CASE REPORT Year : 2023  |  Volume : 14  |  Issue : 2  |  Page : 113-115

Identification of Serratia marcescens in a mother's expressed breast milk

Tahereh Navadifar1, Saba Karam2, Amir Emamie3, Atieh Darbandi4
1 Department of Basic Sciences, Shoushtar Faculty of Medical Sciences, Shushtar, Iran
2 School of Pharmacy, International Campus, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

Date of Submission31-Jan-2023Date of Decision05-Feb-2023Date of Acceptance07-Feb-2023Date of Web Publication04-Jul-2023

Correspondence Address:
Dr. Atieh Darbandi
Department of Microbiology, School of Medicine and Microbial Biotechnology Research Centre, Iran University of Medical Sciences, Shahid Hemmat Highway, Tehran
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_11_23

A 30-year-old female who underwent an emergency cesarean section reported that the breast pump tubing, infant's pacifier, and soiled diapers turned pinkish after 24 h. Serratia marcescens was isolated from the mother's breast milk, breast pump tubing, and infant's stool. This mother had no mastitis or fever symptoms but received antibiotic therapy due to endometriosis and urinary tract infection. The infant had abdominal cramps, heartburn, and frequent bowel movements; however, he was afebrile and received no antibiotics. After 3 months, this infant returned to breastfeeding as his diaper's pinkish color disappeared and the culture of the mother's breast milk was negative.

Keywords: Diaper, expressed breast milk, pink breast milk, Serratia marcescens

How to cite this article:
Navadifar T, Karam S, Emamie A, Darbandi A. Identification of Serratia marcescens in a mother's expressed breast milk. Indian J Med Spec 2023;14:113-5
How to cite this URL:
Navadifar T, Karam S, Emamie A, Darbandi A. Identification of Serratia marcescens in a mother's expressed breast milk. Indian J Med Spec [serial online] 2023 [cited 2023 Jul 4];14:113-5. Available from: http://www.ijms.in/text.asp?2023/14/2/113/380400   Introduction 

Expressed breast milk (EBM) can turn into pinkish color as Serratia marcescens is colonized into it. S. marcescens causes infectious morbidities, including upper respiratory and urinary tract infections (UTIs), septicemia, meningitis, and wound infection, which result in significant morbidity, and even newborn death.[1],[2] We described one case of breast milk and soiled diapers of pinkish color in which S. marcescens was isolated from the mother's breast milk and breast pump.

  Case Report 

Due to intrauterine growth restriction, a 30-year-old woman underwent an emergency cesarean section at 37 weeks' gestation. The mother delivered a healthy baby boy weighing 2850 g. This mother breastfed her baby. Both the mother and her baby were discharged after 24 h. This mother had intermittently used a breast pump to express breast milk for bottle-feeding, but on her infant's 20th day, she reported that the infant's own pacifier, soiled diapers, and soiled mattress held in the bag turned pinkish after 24 h. After a few days, the breast pump tubing also turned into pinkish color [Figure 1].

Figure 1: The nipple of baby milk feeding bottle (left) and the breast pump tubing (right) with pink color

Click here to view

On the other hand, this infant seemed to be fussier than usual, especially in association with breastfeeding, abdominal cramps, heartburn, and frequent bowel movements; however, he was afebrile. The bacterial culture of the mother's breast milk was positive for S. marcescens. Hence, she stopped breastfeeding and began pumping and discarding her breast milk. This mother had no symptoms of mastitis or fever. Cultures of the urine and blood of both mother and her infant were negative, while the culture of her infant's stool was positive for S. marcescens. This infant did not receive any antibiotic therapy, and his diaper pinkish color disappeared after 3 months. After a cesarean delivery, this mother experienced malodorous vaginal and cervical discharge, chills, lethargy, pain following the delivery, and painful urination as well as a history of UTI during pregnancy. She had no history of immune-comprised disease when was evaluated for chronic granulomatous disease, and oxidative burst activity of granulocytes was in a normal range (160 mg intramuscularly every 24 h).

This woman had high levels of inflammatory factors, including C-reactive protein (39.74 mg/dl) and erythrocyte sedimentation rate (40 mm in the 1st h). In the following days according to the doctor's prescription, she had used clindamycin (600 mg intravenously every 6 h) and gentamicin (80 mg intramuscularly every 24 h) for the treatment of endometriosis and cefixime (400 mg orally every 12 h) for the treatment of UTI. After 2 weeks, her malodorous vaginal and cervical discharge continued; hence, the culture of the cervical secretions was requested by the physician, and its result indicated the infection with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae. Furthermore, again the bacterial culture of the mother's breast milk was performed, which was positive for S. marcescens infection in her left breast. Then, this mother was treated with meropenem (1 g intravenously every 8 h) for 10 days. After 10 days, due to the recurrence of endometriosis, meropenem (2 g every 6 h) was administrated intravenously for 10 days. Finally, after 3 months, this infant returned to breastfeeding as his diaper's pinkish color disappeared, and the mother's breast milk culture was negative.

