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On Sep 2018




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Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1331 - 1336 Full Version

Review Article Legionellosis: An update


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2456
Bharti Arora, Kawal Preet Kaur, Bhawna Sethi

1. Professor, Department of Microbiology, 2. Assistant Professor, Department of Microbiology, Maharaja Agrasen Medical College Agroha (Hisar), Haryana India. 3. Assistant Professor, Department of Pathology, Vir Chander Garhwali Government Medical Science & Research Institute, Shrinagar, India.

Correspondence Address :
Dr. Kawal Preet Kaur,
Professor, Department of Microbiology,
HNo 2602 Patel Colony Rajpura Town
(Patiala) Punjab, India.
Phone: 09050551719
E-mail: dockawu25@gmail.com

Abstract

Legionella is an important cause of adult pneumonia and it must be actively considered in both community-acquired and nosocomial pneumonia. The incidence of legionellosis is underestimated for a variety of reasons, which include a lack of clinical awareness, a non-classical presentation, extrapulmonary infections, a delayed seroconversion and a lack of specialized culture facilities or urinary antigen detection tests. More illness is usually found in the summer and in early fall (June to September), but it can occur at any time of the year. It is uncommon in our country, because we are not looking for it hard enough. Unless the doctor looks out and tests for Legionella, these cases are invariably missed. Physicians need to familiarize themselves with the disease, as a prompt recognition and an early treatment can considerably curtail the total outcome in the affected cases and prevent additional cases. Although many aspects about this disease are clear, there are some dark areas regarding the vaccine development, that need to be further explored and understood. The present article details out almost everything which is known about this disease, along with the review of the recent literature.

