2016;146(9):394396
www.elsevier.es/medicinaclinica
Editorial article
Since Legionella pneumophila (L. pneumophila) was identied in 1976 it has been recognized as a common cause of
hospital-acquired and non-hospital-acquired pneumonia.1 The
term Legionellosis includes 2 different syndromes: Legionnaires
disease, the most common cause of pneumonia caused by Legionella
spp., and Pontiac fever, characterized by fever, headache and myalgia, but without pneumonia.2
The Legionella family consists of 50 species, L. pneumophila being
the most common,3 and within this, serotype 1 is the most frequently isolated. The incidence of community-acquired pneumonia
(CAP) caused by L. pneumophila varies from one area to another,
hovering around 1% in subjects treated as outpatients and 1528%
in hospitalized patients. Twenty ve per cent of these require
admission to an intensive care unit (ICU).4
In Spain L. pneumophila pneumonia is a notiable disease
since 1996. It is important that cases are quickly notied so
that the source can be studied as soon as possible. Outbreaks
are usually related to the contamination of cooling systems and
water tanks, although more frequently L. pneumophila pneumonia appears as sporadic cases, predominantly affecting smokers,
elderly and chronically ill patients or in routine treatment with
glococorticoids.4 Therefore, underdiagnosis of such cases is suspected.
Isolation of the bacteria by culturing respiratory specimens has
been the traditional diagnostic method. It is the only available
method to detect infections caused by any species and serotypes of
Legionella (approximately 1520% of infections are caused by different L. pneumophila species or serotypes). However, the drawback
is the time it takes to grow the microorganism, as well as the serological diagnosis, providing a late diagnosis from a clinical point of
view.5
We must note the signicant diagnostic advance the detection
of L. pneumophila antigen in urine has meant, since it allows an
Please cite this article as: Jodr Snchez S, Barrueco Ferrero M. Neumona por Legionella, cundo solicitar la antigenuria en orina? Med Clin (Barc).
2016;146:394396.
Corresponding author.
E-mail address: sorayajodra 9@hotmail.com (S. Jodra Snchez).
S.L.U. All rights reserved.
2387-0206/ 2015 Elsevier Espana,
etiologic diagnosis almost immediately.57 Since included in clinical practice, it has been shown that L. pneumophila pneumonias
are a lot more prevalent endemic disease than previously thought,
and this has also allowed to detect outbreaks that otherwise would
have gone unnoticed.
The antigen is a soluble component of the Legionellas cell wall
lipopolysaccharide. It is thermostable, and detectable from the
onset of symptomatology and in some cases for many months later.
The results do not appear clearly inuenced by the previous administration of antibiotics.
The antigen diagnostic techniques have evolved signicantly
since their inception by agglutination with latex particles, passive hemagglutination or radioimmunoassay. The latter was the
rst useful, sensitive and specic technique. It has 60% sensitivity in direct urine and 80% in concentrated urine, with a 100%
specicity in both cases. Currently these techniques have been
replaced by enzyme immunoassay and membrane immunochromatography, with a sensitivity in concentrated urine ranging
8090% and a 98100% specicity. Both systems have a similar
performance, although with 2 clear advantages for immunochromatography: a specic laboratory is not necessary and it is
faster (15 vs 90 min). These techniques detect L. pneumophila,
serogroup 1antigen, implying the possibility of false negative if
a secondary infection with L. pneumophila serogroup. However,
some enzyme immunoassay techniques are already able to detect
all serogroups of L. pneumophila and other Legionella species, but
this does not guarantee the same sensitivity for all serogroups
and species. False positives have been detected in patients with
serum sickness and in those who have had a previous infection
by Legionella, since positivity may be evident from day one and in
some cases it may last for more than a year. It should be noted
that the heat treatment of the urine does not mean the disappearance of positivity but it eliminates false positives in negative
samples.5,8,9
In the latest guidelines of the American Thoracic Society on
the CAP, L. pneumophila is the fth etiology, considering frequency, in patients requiring hospitalization and the third among
those requiring ICU admission. This regulation recommends early
identication of causative agents of pneumonia, since it requires
changes in antibiotic coverage and also due to the epidemiological
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16. Nelson KE. Emerging and new infectious diseases. In: Nelson KE,
Williams CM, Graham NMH, editors. Infectious disease epidemiology. Theory and practice. Gaithersburg: Aspen Publishers, Inc.; 2001.
p. 3334.
17. Falc V, Molina I, Juste C, Crespo M, Almirante B, Pigrau C, et al. Treatment for Legionnairess disease. Macrolides or quinolones? Enferm
Infecc Microbiol Clin. 2006;24:3604.
18. National Institute por Health and Care Excellence. NICE clinical
guideline 191. Pneumonia: diagnosis and management of community and hospital-acquired pneumonia in adults; 2014. p. 178.
Available from: guidance.nice.org.uk/cg19.