E.sakasaki in powdered infant formula

Enterobacter sakazakii,[object Object],In Powdered Infant Formula,[object Object],DR. ABDULRAHMAN LOTFY,[object Object],Preventive Medicine – Jahra Hospital,[object Object],October 2011,[object Object]

FDA warning to health professionals,[object Object],powdered infant formula not to be used in neonatal intensive care settings.,[object Object]

Enterobacter sakazakii,[object Object], Opportunistic pathogen that can cause infections such as necrotizing enterocolitis, bacteremia, meningitis and brain abscess/lesions. ,[object Object],The species was defined in 1980, by Farmer et al. ,[object Object]

The Organism ,[object Object],Gram-negative straight rod,[object Object],Enterobacteriaciae family (Coliform bacterium).,[object Object],the cells are motile (flagellated) and do not form spores.,[object Object]

Electron Microscope Photo,[object Object],web site (http://www.magma.ca/~scimat/E_sakaza.htm).,[object Object]

What is the magnitude of the problem?,[object Object], The frequency in infants appears to be very low, yet the disease is devastating.,[object Object],Despite the low frequency of reported infections, mortality rate is relatively high (33%).,[object Object]

CLINICAL MANIFESTATIONS & ,[object Object],Clinical Manifestations Complications:,[object Object],Ventriculitis (inflammation in the ventricles of the brain).,[object Object],Brain cysts and abscesses,,[object Object],Cerebral infarction, ,[object Object],Hydrocephalus (abnormal increase in the amount of cerebrospinal fluid within the cranial cavity,[object Object],Necrotizing enterocolitis (localized death of small and large intestine tissues).,[object Object],Death may occur within a few hours to several days.,[object Object]

Mortality Rate:,[object Object]

Fatality From Meningitis*,[object Object],*Only one death has been reported in the absence of meningitis, a neonate exhibiting bacteremia.,[object Object]

Antibiotic Susceptibility of E. sakazakii,[object Object],Susceptibility ,[object Object],Resistence,[object Object],Ampicillin, ,[object Object],Tetracycline,,[object Object],Chloramphenicol,,[object Object],Gentamicin, and,[object Object],third-generation cephalosporins. ,[object Object],aminoglycosides :,[object Object],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.,[object Object],Cefazolin, and,[object Object],extended-spectrum penicillins.,[object Object]

Sporadic cases and outbreaks of Enterobacter sakazakii infection for which powdered infant formula (PIF) was implicated as the source agent.,[object Object],Drudy D et al. Clin Infect Dis. 2006;42:996-1002,[object Object],© 2006 by the Infectious Diseases Society of America,[object Object]

Is the risk similar in all regions and countries?,[object Object],Reporting only in a few developed countries,[object Object]

A significant public health problem,[object Object]

Source of E. sakazakii Infections,[object Object],In early cases of E. sakazakii infections, an environmental source of the organism could not be identified,[object Object],Vertical transmission is not documented.,[object Object],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.,[object Object]

Ecology of E. sakazakii,[object Object]

E. Sakazakii and flies,[object Object],household flies, were found to carry E. sakazakii.,[object Object],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. ,[object Object]

Foods from which the organism has been isolated,[object Object],Meat & minced beef,,[object Object], Sausages,[object Object],Vegetables,(Lettuce, alfalfa sprouts),[object Object],Tofu;,[object Object], Bread,,[object Object], Cheese;,[object Object], Rice seed,[object Object],•Herbs & spices,[object Object],•Sous (licorice drink),[object Object],•Dried products (infant cereal,, spices, whey, egg yolk , flour/meal),[object Object]

Occurrence in food production environments and households,[object Object]

PIF and E. sakazakii ,[object Object],Powdered milk substitute infant formulas are the principal sources from which E. sakazakii has been isolated. ,[object Object]

WHO – NO E.s. in BF. ,[object Object],In the current state of knowledge, no exclusively BF infants have been reported to have Enterobacter sakazakii infections.,[object Object], 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.,[object Object]

Survey - 1988 ,[object Object],E . sakazakii was isolated from 20 of 141 dried infant formulas from 35 countries in a 1988 survey,[object Object]

latest study ( 2008 published 2010) ,[object Object],In 2008 a study was done in Japan showed that E.sakazakii isolated in 6% of PIF samples suggesting that commercially available PIF products can be contaminated with this type of bacteria ,[object Object]

E.sakasaki in powdered infant formula

How does infant formula get contaminated with Enterobacter sakazakii? ,[object Object],Basically there are three routes by which Enterobacter sakazakii can enter infant formula:,[object Object]

1. Raw material used for producing the formula;,[object Object],2. Contamination of the formula or other dry ingredients after pasteurization,[object Object],3. Contamination of the formula as it is being reconstituted by the caregiver just prior to feeding.,[object Object]

colony-forming unit (CFU ),[object Object],is a measure of viable bacterial or fungal numbers. Unlike direct microscopic counts 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.,[object Object]

Current Regulations Affecting Occurrence of E. sakazakii in Powdered Infant Formulas,[object Object],Regulations governing the prevalence of E. sakazakii in powdered infant formulas falls under the hygienic requirements for allowable levels of coliforms.,[object Object], For the Codex Alimentarius, these requirements include:,[object Object],minimum of four of five control samples with < 3 coliforms/g and ,[object Object],a maximum of one of five control samples with >3 but ≤ 20 coliforms/g. ,[object Object],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.,[object Object]

What ,[object Object],do we ,[object Object],do now??,[object Object]

Recommendations & Preventative Strategies ,[object Object],The promotion of breast milk feeding,,[object Object],The World Health Organization recommends that infants should be exclusively breast-fed for the first 6 months of life.,[object Object], Infants who are not breast-fed should be provided with a suitable breast milk substitute, formulated in accordance with Codex Alimentarius Commission standards. ,[object Object],To reduce the risk of infection in infants fed PIF, recommendations have been made for the preparation and storage of PIF,[object Object]

[object Object],Take care , E.sakazakii ,[object Object],inside ,[object Object]

Education:,[object Object],The ideal practice of re-warming of reconstituted formula. ,[object Object],Better understanding of the progression and pathogenesis ES related diseases,[object Object]

Why education? ,[object Object],Many individuals unaware that PIF is not a sterile product,[object Object],Lack information on how handling, storage and preparation practices can influence the risk,[object Object],Effective risk communication practices needed for the public and health professionals,[object Object]

Summary & Conclusion,[object Object],E. sakazakiiis a pathogenic microorganism,[object Object],The precise pathogenesis of ES remains a mystery. ,[object Object],Natural habitat is not known yet,[object Object],Found in infant formula,[object Object],Thermo-tolerant ,[object Object],FDA recommend method need some improvement ,[object Object],There are much more work to be done…….,[object Object],Appropriate measures by parents, infant formula manufacturers, and health care providers, as well as understanding of the pathogenesis, are important in the prevention.,[object Object]

THANK YOU ,[object Object],Breastfeeding Is A Tender From The First Moment,[object Object]

E.sakasaki in powdered infant formula

E.sakasaki in powdered infant formula

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