Comparison of Microbiological Loads of Enteral Products Applied in Room Temperature and Intensive Care Conditions

Comparison of Microbiological Loads of Enteral Products Applied in Room Temperature and Intensive Care Conditions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Microbiological Loads of Enteral Products Applied in Room Temperature and Intensive Care Conditions alev yıldız ılıman, Merve YURTTAŞ, Dursun Fırat ERGÜL, Salim TUTKAOĞLU This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4658657/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite the high risk of bacterial contamination, no studies have been found that evaluate the optimal hanging time of open system enteral sets under room temperature and intensive care conditions. This study aims to determine the differences in microbial loads of solutions taken from open system enteral feeding sets hanging for 24 hours under room temperature and intensive care conditions. Methods This study is a descriptive type of research. The study sample consisted of a total of 40 samples, with 20 samples under room temperature and 20 samples under intensive care conditions. A simple random sampling method was used for sample selection. The assessment of microbial quality was based on the U.S. Food and Drug Administration (FDA) online Bacteriological Analytical Manual. Results In this study, it was determined that 5% of the samples taken from intensive care and 15% of the samples taken at room temperature exceeded the accepted limit for aerobic mesophilic bacteria count. The count of catalase and coagulase-negative Staphylococcus spp. was 5% in intensive care samples and 40% in room temperature samples. The total coliform count was not detected in intensive care samples but was 35% in room temperature samples. E. coli was not detected in either group. Conclusion Differences in microbial loads were observed when commercial enteral solutions were administered using open system enteral feeding sets under room and intensive care conditions for 24 hours. Therefore, large-scale studies are needed to determine the safe use of open system enteral feeding sets under room temperature conditions. Nutrition & Dietetics General Microbiology Nutrition enteral feeding microbiological loads intensive care room temperature INTRODUCTION Enteral nutrition, which maintains the natural integrity of the intestinal mucosa and sustains gastrointestinal function, is widely adopted due to its simple and cost-effective nature. Its use, initially prevalent in intensive care units, has now extended to regular hospital wards, long-term care facilities, and home settings. However, the increasing utilization of enteral nutrition products at room temperature raises concerns regarding their microbiological safety in various environmental conditions [ 1 , 2 ]. Contamination of enteral products can result in severe complications such as diarrhoea, abdominal distension, aspiration pneumonia, and sepsis [ 3 ]. Therefore, identifying sources of contamination in enteral nutrition products and equipment under diverse environmental conditions and implementing necessary precautions are crucial for patient safety [ 4 ]. Research findings indicate that the frequency of enteral contamination is higher in open system enteral sets compared to closed system sets[ 5 , 6 ]. It was explained with various factors that cause contamination in the open system enteral nutrition. The reasons for contamination in open system enteral nutrition have been explained by various factors. In open systems, factors contributing to contamination include increased frequency of contact due to feeding every 8 hours, direct exposure of the food to air, ambient temperature, and hanging time. In some studies on open systems, microbiological growth has been found to be within safe limits [ 3 , 4 ], while in others, it has been determined to be outside safe limits [ 7 – 9 ]. However, there are very few studies available that examine the microbiological load of open system enteral products at different ambient temperatures. In one of these studies, it was determined that there was no microbial growth in products hanging for 6 hours at two ambient temperatures (25°C and 32°C)[ 9 ]. In another study, it was found that after 8 hours of hanging at two ambient temperatures (23,3°C and 32,5°C), microbial growth in enteral products was low and within safe limits[ 10 ]. However, open system enteral sets are supposed to remain hanging for 24 hours. That’s because enteral products must have microbial loads within safe limits until they are administered to the patient. Nevertheless, in these studies, samples were taken from sets hanging for only 6–8 hours. Determining the microbiological quality of samples taken from open system enteral sets over a 24-hour period is important for ensuring patient safety. Manufacturing companies recommend the use of open system enteral sets for up to 24 hours [ 11 ]. This recommendation is based on room temperature conditions. While the average temperature in intensive care units fluctuates between 20–24°C, temperatures can reach up to 35°C in room temperature conditions. In this context, it is important to determine whether there are differences in the bacterial microbiological loads of open system enteral nutrition products according to different ambient temperatures, especially for ensuring patient safety in immunocompromised patients. This descriptive study aimed to determine the differences in microbial loads of solutions obtained from open system enteral sets used for 24 hours under room temperature and intensive care unit conditions. MATERIALS AND METHODS Research Design This study was designed according to the final test design, which is one of the quantitative research designs. The enteral solutions analyzed in the study were collected from the Intensive Care and Palliative units of a university hospital in April 2024. Food samples were considered sterile upon initial opening, so no pre-test was applied. Administration of Enteral Products Commercial enteral solutions are administered to patients in this hospital using open system enteral sets. The commercial enteral solutions and open system enteral sets used are sterile. Enteral solutions are added to the sets at intervals of 4–8 hours. The sets are replaced after 24 hours of use. Nurses do not use a standard protocol when preparing and administering enteral products. Ethical Aspect of the Study No procedures (interventions) were performed on patients in the study. Ethical approval was obtained from the Non-Interventional Ethics Committee of Amasya University (ID NO:E-76988455-050.04-190659). Necessary institutional permissions were obtained from the university hospital where the study was conducted. Sampling While determining the number of samples, the number of samples in similar studies was taken into account [ 12 , 13 ]. The sample of the study consists of a total of 40 samples, with 20 samples under room conditions and 20 samples under intensive care unit conditions. Simple random sampling method was employed for sample selection. Sample Collection Process Samples were obtained from open system enteral sets in the intensive care and palliative units of the hospital. During the data collection process, daily average temperature values were recorded in the palliative and intensive care units. Enteral nutrition supplements were administered to the open system enteral feeding set at intervals of 4–8 hours in both units, and the set, which had been in use for a 24-hour period, was disconnected from the patient by a nurse. The distal end of the enteral set, the point connecting the set with the patient, was wiped with an alcohol-sterile gauze pad by the researcher. Subsequently, 5 mL of feeding solution was discarded, and then 15 mL of feeding solution was transferred to a sterile sample container. Aseptic techniques were observed during the sample collection process, and the feeding solutions were not contaminated. The collected samples were transported to the laboratory within 1 hour using a cooler bag and stored at + 4°C until analysis. Microbiological Analysis Homogenization of Enteral Nutrition Samples For microbiological culturing, a 10 mL sample was homogenized in 90 mL of 0.1% sterile buffered peptone water for at least 2 minutes. From this mixture, 1 mL was added to tubes containing 9 mL of sterile peptone water, and serial dilutions were prepared up to 10⁻⁶ [ 14 ]. These dilutions were then plated onto culture media. Microbiological Bacterial Counts For the enumeration of total aerobic bacteria, S. aureus , coliform group, and E. coli, the spread plate method was used on the following media: standard plate count agar (PCA, Condalab, Madrid, Spain), baird parker agar with egg yolk (BPA, Condalab, Madrid, Spain), violet red bile lactose agar (VRBLA, Condalab, Madrid, Spain), and chromocult TBX agar (TBX, Condalab, Madrid, Spain), respectively. Samples were incubated at 35–37°C and 44°C for 24–48 hours before counting. On plate count agar, all colonies were considered as total aerobic bacteria. On VRBLA, dark red colonies surrounded by a red zone were considered coliforms. On baird parker agar, black shiny colonies with a surrounding clear zone were considered S. aureus . On TBX agar, blue-green colonies were considered E. coli. Total Aerobic Mesophilic Bacterial Count (TAMB) Plate Count Agar was used for the total aerobic mesophilic bacterial count. From the prepared dilutions, 0.1 mL was inoculated onto Plate Count Agar plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 35–37°C for 48 hours. White colonies were considered aerobic bacteria [ 3 ]. Coliform Bacterial Count Violet Red Bile Agar (VRBA, Condalab, Madrid, Spain) was used for coliform bacterial count. From the prepared dilutions, 0.1 mL was inoculated onto VRBA plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 35–37°C for 24 hours. Dark red colonies were considered coliform bacteria [ 9 , 15 ]. E. coli Count Chromocult TBX Agar (TBX, Condalab, Madrid, Spain) was used for E. coli count. From the prepared dilutions, 0.1 mL was inoculated onto TBX plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 44°C for 24 hours. Blue-green colonies were considered E. Coli [ 15 , 16 ]. Staphylococcus aureus Count Egg yolk-added Baird Parker agar (BPA, Condalab, Madrid, Spain) was used for Staphylococcus aureus count. From the prepared dilutions, 0.1 mL was inoculated onto BPA plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 35–37°C for 24 hours. Clear zones surrounded by shiny black colonies were considered Staphylococcus aureus [ 17 ]. Catalase Test A sterile loop was used to collect a sample from fresh bacterial culture onto a clean slide. 