A case of legionella pneumonia caused by home use of continuous positive airway pressure

Abstract

A 67-year-old woman with morbid obesity and severe obstructive sleep apnea presented to the emergency department with 2 days of productive cough, fever, shortness of breath and loose stools. A chest x-ray showed extensive bilateral infiltrates, and she was quickly intubated for acute hypoxic respiratory failure. A urine legionella antigen test was positive, and she was admitted to the intensive care unit with a diagnosis of severe legionella pneumonia. She improved over the next week with a course of levofloxacin. Once improved, the state health department visited her home and interviewed her husband and determined that she had not been cleaning her continuous positive pressure mask, tubing and humidifier appropriately. They concluded that the legionella likely came from her continuous positive airway pressure equipment. Cases of legionella pneumonia have frequently been reported through infected water supplies and even respiratory equipment. It is crucial that the mask and tubing used with these devices are cleaned appropriately to minimize the risk of infection.

Obstructive Sleep Apnea and Acute Lower Respiratory Tract Infections: A Narrative Literature Review

“…Infrequent cleaning, improper handling, and the use of humidification with CPAP can create an environment that allows for the growth of microorganisms and subsequently increases the risk of infections [ 138 , 139 ]. Some studies, as well as several case reports, have suggested that CPAP therapy may increase the risk of respiratory infections in CPAP users [ 120 , 121 , 140 , 141 , 142 ]. Therefore, regular cleaning and maintenance of CPAP equipment are necessary to mitigate these potential risks [ 143 ].…”

“…Case reports indicate OSA patients may develop Legionnaires’ disease from CPAP machines [ 120 , 121 ]. If Legionella is suspected, characterized by relative bradycardia, diarrhea, neurological disturbances, and/or hyponatremia [ 122 ], early testing for Legionella urine antigen and treatment with a respiratory fluoroquinolone over macrolides should be considered [ 123 ].…”

Late-onset bleb-associated endophthalmitis and continuous positive airway pressure

“…A recent study indicated a poor frequency of device cleaning by the majority of CPAP users, 26 yet in published literature few guidelines exist regarding CPAP maintenance. One recommendation is to clean the device with distilled water daily and allow it to air dry 39 ; even so, unpressurized water alone may not suffice to disperse bacteria which have settled on the small and uneven surfaces of the facemask or within the ribbed tubing. Thus, the efficacy of adequate device cleaning appears complex as the internal surfaces are possible sites for microorganism adherence and colonization.…”