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Enterobacter sakazakii in Infant Foods -Should We Be Concerned?
Dr. Jeff FarberDirector
Bureau of Microbial HazardsFood Directorate
Health Products and Food BranchHealth Canada
2
3
Outline of Presentation
1. General Biology2. Ecology3. Methodology4. Epidemiology/Disease 5. Pathogenicity6. Control7. Summary
Enterobacter sakazakii
1. GENERAL BIOLOGY
5
Enterobacter sakazakii
• Gram-negative rod; Enterobacteriaceaefamily
• Non-spore forming, Motile• 1980, designated as a unique species
based on differences from E. cloacae in DNA relatedness, pigment production and biochemical reactions (sorbitol, "-glucosidase)
6
Enterobacter sakazakii
• 14 or 15 Biogroups• Biochemical
reactions; motility • Produces a capsule • Genetically diverse
(4 clusters; 2 lineages described to-date)
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Resistance to Treatments
Great deal of information available about Enterobacteriaceae in general, not much on E. sakazakii
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Resistance to Dessication
Isolation from dried foods indicates resistance to dryingStationary phase cells of E. sakazakii more
resistant to dessication than other Enterobacteriaceae (E. coli, Salmonella, etc.)Appears to be associated with accumulation
of trehalose
Breeuwer et al., JAM, 2003
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Resistance to Dehydration
1.0
2.0
3.0
4.0
5.0
6.0
7.0
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700
Storage Duration (days)
Pop
ulat
ion
Den
sity
[L
og(c
fu/m
l)]
EdelsonEdelson--Mammel and Buchanan, 2005Mammel and Buchanan, 2005
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Resistance to Heat
Distribution of D58°C-values for 12 E. sakazakii strains
0
1
2
3
4
5
6
# of
Str
ains
0-100 100-200
200-300
300-400
400-500
500-600
D-value (sec)
Edel
son
Edel
son --
Mam
mel
Mam
mel
and
Buc
hana
n, 2
004
and
Buc
hana
n, 2
004
11
Summary
Not a particularly thermally-resistant microorganism Substantial diversity in thermal resistance among strainsSpecific information on its resistance to other treatments starting to emerge (e.g., HPP, acid-tolerance) Genetically diverse
Enterobacter sakazakii
2. ECOLOGY
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Environmental Sources of E. sakazakii
• Dust• Fruit flies,
house/stable flies• Rats• Soil, rhizosphere• Sediment, wetlands
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Foods/food ingredients from which the organism has been isolated
• Cured meat, minced beef, sausages
• Lettuce, vegetables, alfalfa sprouts
• Tofu; bread, cheese; rice seed• Herbs & spices• Sous (licorice drink)• Dried products (infant cereal,
vegs., spices, whey, egg yolk/eggnog, flour/meal)
• Mother’s milk
15
Incidence of E. sakazakiiin PIF
Samples positive (%) Reference
20/141(14) Muytjens (1988)
8/58 (13.8) Leuschner et al. (2004)35/3,467 (1.0) IFC (2004)
8/120 (6.7) N-White & Farber (1997)8/210 (3.8) Heuvelink et al. (2001)3/141 (2.1) Heuvelink et al. (2003)
1/835 (0.12) WHO (2004)
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Occurrence in food production environments and households
Site Samples positive for E. sakazakii (%)
Milk powder factory 14/68 (21)Chocolate factory 2/8 (25)
Cereal factory 4/9 (44)Potato flour factory 4/15 (27)Pasta factory 6/25 (23)Households 5/16 (31)
Kandhai et al., 2004; Lancet
Growth of E. sakazakii
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E. sakazakii –Growth in PIF
Temp. Lag time Gen. time Reference6oC ND 13.7 h Iversen et al. (2004)10oC 19-47 h 4.2-5.5 h N-White & Farber (1997)21oC ND 1.7 h Iversen et al. (2004)23oC 1.8-3.4 h
3.9-4.7 h37-44 min43 min
N-White & Farber (1997)Lenati (2005)
37oC ND2.2-3.0 h
19-21 min17.4 min
Iversen et al. (2004)Lenati (2005)
ND=Not Determined
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Growth of E. sakazakii in breast milk, breast milk with fortifiers,and infant formula at 23ºC
