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Healthcare-related Legionnaires’ disease has a devastating impact on high risk patients, with a case fatality rate of 30-50%. Legionella prevention and control in hospitals is therefore crucial. To control Legionella water colonisation in a hospital setting we evaluated the effect of pipeline improvements and temperature increase, analysing 237 samples over a two-year period (first year: 129, second year: 108). In the first year, 25.58% of samples were positive for Legionella and 16.67% for amoeba. Assessing the distance of the points analysed from the hot water tank, the most distal points presented higher proportion of Legionella colonisation and lower temperatures (nearest points: 6.4% colonised, and temperature 61.4°C; most distal points: 50% and temperature 59.1°C). After the first year, the hot water system was repaired and the temperature stabilised. This led to a dramatic reduction in Legionella colonisation, which was negative in all the samples analysed; however, amoeba colonisation remained stable. This study shows the importance of keeping the temperature stable throughout the circuit, at around 60°C. Special attention should be paid to the most distal points of the circuit; a fall in temperature at these weak points would favour the colonisation and spread of Legionella, because amoeba (the main Legionella reservoir) are not affected by temperature.

To study the presence of SARS-CoV-2 on surfaces (high, medium and low contact) and airs in non-sanitary spaces with high public influx to evaluate the risk of environmental contagion.Surfaces and airs were analysed by RT-qPCR to detect the presence of SARS-CoV-2.394 surfaces and air samples were obtained from spaces with high public influx such as offices, shopping centres and nursing homes. The virus was not detected in any of the samples analysed.Although we cannot emphatically conclude that there is no risk of environmental 27 infection by SARS-CoV-2 in non-sanitary spaces, we can affirm that the risk is almost non- existent.

Legionella is a pathogenic bacterium, ubiquitous in freshwater environments and able to colonise man-made water systems from which it can be transmitted to humans during outbreaks. The prevention of such outbreaks requires a fast, low cost, automated and often portable detection system. In this work, we present a combination of sample concentration, immunoassay detection, and measurement by chronoamperometry. A nitrocellulose microfiltration membrane is used as support for both the water sample concentration and the Legionella immunodetection. The horseradish peroxidase enzymatic label of the antibodies permits using the redox substrate 3,3′,5,5′-Tetramethylbenzidine to generate current changes proportional to the bacterial concentration present in drinking water. Carbon screen-printed electrodes are employed in the chronoamperometric measurements. Our system reduces the detection time: from the 10 days required by the conventional culture-based methods, to 2–3 h, which could be crucial to avoid outbreaks. Additionally, the system shows a linear response (R2 value of 0.99), being able to detect a range of Legionella concentrations between 101 and 104 cfu·mL−1 with a detection limit (LoD) of 4 cfu·mL−1.

Although measures to minimize Legionella colonization in sanitary hot water installations are well established, there is little evidence of their long-term effectiveness in hospital buildings. During an 8 year period, hot water in a large hospital building was sampled monthly in areas with suitable dimensioning and recirculation and in areas with dead legs and low-use taps. In the former areas, the percentage of Legioneffa-negative samples was 83.2% when the temperature was >= 55%, 64.9% when between 50.1 degrees C and 54.0 degrees C, and 51.6% when = 10(3) cfu/L were observed. In poorly designed areas, only 44.7% of samples were negative, and 28.9% presented >= 10(3) cfu/L although reaching 55 degrees C. In these areas, multivariate analysis showed that if hot water supplies were not used daily, the risk of Legionella colonization was greater than two-fold (odds ratio: 2.84; 95% confidence interval: 1.26-6.41), and the risk of finding Legionella concentrations >= 10(3) cfu/L was more than three-fold (odds ratio: 3.18; 95% confidence interval: 1.36-7.46), regardless the temperature. These findings indicate that the effectiveness of maintaining sanitary hot water at a minimum temperature of 55 degrees C is significantly better than that at 50 degrees C for the environmental control of Legionella but only in installations with suitable dimensioning and recirculation. In installations that do not meet these conditions, high temperatures alone result in insufficient control. (C) 2018 Elsevier Ltd. All rights reserved.

Waterborne pathogens are a global concern for public health worldwide. Despite continuing efforts to maintain water safety, water quality is still affected by deterioration and pollution. Legionella pneumophila colonizes man-made water systems and can infect humans causing Legionnaire's disease (LD), pneumonia. The prevention of LD is a public health issue and requires specific systems to control and detect these microorganisms. Culture plate is the only technique currently approved, but requires more than 10 days to obtain results. A rapid test that inform in hours about the presence of Legionella pneumophila in water samples will improve the control of this pathogen colonization. In order to control colonization by L. pneumophila we developed a membrane filter method to capture and immunodetect this microorganism in water samples. This membrane filter is used to retain the bacteria using a nitrocellulose disc inside a home-made cartridge. Subsequently we perform the immunodetection of the bacteria retained in the nitrocellulose (blocking, antibody incubation, washings and developing). On comparing our test with the gold-standard, the most important finding is the considerably reduction in time maintaining the same detection limit. This rapid test is easily automated for L. pneumophila detection allowing a comprehensive surveillance of L. pneumophila in water facilities and reducing the variability in the analyses due to the low need for manipulation. Moreover, corrective measures may be applied the same day of the analysis. This method considerably reduces the detection time compared with the conventional, gold-standard detection culture method that requires more than 10 days, being decisive to prevent outbreaks.

