rifampin and Legionellosis

While Legionella is a common cause of pneumonia, extrapulmonary infections like arthritis are scarce. Here, we describe a case of monoarthritis due to Legionella bozemanii, with no history of pneumonia. We provide a literature review of the 9 previously published Legionella arthritis and highlight a dichotomous epidemiology suggesting different physiopathological pathways leading to joint infection.. A 56-year old woman under immunosuppressive treatment by oral and intra-articular corticosteroids, methotrexate, and tocilizumab for an anti-synthetase syndrome was hospitalized for worsening pain and swelling of the left wrist for 3 days. Clinical examination showed left wrist synovitis and no fever. The arthritis occurred a few days after an accidental fall on wet asphalt responsible for a cutaneous wound followed by a corticosteroid intra-articular injection. Due to both the negativity of conventional culture of articular fluid and suspicion of infection, 16S rRNA and specific PCRs were performed leading to the identification of L. bozemanii. Legionella-specific culture of the articular fluid was performed retrospectively and isolated L. bozemanii. The empiric antibiotic therapy was switched for oral levofloxacin and rifampin and the patient recovered after a 12-week treatment.. We report a case of L. bozemanii monoarthritis in an immunosuppressed woman, following a fall on wet asphalt and intra-articular corticosteroid injection. The review of the literature found that the clinical presentation reveals the mode of infection and the bacterial species. Monoarthritis more likely occurred after inoculation in patients under immunosuppressive therapy and were associated with non-Legionella pneumophila serogroup 1 (Lp1) strains that predominate in the environment. Polyarthritis were more likely secondary legionellosis localizations after blood spread of Lp1, the most frequently found in pneumonia. In both settings, 16S rRNA and Legionella-specific PCR were key factors for the diagnosis.

Topics: Accidental Falls; Administration, Oral; Adrenal Cortex Hormones; Arthritis, Infectious; Female; Humans; Hydrocarbons; Immunocompromised Host; Injections, Intra-Articular; Legionellaceae; Legionellosis; Levofloxacin; Middle Aged; Polymerase Chain Reaction; Rifampin; RNA, Ribosomal, 16S; Treatment Outcome

Legionella spp. are an important cause of pulmonary and rarely extrapulmonary infections. L. cincinnatiensis has only been implicated in five cases to date. We herein report the first case of L. cincinnatiensis septic arthritis in a 90-year old lady with a past medical history of chronic kidney disease. She developed septic arthritis of her left wrist after having received intraarticular corticosteroid injections and oral corticosteroids administered for presumed chondrocalcinosis. Appropriate antimicrobial treatment of L. cincinnatiensis septic arthritis was delayed until identification of this organism in joint biopsies by broad-range bacterial PCR targeting the 16S rRNA gene with subsequent rDNA sequence analysis and by culture on special media. Reviewing all reported cases of septic arthritis caused by Legionella spp. other than L. cincinnatiensis it is notable that diagnosis was established by PCR in the majority of cases and only subsequently confirmed by special culture. Although most patients were immunosuppressed, outcome was favourable. Treatment consisted of a fluoroquinolone alone or in combination with rifampicin or a macrolide. Our case highlights the need for a high index of suspicion for infections with unusual/fastidious organisms when symptoms are suggestive of septic arthritis but conventional methods fail to identify a causative organism.

Topics: Aged, 80 and over; Anti-Infective Agents; Arthritis, Infectious; Female; Fluoroquinolones; Humans; Immunocompromised Host; Legionella; Legionellosis; Macrolides; Rifampin; RNA, Bacterial; RNA, Ribosomal, 16S; Switzerland; Treatment Outcome

As in other countries, pneumonia due to Legionella bacteria occurs in Denmark. Even so, legionellosis is rarely diagnosed and often late in the course of illness. This may be due both to the variable and nonspecific clinical picture of the infection, and to the fact that currently available diagnostic methods are inadequate in a clinical context. Even in severe cases, the prognosis of Legionnaires' disease is quite good, if adequate antibiotic therapy is instituted early in the course of illness. The treatment of Legionnaires' disease differs from the treatment of most other pneumonias; frequently, therapy must be completed solely on a basis of clinical suspicion. The present diagnostic state may be improved by an increased awareness of the disease and its clinical manifestations, as well as by improved laboratory diagnosis.

