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Copyright (c) 2025 Tuwayrish Fahad Tuwayrish Aldosari Aldosari, Ghada Ebrahim Ali Mabouj, Abdulrahman Nada Alshamari, Ali Abdu Abbas Arishi,, Abdulaziz Mofareh Lagabi, Mousa Ahmed Ali Sahli, Ibrahim Hasen Qiraty, Areej Ahmed Alhamzi, Majed Mohammed Hasan Abukafitah, Asaad Masoud Hamad Darraj, Walaa Homad Mohammed Hakami, Hana Saeed Faqih
This work is licensed under a Creative Commons Attribution 4.0 International License.
Epidemiology, Prevention, and Public Health Management of Legionnaires’ Disease-An Updated Review for Healthcare Professionals.
Corresponding Author(s) : Tuwayrish Fahad Tuwayrish Aldosari Aldosari
Saudi Journal of Medicine and Public Health,
Vol. 2 No. 2 (2025)
Abstract
Background: Legionnaires’ disease (LD), a severe atypical pneumonia caused primarily by Legionella pneumophila, continues to pose significant public health challenges due to underdiagnosis, environmental persistence, and high morbidity and mortality.
Aim: This review aims to provide healthcare professionals with an updated synthesis of the epidemiology, pathophysiology, clinical features, diagnosis, management, and prevention of LD.
Methods: A comprehensive review of current literature and surveillance data was conducted, incorporating clinical, microbiological, and environmental findings related to LD presentations, diagnostic strategies, and therapeutic approaches.
Results: Legionella species remain widely distributed in natural and man made water systems, with serogroup 1 of L. pneumophila responsible for most human infections LD often presents with fever, respiratory symptoms, and extrapulmonary manifestations such as gastrointestinal and neurological signs. Diagnosis requires a combination of urinary antigen testing, cultures, and imaging. Fluoroquinolones and macrolides represent first line therapy, with early treatment significantly improving outcomes Complications include respiratory failure, shock, renal injury, and multiorgan dysfunction, particularly in high risk populations
Conclusion: Early recognition, targeted antimicrobial therapy, and robust water system management are crucial to reducing LD related morbidity and mortality.
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- Graham FF, Hales S, White PS, Baker MG. Review Global seroprevalence of legionellosis - a systematic review and meta-analysis. Sci Rep. 2020 Apr 30;10(1):7337.
- Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, Harris J, Mallison GF, Martin SM, McDade JE, Shepard CC, Brachman PS. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med. 1977 Dec 01;297(22):1189-97.
- McDade JE, Shepard CC, Fraser DW, Tsai TR, Redus MA, Dowdle WR. Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N Engl J Med. 1977 Dec 01;297(22):1197-203.
- Barskey AE, Derado G, Edens C. Rising Incidence of Legionnaires' Disease and Associated Epidemiologic Patterns, United States, 1992-2018. Emerg Infect Dis. 2022 Mar;28(3):527-538.
- Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, Bos LD, Chalmers JD, Derde L, de Waele J, Garnacho-Montero J, Kollef M, Luna CM, Menendez R, Niederman MS, Ponomarev D, Restrepo MI, Rigau D, Schultz MJ, Weiss E, Welte T, Wunderink R. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med. 2023 Jun;49(6):615-632.
- Cooley LA, Pondo T, Francois Watkins LK, Shah P, Schrag S., Active Bacterial Core Surveillance Program of the Emerging Infections Program Network. Population-Based Assessment of Clinical Risk Factors for Legionnaires' Disease. Clin Infect Dis. 2020 May 23;70(11):2428-2431.
- Viasus D, Gaia V, Manzur-Barbur C, Carratalà J. Legionnaires' Disease: Update on Diagnosis and Treatment. Infect Dis Ther. 2022 Jun;11(3):973-986.
- Miyashita N. Legionella prediction score. Respir Investig. 2024 Mar;62(2):305-306.
- Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010 Mar;24(1):73-105.
- Niculita-Hirzel H, Vanhove AS, Leclerc L, Girardot F, Pourchez J, Allegra S. Risk Exposure to Legionella pneumophila during Showering: The Difference between a Classical and a Water Saving Shower System. Int J Environ Res Public Health. 2022 Mar 10;19(6)
- Palusińska-Szysz M, Simões M. Editorial: Legionella pneumophila-transmission, pathogenesis, host-pathogen interaction, prevention and treatment. Front Microbiol. 2024;15:1364620.
