Epidemiology and pathogenesis of Listeria monocytogenes infection

Authors:: Michael S Gelfand, MD; Geeta K Swamy, MD; Jennifer L Thompson, MD
Section Editors:: Daniel J Sexton, MD; Morven S Edwards, MD
Deputy Editor:: Milana Bogorodskaya, MD

Literature review current through: Jan 2024.

This topic last updated: Nov 20, 2023.

INTRODUCTION — Listeria monocytogenes is an important bacterial pathogen in immunosuppressed patients, individuals at the extremes of age including neonates and older adults, pregnant women, and, occasionally, previously healthy individuals. Invasion of the central nervous system (meningitis or meningoencephalitis) and bacteremia are the principal clinical manifestations of listerial infection in these hosts. In contrast, normal hosts who ingest high numbers of Listeria may develop self-limited febrile gastroenteritis.

The epidemiology, microbiology, and pathogenesis of listerial infection will be reviewed here. The clinical manifestations, diagnosis, treatment, prognosis, and prevention of listerial infections are discussed separately. (See "Clinical manifestations and diagnosis of Listeria monocytogenes infection" and "Treatment and prevention of Listeria monocytogenes infection".)

MICROBIOLOGY — L. monocytogenes is the only Listeria species that regularly infects humans, although rare cases of human infections with Listeria ivanovii (a pathogen of ruminants) and Listeria grayi have been reported [1,2]. Listeria is an aerobic and facultatively anaerobic, motile, beta-hemolytic, non–spore-forming, short, gram-positive rod that exhibits characteristic tumbling motility by light microscopy (movie 1 and picture 1) [3,4]. Listeria occurs singly or in short chains. On Gram stain, Listeria may resemble pneumococci (diplococci), enterococci, or diphtheroids (Corynebacteria) or be gram variable and be confused with Haemophilus species (picture 2) [3-5]. In particular, when a positive blood or cerebrospinal fluid culture is preliminarily identified as diphtheroids, the clinician should consider the possibility that the isolate represents Listeria [3].

Listeria produces a characteristic appearance on blood agar with small zones of clear beta-hemolysis around each colony (picture 3). Listeria grows well at refrigeration temperatures (4° to 10°C). Rarely, the "cold enrichment" technique and selective media are used when attempting to isolate Listeria from mixed cultures, such as stool [4].

PATHOGENESIS — Listeria is a facultative intracellular parasite [6]. The primary habitat of Listeria is the soil and decaying vegetable matter. Most Listeria infections in adults are thought to result from oral ingestion and subsequent intestinal mucosal penetration and systemic infection (movie 2).

Listeria has a predilection for placental and fetal tissue; the mechanism is not well understood [7]. During maternal bacteremia, Listeria can cross the placenta and infects the fetus. Increased disease susceptibility and disease severity during pregnancy may be attributable in part to alterations in the immune system during pregnancy, during which there is a shift between innate and humoral immunity, leading to upregulation of Th-2 mediated immunity and a decrease in Th-1 mediated immunity [8-10]. (See "Clinical manifestations and diagnosis of Listeria monocytogenes infection", section on 'Clinical manifestations'.)

Immunity to Listeria relies mainly on T cell lymphokine activation of macrophages, which clear Listeria from the blood [11-13]. Interleukin 18 appears to play a role in protection against Listeria by enhancing bacterial clearance, even in the absence of interferon (IFN)-gamma, and by stimulating macrophages to secrete tumor necrosis factor and nitric oxide [12]. On the other hand, factors that impair macrophage survival or function are associated with increased susceptibility to listerial infection [13,14].

There is increasing evidence that IFN signaling enhances susceptibility to L. monocytogenes infection [15-17]. Mice deficient in either IFN regulatory factor or the IFN receptor are profoundly resistant to infection caused by L. monocytogenes compared with wild-type mice [16,17].

