It is not often that we think of Legionnaires’ disease, the form of pneumonia brought on by inhaling aerosolized water containing Legionella pneumophila bacteria. But when the illness rears its ugly head, the results can be disastrous for those exposed.  

In long-term care facilities, patients are at particular risk due to age – in some cases being bedridden and with the presence of multiple comorbidities. Having a weakened immune system also increases the risk of contracting Legionnaires’ disease, rendering exposure prevention particularly important in these environments.

When thinking about Legionella, most people think about water cooling towers and central water heating systems. But the truth is that Legionella can lurk in the most unlikely – and seemingly innocuous – of places. The bacteria can colonize and grow anywhere that water is present and the growth parameters are met, including drinking fountains, water coolers and ice dispensers, dental water lines and showers. 

Despite a utility company’s best attempts at disinfection, complete eradication in plumbing systems and drinking water is very unlikely because the bacteria is naturally occurring in the outdoor environment. Consequently, low numbers of the organism – just enough to be problematic – may still enter buildings from public water sources, colonizing pipes and water reservoirs.

As a result, the key to preventing Legionnaires’ disease in long term care facilities is preventing the colonization and growth of bacteria anywhere water is used or stored. For such routine prevention, the first and simplest approach is to keep water temperatures and chlorine levels at a level that inhibits bacteria growth. The Centers for Disease Control and Prevention recommends maintaining hot water temperatures – at or above 60°C (140°F) – with periodic increases to >65°C (>150°F) or chlorination with flush. Other approaches have also been used, including copper-silver ionization or the use of chlorine dioxide.

Regardless of the treatment method selected, long-term care facilities will see the best results if they establish validation procedures to assure adequate continual biological control. Prevention is an ongoing battle, and the bedrock of any infection control and prevention program’s comprehensive approach. In addition to Legionella prevention, facilities should establish a core environmental cleaning and disinfection program for prevention of infection. This program should include:

  • Daily surface disinfection with products that are proven against epidemiologically-important pathogens that can survive on surfaces
  • Enhanced cleaning and disinfection with a focus on all touchable surfaces
  • Increased cleaning and disinfection during the cold winter months in high traffic areas
  • Education on the importance of cleaning and disinfection for all staff
  • Ongoing monitoring of the environmental practices and protocols
  • Effective communication among all departments

Unfortunately, this naturally occurring environmental pathogen is not going away anytime soon. But by adhering to recommended protocols outlined by the CDC and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), the risks to long term care facilities and their patients can be greatly reduced.

Amanda Thornton, RN, MSN, is a clinical science liaison at PDI.