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
0 2 4 6 8 10 12 14 16 18 20 22 24
time (h)
log
(CFU
/ml)
breast milk breast milk + fortifier infant formula
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0
1
2
3
4
5
6
7
8
9
8 12 24 48
Time (h)
log
CFU
/ m
l 12oC
21oC
30oC
* Initial population 0.27 CFU/ml
Generation time 43-57 min at 30oC
Growth of E. sakazakii in infant rice cereal rehydrated with liquid infant formula
(Adapted from Richards et al., 2005)
Enterobacter sakazakii
3. METHODOLOGY
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Methodology – E. sakazakii
Distilled water/BPW* Pre-enrichment
Selective enrichmentmLST+van*/EE broth
ESIA*/VRBG Agar Selection
*ISO MethodTSA 25°C; 2-3d
Identification
Yellow colonies, API 20E, Oxidase
23
Medium - Druggan-Forsythe-Iversen Agar (DFI)
• Based on the alpha-glucosidase reaction
• Produces blue-green colonies on a pale yellow medium
• Proteus spp.- grey• Deoxycholate for
Gram-positivesIversen & Forsythe 2004
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Composition of R & F® E. sakazakiiChromogenic Medium
Blue-black• Carbohydrates; Sorbitol –
16.1%; D-Arabitol – 8.1%; Adonitol – 12.9%
• Bile Salts – 2.0%• Sodium chloride – 8.1%• Chromogenic substrates (X-
alpha-D-Glucopyranoside & X-β-D-Cellobioside) at 0.25% each
• Phenol red – 0.16%• Cefsulodin and Vancomycin
MelibioseSucrose
Restaino et al., 2006
E. sakazakii Dupont BAX®Detection Method
25g sample
225 ml mLST broth with vancomycin
Incubate 45°C/20-22h
Enrichment
Day 1
Add 10µl to 500 µl BHI broth (RT)
Incubate 37°C/3h
Use 5 µl in PCR ReactionDay 2
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Pathatrix Method
Magnet
Target Bacteria
Antibodies
Magnetic beads
Debris Non Specific bacteria
27
Sample Overview for
E. sakazakii in Infant Formula
100g + 900ml BPW
Static Incubation at 42ºC for 6h
Run 250 ml sample on Pathatrix for 30 min
Plate beads onto DFI plates 1 min
Overnight Incubation - ~ 16 h * Current FDA method = 4 days to colony Total test time = ~23h*
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Summary of Benefits of PATHATRIX E. sakazakiiAssay Format
• Analyzes large sample size• Simple to operate • Colonies isolated within
24h• Easy analysis of pooled
samples • Minimal training costs• Ability to rapidly identify
problem in production environment
29
Some Methodological Issues
• Yellow non-diffusible pigment production is not a unique trait
• Reports of white E. sakazakii strains• Biochemical kits not all that reliable
30
One Possible solution
• An artificial neural network has been applied to identify factors which discriminate E. sakazakii from similar, closely related organisms (Iversen et al., 2006)
• This predicted that tests for the metabolism of glucose-1-phosphate, sucrose and arginine gave the highest discrimination
31
Rapid Methods
• Real-time PCR (Malorny & Wagner, 2005; Seo & Brackett, 2005; Liu et al., 2006)
• PCR targeting 16S rRNA(Lehner et al., 2004); ompA(Nair et al., 2006); alpha-glucosidase (Lehner et al., 2006); 16S-23S rDNA spacer region (Liu et al., 2006)
• 16S RNA in-situ Hy test (VIT); uses epiF microscopy
32
Molecular typing
• Plasmid typing• RAPD• Ribotyping• PFGE• MLST
Enterobacter sakazakii
4. EPIDEMIOLOGY / DISEASE
34
E. sakazakii infections
• About 90 cases worldwide, 80% of them in infants < 1 y old
• Among infants, most cases are 0-2 months of age
• Conclusion: Group at particular risk is infants (<1 year)
• Greatest risk: neonates (<28d) and immunocompromised, especially those of LBW (<2500 g) and also those < 2 months of age
35
Symptoms of E. sakazakii infection
• Asymptomatic babies colonized with the organism
• Sepsis/bacteremia with a bleeding tendency
• Devastating CNS involvement, i.e., meningitis, meningoencephalitis
• A whole host of sequelae
36
Sequelae –E. sakazakii infection
• Tropism for the CNS– Ventriculitis– Brain cysts and abscesses/lesions– Cerebral infarction– Retarded neural development– Late development of hydrocephalus