Keywords

Legionella, Legionellosis, Pneumonia, Treatment

In 1976, an explosive outbreak of pneumonia occurred among the persons who attended an American Legion convention in Philadelphia (1). A total of 221 persons became ill with pneumonia, and 34 of them died. Later, in January 1977, Dr.Joseph McDade of the Centers for Disease Control isolated the bacterium which caused the outbreak (2). Legionella pneumophila, the agent of this outbreak, became the first named member of the family, Legionellaceae. Although this bacterium was found before 1976, more illness from the Legionnaires’ disease is being detected now. This is because we are looking for this disease whenever a patient has pneumonia. Currently, the family, Legionellaceae, comprises of 48 species with 70 serogroups (3). Legionella pneumophila contains 14 serogroups; the serogroups [1,4] and 6 are the most commonly implicated ones in human infections (4). To date, 20 species other than L. pneumophila have been associated with human infections (Table/Fig 1), among which L. micdadei, L. bozemani, L. dumoffii and L. longbeachae are the most common ones (5),(6). Legionellosis refers to the two clinical syndromes (Pontiac fever and Legionnaires’ disease) which are caused by the bacteria of the genus, Legionella. New diagnostic, therapeutic and preventive modalities are being developed to tackle this fatal disease of mankind.
The organism
Identification Legionellae appear as lightly staining, pleomorphic, and thin gram-negative rods. They grow on BCYE agar, but not on media which does not have L-cysteine. Their growth is slow (3 to 5 days) and the colonies show the characteristic “ground glass” appearance. Specific staining with fluorescein-labeled antibodies can confirm Microbiology Sectionthe identity of the organisms. Legionellae stain much more readily in the tissues with the Diff-Quik, Giemsa or the Gram-Weigert stains than they do with the traditional Gram staining. Legionella are strictly aerobic and nutritionally fastidious. They require media which are supplemented with L-cysteine and iron for their primary isolation. They can be grown on Buffered Charcoal Yeast-Extract (BCYE) agar (7) and Mueller- Hinton medium which contains 1% haemoglobin and 1% Isovitalex (8). These organisms are non-fermentative and they derive energy from the metabolism of amino acids (9). Most of the species are motile and catalase-positive, they liquefy gelatine, and they do not reduce nitrate or hydrolyze urea. The sodium hippurate hydrolysis test is positive for L. Pneumophila (10) and negative for a majority of the other Legionella species. Legionellae are asaccharolytic and weakly catalase or oxidase-positive. In contrast to the identification of the genus, the species classification requires the help of reference laboratories. Although the biochemical tests and the ability of the rods to fluoresce under long-wave ultraviolet light are useful for differentiating the species, the species can be identified definitively only through an analysis of the major branched-chain fatty acids in the cell wall and by nucleic acid genetic studies (42). Initially, legionellae were identified to the serogroups level by using polyclonal or monoclonal antisera. But now, the L. pneumophila serogroup 1 can be divided into a number of subtypes by various molecular techniques. The various techniques include pulsed-field gel electrophoresis (PFGE), arbitrarily primed PCR (AP-PCR), electrophoretic alloenzyme typing, plasmid typing, restriction fragment length polymorphism, ribotyping and amplified fragment length polymorphism. Subtyping is used to match the environmental isolates with the patient isolates which are obtained during investigations on the legionellosis outbreak.
Differential diagnosis
The Legionnaires’ disease is often included in the differential diagnosis of “atypical pneumonia” along with infections which are caused by Chlamydia pneumoniae, C.psittaci, Mycoplasma pneumoniae, Coxiella burnetii and some viruses. The clinical similarities among these types of pneumonia include a relatively non-productive cough and a low incidence of grossly purulent sputum. However, the clinical manifestations of Legionnaires’ disease are usually more severe than those of most cases of the “atypical” pneumonia. Diarrhoea and hyponatraemia occur significantly more often in Legionnaires’ disease than in other forms of pneumonia. The findings on chest radiography do not serve to distinguish Legionnaires’ disease from pneumonias of other aetiologies (38). Depending upon their growth on the BCYE agar, legionellae should be differentiated from Francisella tularensis, Bordetella pertussis and certain thermophilic spore-forming bacilli. In contrast to the Francisella spp., which produce acid from carbohydrates, the Legionella spp. neither ferment nor oxidize carbohydrates. The Legionella spp. produce the characteristic branched- chain fatty acids in their cell wall, which help in differentiating them from other organisms (39).
Laboratratory diagnosis
The diagnosis of Legionnaires’ disease requires special microbiological tests (Table/Fig 3). Various abnormalities which have been noted in Legionella pneumonia are hyponatraemia, thrombocytopaenia, haematuria, hypophosphataemia and abnormal liver function tests. Saline or sodium salt-based buffers should not be used in processing or transporting the specimens which contain legionellae because of the inhibitory effects of sodium on the Legionella spp. The culture of the respiratory secretions is the most specific and the most sensitive test. When the sputum is cultured, it is best to pretreat the sample by either acidification or heat. Bahl et al., (40) from Delhi used culture sensitivity, direct fluorescence and ELISA for the lower respiratory tract infections. Chaudhary et al., (41) reported the role of ELISA in the detection of L.pneumophila. PCR of the serum has been used for the identification of Legionella.