Legionella is a pathogenic bacterium, ubiquitous in freshwater environments and able to colonise man-made water systems from which it can be transmitted to humans during outbreaks. The prevention of such outbreaks requires a fast, low cost, automated and often portable detection system. In this work, we present a combination of sample concentration, immunoassay detection, and measurement by chronoamperometry. A nitrocellulose microfiltration membrane is used as support for both the water sample concentration and the Legionella immunodetection. The horseradish peroxidase enzymatic label of the antibodies permits using the redox substrate 3,3&prime, 5,5&prime, Tetramethylbenzidine to generate current changes proportional to the bacterial concentration present in drinking water. Carbon screen-printed electrodes are employed in the chronoamperometric measurements. Our system reduces the detection time: from the 10 days required by the conventional culture-based methods, to 2&ndash, 3 h, which could be crucial to avoid outbreaks. Additionally, the system shows a linear response (R2 value of 0.99), being able to detect a range of Legionella concentrations between 101 and 104 cfu&middot, mL&minus, 1 with a detection limit (LoD) of 4 cfu&middot, 1.

Aim: To compare the discriminatory power of pulsed-field gel electrophoresis (PFGE) and sequence-based typing (SBT) in Legionella outbreaks for determining the infection source. Materials & methods: Twenty-five investigations of Legionnaires’ disease were analyzed by PFGE, SBT and Dresden monoclonal antibody. Results: The results suggested that monoclonal antibody could reduce the number of Legionella isolates to be characterized by molecular methods. The epidemiological concordance PFGE–SBT was 100%, while the molecular concordance was 64%. Adjusted Wallace index (AW) showed that PFGE has better discriminatory power than SBT (AWSBT→PFGE = 0.767; AWPFGE→SBT = 1). The discrepancies appeared mostly in sequence type (ST) 1, a worldwide distributed ST for which PFGE discriminated different profiles. Conclusion: SBT discriminatory power was not sufficient verifying the infection source, especially in worldwide distributed STs, which were classified into different PFGE patterns.

Infectious diseases have a high incidence in the population, causing a major impact on global health. In vitro culture of microorganisms is the first technique applied for infection diagnosis which is laborious and time consuming. In recent decades, efforts have been focused on the applicability of «Omics» sciences, highlighting the progress provided by proteomic techniques in the field of infectious diseases. This review describes the management, processing and analysis of biological samples for proteomic research.

Introduction The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travelers for work reasons (TWR). Methods Observational, retrospective study. The study population included TWR who were attended before traveling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups. Results In 2007 and 2012 a total of 9197 travelers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 ( p p = .05), more comorbidity ( p = .018) and a greater proportion of stays in rural areas ( p = .0009) for longer time periods ( p = .001). Conclusions At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population.

Resumen Introduccion La crisis economica mundial condiciona la migracion de trabajadores europeos hacia paises en vias de desarrollo con alta incidencia de enfermedades infecciosas. El objetivo de este estudio es valorar si este contexto produce un aumento de los riesgos de los viajeros internacionales que se desplazan por motivos laborales (VML). Metodos Estudio observacional retrospectivo. La poblacion de estudio fueron los VML atendidos antes de su viaje en una Unidad de Salud Internacional durante los anos 2007 (ano anterior al inicio de la crisis europea) y 2012 (con la crisis estructural establecida). Se realizo un analisis comparativo sociodemografico y de los factores de riesgo presentes entre ambos grupos. Resultados En 2007 y 2012 se atendieron un total de 9.197 viajeros. Los VML fueron 344 (3,4%); en 2007, 101 (2,8%) y en 2012, 243 (4,5%) (p Conclusiones A 5 anos del inicio de la crisis economica, existe una variacion en el perfil del VML. Su numero ha aumentado significativamente, asi como la proporcion de los que presentan factores de riesgo para contraer enfermedades importadas. Las Unidades de Salud Internacional deberian adaptarse a las nuevas circunstancias y adoptar medidas preventivas en dicho colectivo.

Summary Background The invasive mosquito Aedes albopictus, with proven vectorial ability to transmit European autochthonous cycles of dengue and chikungunya virus, has currently colonized every coastal department of Eastern Spain. The main objective of the study was to define the epidemiological and clinical characteristics as well as the trends of these two arboviral diseases in a European area heavily colonized by Ae. albopictus. Method A voluntarily-based, prospective and multicenter surveillance study was performed in all medical units of the North Metropolitan area of Barcelona (406,000 inhabitants, Catalonia; Spain) with diagnostic capability from 2009 to 2013. Since any possible increase in arboviral cases could be justified by changes in traveling behaviors along the study period (especially longer trips) the trend showed by these two arboviral diseases was compared with that displayed by malaria cases during the same period. Results 38 out of 52 (73.1%) suspected cases could be serologically confirmed (IgM+): dengue 34/38 (89.5%) and chikungunya 4/38 (11.5%). No autochthonous cases were identified. The overall incidence of both arboviruses was 0.19 cases/10,000 inhabitants-year (95% CI: 0.07–0.3); dengue = 0.17 cases/10,000 inhabitants-year (95% CI: 0.05–0.3), and chikungunya = 0.02 cases/10,000 inhabitants-year (95% CI: 0.001–0.03). The Incidence Relative Risk of arboviral disease between 2009 and 2013 shown a significant trend (IRR = 1.27. IC 95%: 1.01–1.59; p = 0.043) when compared with that displayed by malaria (IRR = 1.04. IC 95%: 0.924–1.192). If no unexpected circumstances concur, the arboviral disease incidence tax would equal that of malaria about 2021–2022. Conclusions The incidence of dengue and chikungunya is steadily increasing in the North Metropolitan area of Barcelona, a region densely colonized by Ae. albopictus, at the entire expense of imported cases (especially Visiting Friends and Relatives travelers). To date, no secondary autochthonous cases have been identified and, thus, they have not taken part in this rise.