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Summary of Infant Characteristics By Syndrome
Characteristics Bacteremia Meningitis
Gestational age Younger Older
Birth weight Extremely low Low
Age at onset > 1 month < 1 week
Severe outcome Rare Usual
Bowen and Braden, 2006
38
Hypotheses
• Very premature, extremely low-birth-weight infants are more likely to be fed– IV nutrition early in life– Sterile, liquid formula next– Non-sterile, powdered formula later
• Less premature, heavier infants are more likely to be fed powdered formula from the time they are born
• Greatest risk for meningitis is in the first weeks of life
Bowen and Braden, 2006
39
Human sites where the Organism has been isolated
• CSF, Blood• Urine, stool• Stomach aspirate• Respiratory Tract
(sputum, nose, throat)
• Skin, wounds
40
Mortality Rates, Minimum Infectious Dose and Incubation Period
• Mortality Rates – reported as high as 50%, but in recent years has declined to <20%
• MID – Unknown at this point; likely depends on age/weight of patient and health status
• IP – appears to be short, but is unknown
41
E. sakazakii –Important Chronology
• First reported cases – Urmenyi (1961); pigmented coliforms
• Farmer et al. (1980) – E. sakazakii• Kleiman et al.; Adamson et al. (1981);
previously healthy 5-wk old infants• First case in an adult – Jimenez (1982)• Muytjens (1983) – first to propose possible
link to powdered infant formula
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Outbreaks linked to PIF
Location Cases Comments ReferenceIceland 3 (1 death) 2 normal term infants;
1 Down'sBiering et al., 1989
Tennessee 4; 3 sepsis, 1 bloody diarrhea
Es; 8 cfu/100g Simmons et al., 1989
Belgium 12 6/12 with NEC positive for Es
Van Acker et al., 2001
Tennessee 9 1 confirmed, 2 suspect, 6 colonized
Himelright et al., 2001
Israel 5 3 colonized only Bar-Oz et al., 2001
New Zealand 5 (1 death) 4 colonized 2004France 9 (2 deaths) 5 colonized AFSSA, 2005
43
Case study -Van Acker et al. (2001)
• 12 cases – Belgium, 1998• 6/12 neonates had positive cultures for
E. sakazakii vs. 0/38 without NEC (p<0.001)
• 10/12 neonates with NEC drank the same PIF (Alfaré)
• Organism isolated from prepared formula as well as from unopened cans
44
Van Acker et al. (2001) –Noteworthy Points
• After use of implicated formula stopped, no more cases were observed
• Coliform results met Codex, but not Belgian standards
• A closely related E. sakazakii strain had been isolated 4 years earlier from the gastrostomy tube of an infant fed the same brand of formula
45
Outbreak in France
• Another outbreak due to E. sakazakii occurred in France in 2004 (Coignard and Vaillant, 2006; Coignard et al., 2006)
• A total of 9 cases were reported, with 2 deaths • Syndromes included fatal meningitis (2),
conjunctivitis (1), hemorrhagic colitis (1) and colonization (5)
• All infants were premature and under 2000 g (low-birth-weight), except for the infant with colitis who weighed 3250g and was born at 37 weeks of gestation
46
Outbreak in France
• Public health officials saw 2 E. sak meningitis cases a week apart – triggered an investigation
• 4 implicated lots over a 6-month period were contaminated at levels ranging from 1-10 cfu/100 g; the 2 more highly contaminated lots were involved in 8 of the 9 cases
• Hospitals were storing formula for longer than 24h in the refrigerator, with no temperature control
Enterobacter sakazakii
5. PATHOGENICITY
Pathogenesis of E. sakazakii infection
Crossing of gastrointestinal barrier leads to sepsis, bacteremia
Ingestion of contaminated food: most likely route of entry
Blood-brain barrier passage leads to meningitis, ventriculitis, brain abscess, infraction, cyst formation leading in most cases to neurological sequelae
Gastrointestinal symptoms include necrotizing enterocolitis and diarrhoea
How to mimic infectious process seen in LBW neonates?
