Legionellosis death after water birth sparks call for stricter infection control protocols

Fritschel E. Emerg Infect Dis. 2015;doi:10.3201/eid2101.140846.

December 26, 2014

Improved infection control standardization and compliance may be required for midwives overseeing home water births in Texas, according to recent findings.

Researchers from the Texas Department of State Health Services (TDSHS) investigated a 2014 case of fatal Legionella pneumophila serogroup 1 infection in an infant delivered by water birth. The infant presented to a local pediatric hospital at 6 days old with loose feces, cyanosis and respiratory failure. Due to sepsis, the infant was placed on extracorporeal membrane oxygenation and was prescribed ampicillin and gentamicin.

Initial tests screened for the presence of Escherichia coli, group B streptococcus and listeria, but the child’s water birth delivery and signs of fulminant sepsis and respiratory failure were more consistent with legionellosis. Diagnosis of L. pneumophila serogroup 1 infection was confirmed on day four of the child’s hospitalization through Legionella urinary antigen and PCR testing. The infant died after 19 days in the hospital, andLegionella was confirmed as the cause of death.

The birth was facilitated by a licensed midwifery center, which used a jetted, soft-sided collapsible tub with water. The water came from a private borehole well, and commercial water purifying spa drops were added upon filling the tub. The enzyme-based drops did not contain chlorine, and the water had not undergone any recent filtration or chemical disinfection. The water circulated in the tub at approximately 37°C until 2 days before the delivery, and was then drained, refilled with well water and circulated until the birth. There were no complications during birth, which occurred at term via vaginal delivery with assistance from a certified professional midwife.

The pregnancy was reportedly healthy, and there was no maternal travel during the 12 months before delivery. Testing of the delivery tub and private water source was recommended by the TDSHS and conducted by a CDC-certified laboratory. Both swab culture isolation and the well water did not yield evidence of Legionella.

While these tests did not confirm any environmental correlations, several measures of the birthing were insufficient, the researchers wrote. The midwifery center’s use of a recreational jetted tub with internal tubing was not approved for use, as such tubs can be difficult to disinfect. Water treatment inside this tub consisted of an unapproved additive, with water circulating at 37°C for a prolonged period. Moreover, no written or enforced procedures were provided by the midwifery center for employees to follow throughout the delivery.

In response, the TDSHS has drafted recommendations for the midwifery center associated with this Legionellainfection. The document provides guidelines for birthing tub sanitation and water birth protocols, and calls for more uniformity in the education and certification of midwives.

“Findings from this investigation revealed a gap in the standardization and implementation of infection control practices for midwives during home water birth,” the researchers wrote. “The death highlighted the need for infection control education, client awareness, and standardization of cleaning procedures in Texas midwife facilities.”

Disclosure: The researchers report no relevant financial disclosures.