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June 6, 1990, Vol 263, No. 21 >
ARTICLE | June 6, 1990

Association of Shower Use With Legionnaires' Disease: Title and subTitle BreakPossible Role of Amoebae FREE

Robert F. Breiman, MD; Barry S. Fields, PhD; Gary N. Sanden, MS; LaJean Volmer; Arlin Meier; John S. Spika, MD
[+] Author Affiliations

Reprint requests to Respiratory Diseases Branch, Division of Bacterial Diseases, Center for Infectious Diseases, Centers for Disease Control, Bldg 1, Room 5047, MS C09, Atlanta, GA 30333 (Dr Breiman).


JAMA. 1990;263(21):2924-2926. doi:10.1001/jama.1990.03440210074036
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References

OUTBREAKS of legionnaires' disease (LD) have been linked to aerosols from evaporative condensers and cooling towers,1,2 whirlpool spas,3 respiratory therapy equipment,4 and humidifiers.5 An association between shower use and LD has been hypothesized but not epidemiologically demonstrated.6-11 Prevention of LD is limited by a lack of understanding of the ecology of Legionella pneumophila. Monitoring aerosolproducing sites for L pneumophila can be misleading since the bacteria are found often in water sources without a known disease association.12

Factors essential for Legionella multiplication in water are poorly understood, but the bacteria multiply extracellularly on supplemented culture media.13,14 Nutritional requirements of the genus are unlikely to be met in most water sources; however, these bacteria do multiply inside protozoa,15-17 which are common to aquatic environments. Legionella pneumophila grows in water samples with amoebae but not in those without viable amoebae.17 Recognition of the association