3% hydrogen peroxide (H2O2) was added, and the release of gas was observed. If gas was released, the test was considered catalase-positive; if no gas was released, it was considered catalase-negative. Coagulase Test For the coagulase test, 0.5 mL of fresh blood plasma and 0.5 mL of culture previously grown on solid media and produced in Brain Heart Infusion Broth were used. The blood plasma and bacterial culture were placed in a sterile tube and incubated at 37°C, with incubation intervals of 1, 3, 6 and 24 hours respectively. Tubes showing clotting were considered positive. Evaluation of Microbiological Analysis Results In our study, the evaluation criteria for microbial quality were based on the U.S. Food and Drug Administration (FDA) Bacteriological Analytical Manual. According to the FDA, the criteria for evaluating the microbial load of enteral nutrition are as follows: When the aerobic microbial count exceeds 10 4 CFU/ml in a sample, If the microbial count is > 10 3 CFU/ml in 3 or more samples, If the counts of S. aureus, coliforms, and E. coli are greater than 3, the sample is considered unacceptable in terms of microbiological safety [ 9 , 18 ]. Statistical Analysis Statistical analysis was performed using IBM SPSS 25 package program to determine the differences between the two groups. Since the sample size was less than 30 in both groups, the nonparametric Mann-Whitney U test was used, and the results were considered significant at p < 0.05. RESULTS The microbiological count results and percentage ratios of enteral nutrition samples are provided in Tables 1 and 2 . During the data collection process, the temperature in the intensive care unit ranged from 22.1–24.2°C, while the room temperature ranged from 25.2–33.3°C. It was determined that 5% of the samples taken from the intensive care unit and 15% of the samples taken at room temperature exceeded the FDA limit for aerobic mesophilic bacteria count. In the remaining samples for both groups (95% and 85% respectively), growth was observed, but it did not exceed the values specified by the FDA. Catalase and coagulase-negative Staphylococcus sp. were identified in 5% and 40% of the samples from the intensive care unit and room temperature respectively. Total coliform count was not detected in intensive care unit samples, whereas it was determined in 35% of the room temperature samples. E. coli was not detected in either group. After calculating the log values (CFU/g), Mann-Whitney U test was used to compare the contamination loads of samples taken under intensive care and room conditions. The difference between the contamination loads of the two groups was found to be statistically significant for aerobic mesophilic bacteria count (Table 3 ; p < 0.05). On the other hand, upon comparing the contamination loads of Staphylococcus sp. and E. coli between the groups, the researcher came to the conclusion that the difference was statistically negligible (p > 0.05). DISCUSSION In recent years, patient safety has become a priority in the healthcare system. Frequently implemented in intensive care units, enteral nutrition, poses various risks, causing serious problems for patient safety. One of these risks is the contamination of enteral solutions with pathogenic microorganisms. In the two studies conducted with commercial enteral products in Turkey, microbial growth was not detected. However, in those studies, the samples were taken from closed sterile containers, which makes the results inconclusive because it is expected that the microbial load of enteral products remains within safe limits from the initial stage until the completion of infusion. Therefore, the aim of this study is to determine the microbiological quality of open system enteral sets that have been infused under both room and intensive care conditions.To achieve this goal, samples were evaluated for total aerobic bacteria, coliforms, S. aureus , and E. coli microorganisms. In this study, it was determined that 5% of samples taken from the open system enteral set in intensive care conditions after 24 hours, and 15% of samples taken in room conditions exceeded the acceptable threshold value for Total Aerobic Mesophilic Bacteria (TAMB) (> 103). When similar studies conducted in intensive care conditions were examined, it was found that there was no growth in samples taken at 24 hours in the studies by Hatakeyama and Aso (2021) and at 4 hours in the study by Vieira et al. (2018), while in the study by Baniardalan et al. (2014), it was determined that 27 (96%) out of the samples taken at 18 hours had TAMB counts > 103 [ 7 , 8 , 19 ]. In studies conducted under room conditions, Johnson (2019) and Mokhalalati (2004) reported that TAMB bacterial counts were within safe limits ( 103, Sullivian et al. (2001) reported that 92% of samples taken at 4 hours had aerobic bacteria counts > 10³, and in the study by Herlick et al. (2000), it was determined that 78% of samples taken at 48 hours had aerobic bacteria counts ≥ 105 [ 3 , 14 , 15 , 20 – 22 ]. In most of these studies, when the aerobic microorganism count exceeded 10⁴ cfu/mL in one sample or if the microorganism count exceeded > 10³ cfu/mL in three or more samples, enteral products were considered unacceptable in terms of microbiological safety, while in only one study, 10 5 was used as the threshold value. One reason for the difference in the results of the study is the sampling times. While in some studies with sampling times of 4 and 8 hours, it was determined that there was no growth or very low growth [ 3 , 19 – 21 ], in some studies, it was found that there was growth even at 4 hours [ 14 , 15 ]. Open system enteral nutrition sets are used for up to 24 hours with feedings of every 8 hours. Many studies in the literature suggest that the longer the exposure time and frequency of contact, the higher the risk of contamination, indicating that even if enteral products and sets are contaminated once during preparation and administration, there may be growth even in the early hours of infusion, while if there is no contamination, there may be no growth even at 24 hours [ 8 ]. The results obtained from studies with closed system enteral products hanging for 24-48-72 hours support this. Another reason for the difference between studies may be the ambient temperature. The optimum growth temperature for TAB is generally around 15–20°C, but they can grow at temperatures as low as -10°C. As a result, we can say that both intensive care and room conditions are suitable for TAB growth. It is known that the rate of microbial growth is parallel to the ambient temperature. Our study findings confirm the literature information because in our study, it was found that there was growth in both groups, but the rate of growth in room conditions was higher than in intensive care, which was statistically significant. When similar studies are examined; Perry et al. (2015) reported that there was no growth in samples taken at 8 hours at different ambient temperatures (23.3°C and 32.5°C), and Lakananurak et al. (2020) reported that there was no growth in samples taken at 6 hours at temperatures (25°C and 32°C) [ 9 , 10 ]. Also, in some studies conducted with closed systems, it was found that there was no growth even at high ambient temperatures. These results indicate that provided enteral products are not contaminated, there is no microbial growth even at high ambient temperatures. In other words, ambient temperature is not the main factor affecting contamination of enteral products. The fact that there is no growth in samples taken at 24–48 hours from closed system enteral products at high ambient temperatures strengthens this finding. Therefore, we can say that the primary risk of microbial growth in enteral products is contamination, and ambient temperature and hanging time are only a risk if there is contamination. Total Aerobic Mesophilic Bacteria (TAMB) is an important indicator used to assess the hygiene level of food products. This parameter provides information about the level of contamination and spoilage of food. When enteral products are stored under inappropriate conditions or the usage time is extended, the potential risks of these products increase. Even if they are microbiologically safe, once they are opened and prepared in clinical conditions, they can easily become contaminated with microorganisms. This can lead to undesirable consequences in clinical environments especially