Wednesday, April 27, 2005

Legionella Pneumonia (Legionnaires' Disease) at New York Presbyterian / Columbia University Medical Center

When I was an intern, an otherwise healthy 21 year old man who worked at a nearby pizza place was admitted with pneumonia. He rapidly went into shock and died within a few days. He had Legionella, presumably acquired from the water supply at his workplace. The most horrific cases of pneumonia I've seen in immunocompetent young people have been Legionella.

At New York Presbyterian, at least four patients recently acquired Legionella from the hospital's water supply. From the New York Times:

Legionnaires' disease is a bacterial infection with pneumonia-like symptoms that first became widely known after a 1976 outbreak killed 34 people attending an American Legion convention in Philadelphia. According to the Centers for Disease Control and Prevention, 8,000 to 18,000 people contract the disease each year in the United States, and it is rarely fatal except for people with weakened immune systems.

The hospital's disclosure deepened a mystery surrounding what had appeared to be a minor, nonlethal outbreak of the disease at the Milstein building last month. Four patients contracted the disease from the tainted water; two were treated and discharged, the hospital said, and two died...

Traces of the bacteria that cause Legionnaires' disease are almost always present in New York City's water supply. Dr. Victor Yu, the chief of infectious diseases at the Pittsburgh Veterans Administration Health Care Center and an expert on the disease, estimated that the bacteria were present in the water supplies of about 70 percent of city hospitals.

"At many hospitals there are probably people contracting it and dying from it without anyone knowing it," said Dr. Yu...

I heard Dr. Yu lecture on hospital-acquired pneumonia a few years ago. I asked whether, given the presence of Legionella in hospitals, we should be empirically treating and testing for this organism in every hospitalized patient with a new pneumonia. He said there was no right answer to this question. (For Dr. Yu's reply, see below.) It isn't standard practice to tailor the antibiotic coverage of hospital-acquired pneumonia to always cover Legionella. Should this change?

(Hospital-acquired Legionella is apparently not rare. A Medline search of "Legionella and hospital-acquired pneumonia" is here.)

Addendum: Dr. Yu was kind enough to correct my post and direct me to guidelines on Legionella. This was his response:

Thank you for referring me to your blog and your overview of Legionnaires disease.

I think there is a difference in what you remembered and what I might have said. In regard to the question as to whether "every patient hospitalized for pneumonia should undergo legionella testing given its presence in the water supply", you claimed that I said that "there was no right answer".

There certainly is a right answer and it is the one that you proposed. Absolutely, if legionella is in the water supply you MUST perform legionella testing for every hospitalized patient with a new pneumonia. That has been my message to all physicians since I first advocated it in 1986 in a review article on hosp-acquired LD for Mort Swartz/Jack Remington book on infections. It is embedded in the ACHD Guidelines on our website ( and all my review articles on this subject. That is why I am such a forceful advocate for routine testing for legionella in the water. If legionella is found, the lab tests for legionella should be available in-house and performed for all patients with hosp-acquired pneumonia. If there is uncertainty on the etiology of the pneumonia, a quinolone should be given empirically, both for gram-neg rod and legionella coverage. See any of my review articles and the ACHD Guidelines, pages 6 - 7. Figs 1 and 2 on the Home Page of

More posts on Legionella are here.

1 comment:

Sarah said...

Those seem to be old cases but right now in the South Island of New Zealand there is an outbreak of Legionnaires' which is causing significant concern because they can't isolate the building it's coming from!