MRSA nasal carriage was detected in 15.7% of 204 residents from 6 nursing homes (NHs) in the Osona region (Barcelona, Spain), and the MRSA-ST398 lineage was identified in 15.6% of MRSA-positive residents and in 2.5% of all NH residents evaluated. Most MRSA-ST398 carriers (4 of 5) had direct or indirect contact with pig farms.Infect Control Hosp Epidemiol 2018;39:90–93

Legionella pneumophila is responsible for Legionnaires' disease (LD). Its detection in both environmental and clinical samples is mainly performed by culture plate method which requires up to 10 days to obtain results. Nowadays, there are commercial antibodies against this bacterium, but they have not been tested against all subgroups of L. pneumophila sg 1 or serogroups 1–16 or their cross-reactions with other non-Legionella bacteria. Indeed, many of these antibodies became available when only 8 serogroups of L. pneumophila had been described. We tested 7 antibodies and found that 2 (Mab 8/5 and OBT) specifically detected all the subgroups of L. pneumophila sg 1, one without cross-reactions (Mab8/5). Moreover, the LP3IIG2 antibody detected almost all serogroups tested with lower rates of cross-reactivity, resulting in a specific sensitive antibody for the detection of L. pneumophila. LP3IIG2 presented higher rate of cross-reactivity against respiratory non-Legionella isolates, thereby contraindicating its clinical applicability., The authors acknowledge the sponsorship by Gas Natural Fenosa and financial support from CIBER and CERCA Programme/Generalitat de Catalunya. N.U. (TECSPR15-1-0046) and O.C (TECSPR14-2-0034) have received funding from the People Programme (Marie Curie Actions) of the 7th Framework Programme of the European Union (FP7/2007–2013), TECNIOspring program from the Agency for Business Competitiveness of the Government of Catalonia (ACCIÓ).

The microbial quality of water is a key aspect to avoid environmental and public health problems. The low pathogen concentration needed to produce a disease outbreak makes it essential to process large water volumes and use sensitive and specific methods such as immunoassays for its detection. In the present work, we describe the development of a device based on microfiltration membranes to integrate the concentration and the immunodetection of waterborne bacteria. A microfiltration membrane treatment protocol was designed to reduce the non-specific binding of antibodies, for which different blocking agents were tested. Thus, the proof of concept of the microbial detection system was also carried out using Escherichia coli as the bacterial pathogen model. E. coli suspensions were filtered through the membranes at 0.5 mL s−1, and the E. coli concentration measurements were made by absorbance, at 620 nm, of the resultant product of the enzymatic reaction among the horseradish peroxidase (HRP) bonded to the antibody, and the substrate 3,3′,5,5′-tetramethylbenzidine (TMB). The results showed that the homemade concentration system together with the developed membrane treatment protocol is able to detect E. coli cells with a limit of detection (LoD) of about 100 CFU in 100 mL., The authors acknowledge financial support from the Spanish Ministry of Economy and Competitiveness (BACSYS pro- ject CTQ2014-54553-C3-1-R). N.U. and O.C. acknowledge funding from the People Programme (Marie Curie Actions) of the 7th Framework Programme of the E uropean Union (FP7/2007-2013), TECNIO-spring program from the Agency for Business Competitiveness of the Government of Catalonia (ACCIÓ). J.J.E. ac- knowledges financial support from the Catalan Industrial Doctorate pro- gram and Waterologies. S.L. and N.P. acknowledge financial support from Gas Natural Fenosa.

Molecular epidemiologic studies of Legionella have shown different molecular types coexisting in the same environment, with only one having the ability to trigger an outbreak. We therefore studied the proteome of isolates of these different molecular types in search of the proteins responsible for infection. In this study, we performed a differential proteomic analysis between patient-related and non-patient-related environmental isolates using two-dimensional difference gel electrophoresis (2D-DIGE) combined with mass spectrometry. Sixty-three spots were observed as being different between the two groups; 31 spots were identified corresponding to 23 different proteins. Patient-related isolates overexpressed proteins associated with metabolism, with enzymes of the tricarboxylic acid cycle and the degradation pathways being the most abundant proteins identified. However, the largest group of non-patient-related proteins was associated with stress response. Furthermore, the MOMP protein was located in different spots depending on their patient-related or non-patient-related origin, suggesting different post-translational modifications. According to these results, different bacterial adaptation pathways are activated in stress conditions which influence their ability to produce infection.