for immunocompromised patients. In our study, Staphylococcus sp. bacteria, which can survive under dry conditions (on surfaces and clothing) due to their ability to withstand solid-state and low water activity conditions, were also examined. While 5% of samples taken in intensive care and 40% in room conditions were found to be catalase and coagulase-negative Staphylococcus sp. , the difference between groups was statistically negligible (p > 0.05). When similar studies were examined; Baniardalan et al. (2014) reported higher growth rates in intensive care, with 24 (86%) compared to our study [ 7 ]. Lafourcade et al. (2002) found similar results to our study, but this study was conducted using a closed system enteral set [ 23 ]. In studies conducted under room conditions; Moazen et al. (2014) and Da Silva (2015) reported that only 1% (5%) and 1% (12.5%) were coagulase-positive, respectively, while in other studies, very low rates or no growth were observed [ 3 , 14 , 21 , 24 – 26 ]. In all of these studies, as in our study, if the microorganism count of S. aureus was greater than 3, it was considered unacceptable in terms of microbiological safety. The difference in microorganism rates between studies can be attributed to the sample size. Furthermore, while growth occurred in open system enteral solutions used at different ambient temperatures, the fact that no growth occurred in closed system enteral products even at high ambient temperatures and hanging times over 24 hours is an important finding. Additionally, studies conducted with commercial powdered enteral products and blenderized enteral products have shown much higher rates. This indicates that the increased frequency of contact during preparation and administration increases the risk of contamination. Staphylococcus sp. is a bacterium that can cause various infections in humans. Additionally, they are commonly found in foods, food establishments, hands of food handlers, hospital personnel, and hospital environments. These bacteria are usually heavily present in the nose and throat cavity. The transmission of Staphylococcus sp. can occur through close or direct contact from one person to another, or through food contamination. Considering the routes of transmission, the low microorganism rates found in intensive care environments may suggest that mask usage, air conditioning, and negative pressure ventilation may be contributing factors. Additionally, the more frequent handwashing and adherence to hygiene rules by nurses working in the intensive care unit have also prevented the contamination of enteral products. Another microorganism examined in our study is coliform. While coliforms were not detected in intensive care samples, 35% of samples taken under room conditions were determined to have a total coliform count > 10 3 . In studies conducted in intensive care, Moazen et al. (2014) and Pinto et al. (2015) reported that coliforms did not develop [ 14 , 24 ]. In some of the studies conducted under room conditions, coliform rates were lower than our study, with Da Silva et al. (9%) > 3 cfu/mL, and in some studies, no contamination was detected [ 3 , 27 , 28 ]. Mahinkazemi et al. (2017) found high coliform rates in commercial powdered products, with 8% (33.3%) [ 7 , 29 ]. Carvallo et al. (2000) detected coliforms in tap water used in enteral products [ 30 ]. One of the reasons for coliform growth in our study may be the water added to the sets. This finding indicates that the use of water whose sterility cannot be ensured may be a source of contamination in enteral products. Another cause of contamination is the connection points of open system enteral sets. This risk is particularly higher at the connection point to the patient tube [ 28 , 31 , 32 ]. Coliform bacterial growth in enteral nutrition products is generally an undesirable condition. Coliform bacteria can often be an indicator of fecal contamination. These bacteria can be found in places like the digestive system, and contamination of such products can occur due to factors such as unhygienic production processes or inadequate storage conditions. While a potential contamination in enteral nutrition products may not be a significant problem in terms of food safety during the production process, it raises concerns about the risk of contamination during the preparation of the patient's nutrition products. It is of most importance that enteral nutrition products be sterile, both for food safety and for the patient to receive the necessary nutrients completely. Therefore, the use of sterile sets in enteral nutrition practice, the application of aseptic techniques during the preparation and administration of products, and meticulous attention to personnel hygiene are essential. CONCLUSION The primary aim of this study was to determine if there were be differences in microbial loads in open system enteral nutrition products at different ambient temperatures. Some findings of the research supported this hypothesis. Specifically, the total aerobic mesophilic bacteria (TAMB) and coliform microbial loads in open system enteral products varied according to ambient temperature. However, no differences were identified in the microbial loads of E. coli and Staphylococcus spp. These findings are significant concerning the risks that may arise during the administration of enteral products. Failure to pay attention to these risks may compromise patient safety. Nonetheless, the study has certain limitations. One limitation is the small sample size and the fact that the study was conducted at a single center during the winter season. Since climates are determinative of ambient temperature, it is recommended that the study be conducted with a larger sample size and across different climates and centers. Additionally, the use of advanced analytical methods when detecting pathogenic microorganisms could enhance the evidence strength of such studies. In this study, while the TAMB and coliform counts in open system enteral products at different temperatures differed from each other, no differences were observed in the counts of E. coli and Staphylococcus spp. Adhering to hygiene and sanitation rules is crucial for the safety of all patients. Especially for patients on enteral feeding, who often have compromised immune systems, any lapse in these rules can lead to foodborne illnesses. Furthermore, an increase in microbial load poses a threat to patient health. 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JPEN J Parenter Enter Nutr 30(6):519–525 Tables Table 1: Microorganism Counts in Enteral Nutrients at Different Temperatures (CFU/mL) Intensive Care (CFU/mL) Room Temperature (CFU/mL) Sample TAMB Stap . sp Total Coliforms E.coli Sample TAMB Stap . sp Total Coliforms E.coli 1Y <10 10² <10 10¹ 1D(46) 5x10⁴ 14x10² 5x10³ <10 2Y <10 <10 <10 <10 2D(48) 6x10³ 70x10² <10 <10 3Y <10 <10 <10 <10 3D(50) <10 <10 <10 <10 4Y <10 <10 <10 <10 4D(4) <10 <10 <10 <10 5Y 10³ <10 <10 <10 5D(5) <10 <10 <10 <10 6Y <10 <10 <10 <10 6D(6) 4x10³ 4x10² 3x10³ <10 7Y 10¹ <10 <10 <10 7D(46) <10 <10 <10 <10 8Y 2x10¹ <10 <10 <10 8D(47) <10 <10 <10 <10 9Y <10 <10 <10 <10 9D 10³ 11x10¹ 11x10² <10 10Y <10 <10 <10 <10 10D 15x10³ <10 5x10² <10 11Y <10 <10 <10 <10 11D 42x10⁵ 15x10⁴ 3x10² <10 12Y 20x10⁴ <10 <10 <10 12D <10 <10 <10 <10 13Y 2x10¹ <10 <10 <10 13D <10 <10 <10 <10 14Y <10 <10 <10 <10 14D <10 <10 <10 <10 15Y <10 <10 <10 <10 15D <10 15x10¹ <10 <10 16Y <10 <10 <10 <10 16D <10 <10 <10 <10 17Y 10¹ <10 <10 <10 17D 207x10⁵ 18x10⁴ 7x10³ <10 18Y <10 <10 <10 <10 18D <10 8x10² 20x10⁴ <10 19Y <10 <10 <10 <10 19D <10 <10 <10 <10 20Y <10 <10 <10 <10 20D <10 <10 <10 10⁴) %5 10⁴) %40 %35 <10 Table 3: Comparison of Microbial Load in Intensive Care and Standard Room Conditions Intensive Care Room Temperature Z-test P value Min Max Min Max TAMB <10 20x10¯⁴ <10 207x10¯⁵ -3.120 0.002 <10 <10 <10 20x10¯⁴ -2.859 0.004 Stap:Stafilokokus Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4658657","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321351268,"identity":"36dd1781-b0b7-428b-93af-d97d3a3e4120","order_by":0,"name":"alev yıldız ılıman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDACdhBhYMEDJBkfwEV58GlhBmuRAKlhNkDWIoFfC0SeDaEKnxb+ZuZjEgwFEjK67WePVfzMsbM3OH6A8cHbNoY68wbsWiQOs6VJgBxmdiYv7WbvtuTEDWcSmA3ntjFIyBzAYc1hHmMDsJYDOWY3eLcxJxgcSGCT5gVqweUy+cP8nyFazr8xK/y7rd7e4PwD9t/4tBgc5gGGLUjLjRwzZt5thxk33EhgY8anxfAwm+GDBLCWN8bSstuOJ8688bBZcs45CckZOLTIHW9+cODDHxt7s/M5hh/fbqu25zuffPDDmzIbftwRAwQJyByFA4wNDPhiEhPIN5CgeBSMglEwCkYEAAB0i1EzCCY9XgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-7957-8873","institution":"","correspondingAuthor":true,"prefix":"","firstName":"alev","middleName":"yıldız","lastName":"ılıman","suffix":""},{"id":321351269,"identity":"1123c7cc-52ac-4622-b4ba-ffebdd24fca8","order_by":1,"name":"Merve YURTTAŞ","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"","lastName":"YURTTAŞ","suffix":""},{"id":321351270,"identity":"ccf58eab-0ec1-425c-8717-e7d301ef9a52","order_by":2,"name":"Dursun Fırat ERGÜL","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Dursun","middleName":"Fırat","lastName":"ERGÜL","suffix":""},{"id":321351271,"identity":"62debd7e-4b56-448b-8559-e6452134c647","order_by":3,"name":"Salim TUTKAOĞLU","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Salim","middleName":"","lastName":"TUTKAOĞLU","suffix":""}],"badges":[],"createdAt":"2024-06-29 09:43:41","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4658657/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4658657/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59475561,"identity":"1164166a-bdc1-4193-9af7-96edce7db541","added_by":"auto","created_at":"2024-07-02 08:47:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":586549,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4658657/v1/c759a4f3-eccb-4a1c-ac7f-b38794249522.