- Priest PC, Slow S, Chambers ST, Cameron CM, Balm MN, Beale MW, Blackmore TK, Burns AD, Drinković D, Elvy JA, Everts RJ, Hammer DA, Huggan PJ, Mansell CJ, Raeder VM, Roberts SA, Robinson MC, Sathyendran V, Taylor SL, Thompson AW, Ussher JE, van der Linden AJ, Williams MJ, Podmore RG, Anderson TP, Barratt K, Mitchell JL, Harte DJ, Hope VT, Murdoch DR. The burden of Legionnaires' disease in New Zealand (LegiNZ): a national surveillance study. Lancet Infect Dis. 2019 Jul;19(7):770-777.
- Ishikawa K, Nakamura T, Matsuo T, Kawai F, Murakami H, Aoki K, Nagasawa T, Uehara Y, Mori N. Clinical Presentation of Legionella pneumophila Serogroup 1-Associated Pneumonia and Diffuse Alveolar Hemorrhage: A Case Report and Literature Review. Am J Case Rep. 2022 Jul 12;23:e936309.
- Rebellato S, Lee C, Gardner C, Kivilahti K, Wallace J, Hachborn D, Fenik J, Majury A, Kim J, Murphy A, Minnery J. Community Legionella outbreak linked to a cooling tower, 2022. Can Commun Dis Rep. 2023 Sep 01;49(9):380-386.
- Kirpich A, Shishkin A, Lhewa P, Yang C, von Fricken ME, Norris MH, Weppelmann TA. An investigation of the seasonal relationships between meteorological factors, water quality, and sporadic cases of Legionnaires' disease in Washington, DC. Epidemiol Infect. 2023 May 15;151:e88.
- Rello J, Allam C, Ruiz-Spinelli A, Jarraud S. Severe Legionnaires' disease. Ann Intensive Care. 2024 Apr 02;14(1):51.
- Fu Y, Macwan V, Heineman RE, Terebiznik MR, Harrison RE. Legionella pneumophila Infection of Human Macrophages Retains Golgi Structure but Reduces O-Glycans. Pathogens. 2022 Aug 12;11(8)
- Beauté J, Plachouras D, Sandin S, Giesecke J, Sparén P. Healthcare-Associated Legionnaires' Disease, Europe, 2008-2017. Emerg Infect Dis. 2020 Oct;26(10):2309-2318.
- Soda EA, Barskey AE, Shah PP, Schrag S, Whitney CG, Arduino MJ, Reddy SC, Kunz JM, Hunter CM, Raphael BH, Cooley LA. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Jun 09;66(22):584-589.
- Dagan A, Epstein D, Mahagneh A, Nashashibi J, Geffen Y, Neuberger A, Miller A. Community-acquired versus nosocomial Legionella pneumonia: factors associated with Legionella-related mortality. Eur J Clin Microbiol Infect Dis. 2021 Jul;40(7):1419-1426.
- Graham FF, Finn N, White P, Hales S, Baker MG. Global Perspective of Legionella Infection in Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Observational Studies. Int J Environ Res Public Health. 2022 Feb 08;19(3)
- Shames SR, Liu L, Havey JC, Schofield WB, Goodman AL, Roy CR. Multiple Legionella pneumophila effector virulence phenotypes revealed through high-throughput analysis of targeted mutant libraries. Proc Natl Acad Sci U S A. 2017 Nov 28;114(48):E10446-E10454.
- Allam C, Mouton W, Testaert H, Ginevra C, Fessy N, Ibranosyan M, Descours G, Beraud L, Guillemot J, Chapalain A, Albert-Vega C, Richard JC, Argaud L, Friggeri A, Labeye V, Jamilloux Y, Freymond N, Venet F, Lina G, Doublet P, Ader F, Trouillet-Assant S, Jarraud S. Hyper-inflammatory profile and immunoparalysis in patients with severe Legionnaires' disease. Front Cell Infect Microbiol. 2023;13:1252515.
- Lattimer GL, Rachman RA, Scarlato M. Legionnaires' disease pneumonia: histopathologic features and comparison with microbial and chemical pneumonias. Ann Clin Lab Sci. 1979 Sep-Oct;9(5):353-61.
- Winn WC, Myerowitz RL. The pathology of the Legionella pneumonias. A review of 74 cases and the literature. Hum Pathol. 1981 May;12(5):401-22.
- Bai L, Yang W, Li Y. Clinical and Laboratory Diagnosis of Legionella Pneumonia. Diagnostics (Basel). 2023 Jan 12;13(2)
- Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 01;200(7):e45-e67.
