Legionella Indoor Air Contamination in Healthcare Environments

  • Maria Teresa MontagnaEmail author
  • Osvalda De Giglio
  • Maria Luisa Cristina
  • Roberto Albertini
  • Cesira PasquarellaEmail author
  • GISIO-SItI Working Group
  • AIA Working Group
  • SIMPIOS Working Group
Part of the SpringerBriefs in Public Health book series (BRIEFSPUBLIC)


Legionella spp. is a ubiquitous intracellular microorganism in aquatic environments both natural and artificial. Although Legionella pneumophila sg 1 and sg 6 are the main causes of disease, other species have recently been associated with cases of legionellosis. Since 2000, some international documents related to the control and prevention of Legionnaires’ disease have been issued, providing different environmental matrices’ sampling, but not for air. To date, the control on water mains is preferred; however, air sampling could be a useful tool for exposure evaluation. To sample biological particles in the air, active and passive methods can be used. Several studies have compared the values of microbial counts obtained with these sampling methods, attaining discordant results. Based on this scientific background and on the experience about Legionella spp. contamination and air microbial sampling in health care environments, GISIO-SItI, AIA, and SIMPIOS promoted two multicenter studies focused on identifying a standardized sampling protocol to detect the airborne contamination coming from water sources contaminated with Legionella spp.


