Legionnaires' disease

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Related to Legionnaires' disease: pneumonia, Pontiac fever, Legionellosis

Legionnaires' Disease



Legionnaires' disease is a type of pneumonia caused by Legionella bacteria. The bacterial species responsible for Legionnaires' disease is L. pneumophila. Major symptoms include fever, chills, muscle aches, and a cough that is initially nonproductive. Definitive diagnosis relies on specific laboratory tests for the bacteria, bacterial antigens, or antibodies produced by the body's immune system. As with other types of pneumonia, Legionnaires' disease poses the greatest threat to people who are elderly, ill, or immunocompromised.


Legionella bacteria were first identified as a cause of pneumonia in 1976, following an outbreak of pneumonia among people who had attended an American Legion convention in Philadelphia, Pennsylvania. This eponymous outbreak prompted further investigation into Legionella and it was discovered that earlier unexplained pneumonia outbreaks were linked to the bacteria. The earliest cases of Legionnaires' disease were shown to have occurred in 1965, but samples of the bacteria exist from 1947.
Exposure to the Legionella bacteria doesn't necessarily lead to infection. According to some studies, an estimated 5-10% of the American population show serologic evidence of exposure, the majority of whom do not develop symptoms of an infection. Legionella bacteria account for 2-15% of the total number of pneumonia cases requiring hospitalization in the United States.
There are at least 40 types of Legionella bacteria, half of which are capable of producing disease in humans. A disease that arises from infection by Legionella bacteria is referred to as legionellosis. The L. pneumophila bacterium, the root cause of Legionnaires' disease, causes 90% of legionellosis cases. The second most common cause of legionellosis is the L. micdadei bacterium, which produces the Philadelphia pneumonia-causing agent.
Approximately 10,000-40,000 people in the United States develop Legionnaires' disease annually. The people who are the most likely to become ill are over age 50. The risk is greater for people who suffer from health conditions such as malignancy, diabetes, lung disease, or kidney disease. Other risk factors include immunosuppressive therapy and cigarette smoking. Legionnaires' disease has occurred in children, but typically it has been confined to newborns receiving respiratory therapy, children who have had recent operations, and children who are immunosuppressed. People with HIV infection and AIDS do not seem to contract Legionnaires' disease with any greater frequency than the rest of the population, however, if contracted, the disease is likely to be more severe compared to other cases.
Cases of Legionnaires' disease that occur in conjunction with an outbreak, or epidemic, are more likely to be diagnosed quickly. Early diagnosis aids effective and successful treatment. During epidemic outbreaks, fatalities have ranged from 5% for previously healthy individuals to 24% for individuals with underlying illnesses. Sporadic cases (that is, cases unrelated to a wider outbreak) are harder to detect and treatment may be delayed pending an accurate diagnosis. The overall fatality rate for sporadic cases ranges from 10-19%. The outlook is bleaker in severe cases that require respiratory support or dialysis. In such cases, fatality may reach 67%.

