Characteristics of Legionnaires’ Disease Cases Hospitalized at a Specialized Infectious Disease Hospital, 2023–2024, with a Focus on Clusters Associated with Travel to a Spa Resort

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript deals with a rare infection caused by Legionella pneumophila. In Romania, this infection is uncommon, and its management is sometimes delayed by physicians who have never encountered the disease.

There are several interesting aspects to this research, but in its current version, it is not acceptable for publication. On the positive side, the authors did a great job describing the symptomology of two of the patients. However, there were also several negative aspects that need to be addressed:

• English needs to be improved. A thorough read-through is necessary.
• The introduction is too long and repetitive.
• Unclear what the materials and methods section tries to describe. Please rewrite this section, and it would be better if you made subdivisions. In its present form, it is just a long story.
• The Results section is again too long and mostly describes the two clinical cases. Would it not be better to move these cases to the methods section?
• The results and the discussion sections are also very long and repetitive.
• In the Limitations to the Study, please expand. Make a point that only 31 cases were studied in the study, cases from a single clinic, etc.
• Rationale for expanding on the two clinical cases. Was it to raise awareness among other physicians of this disease in the country?
• Legionella pneumophila needs to be isolated throughout the manuscript. Furthermore, once a section is started, you only need to spell out the name once and then abbreviate it as L. pneumophila. 

 

Comments on the Quality of English Language This is a well-timed and clinically relevant study with several strengths but also weaknesses that need improvement before it is ready for publication. The major concern is the manuscript's repetitive nature. The sections are long and fail to provide either relevant or unique information. The authors need to emphasize the project's primary goal; otherwise, this reads more like a clinical case review.  

Author Response

1. English needs to be improved. A thorough read-through is necessary.

We thank the reviewer for this comment. The manuscript has been revised to improve the English language, clarity, and readability.

2. The introduction is too long and repetitive.

We agree with the reviewer’s assessment and the introductory section was shortened where possible; however, we considered it important to retain key information on the epidemiological, clinical and laboratory characteristics of Legionnaires' disease. This information is particularly relevant given that, in Romania, the Legionnaires' disease is still underdiagnosed and underreported.

3. Unclear what the materials and methods section tries to describe. Please rewrite this section, and it would be better if you made subdivisions. In its present form, it is just a long story.

We thank the reviewer for this suggestion. Subdivisions have been added to this section and are visible (with track changes) in the revised version of the manuscript.

We chose to emphasize the description of the legionellosis surveillance system in Romania given that this journal issue is dedicated to surveillance in Romania. Additionally, we believe that awareness of legionellosis, as well as its surveillance and reporting mechanisms, remains limited within the medical community in our country. Therefore, providing this context is both relevant and necessary.

4. The Results section is again too long and mostly describes the two clinical cases. Would it not be better to move these cases to the methods section?

We thank the reviewer for this suggestion and the introductory section was shortened where possible. We have chosen to retain the description of the clinical cases within this section, as they represent key findings of the study rather than methodological elements.

5. The results and the discussion sections are also very long and repetitive.

We thank the reviewer for this comment. Both the Results and Discussion sections were revised in order to reduce length and eliminate repetitive content. The changes are made with track changes and are visible in the revised version of the manuscript.

6. In the Limitations to the Study, please expand. Make a point that only 31 cases were studied in the study, cases from a single clinic, etc.

We agree with the reviewer's comments and the limitations of our study were modified as follows: The limitations of our study are related to its retrospective design, which resulted in a high rate of missing epidemiologic linkage data. Additionally, the inclusion of only 31  hospitalized patients from a single specialized infectious diseases hospital patients limits the generalizability of our findings to the broader population.

7. Rationale for expanding on the two clinical cases. Was it to raise awareness among other physicians of this disease in the country?

We aimed to highlight the heterogeneity of clinical symptoms across different age groups and to increase awareness of the underdiagnosis of this disease among physicians from specialties other than infectious diseases, particularly pediatricians.

8. Legionella pneumophilaneeds to be isolated throughout the manuscript. Furthermore, once a section is started, you only need to spell out the name once and then abbreviate it as L. pneumophila. 

Thank you for the comment. We made the suggested change.

Comments on the Quality of English Language

This is a well-timed and clinically relevant study with several strengths but also weaknesses that need improvement before it is ready for publication. The major concern is the manuscript's repetitive nature. The sections are long and fail to provide either relevant or unique information. The authors need to emphasize the project's primary goal; otherwise, this reads more like a clinical case review.  

We restated the aim in order to underline the importance of this research and to reflect the results of our study: The aim of this study is to present the characteristics of Legionnaires’ disease cases admitted to a specialized infectious disease hospital for two years, 2023 and 2024, and to describe a cluster of two cases, a father and son, associated with travel to a spa resort. Also, we aimed to highlight the heterogeneity of clinical symptoms across different age groups and to increase awareness of the underdiagnosis of this disease among physicians from specialties other than infectious diseases, particularly pediatricians.

Reviewer 2 Report

Comments and Suggestions for Authors

This is an excellent presentation of this set of cases of Legionnaire's Disease (LD) in Romania. LD is still an underdiagnosed disease. In isolating this case of a father and child group of cases, the authors have provided a real service. The Introduction is a very able review of the history of this disease, which repeatedly takes public health inspection services by surprise as they do not monitor adequately water sources, especially air conditioning systems. 

Table 1 needs fleshing out with columns that show the statistical difference among the categories for each variable (sex, age, etc.). The authors are using a weak statistical tool, Microsoft Excel. They can improve this by moving to a dedicated statistical program  that typically does Table 1's for papers.

I will note that I worked on finding the source of the 2nd outbreak of Legionnaires Disease back in 1978 in New York City. In terms of public health monitoring for this disease, not much has changed in the almost 50 years since then. 

Author Response

Table 1 needs fleshing out with columns that show the statistical difference among the categories for each variable (sex, age, etc.). The authors are using a weak statistical tool, Microsoft Excel. They can improve this by moving to a dedicated statistical program  that typically does Table 1's for papers.

We thank you for this insightful comment. However, given the descriptive nature of our study and the relatively small sample size (n < 100), we did not perform statistical comparisons by age and sex. In particular, the cohort included only a single pediatric patient, which precludes any meaningful subgroup analysis.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have provided a much-improved version of the manuscript. Clarifications and redundancies have been removed, and the manuscript reads much better now. I am very pleased by the improvements that helped overcome so many limitations. 

Comments on the Quality of English Language

This is a well-timed and clinically relevant study with several strengths but also weaknesses that need improvement before it is ready for publication. The major concern is the manuscript's repetitive nature. The sections are long and fail to provide either relevant or unique information. The authors need to emphasize the project's primary goal; otherwise, this reads more like a clinical case review.