Listeria can initially enter cells by a mechanism that may involve binding of a bacterial protein (internalin) to E-cadherin (CDH1) on the host cell [18,19]. Another possible mechanism is via LapB, a sortase A–anchored surface protein that may be necessary for adhesion to and entry into mammalian cells [20]. The organism then uses a unique mechanism of spreading from cell to cell without exposing itself to an extracellular environment [19]. It accomplishes this by subverting the actin-based cellular contractile mechanism; propulsion within the cytoplasm of infected host cells and cell-to-cell spread are thought to be driven by actin polymerization at the bacterial cell surface and the formation of a comet tail [11]. Both protein components in the host cell cytoplasm (particularly profilin, a host actin monomer-binding protein) and a bacterial surface protein (called ActA) are required for actin assembly by Listeria [21-23].

Listeriolysin O, a pore-forming toxin, is a cholesterol-dependent cytolysin and is the main virulence factor of L. monocytogenes. It induces T cell receptor (TCR) unresponsiveness by driving the expression of negative regulators of TCR signaling and suppresses antigen-induced T cell activation [24]. In addition, listeriolysin O impairs posttranslational modification of host cell proteins and interferes with the host immune response [25].

L. monocytogenes genotype sequence type 6 has been associated with unfavorable outcomes [26]. (See "Treatment and prevention of Listeria monocytogenes infection", section on 'Outcomes'.)

CLINICAL EPIDEMIOLOGY — The primary habitat of Listeria is the soil and decaying vegetable matter. It has been isolated from dust, numerous human food products, animal feed, water, sewage, numerous species of animals, and asymptomatic humans [3,4]. Approximately 0.8 to 3.4 percent of healthy individuals are fecal excretors of Listeria [27]. Dietary preferences and food processing techniques may contribute to the differences in rates of asymptomatic excretion.

Incidence of infection — The United States Centers for Disease Control and Prevention uses an "enhanced surveillance system" that collects reports of laboratory-confirmed cases of listeriosis [28]. However, because many cases may be clinically mild and go undetected, the actual incidence of listeriosis is unknown. Incidence of laboratory-confirmed cases of listeriosis ranges between 0.3 to 0.6 cases per 100,000 persons [29-31]. In adults ≥65 years of age, incidence is around 1.3 cases per 100,000 population, and in pregnant individuals, the incidence in the United States is estimated to be 3.0 cases per 100,000 population. The highest incidence has been observed in pregnant Hispanic women (7.0 cases per 100,000 population).

Based on laboratory reports, an estimated 1500 to 3000 cases of listeriosis occur annually, with mortality rates ranging from 10 to 15 percent for nonpregnant individuals and up to 20 percent for neonatal deaths or fetal loss [29,30,32]. In a study of foodborne illnesses in the United States, Listeria had the third highest mortality rate (approximately 16 percent compared with 35 percent with Vibrio vulnificus and 17 percent with Clostridium botulinum [botulism]) and accounted for approximately 19 percent of all deaths from foodborne infection [32]. However, it should be noted that mortality rates are often subject to reporting bias. Since it is more likely that severe or fatal cases are reported and that mild cases are unreported and undiagnosed, the actual case-fatality rate is probably lower than 16 percent. Nonperinatal listeriosis-associated deaths in the United States have decreased from 1990 to 2005, paralleling the decreasing trend in incidence [33].

An increasing rate of listeriosis has been reported in several European countries [34]. Decreased concentration of salt in prepared foods has been proposed as a possible cause of this trend. In a study from England, an association between living in a socioeconomically depressed neighborhood and becoming ill with listeriosis was observed [35]. Individuals who purchased food from small local food stores and convenience stores were more likely to develop listeriosis than the general population.

The types of illness that can occur are reviewed elsewhere. (See "Clinical manifestations and diagnosis of Listeria monocytogenes infection".)

Sporadic illness — In general, invasive listeriosis typically occurs as a sporadic illness, while listerial gastroenteritis is more commonly identified in the context of an outbreak since there is no routine stool testing for Listeria. In a report from the United States Foodborne Diseases Active Surveillance Network (FoodNet) including 249 cases of culture-confirmed cases of listeriosis in nine states between 2000 and 2003, 95 percent were sporadic [36]. (See 'Food epidemiology and outbreaks' below.)

In a two-year population-based survey of 7775 stool specimens submitted for evaluation of diarrheal illness, Listeria spp were recovered in 0.5 percent of specimens [27]. Thus, routine screening of stool samples for Listeria is not warranted.