REFERENCES

1 +
Dondero TJ, Rentdorff RC, Mallison GF, et al.  An outbreak of legionnaires' disease associated with a contaminated air-conditioning cooling tower . N Engl J Med. 1980;;302:365-370.
2 +
Breiman RF, Cozen W, Fields BS, et al.  Role of air-sampling in an investigation of an outbreak of legionnaires' disease associated with exposure to aerosols from an evaporative condenser . J Infect Dis. In press.
3 +
Vogt RL, Hudson PJ, Orciari L, Heun EM, Woods TC.  Legionnaires' disease and a whirlpool spa . Ann Intern Med. 1987;;107:596.
4 +
Arnow PM, Chou T, Weil D, Shapiro EN, Kretzschmar C.  Nosocomial legionnaires' disease caused by aerosolized tap water from respiratory devices . J Infect Dis. 1982;;146:460-467.
5 +
Zuravleff JJ, Yu VL, Shonnard JW, Rihs JD, Best M.  Legionella pneumophila contamination of a hospital humidifier: demonstration of aerosol transmission and subsequent subclinical infection in exposed guinea pigs . Am Rev Respir Dis. 1983;;128:657-661.
6 +
Shands KN, Ho JL, Meyer RD, et al.  Potable water as a source of legionnaires' disease . JAMA. 1985;;253:1412-1416.
7 +
Helms CM, Massanari RM, Zeitler R, et al.  Legionnaires' disease associated with a hospital hot water system: a cluster of 24 nosocomial cases . Ann Intern Med. 1983;;99:172-178.
8 +
Hanrahan JP, Morse DL, Scharf VB, et al.  A community hospital outbreak of legionellosis: transmission by potable hot water . Am J Epidemiol. 1987;;125:639-649.
9 +
Tobin JO, Dunnill MS, French M, et al.  Legionnaires' disease in a transplant unit: isolation of the causative agent from shower baths . Lancet . 1980;;2:118-121.
10 +
Cordes LG, Wiesenthal AW, Gorman GW, et al.  Isolation of Legionella pneumophila from hospital shower heads . Ann Intern Med. 1981;;94:195-197.
11 +
Stout J, Yu VL, Vickers RM, et al.  Ubiquitousness of Legionella pneumophila in the water supply of a hospital with endemic legionnaires' disease . N Engl J Med. 1982;;306:466-468.
12 +
Redd SC, Cohen ML.  Legionella in water: what should be done? JAMA. 1987;;257:1221-1222.
13 +
Feeley JC, Gorman GW, Weaver RE, Mackel DC, Smith HW.  Primary isolation media for legionnaires' disease bacterium . J Clin Microbiol. 1978;; 8:320-325.
14 +
Tesh MJ, Miller RD.  Amino acid requirements for Legionella pneumophila growth . J Clin Microbiol. 1981;;13:865-869.
15 +
Rowbotham TJ.  Preliminary report on the pathogenicity of Legionella pneumophila for freshwater and soil amoebae . J Clin Pathol. 1980;;33: 1179-1183.
16 +
Fields BS, Shotts EB, Feeley JC, Gorman GW, Martin WT.  Proliferation of Legionella pneumophila as an intracellular parasite of the ciliated protozoan Tetrahymena pyriformis . Appl Environ Microbiol. 1984;;47:467-471.
17 +
Fields BS, Sanden GN, Barbaree JM, et al.  Intracellular multiplication of Legionella pneumophila in amoebae isolated from hospital hot water tanks . Curr Microbiol. 1989;;18:131-137.
18 +
Joly JR, McKinney RM, Tobin JO, Bibb WF, Watkins ID, Ramsay D.  Development of a standardized subgrouping scheme for Legionella pneumophila serogroup 1 using monoclonal antibodies . J Clin Microbiol. 1986;;23:768-771.
19 +
Fields BS, Barbaree JM, Shotts EB, et al.  Comparison of guinea pig and protozoan models for determining virulence of Legionella species . Infect Immun. 1986;;53:553-559.
20 +
Anand CM, Skinner AR, Malic A, Kurtz JB.  Interaction of L pneumophila and a free-living amoeba (Acanthamoeba palestinensis) . J Hyg (Camb) . 1983;;91:167-178.
21 +
Tyndall RL, Domingue EL.  Cocultivation of Legionella pneumophila and free-living amoebae . Appl Environ Microbiol. 1982;;44:954-959.
22 +
Horwitz MA, Silverstein SC.  Legionnaires' disease bacterium (Legionella pneumophila) multiplies intracellularly in human monocytes . J Clin Invest. 1980;;66:441-450.
23 +
Sanden GN, Fields BS, Barbaree JM, Feeley JC.  Viability of Legionella pneumophila in cholinefree [sic] water at elevated temperatures . Curr Microbiol. 1989;;18:61-65.
24 +
Bartlett CLR, Macrae AD, Macfarlane JT.  Surveillance, control, and prevention . In: Legionella Infections . 1st ed. London, England: Edward Arnold Ltd; 1986;:145-148.
25 +
Rice EW, Huff JC, Schaefer FW III.  Inactivation of Giardia cysts by chlorine . Appl Environ Microbiol . 1982;;43:250-257.