Epidemiology
Most of the members of Legionellaceae are found worldwide and they occur naturally in aquatic sources such as lakes, rivers, hot springs, ground water and mud (11). L. longbeachae has been isolated from soil (12),(13). Legionellae resist the usual chlorination of the water treatment facilities and they subsequently gain entry into and colonize the human-made water supplies (14),(15). Hot water systems, cooling towers, showers,(16) evaporative condensers, ornamental fountains, whirlpools (17) and humidifiers are their artificial reservoirs. These have been implicated frequently in the outbreaks of the Legionnaires’ diseases (Table/Fig 2). A large outbreak at a flower show in the Netherlands was traced to the whirlpool spas which were used in the exhibits (18). Legionellae can grow and proliferate in human-constructed aquatic reservoirs. The factors which are known to enhance the colonization and the amplification of legionellae include warm temperatures (250C to 420C), stagnation, and the presence of biofilms on the surfaces of pipes which contain commensal bacteria, ciliated protozoa, algae and amoebae (19). The biofilms protect Legionella from the direct exposure to ultraviolet (UV) light, desiccation, and the chemicals which are used to control its growth. Rowbotham was the first to report that the Legionella species multiply in close association with the free-living amoebae of the genera, Acanthamoeba and Naegleria (20). Others have confirmed and extended these observations, not only with Acanthamoeba and Naegleria, but also with other amoebae such as Hartmanella and the ciliate Tetrahymena (21),(22). The amoebae may protect legionellae within their cysts against the effects of chlorine (23). The Centres for Disease Control and Prevention (CDC) has estimated that between 10,000 and 20,000 cases of the Legionnaires’ disease occur each year in the United States (24). Although sporadic outbreaks of the disease occur throughout the year, most of the epidemics of its infection occur in late summer and autumn, presumably because the organism proliferates in water reservoirs during the warm months (25). The most common risk factors for the Legionnaires’ disease are cigarette smoking, chronic lung disease, malignancy, advanced age, and immunosuppression (26). Elderly persons are at a greatest risk of the disease because of their decreased cellular immunity and compromised pulmonary function. Almost 25% of the reported cases are acquired in hospitals, presumably because of the predominance of the high-risk patients. Surgery is an prominent predisposing factor in nosocomial infections, with transplant recipients being at the highest risk. Although the disease has been under-reported, travel, hotel, and resort related outbreaks are being reported each year (27). In the outbreaks of Legionnaires’ disease, the attack rates for the exposed high-risk population are usually low (<5%) as opposed to Pontiac fever (>90%). Numerous prospective studies have found Legionella to rank among the top four microbial causes of community - acquired pneumonia, accounting for 3 to 15% cases. Between 1980 and 2002, 4402 cases of the Legionnaires’ disease were identified in England and Wales (28).inThe Legionellae species are transmitted to the human hosts from environmental sources, primarily via aerosolized particles. Most of the outbreaks of this disease originate from potable water distribution contamination. The other means of transmission include aspiration of the contaminated water or secretions, direct inoculation into the lung by respiratory therapy equipment (29) ,(30) and surgical wound contamination with tap water (31). Nasogastric tubes have been linked to the nosocomial Legionnaires’ disease (32). Aerosolization of the legionellae by devices which are filled with tap water, which include nebulizers and humidifiers, has caused cases of the Legionnaires’ disease (33). Pontiac fever occurs in epidemics. The high attack rate (>90%) reflects an airborne transmission. A person-to-person transmission or an animal reservoir has not yet been demonstrated. There is no convincing evidence of a carrier state in humans.
Pathogenesis
Legionellae enter the lungs through aspiration or direct inhalation. The alveolar macrophages readily phagocytose the legionellae. Within the macrophages, the legionellae inhibit the phagolysosomal fusion and acidification of the phagosome (34). They continue to 3multiply inside the macrophages and ultimately the cells rupture, thus releasing the organisms, which can then infect other phagocytic cells. Cell-mediated immunity is the primary mechanism of host defence against Legionella. The Legionnaires’ disease is more common and the disease manifestations are more severe in patients with a depressed cell-mediated immunity, which include transplant recipients, patients who are infected with HIV (35) and patients who are receiving glucocorticoids. Legionella usually produces a lobar, segmental or a patchy pulmonary infiltration. Acute purulent pneumonia which involves the alveoli is present, with dense intra-alveolar exudates of macrophages, neutrophils and fibrin. There is little interstitial infiltration. The organisms are facultative intracellular pathogens and they may be found within the macrophages and the neutrophils or extracellularly.