Topics: Diagnosis, Differential; Erythromycin; Humans; Legionellosis; Pneumonia; Rifampin; Serologic Tests

Selection of therapy for legionella infections originated with the clinical observation after the 1976 Philadelphia outbreak that patients treated with erythromycin or tetracycline did better than those who received cephalosporins or aminoglycosides. Early in vitro antibiotic susceptibility studies suggested that rifampin and erythromycin were both active against Legionella pneumophila. However, subsequent in vitro susceptibility studies to other antibiotics have produced variable results, depending on the medium and methodology used. Antibiotic studies within polymorphonuclear leukocytes and alveolar macrophages indicate that those actively concentrated within these cells are predictive of successful therapy. These include erythromycin, rifampin, and certain quinolones. On the other hand, beta-lactam antibiotics such as penicillin, cefoxitin, and imipenem are less likely to be successful because of their lack of concentration within phagocytes. These observations have been confirmed in animal model studies where erythromycin, rifampin, and quinolones have demonstrated efficacy. The addition of rifampin to erythromycin or to doxycycline may be more effective than therapeutic results with either antibiotic alone. Although erythromycin is presently the treatment of choice for legionellosis, the addition of rifampin is recommended, particularly in immunocompromised patients. Doxycycline has served as an appropriate alternative agent, the newer quinolones may be useful and are deserving of carefully designed clinical trials.

Topics: Animals; Anti-Bacterial Agents; Disease Models, Animal; Erythromycin; Guinea Pigs; Humans; Legionellosis; Microbial Sensitivity Tests; Phagocytes; Rifampin

At present, 11 different species of Legionella have been implicated in human disease. It has become apparent that disease caused by Legionella is acquired from a variety of environmental sources and that water is the factor that links many of them. Patients who are immunosuppressed, such as individuals receiving cancer chemotherapy or therapy designed to prevent organ rejection, are particularly susceptible to such environmental sources. It appears that intact cell-mediated immunity is more important in host defense than are adequate numbers of granulocytes or immunoglobulin concentrations. Diagnostic steps should be undertaken in all patients developing nosocomial pneumonia who present with a picture suspicious for this disorder. In the meantime, appropriate antimicrobial therapy with erythromycin and rifampin should be begun. If clusters of cases are detected in a hospital, immediate steps should be taken to attempt to isolate the organism from any aqueous environmental sources, and if found appropriate, steps taken. Awareness of the threat of legionnaires' disease must be maintained among clinicians and hospital epidemiologists because it is unlikely that the problem of nosocomial legionnaires' disease will disappear.

Topics: Anti-Bacterial Agents; Cross Infection; Erythromycin; Humans; Immune Tolerance; Legionellosis; Legionnaires' Disease; Rifampin; United States

Legionella species other than Legionella pneumophila may cause pneumonias and extrapulmonary infections. Most infections are nosocomial or observed in immunocompromised patients and often remain undiagnosed because of the failure of confirmatory culture methods. The therapy is based on macrolides and fluoroquinolones; rifampin and tetracycline are also used.

