Original Article

Implementation of hazard analysis and critical control points (HACCP) for microbial safety of enteral feeding solutions at Imam Khomeini Hospital, Urmia, Iran

Abstract

Background and Objectives: Enteral feeding solutions (gavage) play a vital role in supporting ICU patients who cannot eat by mouth. However, their preparation is vulnerable to microbial contamination, posing serious health risks. This study aimed to assess and improve the microbial safety of enteral feeding solutions prepared at Imam Khomeini Hospital in Urmia, Iran.
Materials and Methods: A three-phase intervention was conducted involving microbial and PCR analyses, source identification, and corrective measures. Initial testing revealed high contamination levels: coliform bacteria (>5×10³ CFU/mL), fungi (>3×10³ CFU/mL), and total mesophilic bacteria (>10⁴ CFU/mL). PCR analysis confirmed the absence of Escherichia coli and Klebsiella spp. Corrective actions—such as installing UV lighting, implementing enhanced cleaning protocols, and replacing the mixing device—were introduced.
Results: Post-intervention analyses showed complete elimination of detectable microbial contamination in the gavage solutions.
Conclusion: This study demonstrates that implementing a HACCP-based approach can effectively eliminate microbial contamination in enteral feeding solutions. The findings support the development of national guidelines and highlight the importance of standardized safety practices to improve patient care in hospital settings.

1. Sinha S, Lath G, Rao S. Safety of enteral nutrition practices: overcoming the contamination challenges. Indian J Crit Care Med 2020; 24: 709-712.
2. Mohamed Elfadil O, Velapati SR, Patel J, Hurt RT, Mundi MS. Enteral nutrition therapy: historical perspective, utilization, and complications. Curr Gastroenterol Rep 2024; 26: 200-210.
3. Adibi S, Afshari A, Norouzy A, Nematy M, Ehsani A, Hashemi M. Microbiological quality of hospital-prepared blenderised tube feeding. J Hum Nutr Diet 2023; 36: 181-190.
4. Rismanbaf A. The necessity of an aseptic environment for the preparation of enteral feeding solutions in Iranian Hospitals. J Res Pharm Pract 2020; 9: 60.
5. Al-Akash H, Abu Arrah A, Bhatti F, Maabreh R, Abu Arrah R. The effect of food safety training program on food safety knowledge and practices in hotels’ and hospitals’ food services. Ital J Food Saf 2022; 11: 9914.
6. Pharmaceutical Microbiology Manual. Office of Regulatory Affairs. Silver Spring, Maryland, USA: FDA; 2020. Available from: https://www.fda.gov/media/88801/download
7. Kayis FB. Antibiotic resistance profiles of Escherichia coli isolated from the floating islands and water of Çat Dam Lake, Adiyaman, Turkey: Antibiotic resistance of E. coli from Floating Islands and water. Indian J Exp Biol 2024; 62: 49-55.
8. Fonseca EL, Ramos ND, Andrade BG, Morais LL, Marin MF, Vicente AC. A one-step multiplex PCR to identify Klebsiella pneumoniae, Klebsiella variicola, and Klebsiella quasipneumoniae in the clinical routine. Diagn Microbiol Infect Dis 2017; 87: 315-317.
9. Memarzadeh F, Olmsted RN, Bartley JM. Applications of ultraviolet germicidal irradiation disinfection in health care facilities: effective adjunct, but not stand-alone technology. Am J Infect Control 2010; 38(5 Suppl 1): S13-S24.
10. Rutala WA, Weber DJ. Disinfection and sterilization in health care facilities: an overview and current issues. Infect Dis Clin North Am 2021; 35: 575-607.
11. Best C. Enteral tube feeding and infection control: how safe is our practice? Br J Nurs 2008; 17: 1036, 1038-1041.
12. Hubbard GP, Van Wyk J, Grinyer L, Onley R, White S, Fleming CA, et al. Appropriate handling and storage reduce the risk of bacterial growth in enteral feeding systems reused within 24 hours. Nutr Clin Pract 2024; 39: 437-449.
13. Jalali M, Sabzghabaee AM, Badri SS, Soltani HA, Maracy MR. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Isfahan, Iran. J Res Med Sci 2009; 14: 149-156.
14. Ahmadinejad M, Moshafi MH, Izadi F, Mousavipour F, Sohrevardi SM. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Kerman, Iran. Adv Pharmacol Ther J 2024; 4: 27-35.
15. Mahinkazemi M, Tarighat-Esfanjani A, Safaiyan A. Bacterial contamination and nutritional adequacy of enteral tube feedings in Iran. Prog Nutr 2017; 19: 283-290.
16. Oliveira MR, Batista CR, Aidoo KE. Application of Hazard Analysis Critical control points system to enteral tube feeding in hospital. J Hum Nutr Diet 2001; 14: 397-403.
17. Kozow JFC, Rabito EI, Kruger JF, Medeiros CO, da Costa RL, Beux MR, et al. Microbiological contamination present in enteral tube feeding prepared in hospitals and/or at home: a systematic review. Nutr Rev 2024; 82: 1226-1238.
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IssueVol 17 No 4 (2025) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijm.v17i4.19251
Keywords
Enteral nutrition Hospitals Food contamination Hazard analysis and critical control points Polymerase chain reaction
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How to Cite
1.
Yousefi M, Koorehpaz K, Bagheri M, Sharifi Y, Rahimirad A, Roosta Y. Implementation of hazard analysis and critical control points (HACCP) for microbial safety of enteral feeding solutions at Imam Khomeini Hospital, Urmia, Iran. Iran J Microbiol. 2025;17(4):606-612.