Resumen Antecedentes y objetivos Como consecuencia inevitable de la inmigracion latinoamericana, Espana y otros paises europeos deben afrontar el abordaje de la infeccion/enfermedad chagasica de la que epidemiologicamente persisten mas interrogantes que respuestas. El objetivo del estudio es describir la poblacion diagnosticada de infeccion/enfermedad chagasica residente en la zona metropolitana norte de Barcelona (406.000 habitantes). Pacientes y metodo El estudio, prospectivo y multicentrico en 3 hospitales y una unidad de salud internacional (2007-2011), incluyo a todos los pacientes con serologia positiva a Trypanosoma cruzi solicitada por la razon que fuere. Resultados Los 139 casos estudiados representan unas incidencias anuales de: a) 0,68/10.000 habitantes, y b) 73,2/10.000 inmigrantes procedentes de zonas endemicas. Estaban enfermos (presentaron alteraciones en alguna prueba complementaria) 80 (57,6%): cardiologicas 62 (44,6%), gastroenterologicas 38 (27,3%) y 20 (14,4%) ambas. Segun el Consenso Brasileno de cardiopatia chagasica, se encontraban en estadio 0 = 84 (60,4%); a = 40 (28,7%); b1 = 4 (2,9%), b2 = 10 (7,2%) y c/d = 1 (0,7%) pacientes. Se indico tratamiento (benznidazol 5 mg/kg/24 h durante 60 dias) en 116 (83,4%) pacientes, y 89 (76,7%) lo completaron. Presentaron efectos secundarios 56 (50,9%), lo que obligo a retirarlo en 21 ocasiones (19,1%). Conclusiones En la zona metropolitana norte de Barcelona han sido diagnosticados menos casos de infeccion/enfermedad chagasica de los esperables. La serie contiene un elevado numero de pacientes enfermos y posiblemente haya un numero elevado de inmigrantes procedentes de zonas endemicas en la fase cronica asintomatica de la infeccion que ignoran su estado.

ResumenIntroducciónLa peregrinación religiosa a Arabia Saudí o Hajj es un precepto básico en la doctrina islámica. Anualmente millones de peregrinos (un 5% procedente de la Unión Europea) se concentran en La Meca después del Ramadán, con los riesgos sanitarios que eso conlleva.MétodosEstudio observacional y prospectivo de una cohorte de peregrinos atendidos en visita de actividades preventivas predesplazamiento en la Unidad de Salud Internacional Metropolitana Norte (Santa Coloma de Gramenet, Barcelona, España) durante 2009-2010.ResultadosSe valoraron 193 peregrinos (135 hombres, 69,9%), con una edad media (DE) de 37,1 (16,9) años. Eran inmigrantes 176 (91,2%), originarios de Pakistán (54,9%), Marruecos (29%), Bangladesh (4,1%) y otros (7,2%). Se desplazaban a Arabia Saudí por una media (DE) de 16,3 (9,2) días; optaban por la peregrinación larga (Hajj) 80 (41,5%) y por la corta (Umra) 113 (58,5%). Presentaban antecedentes patológicos 29 (15%). Se obtuvo una cobertura vacunal superior al 75% para tétanos-difteria, antineumocócica y antimeningocócica tetravalente, y sólo de un 70,4% para la antigripal. Presentaron algún problema de salud 41 (13,5%), el 61% de ellos síntomas de vías respiratorias. Los factores de riesgo independientemente relacionados con presentar enfermedades fueron los días de estancia (odds ratio [OR]=1,06; intervalo de confianza del 95% [IC95%]: 1,01-1,11) y realizar el Hajj frente a la Umra (OR=1,08; IC95%: 1,07-1,12).ConclusionesLos peregrinos a Arabia Saudí procedentes de España son un colectivo fundamentalmente joven y sano. Presentaron un mayor número de enfermedades aquellos con estancias más largas.AbstractIntroductionReligious pilgrimage to Saudi Arabia, or Hajj, is a basic tenet of the Islamic doctrine and, after Ramadan, annually represents the largest human concentration (with up to 5% of from the EU) around the world. Such a gathering entails health risks.MethodsA prospective observational study was conducted of a cohort of pilgrims attended for pre-travel preventive activities in the North Metropolitan International Health Unit (Santa Coloma de Gramenet, Barcelona, Spain) from 2009-2010.ResultsA total of 193 pilgrims were assessed and 135 (69.9%) were men. Their mean age (SD) was 37.1 (16.9) years. Among the pilgrims, 176 (91.2%) were immigrants, mainly from Pakistan (54.9%), Morocco (29%), Bangladesh (4.1%) or other countries (7.2%). The pilgrims stayed in Saudi Arabia a mean (SD) of 16.3 (9.2) days. Eighty (41.5%) opted for the 1 month-long pilgrimage (Hajj) and 113 (58.5%) for the shorter Umra. One or more pathological antecedent was recorded in 29 (15%). Vaccination coverage was >75% for tetanus-diphtheria, pneumococcal and quadrivalent meningitis but was only 70.4% for influenza. After returning, 41 (13.5%) pilgrims reported some health problem; of these, 61% were respiratory tract symptoms. The risk factors independently correlated with the presence of diseases was the number of days in Saudi Arabia (OR=1.06; 95% CI: 1.01-1.11) and taking part in the Hajj compared with the Umra (OR=1.08; 95% CI: 1.07-1.12).ConclusionsReligious pilgrims from Spain to Saudi Arabia are mainly young and healthy. Those with longer stays abroad contracted a higher number of diseases.

Nosocomial pneumonia is the second most frequent cause of nosocomial infection. Most studies have been carried out in intensive care units with patients requiring mechanical ventilation or at high risk for developing nosocomial pneumonia. However, about half of the cases of nosocomial pneumonia occu