Legionella Bioaerosol Indoor air Water 


  1. Agodi A, Auxilia F, Barchitta M, Cristina ML, D’Alessandro D, Mura I, et al, on behalf of the Italian Study Group of Hospital Hygiene (GISIO). Operating theatre ventilation systems and microbial air contamination in total joint replacement surgery: results of the GISIO-ISChIA study. J Hosp Infect. 2015;90:213–9. doi: 10.1016/j.jhin.2015.02.014.
  2. Astley P, Capolongo S, Gola M, Tartaglia A. Operative and design adaptability in healthcare facilities. Technè. 2015;9:162–70. doi: 10.13128/Techne-16118.Google Scholar
  3. Baglioni A, Capolongo S. Ergonomics in planning and reconstruction. G Ital Med Lav Ergon. 2002;24(4):405–9.PubMedGoogle Scholar
  4. Blatny JM, Reif BA, Skogan G, Andreassen O, Hoiby EA, Ask E, et al. Tracking airborne Legionella and Legionella pneumophila at a biological treatment plant. Env Sci Technol. 2008;42:7360–7.CrossRefGoogle Scholar
  5. Buffoli M, Nachiero D, Capolongo S. Flexible healthcare structures: analysis and evaluation of possible strategies and technologies. Ann Ig. 2012;24(6):543–52.PubMedGoogle Scholar
  6. Buffoli M, Bellini E, Bellagarda A, di Noia M, Nickolova M, Capolongo S. Listening to people to cure people: the LpCp—tool, an instrument to evaluate hospital humanization. Ann Ig. 2014a;26(5):447–55. doi: 10.7416/ai.2014.2004.PubMedGoogle Scholar
  7. Buffoli M, Gola M, Rostagno M, Capolongo S, Nachiero D. Making hospitals healthier: how to improve sustainability in healthcare facilities. Ann Ig. 2014b;26(5):418–25. doi: 10.7416/ai.2014.2001.PubMedGoogle Scholar
  8. Capolongo S, Buffoli M, Oppio A, Nachiero D, Barletta MG. Healthy indoor environments: how to assess health performances of construction projects. Environ Eng Manage J. 2013a;12(S11):209–212.Google Scholar
  9. Capolongo S, Buffoli M, Oppio A, Rizzitiello S. Measuring hygiene and health performance of buildings: a multidimensional approach. Ann Ig. 2013b;25(2):151–7. doi: 10.7416/ai.2013.1917.PubMedGoogle Scholar
  10. Chang CW, Chou FC. Methodologies for quantifying culturable, viable, and total Legionella pneumophila in indoor air. Indoor Air. 2011;21(4):291–9. doi: 10.1111/j.1600-0668.2010.00701.x.CrossRefPubMedGoogle Scholar
  11. Chang CW, Hung PY. Methods for detection and quantification of airborne Legionellae around cooling towers. Aerosol Sci Technol. 2012;46(4):369–79.CrossRefGoogle Scholar
  12. Correia AM, Ferreira JS, Borges V, Nunes A, Gomes B, Capucho R, et al. Probable person to person transmission of Legionnaires’ disease. N Engl J Med. 2016;374(5):497–8. doi: 10.1056/NEJMc1505356.CrossRefPubMedGoogle Scholar
  13. Crimi P, Macrina G, Grieco A, Tinteri C, Copello L, Rebora D, et al. Correlation between Legionella contamination in water and surrounding air. Infect Control Hosp Epidemiol. 2006;27(7):771–3. doi: 10.1086/504446.CrossRefPubMedGoogle Scholar
  14. Cristina ML, Spagnolo AM, Sartini M, Dallera M, Ottria G, Perdelli F, et al. Investigation of organizational and hygiene features in dentistry: a pilot study. J Prev Med Hyg. 2009;50:175–80.PubMedGoogle Scholar
  15. D’Alessandro D, Tedesco P, Rebecchi A, Capolongo S. Water use and water saving in Italian hospitals. A preliminary investigation. Ann Ist Super Sanità. 2016;52(1):56–62. doi: 10.4415/ANN_16_01_11.
  16. Deloge-Abarkan M, Ha TL, Robine E, Zmirou-Naviera D, Mathieu L. Detection of airborne Legionella while showering using liquid impingement and fluorescent in situ hybridization (FISH). J Environ Monit. 2007;9:91–7. doi: 10.1039/b610737k.CrossRefPubMedGoogle Scholar
  17. Guarnieri V, Gaia E, Battocchio L, Pitzurra M, Savino A, Pasquarella C, et al. New methods for microbial contamination monitoring: an experiment on board the MIR orbital station. Acta Astronaut. 1997;40:195–201.CrossRefPubMedGoogle Scholar
  18. ISO 14698‐1:2003. Cleanrooms and associated controlled environments: biocontamination control. Part 1: general principles and methods.Google Scholar
  19. Langer V, Hartmann G, Niessner R, Seidel M. Rapid quantification of bioaerosols containing L. pneumophila by Coriolis® µ air sampler and chemiluminescence antibody microarrays. J Aerosol Sci. 2012;48:46–55. doi: 10.1007/s00216-010-4414-0.CrossRefGoogle Scholar
  20. Ministero della Salute. Linee guida per la prevenzione ed il controllo della legionellosi. Approvate in Conferenza Stato-Regioni nella seduta del 7 maggio. Roma: Ministero della Salute; 2015.Google Scholar
  21. Montagna MT, Napoli C, Tatò D, Spilotros G, Barbuti G, Barbuti S. Clinical-environmental surveillance of legionellosis: an experience in Southern Italy. Eur J Epidemiol. 2006;21(4):325–31. doi: 10.1007/s10654-006-0009-7.CrossRefPubMedGoogle Scholar
  22. Montagna MT, Ricci ML, Napoli C, Tato’ D, Scaturro M, Barbuti G, et al. Legionella pneumophila serogroup 5 infection in the presence of multiple environmental contamination. The importance of a bacteriological diagnosis. Italian. J Public Health. 2007;4:71–4.Google Scholar
