Outbreak History, Biofilm Formation, and Preventive Measures for Control of Cronobacter sakazakii in Infant Formula and Infant Care Settings

Abstract

Previously known as Enterobacter sakazakii from 1980 to 2007, Cronobacter sakazakii is an opportunistic bacterium that survives and persists in dry and low-moisture environments, such as powdered infant formula. Although C. sakazakii causes disease in all age groups, infections caused by this pathogen are particularly fatal in infants born premature and those younger than two months. The pathogen has been isolated from various environments such as powdered infant formula manufacturing facilities, healthcare settings, and domestic environments, increasing the chance of infection through cross-contamination. The current study discusses the outbreak history of C. sakazakii and the ability of the microorganism to produce biofilms on biotic and abiotic surfaces. The study further discusses the fate of the pathogen in low-moisture environments, articulates preventive measures for healthcare providers and nursing parents, and delineates interventions that could be utilized in infant formula manufacturing to minimize the risk of contamination with Cronobacter sakazakii.

The Secretion of Toxins and Other Exoproteins of Cronobacter: Role in Virulence, Adaption, and Persistence

“…Cronobacter sakazakii, as described by Iversen et al [1] consists of a group of strains previously reported by Farmer et al [59] as belonging to biogroups 1-4, 7, 8, 11, and 13 of the former E. sakazakii species epithet. C. sakazakii is the predominant Cronobacter species associated with infantile and adult illnesses [4][5][6][7][8][13][14][15]18]. Using the multi-locus sequence typing (MLST) scheme described by Baldwin et al [60], Joseph et al [61], and Joseph and Forsythe [62] showed an association among particular C. sakazakii sequence types (ST), which are found with specific types of illnesses [63,64].…”

“…Urmenyi and Franklin, in 1961, reported the first cases of fatal invasive newborn infections (meningitis) caused by Cronobacter species (reported as a yellow-pigmented Enterobacter cloacae) [16]. Furthermore, Cronobacter was elevated to a global foodborne and public health issue when contaminated lots of powdered infant formula (PIF) or follow-up formula (FUF) were epidemiologically linked to several neonatal and infant septicemia/meningitis outbreaks [17][18][19]. In addition to meningitis, the range of Cronobacter infantile infections have been extended now to include necrotizing enterocolitis (NEC) and bacteremia or sepsis; death can occur within hours from the onset of symptoms [4][5][6][7][8][9]11,13,16,17].…”

“…PIF was thought to be the source of neonatal/infantile infections. However, it is clear now that contamination of reconstituted PIF can occur intrinsically and extrinsically, although the main reservoir(s) and routes(s) of contamination have yet to be determined [18][19][20]. Jason reported surveillance data on 82 Cronobacter cases (between 1958 and 2010) and showed that these infants became ill (defined here as a confirmed culture-positive case of septicemia or meningitis) after ingesting breast milk exclusively (without consumption of PIF, FUF, or powdered human milk fortifiers) prior to illness onset [11].…”

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“…For instance, in Ethiopia it is assumed that the number of infections caused by Cronobacter sakazakii is under reported. Unlike the vast majority of main foodborne pathogens, Cronobacter sakazakii infections are not currently a reportable disease in nearly all states [7]. Cronobacter sakazakii is a threat to infant, neonatal and other susceptible age groups resulted from utilizing contaminated powder infant formula or utensils such as spoons used for reconstitution ( Figure 1).…”

Breastfeeding and the Risk of Infant Illness in Asia: A Review

“…In addition, a known contaminant of formula powder is Chronobacter (formerly Enterobactor) sakazakii. This bacteria is found primarily in dry and dehydrated foods with low water activity, such as herbal teas, starches, and in powdered infant formula [93]. In formula-fed infants it can occasionally cause infections and fatal neonatal cases have been reported from Japan [94].…”