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eComparison of Microbiological Loads of Enteral Products Applied in Room Temperature and Intensive Care Conditions\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eEnteral nutrition, which maintains the natural integrity of the intestinal mucosa and sustains gastrointestinal function, is widely adopted due to its simple and cost-effective nature. Its use, initially prevalent in intensive care units, has now extended to regular hospital wards, long-term care facilities, and home settings. However, the increasing utilization of enteral nutrition products at room temperature raises concerns regarding their microbiological safety in various environmental conditions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContamination of enteral products can result in severe complications such as diarrhoea, abdominal distension, aspiration pneumonia, and sepsis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, identifying sources of contamination in enteral nutrition products and equipment under diverse environmental conditions and implementing necessary precautions are crucial for patient safety [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch findings indicate that the frequency of enteral contamination is higher in open system enteral sets compared to closed system sets[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It was explained with various factors that cause contamination in the open system enteral nutrition. The reasons for contamination in open system enteral nutrition have been explained by various factors. In open systems, factors contributing to contamination include increased frequency of contact due to feeding every 8 hours, direct exposure of the food to air, ambient temperature, and hanging time. In some studies on open systems, microbiological growth has been found to be within safe limits [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], while in others, it has been determined to be outside safe limits [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, there are very few studies available that examine the microbiological load of open system enteral products at different ambient temperatures. In one of these studies, it was determined that there was no microbial growth in products hanging for 6 hours at two ambient temperatures (25\u0026deg;C and 32\u0026deg;C)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In another study, it was found that after 8 hours of hanging at two ambient temperatures (23,3\u0026deg;C and 32,5\u0026deg;C), microbial growth in enteral products was low and within safe limits[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, open system enteral sets are supposed to remain hanging for 24 hours. That\u0026rsquo;s because enteral products must have microbial loads within safe limits until they are administered to the patient. Nevertheless, in these studies, samples were taken from sets hanging for only 6\u0026ndash;8 hours. Determining the microbiological quality of samples taken from open system enteral sets over a 24-hour period is important for ensuring patient safety.\u003c/p\u003e \u003cp\u003eManufacturing companies recommend the use of open system enteral sets for up to 24 hours [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This recommendation is based on room temperature conditions. While the average temperature in intensive care units fluctuates between 20\u0026ndash;24\u0026deg;C, temperatures can reach up to 35\u0026deg;C in room temperature conditions. In this context, it is important to determine whether there are differences in the bacterial microbiological loads of open system enteral nutrition products according to different ambient temperatures, especially for ensuring patient safety in immunocompromised patients. This descriptive study aimed to determine the differences in microbial loads of solutions obtained from open system enteral sets used for 24 hours under room temperature and intensive care unit conditions.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design\u003c/h2\u003e \u003cp\u003e This study was designed according to the final test design, which is one of the quantitative research designs. The enteral solutions analyzed in the study were collected from the Intensive Care and Palliative units of a university hospital in April 2024. Food samples were considered sterile upon initial opening, so no pre-test was applied.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAdministration of Enteral Products\u003c/h2\u003e \u003cp\u003eCommercial enteral solutions are administered to patients in this hospital using open system enteral sets. The commercial enteral solutions and open system enteral sets used are sterile. Enteral solutions are added to the sets at intervals of 4\u0026ndash;8 hours. The sets are replaced after 24 hours of use. Nurses do not use a standard protocol when preparing and administering enteral products.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEthical Aspect of the Study\u003c/h2\u003e \u003cp\u003eNo procedures (interventions) were performed on patients in the study. Ethical approval was obtained from the Non-Interventional Ethics Committee of Amasya University (ID NO:E-76988455-050.04-190659). Necessary institutional permissions were obtained from the university hospital where the study was conducted.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSampling\u003c/h2\u003e \u003cp\u003eWhile determining the number of samples, the number of samples in similar studies was taken into account [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The sample of the study consists of a total of 40 samples, with 20 samples under room conditions and 20 samples under intensive care unit conditions. Simple random sampling method was employed for sample selection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSample Collection Process\u003c/h2\u003e \u003cp\u003eSamples were obtained from open system enteral sets in the intensive care and palliative units of the hospital. During the data collection process, daily average temperature values were recorded in the palliative and intensive care units. Enteral nutrition supplements were administered to the open system enteral feeding set at intervals of 4\u0026ndash;8 hours in both units, and the set, which had been in use for a 24-hour period, was disconnected from the patient by a nurse. The distal end of the enteral set, the point connecting the set with the patient, was wiped with an alcohol-sterile gauze pad by the researcher. Subsequently, 5 mL of feeding solution was discarded, and then 15 mL of feeding solution was transferred to a sterile sample container. Aseptic techniques were observed during the sample collection process, and the feeding solutions were not contaminated. The collected samples were transported to the laboratory within 1 hour using a cooler bag and stored at +\u0026thinsp;4\u0026deg;C until analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMicrobiological Analysis\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eHomogenization of Enteral Nutrition Samples\u003c/h2\u003e \u003cp\u003eFor microbiological culturing, a 10 mL sample was homogenized in 90 mL of 0.1% sterile buffered peptone water for at least 2 minutes. From this mixture, 1 mL was added to tubes containing 9 mL of sterile peptone water, and serial dilutions were prepared up to 10⁻⁶ [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These dilutions were then plated onto culture media.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMicrobiological Bacterial Counts\u003c/h2\u003e \u003cp\u003eFor the enumeration of total aerobic bacteria, \u003cem\u003eS. aureus\u003c/em\u003e, coliform group, and E. coli, the spread plate method was used on the following media: standard plate count agar (PCA, Condalab, Madrid, Spain), baird parker agar with egg yolk (BPA, Condalab, Madrid, Spain), violet red bile lactose agar (VRBLA, Condalab, Madrid, Spain), and chromocult TBX agar (TBX, Condalab, Madrid, Spain), respectively. Samples were incubated at 35\u0026ndash;37\u0026deg;C and 44\u0026deg;C for 24\u0026ndash;48 hours before counting.\u003c/p\u003e \u003cp\u003eOn plate count agar, all colonies were considered as total aerobic bacteria. On VRBLA, dark red colonies surrounded by a red zone were considered coliforms. On baird parker agar, black shiny colonies with a surrounding clear zone were considered \u003cem\u003eS. aureus\u003c/em\u003e. On TBX agar, blue-green colonies were considered \u003cem\u003eE. coli.