Resumen Introduccion Legionella pneumophila (L. pneumophila) fue aislada en tres torres de refrigeracion implicadas en tres brotes de legionelosis comunitaria. En cada una de ellas se encontraron cepas con dos subtipos diferentes de ADN cromosomico. Sin embargo, solo uno de ellos era identico al de las cepas clinicas. Para intentar entender porque solo una de las cepas ambientales produjo los casos clinicos investigamos la virulencia intrinseca de estas cepas. Metodos Se seleccionaron 6 cepas de L. pneumophila sg.1: dos cepas (A1 y B1) procedentes de la torre de refrigeracion 1, dos cepas (A2 y B2) de la torre 2 y dos cepas (A3 y B3) de la torre 3. Las cepas A presentaban un perfil de ADN cromosomico identico a la cepa clinica aislada en los individuos afectados en cada uno de los brotes de legionelosis. La cepa B presentaba un perfil cromosomico diferente. Se realizaron ensayos de replicacion en macrofagos, se determino la presencia del epitopo reconocido por MAb 3/1 y se estudio la cinetica de crecimiento en medio BCYE. Las cepas se tipificaron mediante electroforesis en campo pulsante. Resultados Las cepas A no presentaron mayor grado de virulencia, sin embargo, fueron capaces de crecer y sobrevivir mejor que las cepas B en medio BCYE. Conclusiones Estos resultados sugieren que las cepas mejor adaptadas al medio conseguiran desplazar a las demas y seran capaces de propagarse e infectar a los humanos. La adaptacion a las condiciones ambientales podria desempenar un papel importante en la patogenia de cada cepa.

Fundamento y objetivo En el ano 2001 tuvo lugar en Murcia un brote de enfermedad del legionario (EL) con una de las tasas de mortalidad mas bajas conocidas. Los objetivos de este estudio fueron describir la presentacion clinica y los resultados de los estudios molecular y de virulencia de los aislamientos clinicos de Legionella para correlacionar la baja mortalidad de la serie con la virulencia de la cepa. Pacientes y metodo Estudio prospectivo y descriptivo de un brote de EL en un subgrupo de 86 pacientes. Se analizan datos demograficos, factores de riesgo y evolucion clinica. Se ha practicado subtipificacion molecular mediante electroforesis en campo pulsatil y estudio de citopatogenicidad de los aislamientos clinicos y se han comparado con los de aislamientos procedentes de otros brotes. Resultados La edad media fue de 58,2 anos, con predominio del sexo masculino (77,9%). El tabaquismo fue el factor de riesgo mas frecuente (71,7%). El 70,2% de los pacientes presentaba enfermedades de base. Las manifestaciones clinicas, los datos de laboratorio y la radiologia fueron compatibles con un cuadro de neumonia atipica. La mortalidad fue del 3,2%. Todos los aislamientos clinicos de Legionella pneumophila mostraron el mismo subtipo molecular. En el estudio de citopatogenicidad, las cepas de Legionella procedentes del brote se incluyeron dentro del grupo de menor virulencia. Conclusiones En este subgrupo de pacientes predominaron el sexo masculino, el tabaquismo, la presentacion clinica compatible con neumonia atipica y la baja mortalidad. La baja virulencia de este genotipo molecular de L. pneumophila podria ser causante, en parte, de la baja mortalidad observada en el brote de Murcia.

Objetivo Describir la investigacion de un brote comunitario de legionelosis originado en unas torres de refrigeracion de un hospital. Pacientes y metodos Pacientes diagnosticados de neumonia por Legionella pneumophila serogrupo 1 (L. pneumophila) asociados con el barrio de Vallcarca (Barcelona) en agosto de 2004. La exposicion se determine mediante una encuesta estandarizada. Se llevo a cabo una investigacion ambiental para identificar el foco emisor. Se realizo un analisis descriptivo con calculo de tasas de incidencia, asi como el estudio molecular para documentar la identidad genetica entre las cepas humanas y ambientales aisladas. Resultados Se detectaron 33 casos de neumonia por L. pneumophila. La edad media fue de 68 anos y el 70% de los afectados eran varones. La tasa de incidencia en los mayores de 65 anos residentes a una distancia menor o igual a 200 m del foco emisor fue de 888,9 casos/100.000 habitantes. La tasa de letalidad fue del 6%. Se identificaron cuatro torres de refrigeracion estacionales no censadas ubicadas en un centro sanitario. En todas se aislo L. pneumophila y al menos una colonia de cada instalacion compartia perfil genetico con las cepas aisladas en los pacientes. Conclusiones Se muestra la asociacion de un brote comunitario de neumonia por Legionella y las torres de refrigeracion de un centro sanitario que no estaban censadas. Se remarca la necesidad de notificar cualquier instalacion de riesgo y de realizar un seguimiento para asegurar que cumplen con la legislacion.

Funding: This research was supported by a 2011 foundation grant (04/2011) from the Unnim bank group, through Fundació Caixa Manlleu-Fundació d'Osona per a la Recerca i l'Educació Sanitàries (FORES: in English, Osona Foundation for Health Research and Education; http://www.foresosona.org/), Call V: Health Sciences. Altres ajuts: Unnim bank group, through Fundació Caixa Manlleu - Fundació d'Osona per a la Recerca i l'Educació Sanitàries/04/2011 A livestock-associated clonal lineage (ST398) of methicillin-resistant Staphylococcus aureus (MRSA) has been identified causing colonization or infection in farm workers. The aim of the study was to analyze the prevalence of MRSA-ST398 colonization in pigs and in pig farmers in an area with a high pig population (Osona, Barcelona province, Catalonia, Spain). We performed a cross-sectional prevalence study in Osona (Catalonia, Spain), from June 2014 to June 2015. All pig farm workers from 83 farms were studied. Twenty of these farms were randomly selected for the study of both pigs and farmers: 9 fattening and 11 farrow-to-finish farms. All workers over the age of 18 who agreed to participate were included. Samples were analyzed to identify MRSA-ST398 and their spa type. Eighty-one of the 140 pig farm workers analyzed (57.9% (95% IC: 50.0-66.4%)) were MRSA-positive, all of them ST398. The mean number of years worked on farms was 17.5 ± 12.6 (range:1-50), without significant differences between positive and negative MRSA results (p = 0.763). Over 75% of MRSA-ST398 carriers worked on farms with more than 1250 pigs (p < 0.001). At least one worker tested positive for MRSA-ST398 on all 20 selected pig farms. Ninety-two (46.0% (95% IC: 39.0-53.0%)) of the nasal swabs from 200 pigs from these 20 farms were MRSA-positive, with 50.5% of sows and 41.4% of fattening pigs (p = 0.198) giving MRSA-positive results. All the isolates were tetracycline-resistant, and were identified as MRSA-ST398. The spa type identified most frequently was t011 (62%). Similar spa types and phenotypes of antibiotic resistance were identified in pigs and farmers of 19/20 tested farms. The prevalence of MRSA-ST398 among pig farm workers and pigs on farms in the studied region is very high, and the size of the farm seems to correlate with the frequency of colonization of farmers. The similar spa -types and phenotypes of resistance detected in pigs and workers in most of the farms studied suggest animal-to-human transmission.

