Major Article| Volume 49, ISSUE 8, P1014-1020, August 2021

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Hospital-acquired Legionella pneumonia outbreak at an academic medical center: Lessons learned

Published:February 22, 2021DOI:


      • Copper-Silver water ionization disinfection systems can be overcome resulting in nosocomial Legionella outbreaks.
      • Routine monitoring and enhanced monitoring of potable water systems after structural disruptions should be encouraged.
      • In hospital showering activity is identified as a statistically significant risk factor for contracting Legionella during an outbreak.
      • Showering restriction and point of use water filters can help mitigate outbreaks related to potable water.
      • Multidisciplinary collaboration is encouraged to anticipate and assess for vulnerabilities to Legionella outbreaks.



      An outbreak of Legionella pneumonia occurred at a university hospital using copper-silver ionization for potable water disinfection. We present the epidemiological and laboratory investigation of the outbreak, and associated case-control study.


      Cases were defined by syndrome compatible with Legionella pneumonia with laboratory-confirmed Legionella infection. The water circuit and disinfection system were assessed, and water samples collected for Legionella culture. Whole genome multi-locus sequence typing (wgMLST) was used to compare the genetic similarity of patient and environmental isolates. A case-control study was conducted to identify risk factors for Legionella pneumonia.


      We identified 13 cases of hospital-acquired Legionella. wgMLST revealed >99.9% shared allele content among strains isolated from clinical and water samples. Smoking (P= .008), steroid use (P= .007), and documented shower during hospitalization (P= .03) were risk factors for Legionella pneumonia on multivariable analysis. Environmental assessment identified modifications to the hospital water system had occurred in the month preceding the outbreak. Multiple mitigation efforts and application of point of use water filters stopped the outbreak.


      Potable water system Legionella colonization occurs despite existing copper-silver ionization systems, particularly after structural disruptions. Multidisciplinary collaboration and direct monitoring for Legionella are important for outbreak prevention. Showering is a modifiable risk factor for nosocomial Legionella pneumonia. Shower restriction and point-of-use filters merit consideration during an outbreak.

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