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTotal Aerobic Mesophilic Bacterial Count (TAMB)\u003c/h2\u003e \u003cp\u003ePlate Count Agar was used for the total aerobic mesophilic bacterial count. From the prepared dilutions, 0.1 mL was inoculated onto Plate Count Agar plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 35\u0026ndash;37\u0026deg;C for 48 hours. White colonies were considered aerobic bacteria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eColiform Bacterial Count\u003c/h2\u003e \u003cp\u003eViolet Red Bile Agar (VRBA, Condalab, Madrid, Spain) was used for coliform bacterial count. From the prepared dilutions, 0.1 mL was inoculated onto VRBA plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 35\u0026ndash;37\u0026deg;C for 24 hours. Dark red colonies were considered coliform bacteria [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eE. coli\u003c/b\u003e \u003cb\u003eCount\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChromocult TBX Agar (TBX, Condalab, Madrid, Spain) was used for \u003cem\u003eE. coli\u003c/em\u003e count. From the prepared dilutions, 0.1 mL was inoculated onto TBX plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 44\u0026deg;C for 24 hours. Blue-green colonies were considered E. Coli [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStaphylococcus aureus\u003c/b\u003e \u003cb\u003eCount\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEgg yolk-added Baird Parker agar (BPA, Condalab, Madrid, Spain) was used for Staphylococcus aureus count. From the prepared dilutions, 0.1 mL was inoculated onto BPA plates using the spread plate method with a sterile Drigalski loop. The inoculated plates were incubated at 35\u0026ndash;37\u0026deg;C for 24 hours. Clear zones surrounded by shiny black colonies were considered \u003cem\u003eStaphylococcus aureus\u003c/em\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCatalase Test\u003c/h2\u003e \u003cp\u003eA sterile loop was used to collect a sample from fresh bacterial culture onto a clean slide. 3% hydrogen peroxide (H2O2) was added, and the release of gas was observed. If gas was released, the test was considered catalase-positive; if no gas was released, it was considered catalase-negative.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCoagulase Test\u003c/h2\u003e \u003cp\u003eFor the coagulase test, 0.5 mL of fresh blood plasma and 0.5 mL of culture previously grown on solid media and produced in Brain Heart Infusion Broth were used. The blood plasma and bacterial culture were placed in a sterile tube and incubated at 37\u0026deg;C, with incubation intervals of 1, 3, 6 and 24 hours respectively. Tubes showing clotting were considered positive.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation of Microbiological Analysis Results\u003c/h2\u003e \u003cp\u003eIn our study, the evaluation criteria for microbial quality were based on the U.S. Food and Drug Administration (FDA) Bacteriological Analytical Manual. According to the FDA, the criteria for evaluating the microbial load of enteral nutrition are as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhen the aerobic microbial count exceeds 10\u003csup\u003e4\u003c/sup\u003e CFU/ml in a sample,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIf the microbial count is \u0026gt;\u0026thinsp;10\u003csup\u003e3\u003c/sup\u003e CFU/ml in 3 or more samples,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIf the counts of S. aureus, coliforms, and E. coli are greater than 3, the sample is considered unacceptable in terms of microbiological safety [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS 25 package program to determine the differences between the two groups. Since the sample size was less than 30 in both groups, the nonparametric Mann-Whitney U test was used, and the results were considered significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe microbiological count results and percentage ratios of enteral nutrition samples are provided in Tables 1 and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. During the data collection process, the temperature in the intensive care unit ranged from 22.1\u0026ndash;24.2\u0026deg;C, while the room temperature ranged from 25.2\u0026ndash;33.3\u0026deg;C. It was determined that 5% of the samples taken from the intensive care unit and 15% of the samples taken at room temperature exceeded the FDA limit for aerobic mesophilic bacteria count. In the remaining samples for both groups (95% and 85% respectively), growth was observed, but it did not exceed the values specified by the FDA. Catalase and coagulase-negative Staphylococcus sp. were identified in 5% and 40% of the samples from the intensive care unit and room temperature respectively. Total coliform count was not detected in intensive care unit samples, whereas it was determined in 35% of the room temperature samples. E. coli was not detected in either group.\u003c/p\u003e\n\u003cp\u003eAfter calculating the log values (CFU/g), Mann-Whitney U test was used to compare the contamination loads of samples taken under intensive care and room conditions. The difference between the contamination loads of the two groups was found to be statistically significant for aerobic mesophilic bacteria count (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). On the other hand, upon comparing the contamination loads of Staphylococcus sp. and E. coli between the groups, the researcher came to the conclusion that the difference was statistically negligible (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn recent years, patient safety has become a priority in the healthcare system. Frequently implemented in intensive care units, enteral nutrition, poses various risks, causing serious problems for patient safety. One of these risks is the contamination of enteral solutions with pathogenic microorganisms. In the two studies conducted with commercial enteral products in Turkey, microbial growth was not detected. However, in those studies, the samples were taken from closed sterile containers, which makes the results inconclusive because it is expected that the microbial load of enteral products remains within safe limits from the initial stage until the completion of infusion.\u003c/p\u003e \u003cp\u003eTherefore, the aim of this study is to determine the microbiological quality of open system enteral sets that have been infused under both room and intensive care conditions.To achieve this goal, samples were evaluated for total aerobic bacteria, coliforms, \u003cem\u003eS. aureus\u003c/em\u003e, and \u003cem\u003eE. coli\u003c/em\u003e microorganisms.\u003c/p\u003e \u003cp\u003eIn this study, it was determined that 5% of samples taken from the open system enteral set in intensive care conditions after 24 hours, and 15% of samples taken in room conditions exceeded the acceptable threshold value for Total Aerobic Mesophilic Bacteria (TAMB) (\u0026gt;\u0026thinsp;103). When similar studies conducted in intensive care conditions were examined, it was found that there was no growth in samples taken at 24 hours in the studies by Hatakeyama and Aso (2021) and at 4 hours in the study by Vieira et al. (2018), while in the study by Baniardalan et al. (2014), it was determined that 27 (96%) out of the samples taken at 18 hours had TAMB counts\u0026thinsp;\u0026gt;\u0026thinsp;103 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In studies conducted under room conditions, Johnson (2019) and Mokhalalati (2004) reported that TAMB bacterial counts were within safe limits (\u0026lt;\u0026thinsp;101) in samples taken at 4 hours, Neely et al. (2006) at 8 hours, Pinto et al. (2015) reported that 25% of samples taken at 4 hours had TAB counts\u0026thinsp;\u0026gt;\u0026thinsp;103, Sullivian et al. (2001) reported that 92% of samples taken at 4 hours had aerobic bacteria counts\u0026thinsp;\u0026gt;\u0026thinsp;10\u0026sup3;, and in the study by Herlick et al. (2000), it was determined that 78% of samples taken at 48 hours had aerobic bacteria counts\u0026thinsp;\u0026ge;\u0026thinsp;105 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In most of these studies, when the aerobic microorganism count exceeded 10⁴ cfu/mL in one sample or if the microorganism count exceeded\u0026thinsp;\u0026gt;\u0026thinsp;10\u0026sup3; cfu/mL in three or more samples, enteral products were considered unacceptable in terms of microbiological safety, while in only one study, 10\u003csup\u003e5\u003c/sup\u003e was used as the threshold value. One reason for the difference in the results of the study is the sampling times. While in some studies with sampling times of 4 and 8 hours, it was determined that there was no growth or very low growth [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], in some studies, it was found that there was growth even at 4 hours [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Open system enteral nutrition sets are used for up to 24 hours with feedings of every 8 hours.\u003c/p\u003e \u003cp\u003eMany studies in the literature suggest that the longer the exposure time and frequency of contact, the higher the risk of contamination, indicating that even if enteral products and sets are contaminated once during preparation and administration, there may be growth even in the early hours of infusion, while if there is no contamination, there may be no growth even at 24 hours [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The results obtained from studies with closed system enteral products hanging for 24-48-72 hours support this. Another reason for the difference between studies may be the ambient temperature. The optimum growth temperature for TAB is generally around 15\u0026ndash;20\u0026deg;C, but they can grow at temperatures as low as -10\u0026deg;C. As a result, we can say that both intensive care and room conditions are suitable for TAB growth. It is known that the rate of microbial growth is parallel to the ambient temperature. Our study findings confirm the literature information because in our study, it was found that there was growth in both groups, but the rate of growth in room conditions was higher than in intensive care, which was statistically significant. When similar studies are examined; Perry et al. (2015) reported that there was no growth in samples taken at 8 hours at different ambient temperatures (23.3\u0026deg;C and 32.5\u0026deg;C), and Lakananurak et al. (2020) reported that there was no growth in samples taken at 6 hours at temperatures (25\u0026deg;C and 32\u0026deg;C) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Also, in some studies conducted with closed systems, it was found that there was no growth even at high ambient temperatures. These results indicate that provided enteral products are not contaminated, there is no microbial growth even at high ambient temperatures. In other words, ambient temperature is not the main factor affecting contamination of enteral products. The fact that there is no growth in samples taken at 24\u0026ndash;48 hours from closed system enteral products at high ambient temperatures strengthens this finding. Therefore, we can say that the primary risk of microbial growth in enteral products is contamination, and ambient temperature and hanging time are only a risk if there is contamination.