Topics: Anti-Bacterial Agents; Cross Infection; Fluoroquinolones; Humans; Immunocompromised Host; Legionella; Legionellosis; Macrolides; Pneumonia, Bacterial; Rifampin; Tetracycline

The susceptibility of 140 Legionella spp isolates (106 clinical and 34 environmental isolates) to trovafloxacin (TRFX), levofloxacin (LEVX), moxifloxacin (MOFX), ciprofloxacin (CIPX), ofloxacin (OFLX), erythromycin (ERY), azithromycin (AZI) and rifampicin (RIF) was studied using a standard microdilution method and buffered yeast extract broth (BYE) supplemented with 0.1% alpha-ketoglutarate. The post-antibiotic effects (PAEs) of the study drugs against 10 clinical isolates of Legionella pneumophila sg.1 were compared. The MIC inhibiting 90% of strains tested on BYEalpha broth were 0.008, 0.016, 0.016, 0.06, 0.125, 0.5, 0.5, and 0.004 mg/l for TRFX, LEVX, MOXX, CIP, OFLX, ERY, AZI, and RIF, respectively. The MBC/MIC ratios ranged from one to eight depending on the antibiotic tested: TRFX [1x-2 x MIC], LEVX, MOFX, CIPX and OFLX [1x-4 x MIC], RIF [2x-4 x MIC], ERY and AZI [2x-8 x MIC]. TRFX, RIF, LEVX, MOFX, CIPX, OFLX, ERY and AZI showed similar activity against Legionella species other than L. pneumophila. One-hour exposures to the study antimicrobial agents at a concentration of 4 x MIC resulted in PAEs as follows (average in hours): TRFX: 2.68 h; RIF: 2.63 h; CIPX: 2.62 h; MOFX: 2.56 h; LEVX: 2.41 h; OFLX: 2.25 h; AZI: 1.65 h; and ERY: 1.54 h. In conclusion, our in vitro data confirm that trovafloxacin, levofloxacin, moxifloxacin and rifampicin have excellent bacteriostatic and bactericidal activity against Legionella spp and show significant post-antibiotic effect.

Topics: Anti-Bacterial Agents; Anti-Infective Agents; Aza Compounds; Fluoroquinolones; Humans; Legionella; Legionellosis; Levofloxacin; Microbial Sensitivity Tests; Moxifloxacin; Naphthyridines; Ofloxacin; Quinolines; Rifampin

Legionella jordanis has seldom been reported as a cause of infection in humans. We describe a case of pneumonia due to L. jordanis that occurred in a non-immunocompromised 74-year-old patient and failed to respond to a combination of ceftriaxone and ofloxacin. Cure was achieved only after an erythromycin-rifampin combination was started.

Topics: Aged; Anti-Infective Agents; Ceftriaxone; Drug Therapy, Combination; Erythromycin; Humans; Immunocompetence; Legionella; Legionellosis; Male; Ofloxacin; Pneumonia, Bacterial; Rifampin

Topics: Community-Acquired Infections; Drug Therapy, Combination; Erythromycin; Humans; Legionella; Legionellosis; Male; Middle Aged; Rifampin

Although increasing attention is being given to Legionella pneumonia in Japan, reports of solitary onset of this disease are scant in Japan. The patient, from whom L. dumoffii was isolated, was a 59-year-old male with no underlying disease. He visited our hospital because of fever and cough, and was admitted to our department for X-ray findings consistent with pneumonia. After admission, pulmonary lesions spread rapidly, and based on the suspicion of Legionella pneumonia, drugs such as EM, RFP and MINO were used. However, the patient died on the 26th hospital day. L. dumoffii was isolated from specimens obtained by airway aspiration before death and specimens of lung abscess and airway discharge obtained during autopsy (7 specimens in total). In addition, the L. dumoffii antibody titer in the serum became elevated. This is the first case of L. dumoffii pneumonia reported in Japan. The other case was in an 81-year-old male with underlying disease. He was admitted urgently with suspected pneumonia but died on the following day. L. pneumophila serogroup 5 was isolated from autopsied lung tissue. Fatality is high for this disease, making early diagnosis and treatment with appropriate antibiotics essential. Physicians should bear in mind the possibility of this disease and request the necessary laboratory tests in suspected cases without delay.

Topics: Aged; Aged, 80 and over; Erythromycin; Humans; Legionella; Legionellosis; Male; Middle Aged; Rifampin