title: A recurrent outbreak of nosocomial legionnaires' disease detected by urinary antigen testing: evidence for long-term colonization of a hospital plumbing system.
abstract: BACKGROUND
  In 1994, a hospital reported an increase in nosocomial legionnaires' disease after implementing use of a rapid urinary antigen test for Legionella pneumophila serogroup 1 (Lp-1). This hospital was the site of a previous nosocomial legionnaires' disease outbreak during 1980 to 1982.
  
  
  METHODS
  Infection control records were reviewed to compare rates of nosocomial pneumonia and the proportion of cases attributable to legionnaires' disease during the 1994 outbreak period with those during the same period in 1993. Water samples were collected for Legionella culture from the hospital's potable water system and cooling towers, and isolates were subtyped by monoclonal antibody (MAb) testing and arbitrarily primed polymerase chain reaction (AP-PCR).
  
  
  RESULTS
  Nosocomial pneumonia rates were similar from April through October 1993 and April through October 1994: 5.9 and 6.6 per 1,000 admissions, respectively (rate ratio [RR], 1.1; P=.56); however, 3.2% of nosocomial pneumonias were diagnosed as legionnaires' disease in 1993, compared with 23.9% in 1994 (RR, 9.4; P<.001). In 1994, most legionnaires' disease cases were detected by the urinary antigen testing alone. MAb testing and AP-PCR demonstrated identical patterns among Lp-1 isolates recovered from a patient's respiratory secretions, the hospital potable water system, and stored potable water isolates from the 1980 to 1982 outbreak.
  
  
  CONCLUSIONS
  There may have been persistent transmission of nosocomial legionnaires' disease at this hospital that went undiscovered for many years because there was no active surveillance for legionnaires' disease. Introduction of a rapid urinary antigen test improved case ascertainment. Legionella species can be established in colonized plumbing systems and may pose a risk for infection over prolonged periods.
authors.affiliation: Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: L A
authors.initials: LA
authors.lastname: Lepine
authors.forename: D B
authors.initials: DB
authors.lastname: Jernigan
authors.forename: J C
authors.initials: JC
authors.lastname: Butler
authors.forename: J M
authors.initials: JM
authors.lastname: Pruckler
authors.forename: R F
authors.initials: RF
authors.lastname: Benson
authors.forename: G
authors.initials: G
authors.lastname: Kim
authors.forename: J L
authors.initials: JL
authors.lastname: Hadler
authors.forename: M L
authors.initials: ML
authors.lastname: Cartter
authors.forename: B S
authors.initials: BS
authors.lastname: Fields
mesh_terms: D003237:Connecticut / Q000453:epidemiology; D003428:Cross Infection / Q000175:diagnosis* / Q000453:epidemiology* / Q000635:transmission; D004196:Disease Outbreaks; D006764:Hospitals, Community; D006801:Humans; D007118:Immunoassay; D016952:Legionella pneumophila / Q000302:isolation & purification*; D007877:Legionnaires' Disease / Q000175:diagnosis* / Q000453:epidemiology* / Q000635:transmission; D012498:Sanitary Engineering; D014556:Urine / Q000382:microbiology; D014871:Water Microbiology; D014881:Water Supply