OBJECTIVES: To compare the risk factors, clinical and laboratory features, and outcome of community-acquired pneumonia (CAP) caused by Legionella pneumophila in elderly (aged ≥65) and younger patients. DESIGN: Prospective enrollment of subjects with retrospective data analysis. SETTING: A 630-bed tertiary center in Badalona (Barcelona), Spain. PARTICIPANTS: 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. MEASUREMENTS: Epidemiological, clinical, laboratory, and radiological data and the outcome of the two groups were compared using univariate and multivariate analysis. RESULTS: 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 concentration

The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2)

La neumonia nosocomial es una de las primeras causas de infeccion nosocomial. Aunque su incidencia es mas elevada en los enfermos intubados, alrededor de la mitad de los casos se produce en las areas de hospitalizacion convencional. Sin embargo, existen pocos estudios en este ambito, por lo que la mayoria de los datos procede de series hospitalarias que incluyen a enfermos sometidos a ventilacion mecanica. Las diferencias epidemiologicas entre los enfermos intubados y los ingresados fuera de las unidades de cuidados intensivos sugieren que la etiologia y la actitud terapeutica no son totalmente equiparables en ambos grupos. En el siguiente articulo se revisa la epidemiologia, el diagnostico, el tratamiento y la prevencion de la neumonia nosocomial en las areas de hospitalizacion general.

Background Erythromycin has been the treatment of choice for Legionnaires disease (LD). However, treatment failure and experimental evidence of its bacteriostatic effect have led to evaluation of new drugs such as fluoroquinolones. This study compared the evolution of patients with LD treated with macrolides and fluoroquinolones. Methods A prospective observational study was performed, and 130 patients from three centers were included. Diagnoses were made using Legionella urinary antigen assay in all patients. Patients receiving any antibiotic > 36 h before starting the study therapy were excluded. Group 1 included 76 patients who received macrolides (33 patients with erythromycin and 43 patients with clarithromycin), and group 2 included 54 patients treated with fluoroquinolones (50 patients with levofloxacin and 4 patients with ofloxacin). Results No significant differences were seen between the two groups regarding age, sex, smoking, alcohol intake, underlying diseases, or community/hospital acquisition. The time from onset of LD symptoms until the initiation of antibiotic treatment was 78.5 h and 92.7 h in groups 1 and 2, respectively (p = 0.1). Time to apyrexia was significantly longer in the macrolide group (77.1 h vs 48 h for groups 1 and 2, respectively; p=0.000). There were no differences according to radiology, clinical complications, or mortality. Nevertheless, a trend to a longer hospital stay was observed in the macrolide group (9.9 days vs 7.6 days in groups 1 and 2, respectively; p=0.09). Conclusions Fluoroquinolones were as effective as erythromycin in the treatment of LD. It is of note that time to apyrexia was significantly shorter and hospital stay tended to be shorter in patients receiving fluoroquinolones.

Study objective To know the incidence, epidemiology, etiology, and outcome of hospital-acquired pneumonia (HAP) in non-ICUs adult patients. Setting Twelve Spanish teaching hospitals. Interventions From April 1999 to November 2000, non-ICU HAP was prospectively studied by active, bimonthly 1-week surveillance. Epidemiologic data, etiology, and evolution of pneumonia were recorded. Blood and sputum cultures and Legionella pneumophila and Streptococcus pneumoniae urinary antigen tests were performed. Results We included 186 patients, with complete data available in 165 patients (70.3% male gender; mean age, 63.7 ± 16.9 years [ ± SD]) The mean incidence of HAP was 3 ± 1.4 cases/1,000 hospital admissions. Most patients (64.2%) were in medical wards, had severe underlying diseases (66.6%), and had a hospital stay > 5 days (76.4%). Blood cultures were performed in 139 patients (84.2%), sputum cultures were performed in 89 patients (53.9%), and urinary antigen detection was performed in 123 patients (74.5%). An etiologic diagnosis was obtained in 60 cases (36.4%), and 31 were definitive. The most frequent etiologies were S pneumoniae (16 cases, 14 definitive), L pneumophila (7 cases, 7 definitive), Aspergillus sp (7 cases, 3 definitive), Pseudomonas aeruginosa (7 cases, 2 definitive), and several Enterobacteriaceae (8 cases, 4 definitive). Clinical complications occurred in 52.1% of the cases, and mortality was 26% (13.9% attributed to pneumonia). Conclusions Non-ICU HAP is an important cause of hospital morbidity, observed most frequently in medical wards and elderly patients with severe underlying diseases. In this setting, S pneumoniae and Legionella sp should be considered in addition to other nosocomial pathogens; urinary antigen detection is useful in determining the prevalence of these microorganisms.

