Two Nursing Home Outbreaks of Respiratory Infection with Legionella sainthelensi

Loeb, Mark; Simor, Andrew E.; Mandell, Lionel; Krueger, Paul; McArthur, Margaret; James, Marilyn; Walter, Stephen; Richardson, Elizabeth; Lingley, Michael; Stout, Janet; Stronach, David; McGeer, Allison

OBJECTIVE: To describe outbreaks of infection caused by Legionella sainthelensi occurring in older residents of two nursing homes and to determine risk factors for the development of infection. DESIGN: Descriptive epidemiology and a case‐control study. SETTING: Two nursing homes (140 beds and 254 beds in nursing homes A and B, respectively) located in southern Ontario, Canada, experiencing outbreaks of respiratory tract infection in July and August 1994. SUBJECTS: Case‐residents of the two nursing homes who met clinical and laboratory criteria for Legionella infection. Control‐residents were defined as those who were in the homes during the outbreaks and were asymptomatic. MEASUREMENTS: Active surveillance was conducted in both nursing homes to identify symptomatic residents. Residents with fever or respiratory tract symptoms had nasopharyngeal swabs taken for viral antigen detection and culture, urine for Legionella antigen detection, and acute and convalescent serology for viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. Chest X‐rays were performed, and an attempt was made to obtain blood and sputum cultures. Water samples from shower heads, faucets, and air conditioning units were collected for Legionella culture and polymerase chain reaction (PCR) assay. A case‐control study was done to assess possible risk factors for legionellosis. RESULTS: Twenty‐nine cases — 17 in nursing home A; 12 in nursing home B — were identified. Four (14%) case‐residents had documented pneumonia and four case‐residents died. Univariate analysis revealed that a history of stroke (odds ratio (OR) 2.3 (95% CI, 1.0–5.3)), eating pureed food (OR 4.6 (95% CI, 1.6–12.7)), and having fluids administered with medication (OR 2.5 (95% CI, 1.0–5.9)) were significant risk factors. Cases were less likely to wear dentures (OR .4 (95% CI, .2‐.9)) or to eat solid food (OR .3, (95% CI, .1‐.6)). Only eating pureed food remained significant in a multivariable analysis (OR 4.6 (95% CI, 1.6–13.0, P = .01)). CONCLUSION: This report describes outbreaks of legionellosis in two nursing homes, representing the first reported outbreaks of infection caused by Legionella sainthelensi. The association with illness of dietary characteristics indicative of swallowing disorders suggests that aspiration was the most likely mode of infection. The diagnosis of legionellosis should be considered during outbreaks of respiratory infection in nursing homes. J Am Geriatr Soc 47:547–552, 1999.