- Cunha BA. The diagnostic significance of relative bradycardia in infectious disease. Clin Microbiol Infect. 2000 Dec;6(12):633-4.
- Jones BE, Ramirez JA, Oren E, Soni NJ, Sullivan LR, Restrepo MI, Musher DM, Erstad BL, Pickens C, Vaughn VM, Helgeson SA, Crothers K, Metlay JP, Bissell B, Cao B, Chalmers JD, Dela Cruz CS, Gendlina I, Hojat LS, Laguio-Vila M, Liang SY, Waterer GW, Paine M, Hawkins C, Wilson K. Diagnosis and Management of Community-acquired Pneumonia. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2025 Jul 18;
- Falcone M, Russo A, Tiseo G, Cesaretti M, Guarracino F, Menichetti F. Predictors of intensive care unit admission in patients with Legionella pneumonia: role of the time to appropriate antibiotic therapy. Infection. 2021 Apr;49(2):321-325.
- Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJ., Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect. 2011 Nov;17 Suppl 6(Suppl 6):E1-59.
References
Graham FF, Hales S, White PS, Baker MG. Review Global seroprevalence of legionellosis - a systematic review and meta-analysis. Sci Rep. 2020 Apr 30;10(1):7337.
Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, Harris J, Mallison GF, Martin SM, McDade JE, Shepard CC, Brachman PS. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med. 1977 Dec 01;297(22):1189-97.
McDade JE, Shepard CC, Fraser DW, Tsai TR, Redus MA, Dowdle WR. Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N Engl J Med. 1977 Dec 01;297(22):1197-203.
Barskey AE, Derado G, Edens C. Rising Incidence of Legionnaires' Disease and Associated Epidemiologic Patterns, United States, 1992-2018. Emerg Infect Dis. 2022 Mar;28(3):527-538.
Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, Bos LD, Chalmers JD, Derde L, de Waele J, Garnacho-Montero J, Kollef M, Luna CM, Menendez R, Niederman MS, Ponomarev D, Restrepo MI, Rigau D, Schultz MJ, Weiss E, Welte T, Wunderink R. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med. 2023 Jun;49(6):615-632.
Cooley LA, Pondo T, Francois Watkins LK, Shah P, Schrag S., Active Bacterial Core Surveillance Program of the Emerging Infections Program Network. Population-Based Assessment of Clinical Risk Factors for Legionnaires' Disease. Clin Infect Dis. 2020 May 23;70(11):2428-2431.
Viasus D, Gaia V, Manzur-Barbur C, Carratalà J. Legionnaires' Disease: Update on Diagnosis and Treatment. Infect Dis Ther. 2022 Jun;11(3):973-986.
Miyashita N. Legionella prediction score. Respir Investig. 2024 Mar;62(2):305-306.
Cunha BA. Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010 Mar;24(1):73-105.
Niculita-Hirzel H, Vanhove AS, Leclerc L, Girardot F, Pourchez J, Allegra S. Risk Exposure to Legionella pneumophila during Showering: The Difference between a Classical and a Water Saving Shower System. Int J Environ Res Public Health. 2022 Mar 10;19(6)
Palusińska-Szysz M, Simões M. Editorial: Legionella pneumophila-transmission, pathogenesis, host-pathogen interaction, prevention and treatment. Front Microbiol. 2024;15:1364620.
Priest PC, Slow S, Chambers ST, Cameron CM, Balm MN, Beale MW, Blackmore TK, Burns AD, Drinković D, Elvy JA, Everts RJ, Hammer DA, Huggan PJ, Mansell CJ, Raeder VM, Roberts SA, Robinson MC, Sathyendran V, Taylor SL, Thompson AW, Ussher JE, van der Linden AJ, Williams MJ, Podmore RG, Anderson TP, Barratt K, Mitchell JL, Harte DJ, Hope VT, Murdoch DR. The burden of Legionnaires' disease in New Zealand (LegiNZ): a national surveillance study. Lancet Infect Dis. 2019 Jul;19(7):770-777.
Ishikawa K, Nakamura T, Matsuo T, Kawai F, Murakami H, Aoki K, Nagasawa T, Uehara Y, Mori N. Clinical Presentation of Legionella pneumophila Serogroup 1-Associated Pneumonia and Diffuse Alveolar Hemorrhage: A Case Report and Literature Review. Am J Case Rep. 2022 Jul 12;23:e936309.
