Controlling Legionella—Room for Improvement in Clinical Practices & Water Management

Legionnaires’ disease has been on the rise in the United States since 2000, according to the US Centers for Disease Control and Prevention (CDC); although upwards of 6000 cases were reported in 2016, the CDC stressed that this may, in fact, be an underestimation.

The reason behind this increase in cases remains to be determined; however, it is safe to say that the answer is multifactorial. One such factor is that there has been an increase in the susceptibility of people in the United States; the populating is aging, and there is an increasing number of individuals on immunosuppressive medications.

As the disease receives more media attention—with outbreaks constantly making headlines—Legionnaires’ has become a public health priority, and, as such, efforts to prevent the disease are expanding. Guidelines on controlling the disease have been developed, and regulations focused on improving clinical surveillance of the disease and water management in health care facilities have been put into place in certain jurisdictions.

However, according to a poster presented at the SHEA Spring 2018 Conference, not much is known about diagnostic practices and water management plans in hospitals and how or if they fall in line with available guidance.

For their study, conducted between October and November 2017, investigators completed a cross-sectional survey of US members from the SHEA Research Network. The survey asked participants about the following:

• Clinical protocols for diagnosing Legionnaires’
• Potable and non-potable water system maintenance
• Prevention strategies in place for Legionella
• Knowledge of Legionnaires’ guidelines and regulations

Using descriptive statistics to analyze the results, the investigators found that of 30 respondents (n = 101) who completed the survey, 80% were from facilities with 250 or more beds, 57% were from facilities with transplant or inpatient dialysis units, and 31% were from facilities that had reported health care-associated Legionnaires’ cases within the past 5 years.

Fourteen percent of the facilities represented in the survey reported that they always conduct bacterial culture in addition to nonculture tests to diagnose Legionnaires’, whereas the majority (85%) reported performing culture confirmation “sporadically, mostly (92%) by provider discretion,” according to the authors.

Water management plans are important for the prevention of Legionella growth, especially in health care facilities, which house patients that are at highest risk for Legionnaires’ disease, such as the elderly and those with weakened immune systems. Furthermore, these facilities typically have larger, complex water systems that work to actually promote Legionella growth, according to the CDC, if they aren’t maintained correctly.

The majority of the facilities surveyed in this study reported having a water management plan for potable and non-potable water; 28% reported having a plan in development. Those with infection control expertise were among the personnel most well-represented (97%) and engaged in these systems, followed by facilities/engineering staff (90%), microbiology (52%), compliance/administration (45%), risk management (38%); least engaged were those in public health (10%).

“Although some facilities utilize multiple diagnostic tests and have adopted water management programs, our survey shows that there is room for improvement in both areas in hospitals across the United States,” the study authors concluded.