From Powder to Pathogen: A Systematic Review of Detection, Pathogenicity, and Mitigation of Cronobacter sakazakii in...

Cronobacter sakazakii is an emerging foodborne pathogen that has gained increasing global attention due to its association with severe infections in neonates, particularly meningitis, sepsis, and necrotizing enterocolitis. These infections are often associated with contaminated powdered infant formula (PIF), a nonsterile but commonly used alternative to breast milk. We conducted a systematic review using the PRISMA approach and registered it in PROSPERO to synthesize current scientific knowledge on the detection, pathogenic mechanisms, antimicrobial resistance, and mitigation strategies of C. sakazakii. A total of 82 research articles published between 2009 and 2024 were included. The findings highlight the bacterium's ability to survive under harsh environmental conditions, including desiccation, osmotic stress, and heat, making it a persistent contaminant in food production. Virulence is driven by several genetic determinants, including outer membrane proteins (OmpA and OmpX), invasion-associated genes (InvA and cpa), and iron acquisition systems. Sequence types ST4 and ST1 are consistently linked to neonatal infections and show strong biofilm-forming potential, increasing the risk of recurring contamination in manufacturing environments. The review compares conventional culture-based detection methods with advanced molecular techniques such as polymerase chain reaction (PCR), multilocus sequence typing (MLST), and aptamer-based biosensors, highlighting the need for rapid, cost-effective, and accurate diagnostic tools. While most strains retain antibiotic susceptibility, emerging resistance to β-lactams, macrolides, and cephalothin has been reported, varying by geographic region and strain type. The LED-based decontamination, citral treatments, and antimicrobial packaging materials are promising avenues for prevention. Furthermore, this review underscores the importance of enhanced regulatory oversight, standardized protocols, and public awareness regarding the safe preparation and handling of infant formula, considering the vulnerability of infants. Continued interdisciplinary research and international collaboration are warranted, ensuring microbiological safety and protecting infant health.