Johns Hopkins Antibiotic (ABX) Guide

Listeria Monocytogenes

John G. Bartlett, M.D.

MICROBIOLOGY

  • Small Gram-positive rod.
  • Isolated from environmental sources such as water, sewerage and foodstuffs.
  • Grows on routine media. Micro labs may occasionally confuse with frequent contaminant diphtheroids.
  • Main human pathogen is Listeria monocytogenes. Rarely, L. ivanovii has been described.
  • Ability to grow in wide range of temperatures 4–37°C likely accounts for hardiness and ability to leave many foods in refrigerator capable of causing infection.

CLINICAL[Top]

  • Colonizes colon in 5% of adults.
  • Important cause of foodborne disease in vulnerable populations: pregnancy, compromised cell-mediated immunity, elderly.
  • Important cause meningitis in compromised host (organ transplants, cancer therapy, steroids, lymphoma) and persons >50yrs.
  • Dx: culture from normally sterile site (CSF, blood, etc). Serology (listeriolysin O antibody) helpful in the investigation of foodborne outbreaks.

SITES OF INFECTION[Top]

TREATMENT[Top]

Infections

General Prevention Measures

  • Thoroughly cook animal source food.
  • Thoroughly wash raw vegetables.
  • Avoid unpasteurized milk and food from unpasteurized milk.
  • Wash hands, utensils & cutting boards used with uncooked food.
  • Keep ready-to-eat food cold.

Prevention: High Risk Persons

  • High risk groups: pregnant women, CMI compromise (organ transplants, chronic steroids, infliximab or other TNF-antagonists, cancer chemotherapy, elderly.
  • Avoid soft cheeses: Mexican style, feta, brie, camembert, blue cheese.
  • Leftover foods and ready-to-eat foods should served only steaming hot.
  • May wish to avoid food from delicatessen counters.

Selected Drug Comments

Ampicillin

The drug of choice by virtually all authorities in the field - based on in vitro data, animal models and a small clinical experience. The evidence that it is superior to penicillin is not convincing. The evidence that it is better than cephalosporins is very convincing. Ampicillin is allegedly bacteriostatic to Listeria and this is the reason many advocate the addition of an aminoglycoside.

Cefotaxime

Cephalosporins do not have activity against Listeria. This is important to remember in the empiric selection of drugs for pyogenic meningitis.

Ceftriaxone

Ceftriaxone/cefotaxime. Cephalosporins do not have activity against Listeria. This is important to remember in the empiric selection of drugs for pyogenic meningitis.

Gentamicin

Often added to ampicillin to achieve synergy. It is not clear that this is necessary.

Rifampin

Good in vitro activity, but very limited clinical experience and dangerous for monotherapy of any infection. OK to add.

Trimethoprim + Sulfamethoxazole

TMP-SMX The preferred drug in patients who cannot take ampicillin. This combination has good in vitro activity and is bactericidal vs Listeria.

Vancomycin

There are clinical successes; there are also patients who developed Listeria meningitis while receiving vancomycin.

Drug

Recommendation

OTHER INFORMATION[Top]

  • Major risks: 1) compromised CMI (steroids, transplants, cancer chemo Rx, AIDS); 2) 3rd trimester pregnancy; 3) occasional cases: age >50yrs, diabetes, ulcerative colitis, antacids, cirrhosis.
  • Mortality: meningitis 20%; endocarditis 50%; pregnant women 20% stillbirths.
  • Major source: ingestion unpasteurized milk, fresh cheeses (especially imported, soft, ripened), ice cream, raw vegetables, fermented raw sausages, raw/cooked poultry, raw meats, smoked fish, deli meats and hot dogs.
  • Think Listeria when: "diphtheroids" in CSF, meningitis in compromised host or >50 yrs, fever 3rd trimester, foodborne outbreak w/ negative cultures.

Basis for recommendation[Top]

  • Rados C: Preventing Listeria contamination in foods. FDA Consum 38:10, 2004 Jan-Feb  [PMID:15032197]

    Comment: Keep ready-to-eat food cold
    Rating: Basis for recommendation

  • No authors listed; Medical Letter; Vol. 2; pp. 22;

    Rating: Basis for recommendation

References[Top]

  1. Clauss HE, Lorber B: Central nervous system infection with Listeria monocytogenes. Curr Infect Dis Rep 10:300, 2008   [PMID:18765103]

    Comment: Review highlights: Listeria is the major cause of bacterial meningitis in persons >50 yrs (20%), neonates (20%) and patients with defective cell mediated immunity but not AIDS. Ampicillin is the preferred drug. Prevention: Avoid unpasteurized milk and soft cheese, deli-style meats and poultry products.

