The creation of guidelines is a methodologically complex activity that requires technical expertise, resources and time. Methods of guideline production must meet at least these three criteria: multidisciplinarity, systematic review, and ranked recommendations. In May 2015, the new \"Guidelines for the prevention and control of Legionnaire\'s disease\" were published on the website of the Italian Ministry of Health in order to \"gather, update and integrate in a single document all the previous national recommendations published\". The critical review of the document has led us to conclude that this document does not comply with these three criteria, and we emphasize that guidelines should make decision-making easier, considering the various scientific approaches to a health problem and choosing the one considered most effective. Therefore, the persons responsible for the development of guidelines should strive to widely adopt and use current standards for the development of guidelines as a means to improve patient care and health outcomes.

Legionellosis is an important public health problem in the United States and other countries, and residents of long-term care facilities (LTCFs) are at higher risk for Legionnaires\' disease than the general population. In this study, we reviewed published US and international guidelines for the primary prevention of legionellosis in LTCFs, including nursing homes, skilled nursing facilities, assisted living facilities, and aged care facilities. The results of this review indicate that most guidelines emphasize adequate design and maintenance of water systems and water temperatures; however, guidance regarding routine preventative environmental testing for Legionella bacteria is not uniform among various jurisdictions, and facilities are generally left without clear guidance on this issue. In the United States, the Centers for Disease Control and Prevention does not recommend such testing in LTCFs, in contrast to the Veterans Health Administration and Environmental Protection Agency. Internationally, the World Health Organization recommends routine environmental testing, as do Ireland; France; The Netherlands; South Africa; Vienna, Austria; and Queensland, Australia. Among domestic and international guidelines in favor of environmental testing, recommendations on the frequency of testing for Legionella in water systems vary. Further research to inform recommendations on the usefulness of routine environmental testing and other measures for the primary prevention of legionellosis in this setting is needed.

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OBJECTIVE: The objectives of this study were to investigate the source of and outbreak of Legionnaires\' disease in West Fife in 2004; to control the spread of legionella from this source; and to make recommendations for future practice based on the findings from the investigation.
METHODS: Outbreak investigation.
METHODS: A multi-agency team investigated links between the cases of legionellosis using detailed interviews, movement mapping, a timeline and extensive environmental sampling.
RESULTS: The investigation found evidence that individuals affected by legionella during this outbreak had been in, or near (within 800 m), sullage tanks in Rosyth Dockyard within a period of 4 months.
CONCLUSIONS: In the absence of laboratory isolation of Legionella spp. from the human cases, it was impossible to state definitely that a previously unrecognized source of environmental legionella aerosolization was responsible for the outbreak. However, strong epidemiological and environmental evidence would support this hypothesis.

The standard sequence-based method for the typing of Legionella pneumophila serogroup 1 strains was extended by using the gspA and neuA alleles. The use of neuA as a seventh allele for typing significantly increased the index of discrimination calculated for a panel of unrelated strains (from 0.932 to 0.963) and subdivided some known large common complexes (e.g., 1,4,3,1,1,1). This modification to the standard method is proposed as the method of choice in the epidemiological investigation of L. pneumophila infections.

On 1 July 2002, EWGLINET introduced European guidelines for the control and prevention of travel-associated legionnaires\' disease. This paper presents the results gathered by the surveillance scheme during the first two and a half years of the operation of the guidelines (to the end of 2004). Two hundred and thirty-seven new clusters and 70 cluster updates were identified. Investigations at 146 sites returned positive samples for legionella, and the proportion of positive sites reached over 60% in 2004. Thirty-four cluster sites were reported to have been investigated satisfactorily, but have gone on to be associated with subsequent cases (\'repeater sites\'). Fifty-one sites were published on the European Working Group for Legionella Infections (EWGLI) website; the publication states that EWGLINET cannot be confident that the sites have adequate control measures in place. The operation of the guidelines is discussed, and the situation in Turkey highlighted as a particular success.

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A previously described sequence-based epidemiological typing method for clinical and environmental isolates of Legionella pneumophila serogroup 1 was extended by the investigation of three additional gene targets and modification of one of the previous targets. Excellent typeability, reproducibility, and epidemiological concordance were determined for isolates belonging to both serogroup 1 and the other serogroups investigated. Gene fragments were amplified from genomic DNA, and PCR amplicons were sequenced by using forward and reverse primers. Consensus sequences are entered into an online database, which allows the assignment of individual allele numbers. The resulting sequence-based type or allelic profile comprises a string of the individual allele numbers separated by commas, e.g., 1,4,3,1,1,1, in a predetermined order, i.e., flaA, pilE, asd, mip, mompS, and proA. The index of discrimination (D) obtained with these six loci was calculated following analysis of a panel of 79 unrelated clinical isolates. A D value of > 0.94 was obtained, and this value appears to be sufficient for use in the epidemiological investigation of outbreaks caused by L. pneumophila. The D value rose to 0.98 when the results of the analysis were combined with those of monoclonal antibody subgrouping. Sequence-based typing of L. pneumophila is epidemiologically concordant and discriminatory, and the data are easily transportable. This consensus method will assist in the epidemiological investigation of L. pneumophila infections, especially travel-associated cases, by which it will allow a rapid comparison of isolates obtained in more than one country.

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