Causes and symptoms

Legionnaires' disease is caused by inhaling Legionella bacteria from the environment. Typically, the bacteria are dispersed in aerosols of contaminated water. These aerosols are produced by devices in which warm water can stagnate, such as air-conditioning cooling towers, humidifiers, shower heads, and faucets. There have also been cases linked to whirlpool spa baths and water misters in grocery store produce departments. Aspiration of contaminated water is also a potential source of infection, particularly in hospital-acquired cases of Legionnaires' disease. There is no evidence of person-to-person transmission of Legionnaires' disease.
Once the bacteria are in the lungs, cellular representatives of the body's immune system (alveolar macrophages) congregate to destroy the invaders. The typical macrophage defense is to phagocytose the invader and demolish it in a process analogous to swallowing and digesting it. However, the Legionella bacteria survive being phagocytosed. Instead of being destroyed within the macrophage, they grow and replicate, eventually killing the macrophage. When the macrophage dies, many new Legionella bacteria are released into the lungs and worsen the infection.
Legionnaires' disease develops 2-10 days after exposure to the bacteria. Early symptoms include lethargy, headaches, fever, chills, muscle aches, and a lack of appetite. Respiratory symptoms such as coughing or congestion are usually absent. As the disease progresses, a dry, hacking cough develops and may become productive after a few days. In about a third of Legionnaires' disease cases, blood is present in the sputum. Half of the people who develop Legionnaires' disease suffer shortness of breath and a third complain of breathing-related chest pain. The fever can become quite high, reaching 104 °F (40 °C) in many cases, and may be accompanied by a decreased heart rate.
Although the pneumonia affects the lungs, Legionnaires' disease is accompanied by symptoms that affect other areas of the body. About half the victims experience diarrhea and a quarter have nausea and vomiting and abdominal pain. In about 10% of cases, acute renal failure and scanty urine production accompany the disease. Changes in mental status, such as disorientation, confusion, and hallucinations, also occur in about a quarter of cases.
In addition to Legionnaires' disease, L. pneumophila legionellosis also includes a milder disease, Pontiac fever. Unlike Legionnaires' disease, Pontiac fever does not involve the lower respiratory tract. The symptoms usually appear within 36 hours of exposure and include fever, headache, muscle aches, and lethargy. Symptoms last only a few days and medical intervention is not necessary.


The symptoms of Legionnaires' disease are common to many types of pneumonia and diagnosis of sporadic cases can be difficult. The symptoms and chest x rays that confirm a case of pneumonia are not useful in differentiating between Legionnaires' disease and other pneumonias. If a pneumonia case involves multisystem symptoms, such as diarrhea and vomiting, and an initially dry cough, laboratory tests are done to definitively identify L. pneumophila as the cause of the infection.
If Legionnaires' disease is suspected, several tests are available to reveal or indicate the presence of L. pneumophila bacteria in the body. Since the immune system creates antibodies against infectious agents, examining the blood for these indicators is a key test. The level of immunoglobulins, or antibody molecules, in the blood reveals the presence of infection. In microscopic examination of the patient's sputum, a fluorescent stain linked to antibodies against L. pneumophila can uncover the presence of the bacteria. Other means of revealing the bacteria's presence from patient sputum samples include isolation of the organism on culture media or detection of the bacteria by DNA probe. Another test detects L. pneumophila antigens in the urine.


Most cases of Legionella pneumonia show improvement within 12-48 hours of starting antibiotic therapy. The antibiotic of choice has been erythromycin, sometimes paired with a second antibiotic, rifampin. Tetracycline, alone or with rifampin, is also used to treat Legionnaires' disease, but has had more mixed success in comparison to erythromycin. Other antibiotics that have been used successfully to combat Legionella include doxycycline, clarithromycin, fluorinated quinolones, and trimethoprim/sulfamethoxazole.
The type of antibiotic prescribed by the doctor depends on several factors including the severity of infection, potential allergies, and interaction with previously prescribed drugs. For example, erythromycin interacts with warfarin, a blood thinner. Several drugs, such as penicillins and cephalosporins, are ineffective against the infection. Although they may be deadly to the bacteria in laboratory tests, their chemical structure prevents them from being absorbed into the areas of the lung where the bacteria are present.
In severe cases with complications, antibiotic therapy may be joined by respiratory support. If renal failure occurs, dialysis is required until renal function is recovered.


Appropriate medical treatment has a major impact on recovery from Legionnaires' disease. Outcome is also linked to the victim's general health and absence of complications. If the patient survives the infection, recovery from Legionnaires' disease is complete. Similar to other types of pneumonia, severe cases of Legionnaires' disease may cause scarring in the lung tissue as a result of the infection. Renal failure, if it occurs, is reversible and renal function returns as the patient's health improves. Occasionally, fatigue and weakness may linger for several months after the infection has been successfully treated.


Since the bacteria thrive in warm stagnant water, regularly disinfecting ductwork, pipes, and other areas that may serve as breeding areas is the best method for preventing outbreaks of Legionnaires' disease. Most outbreaks of Legionnaires' disease can be traced to specific points of exposure, such as hospitals, hotels, and other places where people gather. Sporadic cases are harder to determine and there is insufficient evidence to point to exposure in individual homes.