The source of infection in sporadic cases is usually not known, but most cases are thought to be secondary to ingestion of contaminated food [3,4,36-38]. Clinical infection is more likely after ingestion of foods with higher levels of contamination [39]. Infections from animal contact are uncommon, primarily occurring in veterinarians, abattoir workers, and farmers.

The following observations illustrate the range of findings: two were from the Listeria Study Group involving patients seen between 1988 and 1990 and one was from the Foodborne Diseases Active Surveillance Network.

●In a case-control study of 165 patients with culture-confirmed sporadic listeriosis from the Listeria Study Group, 32 percent of cases could be attributed to eating soft cheeses or foods purchased from delicatessen counters [37]. Almost 70 percent of patients were immunosuppressed (cancer, human immunodeficiency virus [HIV] infection, organ transplant recipient, or glucocorticoid therapy); among these patients, undercooked chicken also increased the risk of listeriosis. (See 'Predisposing conditions' below.)

●An accompanying report from the Listeria Study Group involved 123 patients with sporadic listeriosis [38]. L. monocytogenes grew from at least one food specimen (mostly ready-to-eat foods) in the refrigerators of 79 of these patients (64 percent); in 26 (33 percent of patients), at least one food isolate was the same strain as that detected in the corresponding patient. Foods containing higher concentrations of L. monocytogenes were associated with an increased risk of infection.

●A later case-control study from FoodNet in the United States was performed between 2000 and 2003, after the implementation of large-scale pathogen-reduction measures and dissemination of dietary guidelines to the public [36]. In this study, 169 patients with sporadic listeriosis were matched to 376 controls. In multivariable analysis, L. monocytogenes infection was linked to two previously unrecognized foods: eating melons at a commercial establishment or hummus prepared in a commercial establishment.

There are, however, limitations to such case-control studies: only foods associated with a marked elevation in relative risk can be identified, multiple testing may lead to false-positive results, and contaminated foods to which exposure is either rare or common may be missed [39].

Methods used to prevent foodborne infection are described elsewhere. (See "Treatment and prevention of Listeria monocytogenes infection", section on 'Prevention of foodborne infection'.)

Predisposing conditions — Most systemic, invasive listerial infections occur in individuals with one or more predisposing conditions [29,37,40-43]. These include pregnancy, glucocorticoid therapy, other immunocompromising conditions, and age. Of 1651 cases of listeriosis identified in the United States between 2009 and 2011 in the Foodborne Diseases Active Surveillance Network (FoodNet), 58 percent occurred in patients ≥65 years of age, 29 percent in nonpregnant patients <65 years of age, and 14 percent in pregnant women [29]. The median age of patients with non-pregnancy-associated listeriosis was 72 years (interquartile range 61 to 81 years).

The importance of age was illustrated in a four-state, multicenter survey of bacterial meningitis in the United States in 1995 [44]. Listeria accounted for 22 percent of cases in older adults, 23 percent in neonates, and only 4 percent between the ages of 2 and 60. In a FoodNet surveillance study, among nonpregnancy-associated cases in the United States from 2004 to 2009, the incidence of listeriosis increased with increasing age [45]. In persons aged 45 to 59 years, the relative risk of infection was 4.7 (95% CI 3.3-6.8) compared with individuals aged 15 to 44 years. Among individuals ≥85 years of age, the relative risk was 53.8 (95% CI 37.3-78.9). Among children with listeriosis who are outside the neonatal age range, approximately one-half do not have an identifiable underlying condition [46].

Listeria is the most common cause of bacterial meningitis in patients with underlying neoplastic disease, especially lymphoma, in organ transplant recipients and in those receiving glucocorticoids for any reason [3,47]. In a retrospective review of 820 cases of central nervous system listeriosis not associated with pregnancy or the neonatal period, hematologic malignancies and renal transplantation were the two most common predisposing conditions [47]. However, 36 percent of patients had no recognizable underlying diseases.

In the FoodNet study from the United States described above, Hispanic people were at increased risk of listeriosis compared with non-Hispanic people (relative risk [RR] 1.8, 95% CI 1.3-2.5) [45].