The clinical spectrum
The clinical manifestations of the Legionella infections include febrile disease with pneumonia (Legionnaires’ disease) or without a pulmonary involvement (Pontiac fever) and an extrapulmonary infection. Pontiac fever is an acute, self-limiting, flulike illness with a 1 to 2 days incubation period. Fever, headache, malaise, fatigue and myalgia are the most frequent symptoms (36). A complete recovery takes place only within a few days without antibiotic therapy. The name “Pontiac” has been derived from a city with this name in Michigan, that was the site of an outbreak in 1968. The Legionnaires’ disease occurs both sporadically, in the form of community-acquired pneumonia, and in epidemics. The incubation period for the Legionnaires’ disease is 2 to 10 days and the patients usually present with fever (high grade), myalgia, arthralgia and non-productive cough. Pneumonia, dyspnoea and respiratory distress are the clinical features of the progressing disease. Abdominal pain and gastrointestinal symptoms occur in many patients. There may be confusion, delirium, renal failure and encephalopathy (37). The Legionellae may be disseminated to other organs via the blood stream and the lymphatics. So, they may involve the liver, kidney, spleen, heart, bone marrow, lymph nodes, GIT and the central nervous system.
Antimicrobial susceptibility and treatatment
The susceptibility testing of the Legionella species is not standardized or performed routinely. The newer macrolides (especially azithromycin) and the quinolones are now the antibiotics of choice. The Quinolones are the preferred antibiotics for transplant recipients. For the severely ill patients with Legionnaires’ disease, the combination of rifampin plus a macrolide or a quinolone can be used for the initial treatment. However, the use of rifampin is not recommended by the Infectious Disease Society of America (43). Initially, the therapy (3 to 5 days) should be given by the intravenous route, after which an oral therapy can be substituted. The total duration of the therapy in an immunocompetent host is 10 to 14 days and 3 weeks may be required for immunosuppressed patients and those with advanced disease (44). The β-lactam antibiotics are ineffective because most of the isolates produce β-lactamases, and these antibiotics do not penetrate the macrophages. With an appropriate and a timely antibiotic treatment, the mortality which results from the community-acquired Legionnaires’ disease among the immunocompetent patients varies from 0 to 11 %. Without a treatment, the figure may be as high as 31% (45). Pontiac fever requires only symptomatic treatment. Supportive treatment in the form of oxygen, intravenous fluids, and chest physiotherapy is the same as for any other pneumonia.
Prevention
No current vaccine is available. The prevention of legionellosis requires identification of the environmental source of the organism and minimizing the production of aerosols in public places from water that may be contaminated with Legionella. There have been outbreaks which have been associated with mists which were used in supermarkets to make the vegetables look fresh and shiny. Legionellae can be eradicated from water by hyperchlorination and by superheating (>700C) of the water before its distribution (46) If the above measures are not successful, then continuous copper- silver ionization of the water supply may be necessary. Monochloramine is attractive for the municipal water system, because it penetrates better into the biofilms than the free chlorine (47) and results in the reduced production of the disinfection by-products. Its action is slower than that of free chlorine but it is more stable and less corrosive and it provides a better residual disinfectant over a long distribution system. The control of the biofilm- associated legionellae may lead to the most effective control measures which may help in preventing legionellosis. For the hospitals with an outbreak or a hyperendemic Legionella problem, a periodic microbiologic surveillance of the environment, combined with ongoing or repetitive control measures should be considered, unless it can be shown that no new cases of legionellosis have occurred (48). The guidelines for the prevention of nosocomial legionellosis have been published by the Allegheny County Health Department (49). This approach emphasizes an environmental monitoring for the Legionella species. However, the CDC advocates an intensive clinical surveillance without a routine environmental surveillance because L. pneumophila is “ubiquitous” in hospital water systems (50).

Conclusion

Legionellosis is a potentially fatal disease if treatment is not taken in time. The clinically suspected cases of legionellosis should be reported immediately to the epidemiological centres to facilitate a laboratory confirmation of their diagnoses. There is a need for the evaluation of new methods which include ultraviolet light sterilization, ozonation, and the addition of amoebicidal agents for the decontamination of the water supplies. Future studies are required, which should include the development of new diagnostic modalities, biocides and vaccine development.

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DOI and Others

ID: JCDR/2012/4582:2456

Financial OR OTHER COMPETING INTERESTS:
None.
Date of Submission: Jun 06, 2012
Date of Peer Review: Jun 14, 2012
Date of Acceptance: Aug 26, 2012
Date of Publishing: Sep 30, 2012

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