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[Evaluation of a Legionella outbreak emerged in a recently opening hotel].
[legionellosis]
Legionnaires
'
disease
(
LD
)
is
a
systemic
infection
caused
by
Legionella
species
especially
colonized
in
the
water
systems
.
Hotels
are
common
locations
in
which
waterwork-associated
sporadic
or
epidemic
legionellosis
can
be
detected
.
The
aim
of
this
study
was
to
evaluate
a
small
Legionella
outbreak
emerged
in
a
recently
opened
600
-
bed
hotel
in
Alanya
,
a
touristic
county
in
Mediterranean
part
of
Turkey
.
A
66
years
old
male
patient
who
stayed
in
this
hotel
opened
on
May
15
th
,
2009
,
was
admitted
to
our
hospital
on
May
21
st
,
2009
with
the
complaints
of
high
fever
,
headache
and
diarrhea
lasting
for
three
days
.
Since
chest
X-
ray
revealed
non-homogenous
density
increase
in
left
middle
and
inferior
zone
,
the
patient
was
diagnosed
as
atypical
pneumoniae
and
LD
was
confirmed
by
positive
urinary
Legionella
antigen
test
(
Card
test
,
BinaxNOW
®
Legionella
Urinary
Antigen
Test
;
Alere
Co
,
USA
)
result
.
Following
the
identification
of
the
index
case
,
the
records
of
our
hospital
were
reviewed
and
revealed
another
case
being
treated
with
the
diagnosis
of
community
acquired
pneumonia
who
was
also
the
guest
of
the
same
hotel
.
This
patient
was
then
diagnosed
as
LD
by
positive
urinary
antigen
test
.
Since
new
cases
were
identified
during
the
following
days
(
May
22
,
25
and
26
)
the
Antalya
County
Health
Department
and
hotel
management
were
informed
about
a
cluster
of
LD
.
In
addition
subsequent
investigation
for
environmental
surveillance
and
water
sampling
were
conducted
.
The
LD
diagnosis
and
environmental
inspections
were
performed
according
to
the
procedure
described
in
the
guideline
from
"
Turkish
Ministry
of
Health
Travel-
Associated
Legionnaires
'
Disease
Control
Programme
"
.
Five
definitive
cases
and
one
presumptive
case
of
LD
were
identified
during
the
outbreak
period
(
May
20
-
26
,
2009
)
.
All
of
the
cases
were
successfully
treated
(
intravenous
ciprofloxacin
or
levofloxacin
or
clarithromycin
)
,
however
one
patient
died
due
to
sudden
death
during
sleep
after
being
discharged
.
Since
sputum
samples
could
not
be
obtained
from
the
cases
,
the
diagnosis
were
not
confirmed
by
culture
but
by
urinary
antigen
test
.
Besides
high
antibody
titer
in
single
serum
sample
was
accepted
as
a
diagnostic
marker
.
Additionally
26
cases
who
accommodated
in
the
same
hotel
and
presented
with
high
fever
without
pneumonia
were
treated
in
the
outpatient
clinics
of
our
hospital
.
Urinary
antigen
test
was
performed
in
11
of
those
patients
to
confirm
the
prediagnosis
of
pontiac
fever
,
however
all
were
found
negative
.
Likewise
convalescent
phase
sera
for
the
confirmation
of
the
diagnosis
by
seroconversion
could
not
be
obtained
since
they
all
were
foreign
tourists
.
Investigation
of
water
sources
of
the
hotel
revealed
that
the
municipal
drinking
water
network
had
not
been
connected
yet
and
the
hotel
supplied
water
from
groundwater
sources
.
The
analysis
of
multiple
samples
from
multiple
sites
of
hotel
's
water
system
indicated
that
the
water
temperature
was
between
35
-
45
°
C
and
the
iron
level
was
beyond
the
acceptable
limits
(
245
µg
/
L
)
recommended
for
drinking
water
in
the
regulation
guides
.
These
properties
were
considered
as
the
factors
that
enhanced
the
growth
and
survival
of
Legionella
species
.
Water
samples
were
cultivated
on
BCYE-
_
(
Buffered
Charcoal
Yeast
Extract
a-
Ketoglutarate
)
and
GVPC
(
Glycine-
Vancomycin-
Polymyxin-
Cycloheximide
)
agar
plates
and
11
out
of
a
total
13
samples
yielded
Legionella
spp
.
growth
.
All
isolates
were
identified
as
L
.
pneumophila
serogroup
1
by
specific
antisera
.
Legionella
decontamination
of
hotel
's
water
system
was
managed
by
implementation
of
hyperchlorination
method
as
well
as
superheating
(
>
60
°
C
)
of
water
.
The
hotel
was
not
closed
during
the
outbreak
and
cultures
of
water
samples
obtained
for
one
year
later
did
not
yield
any
Legionella
spp
.
growth
.
This
outbreak
emphasized
that
hotel
residents
are
at
risk
for
acquiring
LD
in
the
presence
of
a
colonized
water
system
,
even
in
a
newly
constructed
building
.
In
conclusion
,
effective
control
and
decontamination
programmes
for
the
prevention
of
Legionella
colonization
should
be
applied
even
in
new
opening
hotels
.
Diseases
Validation
Diseases presenting
"likewise convalescent phase sera for the confirmation of the diagnosis"
symptom
legionellosis
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