Pregnancy — Pregnant women, especially those in the third trimester, are particularly susceptible to Listeria infection and account for up to one-third of reported cases. In the FoodNet study, among women of reproductive age (15 to 44 years), pregnant women were at much greater risk of listeriosis than nonpregnant women (RR 114.6, 95% CI 68.9-205.1) [45]. This risk is thought to be related to changes in the immune system that occur during pregnancy, leading to a decrease in maternal cell mediated immunity, which can increase maternal susceptibility to various infections [8-10]. For unknown reasons, women with twin or triplet pregnancies are at greater risk (risk ratio 3.8 compared with singleton pregnancies) [48].

Listeria infection in pregnant women can lead to fetal loss, premature birth, or infected newborns [49-53]. (See "Clinical manifestations and diagnosis of Listeria monocytogenes infection", section on 'Clinical manifestations'.)

Glucocorticoid therapy — Glucocorticoid therapy is the most important predisposing factor in nonpregnant patients, likely due to the immunosuppressive effects [54,55]. In one report of patients with chronic lymphocytic leukemia, for example, Listeria infection occurred in 7 of 248 patients (2.8 percent) treated with prednisone and fludarabine [54]. In comparison, no listerial infections occurred in 160 patients treated with fludarabine alone or in 387 patients treated with conventional chemotherapeutic agents. However, other studies have shown an association between cancer chemotherapy and listeriosis. (See 'Other risk factors' below.)

Other risk factors — In addition to glucocorticoid therapy, a number of diseases and medications are risk factors for Listeria infection, most of which are associated with at least some degree of immunosuppression [3,29,37,41,43,56,57]:

●Hematologic malignancies [58]

●Solid tumors [58]

●Organ transplantation (especially renal) [37,43,59,60]

●Acquired immunodeficiency syndrome (AIDS) [37]

●Treatment with tumor necrosis factor-alpha antagonists (see "Tumor necrosis factor-alpha inhibitors: Bacterial, viral, and fungal infections", section on 'Listeriosis')

●Diabetes mellitus

●End-stage kidney disease (including hemodialysis and peritoneal dialysis) [61]

●Iron overload [62,63]

●Collagen-vascular diseases

●Other serious chronic nonmalignant diseases

●Colonoscopy [64]

●Liver disease and alcoholism [65]

●Use of proton pump inhibitors [66]

Among nonpregnant patients with listeriosis aged <65 years of age reported to FoodNet between 2009 and 2011, 96 of 130 (74 percent) had an underlying medical condition; the most commonly reported conditions were immunosuppressive therapy (ie, glucocorticoids, chemotherapy, or radiation; in 32 patients), followed by malignancy (in 24 patients), diabetes mellitus (in 11 patients), cirrhosis or liver disease (in 7 patients), kidney injury or nephrotic syndrome (in 7 patients), alcoholism (in 6 patients), and HIV infection (in 6 patients) [29].

Hemochromatosis with cirrhosis and transfusional iron overload in dialysis patients are additional risk factors for listerial infection [62,63]. Several factors may contribute in these settings. Iron overload of macrophages can diminish phagocytosis [62], while high serum iron levels may increase bacterial virulence.

Prior to the use of antiretroviral therapy, the frequency of listerial infection in a prospective population-based surveillance study was increased 65- to 145-fold in patients with AIDS, although still relatively uncommon (115 per 100,000 patients per year) [67]. A low CD4 cell count was presumed to be a predisposing factor; however, the widespread use of trimethoprim-sulfamethoxazole prophylaxis for Pneumocystis jirovecii (formerly Pneumocystis carinii) infection has made the occurrence of Listeria infection in this population less common.

Nosocomial acquisition — Hospital-acquired listeriosis in adults has been reported [68-74]. The mode of acquisition is from ingestion of contaminated foods. In a review of 369 adults with listeriosis worldwide, 16 percent of cases were thought to be nosocomially acquired [68]. In a study from Spain of 102 nonpregnant adults with listeriosis, 30 percent had hospital-acquired infection [69]. While a potentially lengthy incubation period and gastrointestinal carriage make it possible that the microorganism may not have been acquired in the hospital in all patients, two cases of listeriosis in an oncology unit associated with sandwiches consumed in the hospital have been reported [70] (see "Clinical manifestations and diagnosis of Listeria monocytogenes infection", section on 'Clinical manifestations'). Increased immunosuppression associated with hospitalization may be an important factor in the development of listeriosis in patients who were colonized prior to admission [68].