Shuman, H. A., et al. "Intracellular Multiplication of Legionella pneumophila: Human Pathogen of Accidental Tourist?" Current Topics in Microbiology and Immunology 225 (1998): 99.

Key terms

Antibody — A molecule created by the immune system in response to the presence of an antigen. It serves to recognize the invader and help defend the body from infection.
Antigen — A molecule, such as a protein, which is associated with a particular infectious agent. The immune system uses this molecule as the identifying characteristic of the infectious invader.
Culture — A laboratory system for growing bacteria for further study.
DNA probe — An agent that binds directly to a predefined sequence of nucleic acids.
Immunocompromised — Refers to conditions in which the immune system is not functioning properly and cannot adequately protect the body from infection.
Immunoglobulin — The protein molecule that serves as the primary building block of antibodies.
Immunosuppressive therapy — Medical treatment in which the immune system is purposefully thwarted. Such treatment is necessary, for example, to prevent organ rejection in transplant cases.
Legionellosis — A disease caused by infection with a Legionella bacterium.
Media — Substance which contains all the nutrients necessary for bacteria to grow in a culture.
Phagocytosis — The "ingestion" of a piece of matter by a cell.
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.

legionnaires' disease

a pulmonary form of legionellosis, resulting from infection with Legionella pneumophila. The disease acquired its name from an outbreak that occurred during the 1976 convention of the American Legion in Philadelphia. The gram-negative bacillus causing the disease was isolated from the lungs of four persons who attended the convention, contracted the disease, and died from it. The prevalence of legionnaires' disease is not certain but it is estimated that about 7 per cent of the annual cases of pneumonia in the United States are caused by L. pneumophila. Approximately 70 per cent of those cases occur in epidemic form, while the remainder are sporadic infections. The disease is seen most often in middle-aged to elderly men who are cigarette smokers or are immunocompromised. osha has published guidelines to protect workers at risk of being exposed in the workplace.

Specific diagnostic tests include both direct and indirect fluorescent testing for antibodies against L. pneumophila. Other laboratory tests reveal mild leukocytosis; elevated erythrocyte sedimentation rate; increased liver enzymes, especially lactate dehydrogenase; elevated blood urea nitrogen; and abnormal blood gases showing hypoxemia and hypocarbia.

The pulmonary symptoms are typical of pneumonia, but patients do not respond to the usual therapy for pneumonia and there can be permanent lung damage. Possible nonpulmonary complications include liver damage, altered levels of consciousness owing to neuronal involvement, and renal abnormalities that can require renal dialysis.

Treatment consists of antibiotic therapy with macrolides and quinolones. Other antibiotics may also be effective. erythromycin was formerly often used but is no longer the drug of choice. Severe hypoxia requires mechanical ventilation and oxygen therapy. Isolation of the patient is not considered to be necessary; however, respiratory precautions are indicated. Supportive measures to help the patient cope with high fever, nausea and vomiting, and renal failure are essential components of patient care. See also pneumonia.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

Le·gion·naires' dis·ease

an acute infectious disease, caused by Legionella pneumophila, with prodromal influenzalike symptoms and a rapidly rising high fever, followed by severe pneumonia and production of usually nonpurulent sputum, and sometimes mental confusion, hepatic fatty changes, and renal tubular degeneration. It has a high case-fatality rate; acquired from contaminated water, usually by aerosolization rather than being transmitted from person-to-person.
Synonym(s): legionellosis
[American Legion convention, in Philadelphia in 1976, at which many delegates were so affected]
Farlex Partner Medical Dictionary © Farlex 2012

Legionnaires' disease

An acute, sometimes fatal respiratory disease caused by a bacterium of the genus Legionella, especially L. pneumophila, and characterized by severe pneumonia, headache, and a dry cough.
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.