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1 +
Dondero TJ, Rentdorff RC, Mallison GF, et al.  An outbreak of legionnaires' disease associated with a contaminated air-conditioning cooling tower . N Engl J Med. 1980;;302:365-370.
2 +
Breiman RF, Cozen W, Fields BS, et al.  Role of air-sampling in an investigation of an outbreak of legionnaires' disease associated with exposure to aerosols from an evaporative condenser . J Infect Dis. In press.
3 +
Vogt RL, Hudson PJ, Orciari L, Heun EM, Woods TC.  Legionnaires' disease and a whirlpool spa . Ann Intern Med. 1987;;107:596.
4 +
Arnow PM, Chou T, Weil D, Shapiro EN, Kretzschmar C.  Nosocomial legionnaires' disease caused by aerosolized tap water from respiratory devices . J Infect Dis. 1982;;146:460-467.
5 +
Zuravleff JJ, Yu VL, Shonnard JW, Rihs JD, Best M.  Legionella pneumophila contamination of a hospital humidifier: demonstration of aerosol transmission and subsequent subclinical infection in exposed guinea pigs . Am Rev Respir Dis. 1983;;128:657-661.
6 +
Shands KN, Ho JL, Meyer RD, et al.  Potable water as a source of legionnaires' disease . JAMA. 1985;;253:1412-1416.
7 +
Helms CM, Massanari RM, Zeitler R, et al.  Legionnaires' disease associated with a hospital hot water system: a cluster of 24 nosocomial cases . Ann Intern Med. 1983;;99:172-178.
8 +
Hanrahan JP, Morse DL, Scharf VB, et al.  A community hospital outbreak of legionellosis: transmission by potable hot water . Am J Epidemiol. 1987;;125:639-649.
9 +
Tobin JO, Dunnill MS, French M, et al.  Legionnaires' disease in a transplant unit: isolation of the causative agent from shower baths . Lancet . 1980;;2:118-121.
10 +
Cordes LG, Wiesenthal AW, Gorman GW, et al.  Isolation of Legionella pneumophila from hospital shower heads . Ann Intern Med. 1981;;94:195-197.
11 +
Stout J, Yu VL, Vickers RM, et al.  Ubiquitousness of Legionella pneumophila in the water supply of a hospital with endemic legionnaires' disease . N Engl J Med. 1982;;306:466-468.
12 +
Redd SC, Cohen ML.  Legionella in water: what should be done? JAMA. 1987;;257:1221-1222.
13 +
Feeley JC, Gorman GW, Weaver RE, Mackel DC, Smith HW.  Primary isolation media for legionnaires' disease bacterium . J Clin Microbiol. 1978;; 8:320-325.
14 +
Tesh MJ, Miller RD.  Amino acid requirements for Legionella pneumophila growth . J Clin Microbiol. 1981;;13:865-869.
15 +
Rowbotham TJ.  Preliminary report on the pathogenicity of Legionella pneumophila for freshwater and soil amoebae . J Clin Pathol. 1980;;33: 1179-1183.
16 +
Fields BS, Shotts EB, Feeley JC, Gorman GW, Martin WT.  Proliferation of Legionella pneumophila as an intracellular parasite of the ciliated protozoan Tetrahymena pyriformis . Appl Environ Microbiol. 1984;;47:467-471.
17 +
Fields BS, Sanden GN, Barbaree JM, et al.  Intracellular multiplication of Legionella pneumophila in amoebae isolated from hospital hot water tanks . Curr Microbiol. 1989;;18:131-137.
18 +
Joly JR, McKinney RM, Tobin JO, Bibb WF, Watkins ID, Ramsay D.  Development of a standardized subgrouping scheme for Legionella pneumophila serogroup 1 using monoclonal antibodies . J Clin Microbiol. 1986;;23:768-771.
19 +
Fields BS, Barbaree JM, Shotts EB, et al.  Comparison of guinea pig and protozoan models for determining virulence of Legionella species . Infect Immun. 1986;;53:553-559.
20 +
Anand CM, Skinner AR, Malic A, Kurtz JB.  Interaction of L pneumophila and a free-living amoeba (Acanthamoeba palestinensis) . J Hyg (Camb) . 1983;;91:167-178.
21 +
Tyndall RL, Domingue EL.  Cocultivation of Legionella pneumophila and free-living amoebae . Appl Environ Microbiol. 1982;;44:954-959.
22 +
Horwitz MA, Silverstein SC.  Legionnaires' disease bacterium (Legionella pneumophila) multiplies intracellularly in human monocytes . J Clin Invest. 1980;;66:441-450.
23 +
Sanden GN, Fields BS, Barbaree JM, Feeley JC.  Viability of Legionella pneumophila in cholinefree [sic] water at elevated temperatures . Curr Microbiol. 1989;;18:61-65.
24 +
Bartlett CLR, Macrae AD, Macfarlane JT.  Surveillance, control, and prevention . In: Legionella Infections . 1st ed. London, England: Edward Arnold Ltd; 1986;:145-148.
25 +
Rice EW, Huff JC, Schaefer FW III.  Inactivation of Giardia cysts by chlorine . Appl Environ Microbiol . 1982;;43:250-257.

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