In a review of 30 reports of hospital-acquired listeriosis from 13 countries, all patients were immunocompromised in three-quarters of the reports with available data [74]. Foods that were implicated included sandwiches, butter, precut celery, Camembert cheese, sausage, and tuna salad.

FOOD EPIDEMIOLOGY AND OUTBREAKS — Listeria species account for less than 1 percent of reported cases of microbial foodborne disease (table 1) [32].

Listeria is a common low-level contaminant of processed and unprocessed foods of plant and animal origin. The organism can survive and multiply at refrigerator temperatures and over a wide pH range; as a result, even a small amount of contamination may be significant [4]. The attack rate in outbreaks of gastroenteritis ranges from 50 to 100 percent, with mean incubation period about 24 hours (range 6 hours to 10 days) [75].

Foodborne outbreaks of listeriosis have been described in association with a variety of foods, including processed/delicatessen meats, hot dogs, soft cheeses, pâtés, and raw produce (table 2) [50,52,76-87]. Emerging culprits include pasteurized dairy products, ready-to-eat meals, frozen foods, and ready-to-eat salads. Pasteurization may not completely mitigate the risk of listeriosis, and outbreaks have been associated with pasteurized milk as well as soft cheeses made from pasteurized milk [29,77,88]. In addition, a gradual shift in detection of L. monocytogenes contamination in ready-to-eat meals, frozen foods, and ready-to-eat salads has occurred; in 2015 and 2016, only 5 percent of confirmed L. monocytogenes infections originated from the food groups previously associated with listeriosis that were listed in the guidelines issued in 2014 by the American College of Obstetricians and Gynecologists [89,90]. Foods implicated in listeriosis outbreaks in the United States over the past several years are summarized on the United States Centers for Disease Control and Prevention website.

Exposures in restaurants may also contribute to infections; incidence of listeriosis in the United States decreased by 27 percent in 2020 (compared with 2017 to 2019), when many restaurants closed due to the coronavirus disease 2019 (COVID-19) pandemic [91].The extent to which this reduction reflects actual decreases in illness versus decreases in case detection is uncertain.

Issues related to prevention of listeriosis are discussed separately. (See "Treatment and prevention of Listeria monocytogenes infection", section on 'Prevention of foodborne infection'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Listeria infection (The Basics)")

SUMMARY

●Microbiology − Listeria monocytogenes is an aerobic and facultatively anaerobic gram-positive rod that exhibits characteristic tumbling motility by light microscopy (movie 1 and picture 1). On Gram stain, Listeria may resemble pneumococci (diplococci) or diphtheroids (Corynebacteria) or may be gram variable and be confused with Haemophilus species. (See 'Microbiology' above.)

●Pathogenesis − The primary habitat of Listeria is the soil and decaying vegetable matter. Most Listeria infections in adults are thought to result from oral ingestion and subsequent intestinal mucosal penetration and systemic infection (movie 2). (See 'Pathogenesis' above.)

●Epidemiology

•Predisposing conditions − Most systemic, invasive listerial infections occur in individuals with one or more predisposing conditions. These include pregnancy, glucocorticoid therapy, and other immunosuppressive treatments or conditions. Pregnant women, especially in the third trimester, are particularly susceptible and account for up to one-third of reported cases. Glucocorticoid therapy is the most important predisposing factor in nonpregnant patients. Sporadic gastroenteritis is an uncommon illness. (See 'Predisposing conditions' above.)

•Sporadic illness − Most cases (95 percent in a report from the Foodborne Diseases Active Surveillance Network) are sporadic. The source of infection in sporadic cases is usually not known, but most cases are thought to be secondary to ingestion of contaminated food. The organism can survive and multiply at refrigerator temperatures and over a wide range of pH; as a result, even a small amount of contamination may be significant. (See 'Sporadic illness' above.)

●Foodborne outbreaks − Foodborne outbreaks of listeriosis have been described in association with a variety of foods, including processed/delicatessen meats, hot dogs, soft cheeses, pâtés, and raw produce (table 2). (See 'Food epidemiology and outbreaks' above.)

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Topic 1280 Version 60.0

خرید پکیج

Epidemiology and pathogenesis of Listeria monocytogenes infection

References