  Discussion 

S. marcescens, as a motile Gram-negative bacillus, is a member of the family Enterobacteriaceae. This bacterium is unique in its ability to produce prodigiosin pigment in the presence of oxygen, which may be helpful in its identification.[3]S. marcescens is an opportunistic pathogen with a role in nosocomial infections. It has been isolated from hospital equipment, respiratory devices, and breast pumps.[4] Human milk is an excellent culture medium for bacteria growth, and breast pump contamination is one of the particular concerns as EBM has been identified as a potential source of neonatal sepsis, predominantly in preterm infants.[5],[6]Serratia infections in neonates may have potentially devastating effects. S. marcescens isolation from EBM had been described as the source of several health-care-associated outbreaks in neonatal intensive care units (NICUs) over a 6-week period where this bacterium was isolated from cerebral spinal fluid, urine, and blood, respiratory and gastrointestinal tracts of infants.[5] Several reports described the outbreak of Serratia infection in NICUs.[7],[8],[9] Moreover, Gransden et al.[7] described an outbreak in a special care nursery where Serratia contaminated 30 infants and was traced to contaminated breast pumps due to improper cleansing of pumping equipment. However, it is not a new subject. Moreover, Moloney et al.[10] evaluated several electric breast pumps and indicated contamination by several bacterial pathogens, including S. marcescens, Staphylococcus aureus, Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella species,  Escherichia More Details coli, and Acinetobacter species. However, in previous reports, there is no sufficient evidence to prove whether breast pump sterilization may prevent S. marcescens colonization or recurrence after treatment.[6] Furthermore, several reports[5],[11],[12] highlighted that most EBM samples were contaminated with bacterial pathogens. Quinn et al.[6] reviewed Serratia infection in nine infants whose mothers had used breast pumps and indicated that the most common presentation of this infection was pink-colored milk in 87.5% of cases and pink-colored diapers in 38% of infants.

It seems that the bacteria had been transferred from the breast pump to both the pumped milk and the mother's breasts, and consequently, this infant was colonized after ingesting the pumped milk.[1]

This was the first case of Serratia colonization in breast milk and then its isolation from breast pump tubing and infant's stool in our area, Iran. In our case, this infant was not treated for the symptom of fussiness due to other causes, including gastroesophageal reflux and milk protein intolerance, which also are considered leading causes of the infant's fussiness. Furthermore, this infant did not receive any antibiotic therapy. However, his mother received meropenem as a spectrum broad antibiotic for treating endometriosis and Serratia infection. Some studies[2],[13] limited antibiotic therapy only to mothers, while in a study conducted by Widger et al.,[14] antibiotic treatment was initiated for infants due to sepsis risk. In total, antibiotics were not offered as there was no major benefit in treating the mother or the infant at the time.

In conclusion, strict hygiene procedures should be performed during breast milk expression. Routine screening of breast milk given to infants should be considered. Furthermore, further researches require to determine microbial contamination of EBM.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors thank the staff of the Student Research Committee of the Tehran University of Medical Sciences for editorial preparation.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Jones J, Crete J, Neumeier R. A case report of pink breast milk. J Obstet Gynecol Neonatal Nurs 2014;43:625-30.  
    2.Faro J, Katz A, Berens P, Ross PJ. Premature termination of nursing secondary to Serratia marcescens breast pump contamination. Obstet Gynecol 2011;117:485-6.  
    3.Haddix PL, Shanks RM. Prodigiosin pigment of Serratia marcescens is associated with increased biomass production. Arch Microbiol 2018;200:989-99.  
    4.Moles L, Gómez M, Moroder E, Jiménez E, Escuder D, Bustos G, et al. Serratia marcescens colonization in preterm neonates during their neonatal intensive care unit stay. Antimicrob Resist Infect Control 2019;8:135.  
    5.Gad S, Sheta MM, Al-Khalafawi AI, Abu El-Fadl HA, Anany M, Sahmoud S, et al. Expressed breast milk contamination in neonatal intensive care unit. Pediatric Health Med Ther 2021;12:307-13.  
    6.Quinn L, Ailsworth M, Matthews E, Kellams A, Shirley DA. Serratia marcescens colonization causing pink breast milk and pink diapers: A case report and literature review. Breastfeed Med 2018;13:388-94.  
    7.Gransden WR, Webster M, French GL, Phillips I. An outbreak of Serratia marcescens transmitted by contaminated breast pumps in a special care baby unit. J Hosp Infect 1986;7:149-54.  
    8.Yeo KT, Octavia S, Lim K, Lin C, Lin R, Thoon KC, et al. Serratia marcescens in the neonatal intensive care unit: A cluster investigation using molecular methods. J Infect Public Health 2020;13:1006-11.  
    9.Cristina ML, Sartini M, Spagnolo AM. Serratia marcescens infections in neonatal intensive care units (NICUs). Int J Environ Res Public Health 2019;16:610.  
    10.Moloney AC, Quoraishi AH, Parry P, Hall V. A bacteriological examination of breast pumps. J Hosp Infect 1987;9:169-74.  
    11.Mense L, Rößler S, Hanusch R, Roßberg C, Rüdiger M. Bacterial contamination of mechanically extracted breast milk. Am J Perinatol 2014;31:293-8.  
    12.Karimi M, Eslami Z, Shamsi F, Moradi J, Ahmadi AY, Baghianimoghadam B. The effect of educational intervention on decreasing mothers' expressed breast milk bacterial contamination whose infants are admitted to neonatal intensive care unit. J Res Health Sci 2012;13:43-7.  
    13.Statler VA, Smith ML, Fouch BB, Woods CR. A pink milk bottle mystery. J Pediatric Infect Dis Soc 2012;1:347-50.  
    14.Widger J, O'Connell NH, Stack T. Breast milk causing neonatal sepsis and death. Clin Microbiol Infect 2010;16:1796-8.  
    
  [Figure 1]