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Infection
Control
and
Hospital
Epidemiology:
Book
Review Infection Control and Hospital Epidemiology, July 1997. Reviewed by Robert R. Muder, MD; Infectious Disease Section, Veterans' Administration Medical Center, Pittsburgh, Pennsylvania Nosocomial Legionella infection occurs as a consequence of contamination of the hospital environment, particularly the potable water system, with Legionella.. A hospital epidemiologist or risk manager faced with cases of nosocomial legionellosis may have an urgent need to identify and eradicate the source of infection. This urgency may be compounded by an atmosphere of extreme apprehension on the part of patients, the hospital staff, and the public. While it is clear that the occurrence of nosocomial infection indicates the need for finding and eliminating the source of Legionella, there continues to be disagreement among Legionella experts as to the necessity of environmental surveillance for Legionella in the absence of disease. The Centers for Disease Control and Prevention maintains that the risk of nosocomial disease is not predictable from the levels of Legionella in a hospital's potable water system and that routine environmental sampling is not warranted. The group based at the Pittsburgh Veterans' Administration (of which I am a member) maintains that the presence of Legionella in a hospital water system is highly predictive of the occurrence of disease and strongly recommends environmental surveillance. Given this background, a single volume resource for hospitals faced with these questions would be useful indeed. Mr. Freije's approach to the subject is not that of the epidemiologist, microbiologist, or public health official, but that of the risk manager. He appears to have done his homework fairly thoroughly and gives thoughtful consideration to conflicting views. The result is a concise and practical introduction to Legionella control. After a brief introduction to Legionella and legionnaires' disease, the author discusses the rationale for surveillance and gives practical advice on the conduct of environmental surveillance and the handling of cultures. This includes the relative merits of processing cultures in-house, as opposed to utilizing an outside laboratory, along with advice on selecting and evaluating the latter. The author provides a concise introduction to the mechanics of plumbing systems, a topic probably unfamiliar to most hospital epidemiologists, but essential for the understanding of Legionella control in domestic water systems. He outlines routine preventive measures for water systems and air-conditioning systems and covers the major techniques of Legionella eradication, including hyperchlorination, heat-and-flush, ultraviolet light, and silver-copper ionization, giving the pros and cons of each method. He also offers some perspective on the legal and financial ramifications of a hospital's Legionella control efforts--a topic not often discussed by epidemiologists but of great concern to hospital managers. In areas in which uncertainty exists, the author offers guidelines but acknowledges the level of uncertainty involved. For example, the colony counts of legionellae in domestic or cooling tower water that define a significant risk of Legionella are not established. Mr. Freije offers the criteria used by others, including public health agencies and private laboratories offering Legionella surveillance for a fee. He is careful to point out when these recommendations are arbitrary and offers the sensible caution that "in high-risk patient areas, any positive sample is cause for concern, even if the legionellae count is very low." The brief chapter entitled "Response to an Outbreak" covers only the general principle of epidemiological investigation and gives a few suggestions for emergency intervention. It appears to be intended as a brief guide for hospital administrative and engineering personnel rather than a detailed source of practical information for the hospital epidemiologist. The author provides readers with a listing of resources that includes laboratories, equipment manufacturers, professional societies, and individual experts in the field. The latter includes paid consultants, as well as healthcare professionals, willing to offer free advice via telephone. In addition, there is an extensive bibliography. In summary, this work is a concise introduction to the practical problems of Legionella control in health facilities. It will be useful to hospital epidemiologists and infection control personnel needing an introduction to the topic, as well as to hospital management and engineering personnel. Ordering information Item
104, ISBN
0-9649926-4-7,
US$79 If you do not want to order the book by credit card through our secure online system, you may order by check, purchase order, or credit card (Visa, MC, Amex, or Discover) by telephone, fax, or the postal service. Include shipping of $4 to USA, $6 to Canada, or $12 to all other countries (total per order, no matter how many copies). Please order by telephone if you would like Next-day or 2nd-day air (USA only). Contact:
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