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Diagnosis, Treatment, and Prevention

The preferred diagnostic tests for Legionnaires’ disease are culture of lower respiratory secretions (e.g., sputum, bronchoalveolar lavage) on selective media and the Legionella urinary antigen test. Serological assays can be nonspecific and are not recommended in most situations. Best practice is to obtain both sputum culture and the urinary antigen test concurrently. Sputum should ideally be obtained prior to antibiotic administration, but antibiotic treatment should not be delayed to facilitate this process. The urinary antigen test can detect Legionella infections in some cases for days to weeks after treatment.

 

Indications for Legionnaires’ Disease Testing

Listed below are indications that warrant testing patients with pneumonia for Legionnaires’ disease:

  • Patients who have failed outpatient antibiotic treatment for community-acquired pneumonia
  • Patients with severe pneumonia, in particular those requiring intensive care
  • Immunocompromised patients with pneumonia*
  • Patients with a travel history (patients who have traveled away from their home within 10 days before the onset of illness)
  • All patients with pneumonia in the setting of a Legionnaires’ disease outbreak
  • Patients at risk for Legionnaires’ disease with healthcare-associated pneumonia (pneumonia with onset ≥ 481 hours after admission)

The Council of State and Territorial Epidemiologists (CSTE) position statement outlines case definitions for confirmed and suspected legionellosis. Read the position statement.

*May also consider testing for Legionnaires’ disease in patients with other risk factors for Legionnaires’ disease as listed here: https://www.cdc.gov/legionella/clinicians/disease-specifics.html

Testing for healthcare-associated Legionnaires’ disease is especially important if any of the following are identified in a health care facility:

  • Other patients with healthcare-associated Legionnaires’ disease diagnosed in the past 12 months
  • Positive environmental tests for Legionella in the past 2 months
  • Current changes in water quality that may lead to Legionella growth (such as low chlorine levels or nearby construction)

 

Importance of Asking about Travel and Healthcare Exposures

Timely reporting of healthcare-associated cases ensures that steps can be taken to protect these highly susceptible populations.

The majority of recognized Legionnaires’ disease outbreaks are associated with travel (hotels, resorts, cruise ships) or healthcare settings (hospitals, long-term care facilities).2 Approximately 10–15% of all reported cases of Legionnaires’ disease occur in people who have traveled during the 10 days before symptom onset. Outbreaks among travelers can be difficult to detect because of

  • The low attack rate
  • The time interval between exposure and symptom onset
  • Dispersal of people from the source of the outbreak
  • Underdiagnosis of cases

Therefore, collecting and reporting information about overnight travel is important. See Healthcare Investigation Resources for more information about healthcare exposures.

Preferred Diagnostic Tests

Culture

Isolation of Legionella on media that supports growth of Legionella (i.e., Buffered Charcoal Yeast Extract [BCYE] agar) from lower respiratory secretions, lung tissue, pleural fluid, or a normally sterile site is confirmatory and an important method for diagnosis. It can detect other Legionella species and serogroups that the urinary antigen test does not.

Use Culture and Urinary Antigen Tests in Combination

  • Unlike the urinary antigen test, culturing specimens from patients can detect all species and serogroups of Legionella
  • Isolating Legionella from clinical specimens helps investigators identify where exposure occurred and prevent additional cases

Comparing clinical and environmental isolates using serologic and molecular techniques can help identify the source in Legionnaires’ disease outbreak investigations. Because Legionella commonly occurs in the environment, clinical isolates can help interpret the findings of an environmental investigation.

Urinary Antigen Test

The most commonly used laboratory test for diagnosis of Legionnaires’ disease is the urinary antigen test, which detects a molecule of the Legionella bacterium in urine. If the patient has pneumonia and the test is positive, then you should consider the patient to have Legionnaires’ disease. The test can remain positive for a few weeks after infection, even with antibiotic treatment. The urinary antigen test detects the most common cause of Legionnaires’ disease, L. pneumophila serogroup 1. However, all species and serogroups of Legionella are potentially pathogenic, so a patient with a negative urinary antigen result could have Legionnaires’ disease caused by other Legionella species and serogroups.