  23. Montagna MT, De Giglio O, Napoli C, Cannova L, Cristina ML, Deriu MG, et al. Legionella spp. contamination in indoor air: preliminary results of an Italian multicenter study. Epidemiol Prev. 2014:38(6Suppl 2):62–5.Google Scholar
  24. Montagna MT, Cristina ML, De Giglio O, Spagnolo AM, Napoli C, Cannova L, et al. Serological and molecular identification of Legionella spp. isolated from water and surrounding air samples in Italian healthcare facilities. Environ Res. 2016;146:47–50. doi: 10.1016/j.envres.2015.12.015.CrossRefPubMedGoogle Scholar
  25. Napoli C, Fasano F, Iatta R, Barbuti G, Cuna T, Montagna MT. Legionella spp. and legionellosis in south eastern Italy: disease epidemiology and environmental surveillance in community and healthcare facilities. BMC Public Health. 2010;10:660. doi: 10.1186/1471-2458-10-660.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Napoli C, Marcotrigiano V, Montagna MT. Air sampling procedures to evaluate microbial contamination: a comparison between active and passive methods in operating theatres. BMC Public Health. 2012a;12:594. doi: 10.1186/1471-2458-12-594.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Napoli C, Tafuri S, Montenegro L, Cassano M, Notarnicola A, Lattarulo S, et al. Air sampling methods to evaluate microbial contamination in operating theatres: results of a comparative study in an orthopaedics department. J Hosp Infect. 2012b;80:128–32. doi: 10.1016/j.jhin.2011.10.011.CrossRefPubMedGoogle Scholar
  28. Pasquarella C, Pitzurra O, Savino A. The index of microbial air contamination. J Hosp Infect. 2000;46:241–56. doi: 10.1053/jhin.2000.0820.CrossRefPubMedGoogle Scholar
  29. Pasquarella C, Albertini R, Dall’Aglio P, Saccani E, Sansebastiano GE, Signorelli C. Air microbial sampling: the state of the art. Ig Sanità Pubblica 2008;64:79–120.Google Scholar
  30. Pasquarella C, Veronesi L, Castiglia P, Liguori G, Montagna MT, Napoli C, et al. Italian multicentre study on microbial environmental contamination in dental clinics: a pilot study. Sci Total Environ. 2010;408:4045–51. doi: 10.1016/j.scitotenv.2010.05.010.CrossRefPubMedGoogle Scholar
  31. Pasquarella C, Sansebastiano GE, Saccani E, Ugolotti M, Mariotti F, Boccuni C, et al. Proposal for an integrated approach to microbial environmental monitoring in cultural heritage: experience at the Correggio exhibition in Parma. Aerobiologia. 2011;27:203–11. doi: 10.1016/j.jhin.2012.01.007.CrossRefGoogle Scholar
  32. Pasquarella C, Veronesi L, Napoli C, Castiglia P, Liguori G, Rizzetto R, et al. Microbial environmental contamination in Italian dental clinics: a multicenter study yielding recommendations for standardized sampling methods and threshold values. Sci Total Environ. 2012a;420:289–99. doi: 10.1016/j.scitotenv.2012.01.030.CrossRefPubMedGoogle Scholar
  33. Pasquarella C, Vitali P, Saccani E, Manotti P, Boccuni C, Ugolotti M, et al. Microbial air monitoring in operating theatres: experience at the University Hospital of Parma. J Hosp Infect. 2012b;81(1):50–7. doi: 10.1086/663646.CrossRefPubMedGoogle Scholar
  34. Perdelli F, Sartini M, Orlando M, Secchi V, Cristina ML. Relationship between settling microbial load and suspended microbial load in operating rooms. Ann Ig. 2000;12:373–80.PubMedGoogle Scholar
  35. Pitzurra M, Savino A, Pasquarella C. Microbiological environment monitoring (MEM). Ann Ig. 1997;9(6):439–54.PubMedGoogle Scholar
  36. Spagnolo AM, Cristina ML, Casini B, Perdelli F. Legionella pneumophila in healthcare facilities. Rev Med Microbiol. 2013;24:70–80.Google Scholar
  37. WHO. Legionella and the prevention of legionellosis. Copenhagen: WHO; 2007.Google Scholar

Copyright information

© The Author(s) 2017

Authors and Affiliations

  • Maria Teresa Montagna
    • 1
    Email author
  • Osvalda De Giglio
    • 1
  • Maria Luisa Cristina
    • 2
  • Roberto Albertini
    • 3
  • Cesira Pasquarella
    • 4
    Email author
  • GISIO-SItI Working Group
    • 5
  • AIA Working Group
    • 6
  • SIMPIOS Working Group
    • 7
  1. 1.Department of Biomedical Science and Human Oncology—Hygiene SectionUniversity of Bari “Aldo Moro”BariItaly
  2. 2.Department of Health SciencesUniversity of GenoaGenoaItaly
  3. 3.Department of Clinical and Experimental MedicineUniversity of ParmaParmaItaly
  4. 4.Department of Biomedical, Biotechnological and Translation SciencesUniversity of ParmaParmaItaly
  5. 5.GISIO-SItI (Italian Study Group on Hospital Hygiene-Italian Society of Hygiene, Preventive Medicine and Public Health)RomeItaly
  6. 6.Italian Association of AerobiologyScandicciItaly
  7. 7.Italian Multidisciplinary Society for Infection Prevention in Healthcare FacilitiesMilanItaly

Personalised recommendations