Study objectives To compare the outcome of Legionnaires disease (LD) in patients with and without HIV infection. Design Retrospective review of clinical charts. Setting Six hundred-bed university hospital. Patients We studied the clinical findings of 64 patients without HIV and 15 patients with HIV. Patients with a serologic diagnosis only were not included. Patients with previous immunosuppressive therapy or transplant recipients were excluded from the former group. In the HIV group, the mean CD4 cell count was 347.5/μL, plasma viral load was undetectable in 50% of the patients, and only one patient (7%) was receiving cotrimoxazole as prophylaxis against Pneumocystis carinii at the time of pneumonia. No differences were observed in the two groups with respect to community or nosocomial acquisition, delay in the initiation of appropriate treatment, the use of macrolides or fluoroquinolones, and Fine score in cases of community-acquired LD. Results Univariate analysis showed that time to apyrexia was longer, and respiratory symptoms, bilateral infiltrates in chest radiograph, hyponatremia, increase in aspartate aminotransferase and creatine phosphokinase (CK), and respiratory failure were more frequent in the HIV group. Mortality was greater in patients with HIV, achieving a statistically significant value of 20%; however, multivariate analysis only confirmed these differences with respect to the increase in CK. Conclusions LD has a more severe clinical presentation and worse evolution in patients with HIV.

Las enfermedades tropicales son por definicion las endemi-cas de paises cuyo ecosistema permite la existencia de re-servorios y vectores que posibilitan el mantenimiento de ci-clos vitales –a veces muy complejos– de microorganismospatogenos. El paradigma de ello son las enfermedades pa-rasitarias. No obstante, a la sombra de la desigualdad exis-tente entre paises ricos y pobres, desde la segunda mitaddel siglo

Objectives Tetracycline resistance (Tet R ) is a phenotypic marker of the livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) CC398 clone. The aim of this study was to analyse the prevalence of MRSA CC398 in patients in contact with healthcare facilities and differences between patients with MRSA-Tet R and MRSA tetracycline-susceptible (Tet S ) strains. Methods Patients diagnosed with MRSA from January 2012 to December 2015 were divided into two groups, MRSA-Tet R and MRSA-Tet S . Epidemiologic and clinical data were evaluated. Molecular analysis was performed (multilocus sequence typing, spa typing) on MRSA-Tet R strains. Results Data from 288 MRSA patients were obtained, and 106 (36.8%) carried MRSA-Tet R (93 typed as CC398 (87.7%); the remaining 13 isolates were ascribed to CC9, CC1, CC121, CC30, CC97, CC146 and CC152). The most frequent spa type was t011 (56.6%, 61/106). Detection of MRSA-Tet R increased over the years (21.9%, 16/73, in 2012; 50.7%, 36/71, in 2015; p R patients vs. 83.3% (95/114) in MRSA-Tet S patients (p R patients in nursing homes was lower than in MRSA-Tet S patients (4.7%, 5/106, vs. 27.5%, 50/182, p R as distinct from MRSA-Tet S was associated with workers on pig farms (49.0%, 52/106, vs. 1.0%, 2/182; p Conclusions Prevalence of MRSA-Tet R (especially CC398) at the hospital level in a Spanish region with intensive pig farming activity is high and is responsible for severe infections. Significant differences were detected in clinical and epidemiologic characteristics among MRSA-Tet R and MRSA-Tet S patients.

Legionella pneumophila has been recognized as an important cause of community-and hospital-acquired pneumonia in both healthy and immunosuppressed patients since its first description in 1976. The authors have systematically used urinary antigen testing as a specific diagnostic test for Legionella infection since 1994. It should also be pointed out that the reporting of Legionnaires’ disease (LD) has been mandatory in Catalonia since 1987. This chapter describes demographic data; clinical, analytical, and radiological characteristics; diagnostic methods; and therapeutic data of a series of community- and hospital-acquired cases of LD collected from 1983 to 2005. It determines trends in demographic and clinical data, individual risk factors, diagnostic methods, and outcome over time. Mortality by nosocomial and community-acquired LD combined has almost significantly decreased over time, which may be due to the earlier diagnosis and changes in treatment.

This chapter compares the individual risk factors, clinical features, and mortality of Legionella pneumonia in hospital and community scenarios. A comparative study was performed from 1983 to 2005, with 425 cases of pneumonia due to Legionella pneumophila being diagnosed during this time. The patients were divided into two groups based on the site of acquisition. Group 1 included 197 patients with community-acquired Legionella pneumonia (CALP), and group 2 included 123 patients with hospital-acquired Legionella pneumonia (HALP). Respiratory symptoms, gastrointestinal, neurological manifestations, and laboratory abnormalities prevailed in the community setting probably for two reasons: first, the CALP patients entered the hospital late because of the lack of specificity in initial symptomatology, allowing extrapulmonary symptoms to develop. Second, in hospitals with endemic legionellosis, the diagnosis and the onset of treatment for nosocomial Legionella pneumonia is immediate because of the high level of suspicion. This makes the extrapulmonary manifestations of Legionella infection less likely to be observed. The best way to prevent HALP is by culturing the hospital water supply, and, if colonized, Legionella tests should be used in any case of hospital-acquired pneumonia.

