestras representativas del tracto respiratorio inferior (> 25 leucocitos y < 10 celulas escamosas por campo). Sin embargo, este criterio no deberia aplicarse en los enfermos granulopenicos ni en las infecciones bacterianas o fungicas causadas por patogenos que no forman parte de la flora comensal (Legionella spp. y Aspergillus spp., entre otros). El cultivo de esputo debe ser interpretado con cautela, incluso cuando es de buena calidad, y en presencia de un microorganismo unico o predominante, en especial para La neumonia sigue siendo una de las infecciones nosocomiales mas frecuentes y una causa importante de morbilidad y mortalidad hospitalaria. En el estudio EPINE1 de 2003 fue la primera causa de infeccion nosocomial, con un 22,3% de los casos. Su incidencia varia entre 5-10 casos/1.000 ingresos segun el tipo de hospital y el servicio estudiados, siendo 6-20 veces superior en los pacientes sometidos a ventilacion mecanica2,3. La mayoria de los estudios se han realizado en las unidades de vigilancia intensiva, por lo que en ocasiones se equiparan los conceptos “neumonia nosocomial” y “neumonia en el ventilado”4,5. Sin embargo, y a pesar de que hasta la mitad de los casos ocurren en las areas de hospitalizacion general medicoquirurgica, existen pocos estudios de la neumonia nosocomial fuera de la unidad de cuidados intensivos (UCI), posiblemente debido a la dispersion de los casos y a la dificultad diagnostica6-9. Las diferencias epidemiologicas entre los pacientes ingresados en las areas de hospitalizacion general (expuestos a aerosoles ambientales y sin la agresion orofaringea asociada a la intubacion) y los enfermos de las unidades de criticos sugieren que la etiologia de la neumonia nosocomial no es totalmente equiparable en ambos grupos. En consecuencia, es necesario un mayor conocimiento de los factores de riesgo y de la etiologia de esta entidad fuera de la UCI para realizar protocolos preventivos, diagnosticos y terapeuticos especificos. El estudio realizado por Barreiro et al10 y publicado en este numero de ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA analiza la incidencia y los factores de riesgo y pronosticos de la neumonia nosocomial en el enfermo ingresado fuera de las UCI. Del mismo se deduce que la neumonia nosocomial es relativamente frecuente en este ambito y tiene una mortalidad elevada (27%). La incidencia observada (3,35 casos/1.000 ingresos) es similar a la del estudio reciente realizado en 12 hospitales espanoles9. El diagnostico de la neumonia intrahospitalaria requiere un sistema de vigilancia adecuado y una valoracion exhaustiva de los posibles casos, ya que puede pasar desapercibida a falta de datos clinicos especificos o ser diagnosticada de forma erronea en presencia de infiltrados pulmonares debidos a otras causas o de fiebre de origen extrarrespiratorio11. La dificultad para realizar pruebas invasivas y la escasa sensibilidad de las tecnicas microbiologicas convencionales hace que el diagnostico sea habi

In February 1996, an 18-year-old girl was admitted to hospital with hemoptysis and a local lesion in the right lower lobe. She was asymptomatic until December 1995, when she developed an unproductive cough. She had dental caries, and 1 month later presented periodontitis and was treated with antibiotics. On admission, she was apyrexial, and chest radiography showed cavitationwithin the right lower lobe. Zhiel^Neelsen staining was negative in several sputum smears, and oropharyngeal contamination was observed on sputum Gram stain. Tuberculin test was negative. A diagnosis of lung abscess was made, and she initially received amoxycillin^clavulanate. Hemoptysis disappeared, lung cavitation reduced and she was discharged. Three months later the pulmonary lesion remained, although the patient was asymptomatic. In June 1996, hemoptysis reappeared and the chest radiography worsened. Bronchoscopic examination showed no endobronchial lesions, and the Zhiel^Neelsen staining and the Lo« wenstein culture of the bronchoalveolar lavage (BAL) were negative. Furthermore, BAL contained no malignant cells. Computed tomographywas performed and is shown above.

Summary Genotypic variability and clonal persistence are important concepts in molecular epidemiology as they facilitate the search for the source of sporadic cases or outbreaks of legionellosis. We studied the genotypic variability and persistence of Legionella pulsed-field gel electrophoresis (PFGE) patterns over time (period > 6 months) in 34 positive cooling towers from two different areas. In area A, radius of 70 km, 52 indistinguishable PFGE patterns were differentiated among the 27 cooling towers. In 13 cooling towers we observed ≥ 2 PFGE patterns. Each cooling tower had its own indistinguishable Legionella PFGE pattern which was not shared with any other cooling tower. In area B, radius of 1 km, 10 indistinguishable PFGE patterns were obtained from the seven cooling towers. In four, we observed ≥ 2 PFGE patterns. Three of these 10 indistinguishable PFGE patterns were shared by more than one cooling tower. In 27 of 34 cooling towers the same PFGE pattern was recovered after 6 months to up to 5 years of follow-up. The large genotypic diversity of Legionella observed in the cooling towers aids in the investigation of community outbreaks of Legionnaires' disease. However, shared patterns in small areas may confound the epidemiological investigation. The persistence of some PFGE patterns in cooling towers makes the recovery of the Legionella isolate causing the outbreak possible over time.

Objectives: The Hospital Universitario Germans Trias i Pujol is a 600-bed center serving 700,000 inhabitants including 1800 patients with HIV infection in Catalonia (Spain). Highly active antiretroviral therapy (HAART) became available at the end of 1996. Thus, the period 1995–1997 was considered appropriate for evaluating possible epidemiological changes in bloodstream infections (BSI) in HIV-infected patients.Methods: All significant bloodstream infections, including mycobacteremia and fungemia, observed in HIV-positive patients from January, 1995 to December, 1997 have been included in the study.Results: One hundred and eighty six cases were evaluated, in whom a decrease in BSI was observed (68 in 1995, 86 in 1996, 32 in 1997). Over time, we observed an improvement in the immunologic situation of the patients (1995: CD4

The aim of this prospective study was to compare patient characteristics, clinical data, and evolution of Legionella pneumophila pneumonia according to the duration of Legionella urinary antigen excretion. Urine samples from 61 patients with Legionella pneumonia diagnosed by detection of urinary antigen were obtained periodically until urinary antigen could no longer be detected. Cases were divided into two groups based on the duration of urinary antigen excretion: group I (46 patients,60 days) and group II (15 patients,or=60 days). Groups were compared for patient characteristics, clinical data, and evolution of pneumonia. Antigen excretionor=60 days was observed significantly more frequently in immunosuppressed patients ( P=0.001) in whom the time to apyrexia was72 h ( P=0.002), although only the time to apyrexia remained significant on multivariate analysis ( P=0.006). In conclusion, the duration of Legionella urinary antigen excretion was60 days in most patients but was longer in immunosuppressed patients with a longer time to defervescence of fever.

We evaluated a commercial enzyme immunoassay (EIA) kit for detection of Legionella pneumophila serogroup 1 soluble antigen by comparing it to radioimmunoassay (RIA), using both concentrated and nonconcentrated urine samples. The sensitivity of EIA was 67.4% in nonconcentrated urine samples and 82.6% in concentrated urine samples. The sensitivity of RIA was 60.9% and 84.8% in nonconcentrated and concentrated urine samples, respectively. Our study indicates that the sensitivity and specificity of EIA are comparable to those of RIA, and that concentrating the antigen by selective ultrafiltration increases sensitivity for both EIA and RIA, with no significant decrease in specificity.