e.sakasaki in powdered infant formula
DESCRIPTION
this lecture was presented in first kuwait iTRANSCRIPT
- 1.Enterobacter sakazakii
In Powdered Infant Formula
DR. ABDULRAHMAN LOTFY
Preventive Medicine Jahra Hospital
October 2011
2. FDA warning to health professionals
powdered infant formula not to be used in neonatal intensive care
settings.
3. Enterobacter sakazakii
Opportunistic pathogen that can cause infections such as
necrotizing enterocolitis, bacteremia, meningitis and brain
abscess/lesions.
The species was defined in 1980, by Farmer et al.
4. The Organism
Gram-negative straight rod
Enterobacteriaciae family (Coliform bacterium).
the cells are motile (flagellated) and do not form spores.
5. Electron Microscope Photo
web site (http://www.magma.ca/~scimat/E_sakaza.htm).
6. What is the magnitude of the problem?
The frequency in infants appears to be very low, yet the disease is
devastating.
Despite the low frequency of reported infections, mortality rate is
relatively high(33%).
7. Risk Factors
8. CLINICAL MANIFESTATIONS &
Clinical Manifestations Complications:
Ventriculitis (inflammation in the ventricles of the brain).
Brain cysts and abscesses,
Cerebral infarction,
Hydrocephalus(abnormal increase in the amount of cerebrospinal
fluid within the cranial cavity
Necrotizing enterocolitis (localized death of small and large
intestine tissues).
Death may occur within a few hours to several days.
9. Mortality Rate:
10. Fatality From Meningitis*
*Only one death has been reportedin the absence of meningitis, a
neonate exhibiting bacteremia.
11. Antibiotic Susceptibility of E. sakazakii
Susceptibility
Resistence
Ampicillin,
Tetracycline,
Chloramphenicol,
Gentamicin, and
third-generation cephalosporins.
aminoglycosides :
Although E. sakazakii isolates are typically susceptible to it ,
such antibiotics are not recommended for primary treatment because
of poor penetration into the central nervous system.
Cefazolin, and
extended-spectrum penicillins.
12. Treatment
13. Sporadic cases and outbreaks of Enterobacter sakazakii
infection for which powdered infant formula (PIF) was implicated as
the source agent.
Drudy D et al. Clin Infect Dis. 2006;42:996-1002
2006 by the Infectious Diseases Society of America
14. Is the risk similar in all regions and countries?
Reporting only in a few developed countries
15. A significant public health problem
16. Source of E. sakazakii Infections
In early cases of E. sakazakii infections, an environmental source
of the organism could not be identified
Vertical transmission is not documented.
Dried infant formula, has been identified epidemiologically as the
source of E. sakazakii in three outbreaks of neonatal meningitis
and linked to one outbreak of necrotizing enterocolitis.
17. Ecology of E. sakazakii
18. E. Sakazakii and flies
household flies, were found to carry E. sakazakii.
Similarly, E. sakazakii has been isolated from the gut flora of
fruit flies, with no differences in distribution between males and
females. Surprisingly, the organism was only isolated from a
culture of fruit flies propagated in 1998 and not from a colony of
flies over 30 years old.
19. Foods from which the organism has been isolated
Meat &minced beef,
Sausages
Vegetables,(Lettuce, alfalfa sprouts)
Tofu;
Bread,
Cheese;
Rice seed
Herbs & spices
Sous (licorice drink)
Dried products (infant cereal,, spices, whey, egg yolk ,
flour/meal)
20. Occurrence in food production environments and households
21. PIF and E. sakazakii
Powdered milk substitute infant formulas are the principal sources
from which E. sakazakii has been isolated.
22. WHO NO E.s. in BF.
In the current state of knowledge, no exclusively BF infants have
been reported to have Enterobacter sakazakii infections.
Based on the available information, in 50-80 % of cases, PIF is
both the vehicle and the source (direct or indirect) of E.
sakazakii induced illness.
23. Survey - 1988
E . sakazakii was isolated from 20 of 141 dried infant formulas
from 35 countries in a 1988 survey
24. lateststudy ( 2008 published 2010)
In 2008 a study was done in Japan showed that E.sakazakiiisolated
in 6% of PIF samples suggesting that commercially available PIF
products can be contaminated with this type of bacteria
25. 26. How does infant formula get contaminated with Enterobacter
sakazakii?
Basically there are three routes by which Enterobacter sakazakii
can enter infant formula:
27. 1. Raw material used for producing the formula;
2. Contamination of the formula or other dry ingredients after
pasteurization
3. Contamination of the formula as it is being reconstituted by the
caregiver just prior to feeding.
28. colony-forming unit(CFU)
is a measure of viablebacterialorfungalnumbers.Unlike
directmicroscopiccounts where all cells, dead and living, are
counted, CFU measures viable cells. For convenience the results are
given as CFU/mL (colony-forming units per milliliter) for liquids,
and CFU/g (colony-forming units per gram) for solids.
29. 30. 31. Current Regulations Affecting Occurrence of E.
sakazakii in Powdered Infant Formulas
Regulations governing the prevalence of E. sakazakii in powdered
infant formulas falls under the hygienicrequirements for allowable
levels of coliforms.
For the Codex Alimentarius, these requirements include:
minimum of four of five control samples with < 3 coliforms/g
and
a maximum of one of five control samples with >3 but 20
coliforms/g.
Based upon these test parameters, dry milk-based infant formula
that contains E.sakazakii at levels of < 1 organism per 100 g of
formula would not be reliably detected.
32. What
do we
do now??
33. Recommendations & Preventative Strategies
The promotion of breast milk feeding,
The World Health Organization recommends that infants should be
exclusively breast-fed for the first 6 months of life.
Infants who are not breast-fed should be provided with a suitable
breast milk substitute, formulated in accordance with Codex
Alimentarius Commission standards.
To reduce the risk of infection in infants fed PIF, recommendations
have been made for the preparation and storage of PIF
34.
- Inclusion of warnings on powdered infant formula packages that they may be contaminated with ES.
Take care , E.sakazakii
inside
35. Education:
The idealpractice of re-warming of reconstituted formula.
Better understanding of the progression and pathogenesis ES related
diseases
36. Why education?
Many individuals unaware that PIF is not a sterile product
Lack information on how handling, storage and preparation practices
can influence the risk
Effective risk communication practices needed for the public and
health professionals
37. Summary & Conclusion
E. sakazakiiis a pathogenic microorganism
The precise pathogenesis of ES remains a mystery.
Natural habitat is not known yet
Found in infant formula
Thermo-tolerant
FDA recommend method need some improvement
There are much more work to be done.
Appropriate measures by parents, infant formula manufacturers, and
health care providers, as well as understanding of the
pathogenesis, are important in the prevention.
38. THANK YOU
Breastfeeding Is A TenderFromThe First Moment