Survival of viable but nonculturable Cronobacter sakazakii in macrophages contributes to infections

Cronobacter sakazakii (C. sakazakii), a pathogen that exists in dry and low-moisture environments, such as powder infant formula (PIF), can enter a viable but nonculturable (VBNC) state under harsh conditions, which enables it to escape traditional detection methods and thus poses a potential public health risk. This study aimed at assessing the virulent nature of VBNC C. sakazakii. Our results showed that VBNC C. sakazakii induced intestinal inflammation in neonatal rats. However, the degree of inflammation was significantly lower than that of culturable bacteria due to decreasing endotoxin production, motility, adhesion, and invasion ability in the VBNC state. From the perspective of bacterial translocation, the numbers of C. sakazakii in the blood, liver, and spleen of rats treated with VBNC cells were in the same order of magnitude as those treated with its culturable counterpart and may lead to the same degree of bacteremia. According to the macrophage survival assays, the survival rate of VBNC C. sakazakii within macrophages was 4.7 times higher than that of culturable cells. Based on these findings, we hypothesize that VBNC C. sakazakii evaded the host immune defense system, penetrated the tissue barrier, and translocated to the bloodstream, liver, and spleen through macrophages. Thus, our study reveals that VBNC C. sakazakii could be a potential risk for infants' health.