 

Sensitivity and Specificity of Diagnostic Tests

Sensitivity varies depending on the quality and timing of clinical specimen collection, as well as technical skill of the laboratory worker performing the test. The table below provides general ranges for the sensitivity and specificity of each diagnostic test.

Test Sensitivity (%) Specificity (%)
Culture 20–80 100
Urinary antigen for L. pneumophila serogroup 1 (Lp1) 70–100 95–100
Paired serology2 80–90 >99
Direct Fluorescent Antibody (DFA) Stain 25–75 ≥95
Polymerase Chain Reaction (PCR)3 95–99 >99

1 Cross reactions with other species and serogroups have been documented.
2 CDC labs do not perform serologic testing for legionellosis diagnosis due to inherent challenges in obtaining appropriate specimens. It is important to note that because paired sera are required, results are delayed and thus may not be useful for acute case diagnosis or during active outbreak investigations.
3 Avni T, Bieber A, Green H, et al. Diagnostic accuracy of PCR alone and compared to urinary antigen testing for detection of Legionella spp.: A systematic review. J Clin Micro. 2016;54(2):401–11.

 

Other Advantages and Disadvantages for Each Diagnostic Test

Test Advantages Disadvantages
Culture
  • Detects all species and serogroups
  • Clinical and environmental isolates can be compared
  • Technically difficult
  • Slow (>5 days to grow)
  • Sensitivity highly dependent on technical skill
  • Affected by appropriate antibiotic treatment
  • Requires BCYE agar, which some laboratories may not have readily available
Urinary Antigen
  • Rapid (same day)
  • Can only be used to detect L. pneumophila serogroup 11 (Lp1) (which may account for up to 84%2 of cases)
  • Does not allow for molecular comparison to environmental isolates
Serology3
  • Possible to detect species and serogroups other than Lp1
  • Must have paired sera collected at acute onset to 2 weeks after symptoms and 3 to 6 weeks later
  • Approximately 5 to 10% of the population has titer 1:≥256 (single acute phase antibody titers of 1: ≥256 do not discriminate between cases of Legionnaires’ disease and other causes of community-acquired pneumonia)
DFA
  • Can be performed on pathologic specimens (usually lung tissue)
  • Possible to detect species and serogroups other than Lp1
  • Technically difficult
  • Reagents may be difficult to obtain
PCR
  • Can be performed on pathologic specimens (usually lung tissue)
  • Rapid
  • Possible to detect species and serogroups other than Lp1
  • Assays vary by laboratory and are not currently commercially available in the United States

1 Cross reactions with other species and serogroups have been documented.
2 Yu V, Plouffe JF, Pastoris MC, et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: An international collaborative survey. J Infect Dis. 2002;186:127–8.
3 CDC labs do not perform serologic testing for legionellosis diagnosis due to inherent challenges in obtaining appropriate specimens. It is important to note that because paired sera are required, results are delayed and thus may not be useful for acute case diagnosis or during active outbreak investigations.

Treatment

If your patient has Legionnaires’ disease, please see the most recent IDSA-ATS guidelines for treatment of community-acquired pneumonia [46 pages] and the most recent IDSA-ATS guidelines for treatment of hospital-acquired pneumonia [51 pages]. Note that first line treatment, however, does not always include Legionella-directed antibiotics (e.g., macrolides and respiratory fluoroquinolones). While it is preferred that you obtain diagnostic testing before antibiotic administration, antibiotic treatment should not be delayed to facilitate this process.

If your patient has Pontiac fever, antibiotic treatment should not be prescribed. It is a self-limited illness that does not benefit from antibiotic treatment. Patients usually recover within 1 week.

 

Prevention

Minimizing Legionella growth in complex building water systems and devices, including potable water, hot tubs, decorative fountains, and cooling towers, is key to preventing infection. Timely identification and reporting of legionellosis cases is also important because this allows public health officials to quickly identify and stop potential clusters and outbreaks by linking new cases to previously reported ones.

 

Reporting

Report cases and outbreaks of Legionnaires’ disease to your local or state health department. Refer to your state health department website to find more information about how to contact your state or local health department.

 

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