Molecular diagnosis of Legionella infections – Clinical utility of front-line screening as part of a pneumonia diagnostic algorithm

  • Naomi J. Gadsby
    Correspondence
    Corresponding author. Tel.: +44 (0)131 242 6069; fax: +44 (0)131 242 6008.
    Affiliations
    Medical Microbiology, Dept Laboratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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  • Author Footnotes
    c Present address: Department of Microbiology, Landspitali, University Hospital of Iceland, 101 Reykjavik, Iceland.
    Kristjan O. Helgason
    Footnotes
    c Present address: Department of Microbiology, Landspitali, University Hospital of Iceland, 101 Reykjavik, Iceland.
    Affiliations
    Medical Microbiology, Dept Laboratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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  • Author Footnotes
    d Present address: Scottish MRSA Reference Laboratory, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.
    Elizabeth M. Dickson
    Footnotes
    d Present address: Scottish MRSA Reference Laboratory, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.
    Affiliations
    Medical Microbiology, Dept Laboratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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  • Author Footnotes
    e Present address: Department of Medical Microbiology, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ, UK.
    Jonathan M. Mills
    Footnotes
    e Present address: Department of Medical Microbiology, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ, UK.
    Affiliations
    Medical Microbiology, Dept Laboratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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  • Diane S.J. Lindsay
    Affiliations
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK
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  • Giles F. Edwards
    Affiliations
    Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK
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  • Mary F. Hanson
    Affiliations
    Medical Microbiology, Dept Laboratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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  • Kate E. Templeton
    Affiliations
    Medical Microbiology, Dept Laboratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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  • in collaboration with theESCMID Study Group for Molecular Diagnostics and the ESCMID Study Group for Legionella Infections, Basel, Switzerland
  • Author Footnotes
    c Present address: Department of Microbiology, Landspitali, University Hospital of Iceland, 101 Reykjavik, Iceland.
    d Present address: Scottish MRSA Reference Laboratory, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.
    e Present address: Department of Medical Microbiology, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ, UK.
Published:November 26, 2015DOI:https://doi.org/10.1016/j.jinf.2015.10.011

      Highlights

      • Legionella is a clinically significant cause of severe LRTI in our centre.
      • Legionella pneumophila PCR testing enabled a rapid response to a LD outbreak in 2012.
      • Syndromic molecular testing identified severe viral LRTI during the LD outbreak.
      • Legionella species PCR detected several cases of Legionella longbeachae LD.
      • These would have been missed by L. pneumophila PCR/urinary antigen testing alone.

      Summary

      Objectives

      Urinary antigen testing for Legionella pneumophila serogroup 1 is the leading rapid diagnostic test for Legionnaires' Disease (LD); however other Legionella species and serogroups can also cause LD. The aim was to determine the utility of front-line L. pneumophila and Legionella species PCR in a severe respiratory infection algorithm.

      Methods

      L. pneumophila and Legionella species duplex real-time PCR was carried out on 1944 specimens from hospitalised patients over a 4 year period in Edinburgh, UK.

      Results

      L. pneumophila was detected by PCR in 49 (2.7%) specimens from 36 patients. During a LD outbreak, combined L. pneumophila respiratory PCR and urinary antigen testing had optimal sensitivity and specificity (92.6% and 98.3% respectively) for the detection of confirmed cases. Legionella species was detected by PCR in 16 (0.9%) specimens from 10 patients. The 5 confirmed and 1 probable cases of Legionella longbeachae LD were both PCR and antibody positive.

      Conclusions

      Front-line L. pneumophila and Legionella species PCR is a valuable addition to urinary antigen testing as part of a well-defined algorithm. Cases of LD due to L. longbeachae might be considered laboratory-confirmed when there is a positive Legionella species PCR result and detection of L. longbeachae specific antibody response.

