Epidemiology and Infection

Research Article

Control of endemic nosocomial Legionnaires' disease by using sterile potable water for high risk patients

T. J. Marriea1a2*, D. Haldanea2, S. Macdonalda3, K. Clarkea3, C. Fanninga3, S. Le Fort-Josta3, G. Bezansona2 and J. Jolya4

a1 Departments of Medicine, Dalhousie University and the Victorial General Hospital, Halifax

a2 Department of Microbiology, Dalhousie University and the Victoria General Hospital, Halifax

a3 The Infection Control Department Victoria General Hospital, Halifax

a4 Nova Scotia and Department of Microbiology Université Laval, Quebec City, Quebec


In a setting where potable water is contaminated with Legionella pneumophila serogroup 1, we performed two case control studies. The first case control study consisted of 17 cases of nosocomial Legionnaires' disease (LD) and 33 control (the patients who were admitted to the ward where the case was admitted immediately before and after the case) subjects. Cases had a higher mortality rate 65% vs 12% (P < 0.004); were more likely to have received assisted ventilation (P < 0.00001); to have nasogastric tubes (P < 0.0004) and to be receiving corticosteroids or other immunosuppressive therapy (P < 0.0001). Based on the results of this study, sterile water was used to flush nasogastric tubes and to dilute nasogastric feeds. Only 3 cases of nosocomial LD occurred during the next year compared with 12 the previous year (P < 0.0001). Nine cases subsequently occurred and formed the basis for the second case-control study. Eighteen control subjects were those patients admitted to the same unit where the case developed LD, immediately before and after the case. The mortality rate for the cases was 89% vs 6% for controls (P < 0.00003). The only other significant difference was that cases were more likely to be receiving corticosteroids or other immunosuppressive therapy 89% vs 39% ( < 0.01). We hypothesized that microaspiration of contaminated potable water by immunocompromised patients was a risk factor for nosocomial Legionnaires' disease. From 17 March 1989 onwards such patients were given only sterile potable water. Only two cases of nosocomial LD occurred from June 1989 to September 1990 and both occurred on units where the sterile water policy was not in effect. We conclude that aspiration of contaminated potable water is a possible route for acquisition of nosocomial LD in our hospital and that provision of sterile potable water to high risk patients (those who are receiving corticosteroids or other immunosuppressive drugs; organ transplant recipients or hospitalized in an intensive care unit) should be mandatory.

(Accepted May 16 1991)


* T. J. Marrie. M.D., Room 4090 A.C.C.. Victoria General Hospital. 1278 Tower Road. Halifax. Nova Scotia. B3H 2Y9.