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Clinical Utility of Testing for Legionella Pneumonia in Central Texas

Rationale: Legionella pneumophila is an uncommon cause of community‐acquired pneumonia in the south central region of the United States, and regular testing may not be cost effective in areas of low incidence. Objectives: To evaluate the incidence of Legionella in central Texas and to determine the cost effectiveness of Legionella urinary antigen testing. Methods: We performed a single‐center retrospective cohort study of patients admitted with pneumonia between January 2001 and December 2013. Patients were identified by Binax Legionella urinary antigen and International Classification of Disease, Ninth Revision codes. Demographic characteristics and clinical history of the confirmed Legionella pneumonia cases were obtained by chart review. Descriptive statistics were used to describe patient characteristics. Measurements and Main Results: Over 12 years, 5,807 patients with 11,377 admissions for pneumonia were tested for Legionella urinary antigen. A positive Legionella urinary antigen was found in 17 patients. Cumulative incidence during the study period was 0.23%. Among the Legionella‐positive patients, intensive care unit admission and median length of stay were 58.8% and 8.5 days, respectively. Most patients (64.7%) met American Thoracic Society criteria for severe pneumonia. All patients empirically received either a macrolide or fluoroquinolone covering Legionella. There were two in‐hospital and three total 90‐day deaths in those with a positive urinary antigen. The estimated cost of screening this population with Legionella urinary antigen was $214,438 over 13 years. Conclusions: This study reveals the low incidence of Legionella pneumonia in central Texas. Use of guideline‐concordant antibiotic treatment provides coverage for Legionella. We speculate that testing in a low‐prevalence area would not influence outcomes or be cost effective.