      Keywords

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      References

        • Svarrer C.W.
        • Lück C.
        • Elverdal P.L.
        • Uldum S.A.
        Immunochromatic kits Xpect Legionella and BinaxNOW Legionella for detection of Legionella pneumophila urinary antigen have low sensitivities for the diagnosis of Legionnaires' disease.
        J Med Microbiol. 2012; 61: 213-217
        • Mercante J.W.
        • Winchell J.M.
        Current and emerging Legionella diagnostics for laboratory and outbreak investigations.
        Clin Microbiol Rev. 2015; 28: 80-118
        • Yu V.L.
        • Plouffe J.F.
        • Pastoris M.C.
        • Stout J.E.
        • Schousboe M.
        • Widmer A.
        • 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: 127-128
        • Muder R.R.
        • Yu V.L.
        Infection due to Legionella species other than L. pneumophila.
        Clin Infect Dis. 2002; 35: 990-998
        • Whiley H.
        • Bentham R.
        Legionella longbeachae and legionellosis.
        Emerg Infect Dis. 2011; 17: 579-583
        • Murdoch D.R.
        • Podmore R.G.
        • Anderson T.P.
        • Barratt K.
        • Maze M.J.
        • French K.E.
        • et al.
        Impact of routine systematic polymerase chain reaction testing on case finding for Legionnaires' disease: a pre-post comparison study.
        Clin Infect Dis. 2013; 57: 1275-1281
        • Lindsay D.S.
        • Brown A.W.
        • Brown D.J.
        • Pravinkumar S.J.
        • Anderson E.
        • Edwards G.F.
        Legionella longbeachae serogroup 1 infections linked to potting compost.
        J Med Microbiol. 2012; 61: 218-222
        • Currie S.L.
        • Beattie T.K.
        • Knapp C.W.
        • Lindsay D.S.
        Legionella spp. in UK composts-a potential public health issue?.
        Clin Microbiol Infect. 2014; 20: O224-O229
        • Beauté J.
        • Zucs P.
        • de Jong B.
        • European Legionnaires' Disease Surveillance Network
        Legionnaires disease in Europe, 2009–2010.
        Euro Surveill. 2013; 18: 20417
        • Reischl U.
        • Linde H.J.
        • Lehn N.
        • Landt O.
        • Barratt K.
        • Wellinghausen N.
        Direct detection and differentiation of Legionella species and Legionella pneumophila in clinical specimens by dual-color real-time PCR and melting curve analysis.
        J Clin Microbiol. 2002; 40: 3814-3817
        • Templeton K.E.
        • Scheltinga S.A.
        • Sillekens P.
        • Crielaard J.W.
        • van Dam A.P.
        • Goossens H.
        • et al.
        Development and clinical evaluation of an internally controlled, single-tube multiplex real-time PCR assay for detection of Legionella pneumophila and other Legionella species.
        J Clin Microbiol. 2003; 41: 4016-4021
        • Bencini M.A.
        • van den Brule A.J.
        • Claas E.C.
        • Hermans M.H.
        • Melchers W.J.
        • Noordhoek G.T.
        • et al.
        Multicenter comparison of molecular methods for detection of Legionella species in sputum samples.
        J Clin Microbiol. 2007; 45: 3390-3392
        • Diederen B.M.
        • Kluytmans J.A.
        • Vandenbroucke-Grauls C.M.
        • Peeters M.F.
        Utility of real-time PCR for diagnosis of Legionnaires' disease in routine clinical practice.
        J Clin Microbiol. 2008; 46: 671-677
        • Svarrer C.W.
        • Uldum S.A.
        The occurrence of Legionella species other than Legionella pneumophila in clinical and environmental samples in Denmark identified by mip gene sequencing and matrix-assisted laser desorption ionization time-of-flight mass spectrometry.
        Clin Microbiol Infect. 2012; 18: 1004-1009
        • Benitez A.J.
        • Winchell J.M.
        Clinical application of a multiplex real-time PCR assay for simultaneous detection of Legionella species, Legionella pneumophila, and Legionella pneumophila serogroup 1.
        J Clin Microbiol. 2013; 51: 348-351
        • McCormick D.
        • Thorn S.
        • Milne D.
        • Evans C.
        • Stevenson J.
        • Llano M.
        • et al.
        Public health response to an outbreak of Legionnaires' disease in Edinburgh, United Kingdom, June 2012.
        Euro Surveill. 2012; 17: 20216
        • Irons J.F.
        • Dunn M.J.
        • Kefala K.
        • Thorn S.
        • Lakha F.
        • Caesar D.
        • et al.
        The effect of a large Legionnaires' disease outbreak in Southwest Edinburgh on acute and critical care services.
        QJM. 2013 Aug 28; 12: 1087-1094
      1. European Legionnaires' Disease Surveillance Network (ELDSNet). EU case definition for Legionnaires’ Disease: Commission Decision of 28 April 2008 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. ECDC www.ecdc.europa.eu.