\u003c/p\u003e \u003cp\u003eTotal Aerobic Mesophilic Bacteria (TAMB) is an important indicator used to assess the hygiene level of food products. This parameter provides information about the level of contamination and spoilage of food. When enteral products are stored under inappropriate conditions or the usage time is extended, the potential risks of these products increase. Even if they are microbiologically safe, once they are opened and prepared in clinical conditions, they can easily become contaminated with microorganisms. This can lead to undesirable consequences in clinical environments especially for immunocompromised patients.\u003c/p\u003e \u003cp\u003eIn our study, Staphylococcus sp. bacteria, which can survive under dry conditions (on surfaces and clothing) due to their ability to withstand solid-state and low water activity conditions, were also examined. While 5% of samples taken in intensive care and 40% in room conditions were found to be catalase and coagulase-negative \u003cem\u003eStaphylococcus sp.\u003c/em\u003e, the difference between groups was statistically negligible (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). When similar studies were examined; Baniardalan et al. (2014) reported higher growth rates in intensive care, with 24 (86%) compared to our study [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Lafourcade et al. (2002) found similar results to our study, but this study was conducted using a closed system enteral set [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In studies conducted under room conditions; Moazen et al. (2014) and Da Silva (2015) reported that only 1% (5%) and 1% (12.5%) were coagulase-positive, respectively, while in other studies, very low rates or no growth were observed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In all of these studies, as in our study, if the microorganism count of \u003cem\u003eS. aureus\u003c/em\u003e was greater than 3, it was considered unacceptable in terms of microbiological safety. The difference in microorganism rates between studies can be attributed to the sample size. Furthermore, while growth occurred in open system enteral solutions used at different ambient temperatures, the fact that no growth occurred in closed system enteral products even at high ambient temperatures and hanging times over 24 hours is an important finding. Additionally, studies conducted with commercial powdered enteral products and blenderized enteral products have shown much higher rates. This indicates that the increased frequency of contact during preparation and administration increases the risk of contamination. Staphylococcus sp. is a bacterium that can cause various infections in humans. Additionally, they are commonly found in foods, food establishments, hands of food handlers, hospital personnel, and hospital environments. These bacteria are usually heavily present in the nose and throat cavity. The transmission of Staphylococcus sp. can occur through close or direct contact from one person to another, or through food contamination. Considering the routes of transmission, the low microorganism rates found in intensive care environments may suggest that mask usage, air conditioning, and negative pressure ventilation may be contributing factors. Additionally, the more frequent handwashing and adherence to hygiene rules by nurses working in the intensive care unit have also prevented the contamination of enteral products.\u003c/p\u003e \u003cp\u003eAnother microorganism examined in our study is coliform. While coliforms were not detected in intensive care samples, 35% of samples taken under room conditions were determined to have a total coliform count\u0026thinsp;\u0026gt;\u0026thinsp;10\u003csup\u003e3\u003c/sup\u003e. In studies conducted in intensive care, Moazen et al. (2014) and Pinto et al. (2015) reported that coliforms did not develop [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In some of the studies conducted under room conditions, coliform rates were lower than our study, with Da Silva et al. (9%)\u0026thinsp;\u0026gt;\u0026thinsp;3 cfu/mL, and in some studies, no contamination was detected [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Mahinkazemi et al. (2017) found high coliform rates in commercial powdered products, with 8% (33.3%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Carvallo et al. (2000) detected coliforms in tap water used in enteral products [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. One of the reasons for coliform growth in our study may be the water added to the sets. This finding indicates that the use of water whose sterility cannot be ensured may be a source of contamination in enteral products. Another cause of contamination is the connection points of open system enteral sets. This risk is particularly higher at the connection point to the patient tube [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Coliform bacterial growth in enteral nutrition products is generally an undesirable condition. Coliform bacteria can often be an indicator of fecal contamination. These bacteria can be found in places like the digestive system, and contamination of such products can occur due to factors such as unhygienic production processes or inadequate storage conditions.\u003c/p\u003e \u003cp\u003eWhile a potential contamination in enteral nutrition products may not be a significant problem in terms of food safety during the production process, it raises concerns about the risk of contamination during the preparation of the patient's nutrition products. It is of most importance that enteral nutrition products be sterile, both for food safety and for the patient to receive the necessary nutrients completely. Therefore, the use of sterile sets in enteral nutrition practice, the application of aseptic techniques during the preparation and administration of products, and meticulous attention to personnel hygiene are essential.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe primary aim of this study was to determine if there were be differences in microbial loads in open system enteral nutrition products at different ambient temperatures. Some findings of the research supported this hypothesis. Specifically, the total aerobic mesophilic bacteria (TAMB) and coliform microbial loads in open system enteral products varied according to ambient temperature. However, no differences were identified in the microbial loads of E. coli and Staphylococcus spp. These findings are significant concerning the risks that may arise during the administration of enteral products. Failure to pay attention to these risks may compromise patient safety.\u003c/p\u003e \u003cp\u003eNonetheless, the study has certain limitations. One limitation is the small sample size and the fact that the study was conducted at a single center during the winter season. Since climates are determinative of ambient temperature, it is recommended that the study be conducted with a larger sample size and across different climates and centers. Additionally, the use of advanced analytical methods when detecting pathogenic microorganisms could enhance the evidence strength of such studies.\u003c/p\u003e \u003cp\u003eIn this study, while the TAMB and coliform counts in open system enteral products at different temperatures differed from each other, no differences were observed in the counts of E. coli and Staphylococcus spp. Adhering to hygiene and sanitation rules is crucial for the safety of all patients. Especially for patients on enteral feeding, who often have compromised immune systems, any lapse in these rules can lead to foodborne illnesses. Furthermore, an increase in microbial load poses a threat to patient health. Therefore, nurses and staff working in wards and intensive care units should store, prepare, and administer enteral nutrition under hygienic conditions and at appropriate temperatures.