Rebellato S, Lee C, Gardner C, Kivilahti K, Wallace J, Hachborn D, Fenik J, Majury A, Kim J, Murphy A, Minnery J. Community Legionella outbreak linked to a cooling tower, 2022. Can Commun Dis Rep. 2023 Sep 01;49(9):380-386.
Kirpich A, Shishkin A, Lhewa P, Yang C, von Fricken ME, Norris MH, Weppelmann TA. An investigation of the seasonal relationships between meteorological factors, water quality, and sporadic cases of Legionnaires' disease in Washington, DC. Epidemiol Infect. 2023 May 15;151:e88.
Rello J, Allam C, Ruiz-Spinelli A, Jarraud S. Severe Legionnaires' disease. Ann Intensive Care. 2024 Apr 02;14(1):51.
Fu Y, Macwan V, Heineman RE, Terebiznik MR, Harrison RE. Legionella pneumophila Infection of Human Macrophages Retains Golgi Structure but Reduces O-Glycans. Pathogens. 2022 Aug 12;11(8)
Beauté J, Plachouras D, Sandin S, Giesecke J, Sparén P. Healthcare-Associated Legionnaires' Disease, Europe, 2008-2017. Emerg Infect Dis. 2020 Oct;26(10):2309-2318.
Soda EA, Barskey AE, Shah PP, Schrag S, Whitney CG, Arduino MJ, Reddy SC, Kunz JM, Hunter CM, Raphael BH, Cooley LA. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Jun 09;66(22):584-589.
Dagan A, Epstein D, Mahagneh A, Nashashibi J, Geffen Y, Neuberger A, Miller A. Community-acquired versus nosocomial Legionella pneumonia: factors associated with Legionella-related mortality. Eur J Clin Microbiol Infect Dis. 2021 Jul;40(7):1419-1426.
Graham FF, Finn N, White P, Hales S, Baker MG. Global Perspective of Legionella Infection in Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Observational Studies. Int J Environ Res Public Health. 2022 Feb 08;19(3)
Shames SR, Liu L, Havey JC, Schofield WB, Goodman AL, Roy CR. Multiple Legionella pneumophila effector virulence phenotypes revealed through high-throughput analysis of targeted mutant libraries. Proc Natl Acad Sci U S A. 2017 Nov 28;114(48):E10446-E10454.
Allam C, Mouton W, Testaert H, Ginevra C, Fessy N, Ibranosyan M, Descours G, Beraud L, Guillemot J, Chapalain A, Albert-Vega C, Richard JC, Argaud L, Friggeri A, Labeye V, Jamilloux Y, Freymond N, Venet F, Lina G, Doublet P, Ader F, Trouillet-Assant S, Jarraud S. Hyper-inflammatory profile and immunoparalysis in patients with severe Legionnaires' disease. Front Cell Infect Microbiol. 2023;13:1252515.
Lattimer GL, Rachman RA, Scarlato M. Legionnaires' disease pneumonia: histopathologic features and comparison with microbial and chemical pneumonias. Ann Clin Lab Sci. 1979 Sep-Oct;9(5):353-61.
Winn WC, Myerowitz RL. The pathology of the Legionella pneumonias. A review of 74 cases and the literature. Hum Pathol. 1981 May;12(5):401-22.
Bai L, Yang W, Li Y. Clinical and Laboratory Diagnosis of Legionella Pneumonia. Diagnostics (Basel). 2023 Jan 12;13(2)
Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 01;200(7):e45-e67.
Cunha BA. The diagnostic significance of relative bradycardia in infectious disease. Clin Microbiol Infect. 2000 Dec;6(12):633-4.
Jones BE, Ramirez JA, Oren E, Soni NJ, Sullivan LR, Restrepo MI, Musher DM, Erstad BL, Pickens C, Vaughn VM, Helgeson SA, Crothers K, Metlay JP, Bissell B, Cao B, Chalmers JD, Dela Cruz CS, Gendlina I, Hojat LS, Laguio-Vila M, Liang SY, Waterer GW, Paine M, Hawkins C, Wilson K. Diagnosis and Management of Community-acquired Pneumonia. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2025 Jul 18;
Falcone M, Russo A, Tiseo G, Cesaretti M, Guarracino F, Menichetti F. Predictors of intensive care unit admission in patients with Legionella pneumonia: role of the time to appropriate antibiotic therapy. Infection. 2021 Apr;49(2):321-325.
Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJ., Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect. 2011 Nov;17 Suppl 6(Suppl 6):E1-59.