Enterobacter sakazakii

General description
Enterobacter sakazakii is a motile, gram-negative, non-spore-forming, rod-shaped
bacterium, that has been found in infant formulas as a contaminant. Enterobacter species
are biochemically similar to Klebsiella, but unlike Klebsiella, Enterobacter is ornithine
positive. E. sakazakii has been found to be more resistant to osmotic and dry stress than
other members of the Enterobacteriaceae family.
Human health effects
Enterobacter sakazakii has been associated with sporadic cases or small outbreaks of
sepsis, meningitis, cerebritis and necrotizing enterocolitis. Most of the infections are seen
in low-birth weight infants (i.e., less than 2,000 g) or infants born premature (i.e., less
than 37 weeks of gestation). Mortality has been reported to be as high as 50% but has
decreased to less than 20% in recent years.
Source and occurrence
The reservoir for E. sakazakii is unknown. Various environmental samples (surface water,
soil, mud, bird faeces) have tested negative. It has been identified in the guts of certain
flies. The organism has been frequently identified in factories that produce milk powder
and other food substances and in households. Commercially produced non-sterile
powdered infant formula has often been implicated as the source of the bacteria during
outbreaks. In a study of 141 powdered infant formulas 20 were found to be culturepositive for E. sakazakii even though the formulas complied with Codex microbial
requirements for coliforms (<3 cfu/g). The bacteria have been found in samples from
newly opened sealed cans. Although sources of the bacteria other than infant formula has
not been identified, environmental sources probably exist.
Routes of exposure
Disease caused by E. sakazakii in infants has been associated with the consumption of
commercially prepared non-sterile infant formula. Contamination has been linked back to
either the infant formula itself or formula preparation equipment (e.g. blenders). Many of
the outbreaks have occurred without identified hygienic lapses during formula
preparation. The organism has not been found in drinking water sources used to prepare
the formula. There is no evidence for person-person or more general environmental
transmission.
Significance in drinking water
There is no evidence that these bacteria are transmitted through drinking water although
it is plausible that the organism could be present in poor quality water. E. sakazakii is
sensitive to disinfectants and presence can be prevented by adequate treatment.
Selected bibliography
Block C et al., (2002). Cluster of Neonatal Infections in Jerusalem due to Unusual
Biochemical Variant of Enterobacter sakazakii. European Journal of Microbiology
and Infectious Disease, Vol. 21:613-616.

Breeuwer P et al. (2003). Desiccation and heat tolerance of Enterobacter sakazakii.

Journal of Applied Microbiology, Vol. 95:967-973.
Kandhai CM, et al. (2004). Occurrence of Enterobacter sakazakii in food production
environments and households. (Research letters) The Lancet, Vol. 363: 39-40.
Hamilton JV, Lehane MJ, and Braig HR (2003). Isolation of Enterobacter sakazakii from
Midgut of Stomoxys calcitrans (letter to the editor), Emerging Infectious Diseases,
Vol. 9(10):1355-1356).
WHO/FAO (2004). Enterobacter sakazakii and other microorganisms in powdered infant
formula, Meeting Report, (Microbiological Risk Assessment Series, 6), World Health
Organization, Food and Agriculture Organization of the United Nations, Geneva.