Nosocomial Legionellosis Associated with Aspiration of Nasogastric Feedings Diluted in Tap Water

Abstract

We speculate that nosocomial Legionella pneumonia occurred due to aspiration of nasogastric tube solutions diluted with tap water. A nursing practice change to use only sterile water to dilute feedings and flush medications for nasogastric administration was instituted. The hot water temperature at the faucet was increased to > or = 131 degrees F (> or = 60 degrees C) to control Legionella. No further nosocomial cases have occurred.