        • Templeton K.E.
        • Scheltinga S.A.
        • Beersma M.F.
        • Kroes A.C.
        • Claas E.C.
        Rapid and sensitive method using multiplex real-time PCR for diagnosis of infections by influenza A and influenza B viruses, respiratory syncytial virus, and parainfluenza viruses 1, 2, 3, and 4.
        J Clin Microbiol. 2004; 42: 1564-1569
        • Heim A.
        • Ebnet C.
        • Harste G.
        • Pring-Åkerblom P.
        Rapid and quantitative detection of human adenovirus by real-time PCR.
        J Med Virol. 2003; 70: 228-239
        • Templeton K.E.
        • Scheltinga S.A.
        • Graffelman A.W.
        • van Schie J.M.
        • Crielaard J.W.
        • Sillekens P.
        • et al.
        Comparison and evaluation of real-time PCR, real-time nucleic acid sequence-based amplification, conventional PCR, and serology for diagnosis of Mycoplasma pneumoniae.
        J Clin Microbiol. 2003; 41: 4366-4371
        • Scheltinga S.A.
        • Templeton K.E.
        • Beersma M.F.
        • Claas E.C.
        Diagnosis of human metapneumovirus and rhinovirus in patients with respiratory tract infections by an internally controlled multiplex real-time RNA PCR.
        J Clin Virol. 2005; 33: 306-311
        • Public Health England
        Investigation of bronchoalveolar lavage, sputum and associated specimens. UK standards for microbiology investigations.
        2014 (B 57 Issue 2.5)
        • Health Protection Scotland
        Cluster of Legionella longbeachae cases in Scotland in September/October 2013.
        Health Protection Scotland, 2014 ([Report])
        • Maze M.J.
        • Slow S.
        • Cumins A.M.
        • Boon K.
        • Goulter P.
        • Podmore R.G.
        • et al.
        Enhanced detection of Legionnaires' disease by PCR testing of induced sputum and throat swabs.
        Eur Respir J. 2014; 43: 644-646
        • Olsen C.W.
        • Elverdal P.
        • Jørgensen C.S.
        • Uldum S.A.
        Comparison of the sensitivity of the Legionella urinary antigen EIA kits from binax and biotest with urine from patients with infections caused by less common serogroups and subgroups of Legionella.
        Eur J Clin Microbiol Infect Dis. 2009; 28: 817-820
        • Held J.
        Increasing the sensitivity of the BinaxNOW Legionella urinary antigen immunochromatographic test by additional readings at later time points.
        J Med Microbiol. 2012; 61: 884-885
        • van der Zee A.
        • Peeters M.
        • de Jong C.
        • Verbakel H.
        • Crielaard J.W.
        • Claas E.C.
        • et al.
        Qiagen DNA extraction kits for sample preparation for Legionella PCR are not suitable for diagnostic purposes.
        J Clin Microbiol. 2002; 40: 1126
        • Maurin M.
        • Hammer L.
        • Gestin B.
        • Timsit J.F.
        • Rogeaux O.
        • Delavena F.
        • et al.
        Quantitative real-time PCR tests for diagnostic and prognostic purposes in cases of legionellosis.
        Clin Microbiol Infect. 2010; 16: 379-384
        • Joseph C.A.
        • Ricketts K.D.
        Legionnaires' disease in Europe 2007–2008.
        Euro Surveill. 2010; 15 (pii=1949)
        • Potts A.
        • Donaghy M.
        • Marley M.
        • Othieno R.
        • Stevenson J.
        • Hyland J.
        • et al.
        Cluster of Legionnaires' disease cases caused by Legionella longbeachae serogroup 1, Scotland, August to September 2013.
        Euro Surveill. 2013; 18 (pii=20656)
      2. Health Protection Scotland (HPS) Weekly Report. Vol. 47. 2013 (No. 2013/38 p331)

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