Le·gion·naires' dis·ease

(lē'jŏ-nārz' di-zēz')
An acute infectious disease, caused by various species of Legionella pneumophila, with prodromal influenzalike symptoms and a rapidly rising high fever, followed by severe pneumonia and production of usually nonpurulent sputum, and sometimes mental confusion, hepatic fatty changes, and renal tubular degeneration. It has a high case-fatality rate; acquired from contaminated water, usually by aerosolization rather than transmission from person to person.
[American Legion convention, in Philadelphia in 1976, at which many delegates took sick]
Medical Dictionary for the Health Professions and Nursing © Farlex 2012

Legionnaires' disease

A type of PNEUMONIA caused by Legionella bacteria which can propagate in warm, moist places such as air-conditioning towers and are spread into the air in water droplets. The disease features headache, muscle aches, diarrhoea, cough, high fever, pneumonia, mental confusion, and kidney and liver damage. The lungs may suffer irremediable damage, and this is the common cause of death. The death rate is about 4%. Most deaths occur among the elderly, the infirm, heavy smokers and heavy drinkers. Treatment is by antibiotics such as ERYTHROMYCIN and RIFAMPICIN. The disease was first recognized in members of the American Legion attending a convention in a hotel in Pennsylvania in 1976.
Collins Dictionary of Medicine © Robert M. Youngson 2004, 2005

Legionnaires’ Disease

DRG Category:177
Mean LOS:8.2 days
Description:MEDICAL: Respiratory Infections and Inflammations With Major CC
DRG Category:207
Mean LOS:14.6 days
Description:MEDICAL: Respiratory System Diagnosis With Ventilator Support 96+ Hours
DRG Category:208
Mean LOS:7 days
Description:MEDICAL: Respiratory System Diagnosis With Ventilator Support < 96 Hours
DRG Category:3
Mean LOS:34.5 days
Description:SURGICAL: Tracheostomy With MV 96+ Hours or Primary Diagnosis Except for Face, Mouth, and Neck With Major Operating Room Procedure

Legionnaires’ disease is an acute bronchopneumonia that was named because of a major outbreak at the 1976 American Legion Convention in Philadelphia, in which 235 American Legionnaires contracted the disease and 34 persons died. It is now known as the most common type of atypical pneumonia in hospitalized patients and the second most common cause of community-acquired bacterial pneumonia. Outbreaks occur in late summer and early fall, and they may be epidemic or confined to a small number of cases. Approximately 18,000 cases occur each year in the United States.

Legionnaires’ disease has an incubation period of 2 to 10 days and is characterized by patchy pulmonary infiltrates, lung consolidation, and flu-like symptoms. Pneumonia is the presenting clinical syndrome in more than 95% of cases. Legionnaires’ disease is spread by direct alveolar infection with the gram-negative bacterium Legionella pneumophila. From the initial site, the infection spreads through the bronchi and through the blood and lymphatic systems. Bacteremia occurs in about 30% of the patients and is the source of nonrespiratory infections in most patients.

Complications are extensive and serious with Legionnaires’ disease. Hypoxemia and acute respiratory failure can result from the severe case of pneumonia. The disease can also cause hypotension and hyponatremia as a result of salt and water loss. Central nervous system involvement is seen in almost 30% of patients. Renal involvement, which ranges from interstitial nephritis to renal failure, may occur. Untreated immunosuppressed patients have a mortality rate of 80%; untreated patients with no immune system compromise have a mortality rate of 25%.


L. pneumophila is an aerobic, gram-negative bacillus that seems to be transmitted by air. It is usually classified as a saprophytic water bacterium because it is natural to bodies of water such as rivers, lakes, streams, and thermally polluted waters. Elevated temperatures (96.8°F to 158°C) enhance growth of the bacterium. L. pneumophila is also found in habitats such as cooling towers, evaporative condensers, and water distribution centers, and it also has been found in soil samples and at excavation sites. Pathogenic microorganisms can enter the lung by aspiration, direct inhalation, or dissemination from another focus of infection.

Genetic considerations

Although Legionnaire’s disease is the result of infection by L. pneumophila, susceptibility has been associated with variants in the Toll-like receptor-5 (TLR5) gene.