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDoley J (2022) Enteral nutrition overview. Nutrients 14(11):2180\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang H, Hou L, Sun HM, Ye SH (2023) Comparison of micronutrients in adult enteral formulas widely used in clinical practice. Food Sci Nutr 11(10):6096\u0026ndash;6105\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson TW, Milton DL, Johnson K, Carter H, Hurt RT, Mundi MS et al (2019) Comparison of Microbial Growth Between Commercial Formula and Blenderized Food for Tube Feeding. Nutr Clin Pract 34(2):257\u0026ndash;263\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyman B, Williams M, Sollazzo J, Hayden A, Hensley P, Dai H et al (2016) Enter Feeding Set Handling Techniques Nutr Clin Pract 32(2):193\u0026ndash;200\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanek VW (2000) Closed versus open enteral delivery systems: a quality improvement study. Nutr Clin Pract 15(5):234\u0026ndash;243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinha RK, Singh A, Kishor A, Richa S, Kumar R, Kumar A (2021) Evaluation of oral hygiene status in patients with hemorrhagic and ischemic stroke. J Pharm Bioallied Sci 13(Suppl 1):S233\u0026ndash;S6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaniardalan M, Sabzghabaee AM, Jalali M, Badri S (2014) Bacterial safety of commercial and handmade enteral feeds in an Iranian teaching hospital. Int J Prev Med 5(5):604\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatakeyama J, Aso S (2021) Bacterial Contamination during Continuous Administration of Liquid Enteral Nutrition Formula in a Sterile Sealed Bag: A Prospective Interventional Study. Ann Nutr Metab 77(1):56\u0026ndash;60\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLakananurak N, Nalinthassanai N, Suansawang W, Panarat P (2020) Optimal hang time of enteral formula at standard room temperature and high temperature. World J Clin Cases 8(19):4410\u0026ndash;4415\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry J, Stankorb SM, Salgueiro M (2015) Microbial contamination of enteral feeding products in thermoneutral and hyperthermal ICU environments. Nutr Clin Pract 30(1):128\u0026ndash;133\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuenter P, Boullata JI, Ayers P, Gervasio J, Malone A, Raymond E et al (2015) Standardized competencies for parenteral nutrition prescribing: the American Society for Parenteral and Enteral Nutrition model. Nutr Clin Pract 30(4):570\u0026ndash;576\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuwahara T, Kaneda S, Shimono K, Inoue Y (2013) Effects of lipid emulsion and multivitamins on the growth of microorganisms in peripheral parenteral nutrition solutions. Int J Med Sci 10(9):1079\u0026ndash;1084\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOmotani S, Murakami K, Naka A, Hatsuda Y, Myotoku M (2023) Differences in the growth of microorganisms depends on the type of semi-solid enteral nutritional supplements. J Pharm Health Care Sci 9(1):27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinto RO, Correia EF, Pereira KC, Costa Sobrinho Pde S, da Silva DF (2015) Microbiological quality and safe handling of enteral diets in a hospital in Minas Gerais, Brazil. Braz J Microbiol 46(2):583\u0026ndash;589\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSullivan MM, Sorreda-Esguerra P, Santos EE, Platon BG, Castro CG, Idrisalman ER et al (2001) Bacterial contamination of blenderized whole food and commercial enteral tube feedings in the Philippines. J Hosp Infect 49(4):268\u0026ndash;273\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo S, Tse M, Boost M (2012) Effect of an infection control programme on bacterial contamination of enteral feed in nursing homes. J Hosp Infect 82(1):49\u0026ndash;55\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStichler JF (2016) Patient Safety: A Priority for Healthcare and for Healthcare Design. HERD 9(4):10\u0026ndash;15\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManual BA (1998) US Food and Drug Administration. Rev\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVieira MMC, Santos VFN, Bottoni A, Morais TB (2018) Nutritional and microbiological quality of commercial and homemade blenderized whole food enteral diets for home-based enteral nutritional therapy in adults. Clin Nutr 37(1):177\u0026ndash;181\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMokhalalati JK, Druyan ME, Shott SB, Comer GM (2004) Microbial, nutritional and physical quality of commercial and hospital prepared tube feedings in Saudi Arabia. Saudi Med J 25(3):331\u0026ndash;341\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeely AN, Mayes T, Gardner J, Kagan RJ, Gottschlich MM (2006) A microbiologic study of enteral feeding hang time in a burn hospital: Can feeding costs be reduced without compromising patient safety? Nutrition in clinical practice. 21(6):610\u0026ndash;616\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerlick SJ, Vogt C, Pangman V, Fallis W (2000) Clinical Research: Comparison of Open Versus Closed Systems of Intermittent Enteral Feeding in Two Long-Term Care Facilities. Nutr Clin Pract 15(6):287\u0026ndash;298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafourcade P, Boulestreau H, Arnaud-Battandier F, Rogues A-M, Texier-Maugein J, Pinganaud G et al (2002) Is a 24-h cyclic closed enteral feeding system microbiologically safe in geriatric patients? Clin Nutr 21(4):315\u0026ndash;320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoazen M, Rahmdel S, ABDOLLAH ZSM, RANJBAR ZM, Mazloomi SM (2014) Microbiological quality of commercial enteral feedings used in two public hospitals in Shiraz, Iran\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHubbard GP, Van Wyk J, Grinyer L, Onley R, White S, Fleming CA et al (2023) Appropriate handling and storage reduce the risk of bacterial growth in enteral feeding systems reused within 24 hours. Nutr Clin Pract\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eda Silva TK, Berbigier MC, Rubin Bde A, Moraes RB, Correa Souza G, Schweigert Perry ID (2015) Phase angle as a prognostic marker in patients with critical illness. Nutr Clin Pract 30(2):261\u0026ndash;265\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eda Silva TK, Berbigier MC, Rubin BA, Moraes RB, Corr\u0026ecirc;a Souza G, Schweigert Perry ID (2015) Phase angle as a prognostic marker in patients with critical illness. Nutr Clin Pract 30(2):261\u0026ndash;265\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilton D, Murphy B, Johnson TW, Carter H, Spurlock AY, Hussey J et al (2022) Low risk for microbial contamination of syringe and tube feeding bag surfaces after multiple reuses with home blenderized tube feeding. Nutr Clin Pract 37(4):907\u0026ndash;912\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahinkazemi M, Tarighat-Esfanjani A, Safaiyan A (2017) Bacterial contamination and nutritional adequacy of enteral tube feedings in Iran. Progr Nutr 19(3):283\u0026ndash;290\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarvalho MLR, Morais TB, Amaral DF, Sigulem DM (2000) Hazard analysis and critical control point system approach in the evaluation of environmental and procedural sources of contamination of enteral feedings in three hospitals. JPEN, Journal of Parenteral and Enteral Nutrition. ;24(5):296\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLafourcade P, Boulestrau H, Arnaud-Battandier F, Rogues AM, Texier-Maugein J, Pinganaud G et al (2002) Is a 24-h cyclic closed enteral feeding system microbiologically safe in geriatric patients? Clin Nutr 21(4):315\u0026ndash;320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathus-Vliegen EM, Bredius MW, Binnekade JM (2006) Analysis of sites of bacterial contamination in an enteral feeding system. JPEN J Parenter Enter Nutr 30(6):519\u0026ndash;525\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"95.92833876221498%\" colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: Microorganism Counts in Enteral Nutrients at Different Temperatures (CFU/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.8130081300813%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eIntensive Care (CFU/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.40650406504065%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Room Temperature (CFU/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003eTAMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStap\u003c/em\u003e. sp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003eTotal Coliforms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003eTAMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStap\u003c/em\u003e. sp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003eTotal Coliforms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e1Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e1D(46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e5x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e14x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e5x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e2Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e2D(48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e6x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e70x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e3Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e3D(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e4Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e4D(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e5Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e5D(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e6Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e6D(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e4x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e4x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e3x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e7Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e7D(46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e8Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e2x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e8D(47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e9Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e9D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