title: Hazard analysis and critical control point system approach in the evaluation of environmental and procedural sources of contamination of enteral feedings in three hospitals.
abstract: BACKGROUND
  The administration of contaminated diets may contribute to severe infections, mainly in immunosuppressed patients. To determine the microbiologic quality of enteral feedings and the critical control points involved in the processing of the formulas, a study was carried out in three hospitals in São Paulo, Brazil.
  
  
  METHODS
  One hundred sixteen diets were evaluated according to the system known as hazard analysis and critical control points (HACCP). The techniques included the monitoring of the cleaning and disinfection of utensils, surfaces, and equipment; time and temperature controls; and microbiologic analyses that comprised the enumeration of facultative aerobic mesophilic bacteria, yeasts and molds, coliforms, and Escherichia coli. The diets were assessed based on the British Dietetic Association and the Food and Drug Administration standards.
  
  
  RESULTS
  The hospital-formulated diets and the commercially made powdered feeds presented statistically significant higher counts of mesophilic bacteria and percentages of no compliance with the standards for coliforms when compared with the commercially prepared, ready-to-feed enteral formula supplied in cans. According to the British standards, 77% and 38% of the diets were inadequate for mesophilic and coliform bacteria, respectively, just after preparation. After 24-hour storage in refrigerators, the percentages rose to 83% and 45%, respectively; the mesophilic and coliforms counts were also significantly higher. The following critical control points (CCP) were identified: cleaning and disinfecting of surfaces, utensils, and equipment; the time spent in preparation; the water used for reconstitution; the final temperature of the diet; the exposure to room temperatures; the lack of a chilling step; the refrigeration temperature; the inadequate disinfecting of the handlers' hands; and the lack of external cleaning and disinfecting of the cans before opening.
  
  
  CONCLUSIONS
  The results of this study are worrisome and show the need for implementation of good practices of hygiene and handling of the diets, and the regular monitoring of their preparation. The microbiologic quality of the enteral diets was compromised according to international standards, representing a potential risk of infection to the patients who require enteral nutrition.
authors.affiliation: Department of Nutrition and Dietetics Universidade Federal de Mato Grosso, São Paulo, Brazil. mirianca@zaz.com.br
authors.forename: M
authors.initials: M
authors.lastname: Lucia Rocha Carvalho
authors.forename: T
authors.initials: T
authors.lastname: Beninga Morais
authors.forename: D
authors.initials: D
authors.lastname: Ferraz Amaral
authors.forename: D
authors.initials: D
authors.lastname: Maria Sigulem
mesh_terms: D001419:Bacteria / Q000302:isolation & purification; D001938:Brazil; D004750:Enteral Nutrition / Q000592:standards*; D004926:Escherichia coli / Q000302:isolation & purification; D005506:Food Contamination / Q000517:prevention & control*; D005511:Food Handling / Q000592:standards*; D005516:Food Microbiology; D005526:Food, Formulated / Q000382:microbiology / Q000592:standards*; D005658:Fungi / Q000302:isolation & purification; D006761:Hospitals; D006801:Humans; D006920:Hygiene; D011786:Quality Control; D012307:Risk Factors; D017751:Safety Management; D013696:Temperature