Gender, ethnic/racial, and life span considerations

Legionnaires’ disease is three times more common in men than in women; it is uncommon in children. At-risk groups include middle-aged or elderly people; patients with a chronic underlying disease such as chronic obstructive pulmonary disease, diabetes mellitus, or chronic renal failure; patients with immunosuppressive disorders such as lymphoma or who receive corticosteroids after organ transplantation; people with alcohol dependence; and cigarette smokers. There are no known racial or ethnic considerations.

Global health considerations

Legionnaires’ disease has been reported throughout the globe and on all populated continents.



Ask about malaise, aching muscles, anorexia, headache, high fever, or recurrent chills. Establish a history of chest pain or coughing, which begins as a nonproductive cough but eventually becomes productive. Ask the patient about gastrointestinal symptoms such as diarrhea, nausea, and vomiting. Because the central nervous system is involved in about 30% of cases, ask the family or significant others if the patient has experienced recent confusion or decreased level of consciousness.

Determine if the patient has been close to a river, lake, or stream, which might have resulted in possible exposure to the bacteria. Establish a work history of employment at an excavation site or water distribution center, in a cooling tower, or near an evaporative condenser. Ask if the patient works or lives in a facility with central air conditioning or humidifiers. Ask if the patient has used a respiratory apparatus or a nasogastric tube in the recent past.

Physical examination

Common symptoms include mild headache, cough, muscle aches, high fever, and chills. Note any neurological signs, such as altered level of consciousness, confusion, or coma. Inspect the patient’s sputum, which may be grayish or rust-colored, nonpurulent, and occasionally blood streaked. Note the respiratory rate, which may be rapid and accompanied by dyspnea.

Determine the breathing; fine or coarse crackles may be audible depending on the stage of the disease process. Auscultate the blood pressure and heart rate; note that some patients develop severe hypotension and bradycardia. Percuss the chest for dullness over areas of secretions and consolidation or pleural effusions. Palpate the peripheral pulses to determine strength.


A previously healthy person with a possible minor upper respiratory infection is at risk for life-threatening complications, such as multiple organ failure. Assess the patient’s ability to cope with a sudden illness. Assess the patient’s level of anxiety and fear.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Sputum culture and sensitivityNegativePresence of L. pneumophilaIdentify infecting organisms
Chest x-rayAir-filled lungsArea of increased density of a lung segment, lobe, or entire lungIdentifies the location and extent of infection

Other Tests: Urinalysis, serology for Legionella (urine antigen testing, indirect fluorescent antibody studies), arterial blood gases, pulse oximetry, complete blood count, blood urea nitrogen, creatinine, serum electrolytes

Primary nursing diagnosis


Infection related to the presence of bacteria


Immune status; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; Hydration; Knowledge: Infection control


Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management; Temperature regulation

Planning and implementation


Antibiotics can be administered before test results are available. Generally, primary therapy is either levofloxacin or azithromycin. Erythromycin, sometimes in combination with rifampin, is also used, but the gastrointestinal effects of both the disease and drug can be cumulative and problematic. Intravenous fluids and electrolyte therapy may be considered when the patient has fluid volume deficit. Careful monitoring of fluid balance is required because of the possible renal complications from interstitial nephritis or renal failure. If renal failure does ensue, the patient may require temporary renal dialysis.

Oxygen per cannula at 2 to 4 L/minute is effective with many patients, although in some patients with respiratory insufficiency, it is necessary to proceed with intubation and assisted ventilation. Atelectasis may occur at any stage of the pneumonia. Pleural effusion may occur, which may require a diagnostic thoracentesis and a chest tube. The patient may need continuous pulse oximetry to monitor the response to mechanical ventilation and suctioning. Continuous cardiac monitoring and hourly urine outputs may be necessary to assess the patient’s response to the disease.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
AntibioticsVaries with drugLevofloxacin (Levaquin), azithromycin (Zithromax), erythromycin, doxycyclineHalt division of bacteria, thereby limiting infection
Rifampin600 mg/day, PO or IVAntitubercularManages severe disease, such as multilobar pneumonia, respiratory failure, endocarditis, or severe immunosuppression; if erythromycin is contraindicated because of allergy, rifampin may be used alone or combined with doxycycline or cotrimoxazole

Other Treatment: Antipyretics


The most important intervention is improvement of airway patency. Retained secretions interfere with gas exchange and may cause slow resolution of the disease. Encourage a high level of fluid intake up to 3 L/day to assist in loosening pulmonary secretions and to replace fluid lost via fever and diaphoresis. Provide meticulous sterile technique during endotracheal suctioning of the patient. Chest physiotherapy may be prescribed to assist with loosening and mobilizing secretions.