In-vivo pathogenicity assessment
Non-primate animal models
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Summary – E. sakazakiipathogenicity
• Suckling mouse bioassay: Of 18 E.sakazakii strains evaluated, four were found to test positive for enterotoxin production
• IP Dosing: Death at 108
• Oral Dosing: 2/18 strains caused death in suckling mouse model
Pagotto et al., 2003; JFP
51
Method
• Animal models (weight; age):– Pigs (6.3–7.2 kg; 5 weeks)– Chicks (1 day)– Rabbits (2.7–3.0 kg; 2 months)– Guinea pigs (300–400g; 3–4 months)– Gerbils (40–50g; 1–2 months); newborns– Rat pups
• Challenged with three (of 30) isolates from ILSI core list:– SK81 (clinical)– 2001 – 10 – 01 (clinical)– MNW2 (food)
52
Method
Oral dose 1x109
cells First phase - 3 isolates
7 and 14 days
Observe signs of Infection / death
Examine organs: spleen, brain, lymph nodes, feces heart, small intestine
Choose best animal model for second
phase (30 isolates)
Collect fecal samples
(Days 1, 3, 7 and 14)
53
Results
• None of the young animal models tested to-date (piglets, chicks, rabbits, guinea pigs, gerbils) have mimicked human clinical symptoms of E. sakazakii infection, including no lethality
• E. sakazakii was recovered from fecal samples of all animals tested
• Newborn gerbils appear promising
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Summary - What do we know about the pathogenicity of this organism?
• Differences in virulence between strains • Can attach to intestinal mucus• Produces enterotoxin-like compounds;
acidic metalloprotease• Can survive passage through the stomach• Healthy young animals and children
appear to be resistant to infection• Unique conditions need to exist for
infection to occur
Enterobacter sakazakii
6. CONTROL
56
Control Measures –Dry Infant Formula
• PIF are not intended to be sterile
• Levels of microorganisms must be kept as low as possible
57
Sites of potential contamination
Raw milk
TransportStorage
Pasteurization
Drying/Blending
Filling Product
StorageTransport
ReconstitutionConsumption
E sakE sak
Factory
FarmHospital/
HomePotential sites forEnvironmentalcontamination
58
The presence of E. sakazakiiin packaged PIF is due to recontamination
• Recontamination is related to the following factors, the first two of which are linked:
1. The presence of these micro-organisms in the processing environment, presenting the possibility that they may get into the processing lines
2. The presence of these micro-organisms, originating from the processing environment (1), on internal surfaces of equipment that are in direct contact with the product; and
3. The presence of these micro-organisms in ingredients added and mixed into the dry base powder after the heat-processing step
59
Presence of Enterobacteriaceaeand E. sakazakii in PIF ingredients
Ingredients N(10g) Coliform or Enterobacteriaceaepositives
E. sakazakiipositives
Vitamins 793 8 0
Dem. whey powder 23 3 0
Sucrose 1691 28 0
Lactose 2219 70 2Banana powder/flakes
105 3 1
Orange powder/flakes
61 1 1
Lecithin 136 1 1
Starch 1389 155 40
Unpublished Industry Survey; FAO/WHO, 2004
60
Control during production
• Reduction of these micro-organisms in the production environment can be achieved through a combination of:
(1)minimizing their entry into high-hygiene zones and
(2)preventing proliferation of those that are already present
61
Monitoring for EB
• Monitoring for EB represents an ideal tool to assess the effectiveness of preventive measures and to detect the occurrence of recontamination
• The methods are simple and provide rapid results allowing for rapid corrections when needed
• Such monitoring can be complemented by testing for E. sakazakii in relevant samples, e.g., in finished product
62
Monitoring for EB
Increases in the levels of EB and/or E. sakazakiiin processing environments can be due to:
