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Legionellosis is a bacterial disease caused by Legionella that can present as either legionnaires disease or Pontiac fever. Legionnaires disease is a severe form of pneumonia that often requires hospitalization. Pontiac fever is a milder disease that is often self-limiting. Legionella is naturally found in freshwater environments but can become a health concern when it grows and spreads in human-made water systems such as hot tubs and large plumbing systems. Inhalation of Legionella-containing water droplets can cause infection, especially in people at increased risk (e.g., immunocompromised individuals). Legionellosis is diagnosed through the combination of urinary antigen laboratory testing and a culture or polymerase chain reaction (PCR) test.
Quick Answers for Clinicians
People who are 50 years or older, current or former smokers, or immunocompromised, and those with chronic lung disease, cancer, or another underlying illness such as diabetes or kidney failure are at increased risk for legionellosis. Additionally, people who have recently traveled with an overnight stay outside of their homes (including a stay in a healthcare facility), those who have used respiratory therapy equipment, and individuals who have had recent exposure to hot tubs are at increased risk for legionellosis.
The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) do not recommend routinely testing for Legionella in adults with community-acquired pneumonia (CAP), except in cases indicated by epidemiologic factors (e.g., recent outbreak or travel) or in cases of severe CAP. In adults with severe CAP, a combination of urinary antigen testing and culture or nucleic acid-based testing such as polymerase chain reaction (PCR) is recommended.
Indications for Testing
Legionnaires Disease
Laboratory testing for legionnaires disease should be considered in patients who have pneumonia (often initially confirmed with a chest X-ray) and meet one or more of the following criteria :
- Lack of response to outpatient antibiotic treatment for community-acquired pneumonia (CAP)
- Severe pneumonia (particularly if intensive care is required)
- Immunocompromised status
- History of recent travel (within 10 days of disease onset)
- Risk for legionnaires disease with healthcare-associated pneumonia
- Exposure to a setting with a legionnaires disease outbreak
Testing for healthcare-associated legionnaires disease is especially important in settings with a confirmed diagnosis within the last 12 months, positive environmental Legionella testing in the past 2 months, or recent changes in water quality that could result in Legionella growth.
Pontiac Fever
Testing for Pontiac fever is generally not indicated because the disease is mild and resolves without treatment. However, if there is a possibility that the patient has been exposed to Legionella at the same time or place as another patient with laboratory-confirmed legionellosis, testing can be considered.
Laboratory Testing
Legionellosis is diagnosed with the combination of a urinary antigen test that detects Legionella pneumophila serogroup 1 and a culture or molecular test that can detect clinically relevant species and serogroups. There are many laboratory tests available for the diagnosis of Legionella. The following table compares the various testing methodologies.
Testing Methodology | Advantages | Disadvantages |
---|---|---|
PCRa | Can be performed on a wide range of sample types, including sputum and lung tissue (although lower respiratory samples are preferred) Detects clinically relevant species and serogroups Fast turnaround time High specificity and sensitivity | Assays may vary by laboratory |
Urinary antigena | Rapid Detects Legionella infection for days to weeks after treatment Provides retrospective evidence of Legionella infection | Does not detect all species or serogroups, so false-negative results are possible Does not enable comparison between clinical and environmental isolates |
Culturea | Detects all species and serogroups of Legionella Enables comparison of clinical and environmental isolates to help determine the source of an outbreak | Technically difficult, requires specialty media Long turnaround time Variable sensitivity Unreliable after initiation of antibiotic treatment |
DFA | Can be performed on lung tissue in addition to respiratory samples Detects multiple species and serogroups Can be used as a confirmatory test for suspected Legionella colonies isolated from culture | Technically difficult Test availability may be limited |
Serology | Detects multiple species and serogroups | Requires paired sera, the first collected within 2 wks of symptom onset and the second collected 3-6 wks later, for accurate analysis Long turnaround time (due to need for paired sera collection) |
aPositive result is considered confirmatory. DFA, direct fluorescent antibody |
ARUP Laboratory Tests
Qualitative Polymerase Chain Reaction
Qualitative Enzyme-Linked Immunosorbent Assay (ELISA)
Qualitative Culture
Direct Fluorescent Antibody Stain
Semi-Quantitative Enzyme-Linked Immunosorbent Assay (ELISA)
References
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CDC - clinical overview of legionnaires' disease
Centers for Disease Control and Prevention. Clinical overview of Legionnaires' disease. Last reviewed Jun 2025; accessed Aug 2025.
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CDC - Laboratory testing for legionella
Centers for Disease Control and Prevention. Laboratory testing for Legionella. Last reviewed Jun 2025; accessed Aug 2025.
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Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67.
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CDC - clinical guidance for legionella infections
Centers for Disease Control and Prevention. Clinical guidance for Legionella infections. Last reviewed Jun 2025; accessed Aug 2025.
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CDC - investigating legionnaires disease
Centers for Disease Control and Prevention. Investigating Legionnaire’s disease: about the data: case definitions. Last reviewed Apr 2024; accessed Aug 2025.