  2. Cabedo L, Picart i Barrot L, Teixidó i Canelles A: Prevalence of Listeria monocytogenes and Salmonella in ready-to-eat food in Catalonia, Spain. J Food Prot 71:855, 2008   [PMID:18468047]

    Comment: Cultures of 1,379 ready-to-eat products showed Listeria in the following: frozen Atlantic bonito fish pies -- 20%, smoked salmon -- 8%, pork luncheon meat -- 11%, chicken croquettes -- 6%, cured, dried sausage -- 17% and cook turkey breast samples -- 20%.

  3. Varma JK et al: Listeria monocytogenes infection from foods prepared in a commercial establishment: a case-control study of potential sources of sporadic illness in the United States. Clin Infect Dis 44:521, 2007 Feb. 15  [PMID:17243054]

    Comment: CDC review of non-outbreak cases in 249 patients. New food sources -- melons and hummus.
    Rating: Important

  4. Brouwer MC et al: Community-acquired Listeria monocytogenes meningitis in adults. Clin Infect Dis 43:1233, 2006 Nov. 15  [PMID:17051485]

    Comment: Review of 30 cases of Listeria meningitis - all were immunocompromised or >50yrs. Gram stain of CSF was pos in 7/25 (28%), Mortality 5/30 (17%).
    Rating: Important

  5. Schlech WF et al: Does sporadic Listeria gastroenteritis exist? A 2-year population-based survey in Nova Scotia, Canada. Clin Infect Dis 41:778, 2005 Sep. 15  [PMID:16107973]

    Comment: Review 7,775 stools submitted for culture - 17 yielded L. monocytogenes . PFGE showed no clusters. Cases tended to have pre-existing GI conditions. Recommendation is to not culture stool for Listeria.

  6. Ooi ST, Lorber B: Gastroenteritis due to Listeria monocytogenes. Clin Infect Dis 40:1327, 2005 May 1  [PMID:15825036]

    Comment: Review of 7 outbreaks of foodborne gastroenteritis due to L. monocytogenes . Symptoms occur 24 hrs after ingestion of large inoculum with fever, watery diarrhea, nausea, headache and arthralgias. Most cases clear within 2 days and don't require antibiotics; consider ampicillin or TMP-SMX in susceptible hosts.

  7. Van Kessel JS et al: Prevalence of Salmonellae, Listeria monocytogenes, and fecal coliforms in bulk tank milk on US dairies. J Dairy Sci 87:2822, 2004   [PMID:15375040]

    Comment: Analysis of 861 bulk tank milk from 21 states showed Listeria in 56 (6.5%); of these 93% were serotypes commonly found in human disease.

  8. Tunkel AR et al: Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 39:1267, 2004 Nov. 1  [PMID:15494903]

    Comment: IDSA Guidelines for meningitis: For L. monocytogenesmeningitis - preferred is Penicillin G or ampicillin (consider adding gentamicin ). Alternatives are TMP-SMX or meropenem . Doses: Amp - 12gm/d, gent 5mg/kg/d, TMP-SMX 10-20mg/kg (TMP)/d.

  9. Safdar A, Armstrong D: Antimicrobial activities against 84 Listeria monocytogenes isolates from patients with systemic listeriosis at a comprehensive cancer center (1955-1997). J Clin Microbiol 41:483, 2003   [PMID:12517901]

    Comment: Data were provided from Sloan-Kettering Hospital for 84 isolates. All were sensitive to cefazolin, rifampin, TMP-SMX, vancomycin, imipenem and ciprofloxacin; nearly all strains (>97%) were sensitive to penicillin, gentamicin, tetracycline and erythromycin. These results may be deceptive due to intracellular location. The best results in animal studies are penicillin & gentamicin. Cipro looks good in vitro but show no effect intracellularly.

  10. Siegman-Igra Y et al: Listeria monocytogenes infection in Israel and review of cases worldwide. Emerg Infect Dis 8:305, 2002   [PMID:11927029]

    Comment: Review of 161 cases and 1808 reported cases. Immunosuppressed 74%, CNS involved 47%, bacteremia 48%, focal disease 4%. Mortality was 36%.

  11. Lecuit M et al: A transgenic model for listeriosis: role of internalin in crossing the intestinal barrier. Science 292:1722, 2001 June 1  [PMID:11387478]

    Comment: The authors describe A NEW VIRULENCE FACTOR for L. monocytogenes - a surface protein that binds to E - cadherin of enterocytes which is a necessary step for translocation.

  12. Centers for Disease Control and Prevention (CDC): Preliminary FoodNet data on the incidence of foodborne illnesses--selected sites, United States, 2000. MMWR Morb Mortal Wkly Rep 50:241, 2001 April 6  [PMID:11310569]

    Comment: FoodNet is a CDC surveillance network that collects data on 9 FOODBORNE DISEASES in 8 cities. Results for 2000 showed a decrease of 101 isolates of L. monocytogenes from a total of 12,631 lab confirmed cases of enteric infection.