To maintain the patient’s comfort, keep the patient protected from drafts. Institute fever-reducing measures if necessary. To ease the patient’s breathing, raise the head of the bed at least 45 degrees and support the patient’s arms with pillows. Provide mouth and skin care and emotional support. Include the patient and family in planning care and allow them to make choices.

Evidence-Based Practice and Health Policy

Schuetz, P., Haubitz, S., Christ-Crain, M., Albrich, W.C., Zimmer, W., & Mueller, B. (2013). Hyponatremia and anti-diuretic hormone in Legionnaires’ disease. BMC Infectious Diseases, 13, 585. doi 10.1186/1471-2334-13-585

  • Investigators conducted a prospective cohort study among 873 pneumonia patients, of which 27 were positive for L. pneumophila, and found that patients with Legionnaires’ disease may be at increased risk for hyponatremia.
  • Sodium levels were significantly lower in the patients with Legionnaires’ disease (mean, 131.6 mmom/L; SD, ± 0.9) when compared with patients without the disease (mean, 135.4 mmom/L; SD, ± 0.2) (p < 0.001).
  • A greater proportion of patients with Legionnaires’ disease had sodium levels below 130 mmol/L when compared with patients without the disease (44.4% versus 8.2%; p < 0.001).

Documentation guidelines

  • Physical findings: Vital signs, head-to-toe assessment, rate of breathing, breath sounds, description of sputum
  • Response to treatments such as chest physiotherapy, oxygen, antipyretics, and fluid therapy
  • Presence of complications: Hypotension, dehydration, chest pain, changes in patterns of urination, laboratory findings

Discharge and home healthcare guidelines

Explain the medications to the patient, including the route, dosage, side effects, and need for taking all antibiotics until they are gone. Explain food and drug interactions. Provide information on smoking-cessation programs. Note the source of the patient’s Legionnaires’ disease; if the cause was from within a patient’s home or workplace, recommend appropriate action to prevent recurrence and decrease chances of further outbreaks. Instruct the patient to contact the physician if she or he has a fever or worsening pleuritic pain. Stress the need to go immediately to the nearest emergency department if the patient becomes acutely short of breath.

Diseases and Disorders, © 2011 Farlex and Partners

Le·gion·naires' dis·ease

(lē'jŏ-nārz' di-zēz')
Acute infectious disease, caused by Legionella pneumophila, with prodromal influenzalike symptoms and a rapidly rising high fever, followed by severe pneumonia and production of usually nonpurulent sputum, and sometimes mental confusion, hepatic fatty changes, and renal tubular degeneration. It has a high case-fatality rate; acquired from contaminated water, usually by aerosolization rather than being transmitted from person-to-person.
[American Legion convention, in Philadelphia in 1976, at which many delegates took sick]
Medical Dictionary for the Dental Professions © Farlex 2012
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Public Health Wales has stressed that each case in Barry has been "extensively investigated" and does not meet the definition of a Legionnaires' disease outbreak.
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asmaalizain@khaleejtimes.com What is Legionnaires' disease?
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To prevent Legionnaires' disease we must understand the environmental factors that allow Legionella bacteria to survive and reach a susceptible host.
The former stage rigger was taken to James Cook University Hospital in Middlesbrough where he was intubated and diagnosed with legionnaires' disease.
Symptoms of Legionnaires' disease typically include high fever, chills and a cough.
"As the scope and depth of the outbreak of Legionnaires' Disease in the South Bronx came into focus last week, I proposed new legislation that would allow the city to be proactive—and not reactive—to such outbreaks.