Bacterial pneumonia continues to be the most frequent pulmonary complication in human immunodeficiency virus (HIV)-infected patients, although its prevalence has decreased with the use of highly active antiretroviral therapy. The most common etiologic agent of community-acquired pneumonia (CAP) in infected and uninfected patients is Streptococcus pneumoniae. Legionella is at present one of the leading causes of CAP in the general population. This chapter compares the epidemiological data, clinical features, outcome, and mortality of pneumonia by S. pneumoniae and by Legionella spp. in HIV-infected patients. An observational, comparative study was performed in 15 HIV patients with CAP by Legionella (group 1) and 46 by S. pneumoniae (group 2). No statistically significant differences were observed between the two groups in either the use of an appropriate antibiotic treatment in the emergency department or in the delay from the presentation of the symptoms until the initiation of an appropriate antibiotic therapy. Legionella pneumonia (LP) should be considered as an opportunistic infection in HIV-infected patients, and the Legionella urinary antigen test should be mandatory whenever we are faced with CAP in an HIV-positive patient.

Colonization of cooling towers (CTs) by Legionella is frequent and has been implicated in many community outbreaks of Legionnaires´ disease (LD). This chapter describes the fluctuation in Legionella counts in CTs over a 1-year period. Ten colonies of each positive culture were selected and characterized by nutritional requirements and by the immunoglutination latex assay test (OXOID). Legionella pneumophila was isolated in 13 of 15 CTs (86.6%). All positive CTs were colonized by L. pneumophila serogroup 1. No seasonal influence was observed with respect to variations in L. pneumophila counts. All of the systems would not have been considered a risk at some sample time during the same season.

Legionella pneumophila has frequently been found in cooling towers (CT) with different DNA subtypes being implicated in community-acquired Legionella infections. The aims of this chapter were to investigate the genotypic variability of L. pneumophila in cooling towers and determine the persistence of the DNA subtypes over time in two different areas. In six cooling towers the authors observed a single DNA subtype, in five, two DNA subtypes, in three cooling towers, three DNA subtypes and in two cooling towers the authors observed fewer than four DNA subtypes. In three of the seven cooling towers the authors observed a single DNA subtype, in two the authors found two DNA subtypes, and in another two, three DNA subtypes were reported. When authors studied the persistence of the DNA subtypes it was found that in 19 of 23 cooling towers (82%) the same DNA subtype was recovered after at least 6 months of follow-up. These results demonstrate the great genotypic variability of Legionella in the cooling towers.

This chapter determines variables related to mortality of Legionnaire's disease (LD). An observational, comparative study was performed from 1983 to 2005, with 408 cases of Legionella pneumonia being diagnosed during this time. The variables studied included demographic characteristics, individual and aspiration risk factors, clinical manifestations, radiological manifestations, diagnostic data, treatment, and outcome. The variables were analyzed using univariate and multivariate logistic regression analysis by SPSS version 12.0. Regarding demographic data and risk factors, patients who died had a higher frequency of underlying diseases than the control group (89.8 versus 66.9%): mainly chronic respiratory disease (42.9 versus 29.6%), chronic heart failure (22.4 versus 10.2%), neoplasm (38.8 versus 15.8%), neurological sequelae (20 versus 7.6%), and inmunosuppressive therapy-mainly corticoids (45.8 versus 14.6%). Despite the improvement in the diagnostic procedures of LD and the use of more efficacious antibiotics against Legionella, chronic heart failure, hematological cancer, and corticotherapy are still bad prognostic factors of LD. Recommendations for prevention of LD should focus on settings in which there are persons at greatest risk for illness or serious outcome.

This chapter determines the prevalence of Legionella spp. and identifies the chromosomal DNA subtypes and the genomic stability of these isolates during a 20-month follow-up period in the potable-water distribution system of a hotel. From June 2003 to March 2005, 110 water samples were collected from a hotel water supply comprising 11 sample collections of water. Legionella pneumophila serogroup (sg.) 1 was isolated in 49 (44.55%) of the 110 samples tested. The cold water distal point was L. pneumophila–positive throughout the whole study period. It should be pointed out that this distal point of cold water was an infrequently used point (roof-top tap) with stagnant water, which may explain the low chlorine levels (range, 0.05 to 0.95 mg of Cl2 per liter), the heating of water during warmer seasons and thus, colonization by Legionella throughout the study period. Environmental isolates of Legionella were genotypically characterized by pulsed-field gel electrophoresis. The number of colonized points was uniform throughout the 20-month study. All L. pneumophila isolates analyzed showed the same chomosomal DNA genotype, which indicated the clone stability over the 20-month follow-up period.

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.

Since 1990 a clone of gentamicin and methicillin-resistant Staphylococcus aureus (MRSA) has remained endemic in our hospital, but since January 1996 a gentamicin-sensitive strain has progressively replaced the previous clone. We characterized the phenotypic and molecular pattern of the MRSA strains isolated in our hospital in 1996 and compared prospectively the epidemiological, clinical and evolutionary characteristics of ninety patients infected or colonized by gentamicin-sensitive MRSA (GS-MRSA) (49) and by gentamicin-resistant MRSA (GR-MRSA) (41). Finally we studied the variation of aminoglycoside consumption in our hospital from 1989 to 1996. We observed two antibiotypes (GS-MRSA and GR-MRSA) corresponding to two major chromosomal patterns. Patients with GS-MRSA usually acquired the infection 72 hours after hospital admission. No significant differences were observed in epidemiological characteristics, clinical presentation and evolution between patients with GS-MRSA and GR-MRSA. Since 1989 aminoglycoside intake in our hospital has decreased by 46%.

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.