  13. American Medical Association et al: Diagnosis and management of foodborne illnesses: a primer for physicians. MMWR Recomm Rep 50:1, 2001 Jan. 26  [PMID:11214980]

    Comment: L. monocytogenes GASTROENTERITIS - incubation period 9-48hrs (2-6wks for invasive disease). Sx are fever, myalgias, nausea & diarrhea. Pregnant women may have mild illness that leads to premature delivery or stillbirth; immunosuppressed pts may get bacteremia or meningitis. Dx - culture blood & CSF; stool not useful due to asymptomatic carriage. Serology to listeriolysin O useful in outbreak.
    Rating: Important

  14. Marco F et al: In vitro activities of 22 antimicrobial agents against Listeria monocytogenes strains isolated in Barcelona, Spain. The Collaborative Study Group of Listeriosis of Barcelona. Diagn Microbiol Infect Dis 38:259, 2000   [PMID:11146253]

    Comment: IN VITRO SENSITIVITY TESTS for 82 strains tested against 22 antimicrobial agents. Ampicillin and gent were universally active. TMP-SMX, tetracycline and rifampin were active vs 99-100%. There was no increase in resistance with sequential analysis over the study period of 1994-98.

  15. Dalton CB et al: An outbreak of gastroenteritis and fever due to Listeria monocytogenes in milk. N Engl J Med 336:100, 1997 Jan. 9  [PMID:8988887]

    Comment: Outbreak of L. monocytogenes as cause of FOODBORNE OUTBREAK among 60 attendees at a Holstein cow show ascribed to post-pasteurization contamination of chocolate milk. Attack rate was 75%; symptoms were diarrhea 79%, fever 72% and chills 65%. The median incubation period was 20hrs and median duration of diarrhea 42hrs. Contamination level was up to 3x10" bacteria/person.

  16. Armstrong RW, Fung PC: Brainstem encephalitis (rhombencephalitis) due to Listeria monocytogenes: case report and review. Clin Infect Dis 16:689, 1993   [PMID:8507761]

    Comment: This is a BRAINSTEM ENCEPHALITIS which is an unusual CNS complication of Listeria that occurs in previously healthy adults. It is analogous to "circling disease" in sheep. Clinical features are biphasic: fever, headache, nausea & vomiting, lasting several days and then cerebellar signs: cranial nerve deficits & hemiparesis. CSF shows increased protein & WBC; culture is positive in 50%. MRI shows rhomboencephalitis.

  17. Durand ML et al: Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 328:21, 1993 Jan. 7  [PMID:8416268]

    Comment: This review showed L. monocytogenes accounted for 29 (11%) of 253 cases of community-acquired MENINGITIS and had a mortality rate of 21%.

  18. Kalstone C: Successful antepartum treatment of listeriosis. Am J Obstet Gynecol 164:57, 1991   [PMID:1986626]

    Comment: Infection in PREGNANCY usually occurs in 3rd trimester, 22% result in stillbirth, susceptibility presumed to be due to compromised CMI of pregnancy, maternal meningitis is rare & early therapy is often effective in protecting the infant.

  19. Gellin BG, Broome CV: Listeriosis. JAMA 261:1313, 1989 March 3  [PMID:2492614]

    Comment: A review of the disease including its major manifestations: 1)bacteremia in pregnant women with 20% rate of stillbirths; 2)meningitis in persons >50 & with compromised cell-mediated immunity 20% mortality; 3)encephalitis or brain abscess 20-40% mortality; 4)endocarditis 40% mortality; 5)foodborne outbreaks with acute self-limited gastroenteritis following large inoculum from contaminated food.

  20. Gallagher PG, Watanakunakorn C: Listeria monocytogenes endocarditis: a review of the literature 1950-1986. Scand J Infect Dis 20:359, 1988   [PMID:3057615]

    Comment: Listeria accounts for about 7% of ENDOCARDITIS cases in adults, usually in patients with pre-existing valve disease. The mortality rate in this review was 48%.

  21. Lorber B; Listeria monocytogenes; Chapter 195 IN: Principles & Practice of Infect Dis, Mandell G, Bennett J & Dolin R. 5th Ed, Churchill Livingston; pp. 2208;

    Comment: AMPICILLIN is regarded as the drug of choice according to: 1)Gellin BG, et al JAMA 1989;261:1313; 2)Neiman R & Lorber B, RID 1980;2:207; 3) Cherubin CE, et al, RID 1991;13:1108; 4)Laretter A, et al, NEJM 1971;285:598; 5)Scheld M, et al, RID 1983;5:S593. The author (B Lorber) considers penicillin to be equally effective. Not effective - chloro, cephalosporin, vancomycin.

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Listeria Monocytogenes
Last updated: April 2, 2012
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