• A massive and sudden entry as a result of, for example, poorly planned construction or maintenance activities or more commonly– The occurrence of conditions which allow the
proliferation of the low number of micro-organisms already present in the environment
– Growth is only possible in the presence of water, therefore this has to be eliminated as much as possible
63
Summary - Control of E. sakazakii
Achieving control of EB and/or E. sakazakii requires the implementation of a number of measures modified according to the needs of individual manufacturing facilities. These measures include:
• The effective implementation of preventive measures (GMP/GHP and HACCP) as originally designed to control Salmonella
• The strengthening of these measures to further minimize entry of the micro-organisms and to avoid their multiplication by excluding water from the processing environment, e.g., the implementation of systematic dry-cleaning
64
Summary - Control of E. sakazakii
Continued -• Selection of suppliers of dry mix ingredients according to
specified needs (e.g., microbiological requirements for dry-mix ingredients)
• The implementation of monitoring and environmental management programs (environmental samples, product contact surfaces, finished products) based on EB as indicators for process hygiene, and E. sakazakii in relevant samples to demonstrate control or to detect deviations and assess the effect of corrective actions
65
Guidelines for safe preparation, storage and handling of PIF
WHO Guidelines
PIF is not a sterile product and may be contaminated with pathogens that can cause serious illness. Correct preparation & handling reduces the risk of illness
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Control measures in Hospitals
• Scenarios that involve periods of holding at room temperatures (both cool and warm) are associated with the greatest risk
• Quick cooling to lower temperatures to minimize growth is essential (i.e., use small containers)
FAO/WHO, 2006
67
Reconstitution
• The highest risk scenarios were associated with reconstitution at temperatures of 40 and 50oC when the formula is not consumed immediately
• Reconstitution with liquid of 70oC is an effective risk mitigation strategy for all scenarios investigated
FAO/WHO, 2006
68
Control measures in Hospitals
• Use of trained personnel to prepare PIF under as aseptic conditions as possible
• Prepared formula products should be rapidly cooled and then refrigerated right away; discarded if not used within 24h after preparation
• Hang times should not exceed 4h• Preparing only a small amount of formula for
each feeding • Alternatives to powdered form if possible
Enterobacter sakazakii
7. SUMMARY
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Future Work
• ILSI grant to look at animal models
• Risk assessment• Codex – Recommended
International Code of Hygienic Practices for Foods for Infants and Children
• ICMSF –criteria/specifications
71
Control measures for Enterobacter sakazakii in PIF
Ho - ΣR + ΣI < FSO
Reducing the concentration/prevalence of intrinsic contamination
Reducing the level of contamination of the reconstituted PIF (e.g., heat) prior to use
Minimise the chance of contamination of reconstituted formula during preparation
Minimize the growth of E. sakazakiifollowing reconstitution prior to consumption
+
72
Summary
• E. sakazakii infection is a rare, but very serious disease
• More data needed on true “susceptible”populations
• More growth data needed • Dose-response models needed
to develop FSOs• More global data needed on PIF
handling, preparation and storing practices
Enterobacter sakazakii in Infant Foods -Should We be Concerned?
Yes
Are we moving in the right direction to control this organism?
Yes