Legionella pneumonia in cancer patients

Legionella is an important cause of nosocomial and community-acquired pneumonia in both immunocompetent and immunosuppressed patients worldwide; however, the clinical course and optimal antibiotic therapy of Legionella pneumonia (LP) in patients with cancer is uncertain. We studied retrospectively the risk factors, clinical manifestations, and outcome of 49 cancer patients with a positive Legionella culture or direct fluorescent antibody (DFA) over a 13-year period (1991-2003). The majority of patients (82%) had an underlying hematologic malignancy, and 37% were bone marrow transplant recipients; 80% of the patients had active malignancy. Lymphopenia (47%), use of systemic corticosteroids (41%), and chemotherapy (63%) were the most common underlying conditions. The laboratory diagnosis was established by positive Legionella culture (n = 8, 16%), DFA (n = 29, 59%), or both (n = 12, 25%). In 4 patients (8%), a positive DFA was deemed to represent false-positive results. There was no temporal or geographic clustering of cases. The majority of the cases had multilobar (61%) or bilateral (55%) pulmonary involvement. The mean time to response to therapy was 8 days; 18 patients (37%) developed complications requiring prolonged duration of treatment (mean, 25 d). The case-fatality rate was 31%. Two patients had relapse of LP despite appropriate therapy. Improved outcome, especially in those with severe pneumonia, seemed to correlate with the use of a combination of antibiotics. LP is an uncommon infection in our patient population but is associated with significant morbidity and mortality. Treatment of LP in cancer patients may require a prolonged course with a regimen that includes a newer macrolide or quinolone.