e11x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e11x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e10Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e10D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e15x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e5x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e11Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e11D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e42x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e15x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e3x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e12Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e20x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e12D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e13Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e2x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e13D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e14Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e14D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e15Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e15D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e15x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e16Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e16D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e17Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e17D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e207x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e18x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e7x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e18Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e18D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e8x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e20x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e19Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e19D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.78048780487805%\" valign=\"top\"\u003e\n \u003cp\u003e20Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.56910569105691%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.967479674796748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.43089430894309%\" valign=\"top\"\u003e\n \u003cp\u003e20D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.382113821138212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.21951219512195%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.05691056910569%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.317073170731708%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Microorganism Rates in Enteral Nutrition Samples Evaluated According to the FDA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.85430463576159%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.1456953642384%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMicroorganism (CFU/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.85430463576159%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\" valign=\"top\"\u003e\n \u003cp\u003eTAMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStap. sp.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.33112582781457%\" valign=\"top\"\u003e\n \u003cp\u003eTotal Coliforms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.85430463576159%\" valign=\"top\"\u003e\n \u003cp\u003eIntensive Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\" valign=\"top\"\u003e\n \u003cp\u003e% 5 (\u0026gt;10⁴)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e%5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.33112582781457%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003e%5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.85430463576159%\" valign=\"top\"\u003e\n \u003cp\u003eRoom Temperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\" valign=\"top\"\u003e\n \u003cp\u003e% 15 (\u0026gt;10⁴)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e%40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.33112582781457%\" valign=\"top\"\u003e\n \u003cp\u003e%35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.033112582781456%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\" style=\"margin-right: calc(31%); width: 69%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\" style=\"width: 101.732%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3: Comparison of Microbial Load in Intensive Care and Standard Room Conditions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.43393148450245%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.200652528548122%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIntensive Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.569331158238175%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eRoom Temperature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eZ-test\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" rowspan=\"2\" valign=\"top\" style=\"width: 7.9212%;\"\u003e\n \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.5119305856833%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.43817787418655%\" valign=\"top\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.390455531453362%\" valign=\"top\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.17353579175705%\" valign=\"top\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.485900216919738%\" valign=\"top\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.43393148450245%\" valign=\"top\"\u003e\n \u003cp\u003eTAMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.866231647634583%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.33442088091354%\" valign=\"top\"\u003e\n \u003cp\u003e20x10\u0026macr;⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.171288743882545%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" valign=\"top\"\u003e\n \u003cp\u003e207x10\u0026macr;⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" valign=\"top\"\u003e\n \u003cp\u003e-3.120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" valign=\"top\" style=\"width: 7.9212%;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.43393148450245%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.866231647634583%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.33442088091354%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.171288743882545%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" valign=\"top\"\u003e\n \u003cp\u003e20x10\u0026macr;⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" valign=\"top\"\u003e\n \u003cp\u003e-2.859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.398042414355627%\" valign=\"top\" style=\"width: 7.9212%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eStap:Stafilokokus\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Amasya University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nutrition, enteral feeding, microbiological loads, intensive care, room temperature","lastPublishedDoi":"10.21203/rs.3.rs-4658657/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4658657/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite the high risk of bacterial contamination, no studies have been found that evaluate the optimal hanging time of open system enteral sets under room temperature and intensive care conditions. This study aims to determine the differences in microbial loads of solutions taken from open system enteral feeding sets hanging for 24 hours under room temperature and intensive care conditions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study is a descriptive type of research. The study sample consisted of a total of 40 samples, with 20 samples under room temperature and 20 samples under intensive care conditions. A simple random sampling method was used for sample selection. The assessment of microbial quality was based on the U.S. Food and Drug Administration (FDA) online Bacteriological Analytical Manual.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn this study, it was determined that 5% of the samples taken from intensive care and 15% of the samples taken at room temperature exceeded the accepted limit for aerobic mesophilic bacteria count. The count of catalase and coagulase-negative Staphylococcus spp. was 5% in intensive care samples and 40% in room temperature samples. The total coliform count was not detected in intensive care samples but was 35% in room temperature samples. E. coli was not detected in either group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e Differences in microbial loads were observed when commercial enteral solutions were administered using open system enteral feeding sets under room and intensive care conditions for 24 hours. Therefore, large-scale studies are needed to determine the safe use of open system enteral feeding sets under room temperature conditions.\u003c/p\u003e","manuscriptTitle":"Comparison of Microbiological Loads of Enteral Products Applied in Room Temperature and Intensive Care Conditions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-02 08:39:42","doi":"10.21203/rs.3.rs-4658657/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c1d07a8-53fc-4433-a449-142c44a66523","owner":[],"postedDate":"July 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":33998716,"name":"Nutrition \u0026 Dietetics"},{"id":33998717,"name":"General Microbiology"}],"tags":[],"updatedAt":"2024-07-02T08:39:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-02 08:39:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4658657","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4658657","identity":"rs-4658657","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}