David W. Fraser

Sporadic Legionellosis in the United States: The First Thousand Cases

As of 30 September 1979, 1005 confirmed cases of sporadic legionellosis caused by Legionella pneumophila serogroups 1 to 4 in U.S. residents had been reported to the Centers for Disease Control; 19% were fatal. All but 2% of the 1005 cases were associated with pneumonia documented by chest radiograph. About 75% of the cases occurred in June through October. The risk of acquiring sporadic legionellosis was increased among males and persons 50 years or older; persons with renal disease necessitating dialysis or transplantation, with chronic bronchitis or emphysema, with diabetes mellitus, and with cancer (10 selected sites or types); persons who smoke; and persons being treated with immunosuppressive drugs. Increasing age and chronic bronchitis or emphysema were associated with increased risk of death. The sensitivity of culturing L. pneumophila from specimens positive by direct immunofluorescence was estimated to be 45%. The distribution of serogroups 1, 2, 3, and 4 of L. pneumophila in 57 fresh, not previously examined direct fluorescent antibody-positive specimens was 84%, 11%, 4%, and 2%, respectively; all 26 strains isolated from these specimens were of one of these four serogroups.

ANTIBIOTIC TREATMENT OF GUINEAPIGS INFECTED WITH AGENT OF LEGIONNAIRES' DISEASE

Erythromycin and rifampicin (rifampin) were able to prevent death of guineapigs given intraperitoneal injections of the agent causing legionnaires disease. Penicillin, chloramphenicol, tetracycline, and gentamicin showed no significant effect. On the basis of clinical experience and experimental observations, erythromycin is recommended for patients suspected to have legionnaires disease. Combined therapy with erythromycin and rifampicin may be justified in patients with confirmed legionnaires disease who are not responding to erythromycin alone or as part of a controlled antibiotic trial among suspected cases during an outbreak of legionnaires disease.

ATYPICAL LEGIONELLA-LIKE ORGANISMS: FASTIDIOUS WATER-ASSOCIATED BACTERIA PATHOGENIC FOR MAN

A group of related bacteria designated atypical Legionella-like organisms (ALLO) has been identified. ALLO, like L. pneumophila, are fastidious gram-negative rods that grow well on charcoal yeast extract (CYE) agar and produce ground glass colonies and browning of modified yeast extract agar. Unlike L. pneumophila, ALLO do not grow well on Feeley-Gorman (FG) agar, and on CYE agar they fluoresce under longwave ultraviolet light. ALLO and L. pneumophila have a similar predominance of branched-chain forms among total cellular fatty acids but have distinctive fatty-acid profiles. 2 patients with culture-verified ALLO pneumonia and 10 with pneumonia of uncertain aetiology who seroconverted to ALLO offer evidence that ALLO may be a cause of community-acquired pneumonia. Like L. pneumophila, ALLO appear to be water-associated; both persons with culture-verified ALLO infection were exposed to fresh water or its contents before becoming ill, and two strains of ALLO were isolated from water or wet environments.

Hemophilus influenzae type b disease in a day-care center. Report of an outbreak.

Four episodes of serious Hemophilus influenzae type b infection occurred in three children attending a day-care center. This was 100 times the expected annual total. The pharyngeal carriage rate of Hib was 60% for siblings of patients, 20% for adult household contacts, and 5% for well children at the center. No carriers were found in control populations. Escherichia coli K100, which cross-reacts serologically with Hib, was found in rectal swabs of 20% of family contacts of patients and 3.5% of well children at the center. It was recovered from two of seven persons who carried Hib in the pharynx and two of 75 who did not (P = 0.035), suggesting that carriage of one organism may facilitate carriage of the other. In a randomized prospective trial with 85 patient contact, Hib carriage was eradicated in all of four carriers given ampicillin and in all of three given rifampin. There were no statistically significant differences in the rate of adverse reactions in the two treatment groups. No further cases were reported.

Epidemiology of pertussis, Atlanta, 1977.

In the period April to October, 1977, an epidemic of pertussis in the outpatient population of a large metropolitan hospital involved 115 cases that were diagnosed by culture or direct fluorescent antibody tests. A study of secondary cases in household contacts showed attack rates of 81% in children under one year of age; attack rates decreased with increasing age to 8% in persons over 20 years of age. Vaccine efficacy was estimated to be 63%. There was no evidence of decreased efficacy with increasing time after vaccination. Fourteen asymptomatic FA-positive individuals were identified; four of these were also culture positive. Four were adults and ten were children. Nine of the ten children had received three or more vaccinations, compared to only 29 of 78 symptomatic children (P = 0.002).

Infections with Legionella pneumophila in Children

Abstract To learn the role of Legionella pneumophila, the agent of Legionnaires disease, in childhood illness, a prospective study was conducted among 52 children younger than four years of age with acute disease of the lower respiratory tract. Viral, mycoplasmal, and bacterial cultures and acute- and convalescent-phase sera were obtained during 64 episodes of acute illness; additional sera were drawn annually for three to five years. On the basis of serologic evidence, none of the acute episodes appeared to be due to L. pneumophila serogroup 1 or 2. However, examination of annual serum specimens showed that 27 (52%) of the children had rises in titer of indirect immunofluorescent antibody (a fourfold or greater rise to a reciprocal titer of ⩾128). Most rises in titer were in response to the serogroup 2 antigen. These results suggest that L. pneumophila is not a common cause of acute respiratory disease in early childhood in the study area but that children are frequently exposed to the organism. Alternatively, the serologic responses might be to unrelated cross-reacting microorganisms.

1974 OUTBREAK OF LEGIONNAIRES' DISEASE DIAGNOSED IN 1977: Clinical and Epidemiological Features

An illness characterized by high fever and pneumonia struck 2.9% of a group of the Independent Order of Odd Fellows attending a convention held in Philadelphia, in September, 1974. The convention headquarters was the hotel where the American Legion met in July, 1976. The epidemiological, clinical, and laboratory characteristics of the illness were nearly identical to those of the disease in American legionnaires in 1976. Illness was significantly associated with attendance at one convention activity held on Monday morning, Sept. 16, 1974, in the grand ballroom of the hotel. A serological survey in February and March, 1977, showed that people who had attended the convention and became ill were more likely to have raised indirect fluorescent antibody titres than persons who had attended and remained well. The illness seen in Odd Fellows members in September, 1974, was caused by the legionnaires disease organism.

Preventing Tetanus in Patients with Wounds

Excerpt Two-thirds of recent tetanus cases in this country have followed puncture wounds, lacerations, and crush injuries (1-3). These are the cases that the physician caring for the wounded patien...

Observations of endotoxin-like activity associated with the Legionnaires' disease bacterium.

Suspensions of Legionnaires disease bacterium stored in sterilized tap water 279–287 days produced gelation ofLimulus amebocyte lysate. A 1-ml suspension of washed cells containing 109 viable organisms had aLimulus amebocyte lysate activity equivalent to 4 mg of endotoxin. This activity remained stable in samples that had been autoclaved at 121°C for 15 min. Both the autoclaved cells and filtrate of autoclaved cells were pyrogenic in inoculated rabbits. The Legionnaires disease bacterium produces a substance or substances that have biological properties associated with endotoxin of more typical Gram-negative bacteria.

Failure of Prophylaxis for Bacterial Endocarditis: American Heart Association Registry

Excerpt To the editor: The American Heart Association (AHA) recognizes that its current recommendations for antibiotic prophylaxis are necessarily empiric (1). This situation has arisen because imp...