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## **Meet the editor**

Prof. Ntambwe Malangu, born in Kabinda, Congo (DRC), is a pharmacoepidemiologist with public health expertise in drug safety issues. He is currently the head of the Department of Epidemiology and Biostatistics at the School of Public Health at Sefako Makgatho Health Sciences University, Pretoria, South Africa, and the production editor for *PULA: Botswana Journal for African* 

*Studies* as well as a reviewer for a handful of international peer-reviewed journals. From 2006, he has been working as an international health consultant and technical advisor with major development partners. Malangu holds a bachelor's degree in Pharmacy from the University of Kinshasa (1991), a Master of Medical Science degree from the Medical University of Southern Africa (2003), and a PhD degree (2007) and a Doctor of Medical Science degree from the University of Limpopo (2012). Malangu has over 60 publications including scientific abstracts and letters, books, book chapters, and full papers.

Contents

**Preface VII**

**Toxicology 3** Ntambwe Malangu

**Section 2 Clinical Toxicology Topics 9**

Virginie Lattard

Edit Gara

Chapter 1 **Introductory Chapter: Linkages Between Clinical and Forensic**

Chapter 2 **Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences 11**

Chapter 3 **Food Poisoning Caused by Bacteria (Food Toxins) 33**

and Graciela Castro-Escarpulli

Elif Bozcal and Melih Dagdeviren

Chapter 6 **Acute Poisoning with Neonicotinoid Insecticide 107**

Sébastien Lefebvre, Isabelle Fourel, Stéphane Queffélec, Dominique Vodovar, Bruno Mégarbane, Etienne Benoit, Virginie Siguret and

Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís

Cecilia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel

Chapter 4 **Carbon Monoxide Intoxication: Experiences from Hungary 73**

Chapter 5 **Toxicity of β-Lactam Antibiotics: Pathophysiology, Molecular Biology and Possible Recovery Strategies 87**

Nicolai Nistor, Otilia Elena Frăsinariu and Violeta Ştreangă

**Section 1 Introduction 1**

## Contents

**Preface XI**


Chapter 7 **Occupational Risk Factors for Acute Pesticide Poisoning among Farmers in Asia 125**

Emine Selcen Darçın, Murat Darçın, Murat Alkan and Gürdoğan Doğrul

Chapter 8 **Activating Carbon Fibers and Date Pits for Use in Liver Toxin Adsorption 137**

Ameereh Seyedzadeh, Asel Mwafy, Waleed Khalil Ahmed, Kamala Pandurangan and Ali Hilal-Alnaqbi

Preface

Poisoning, whether acute or chronic and whether accidental or deliberate, is one of the ma‐ jor causes of morbidity and mortality worldwide. This book is a collection of papers about some common causes of poisoning in humans and animals. Given the fact that applied toxi‐ cology, in its various forms (clinical, occupational, forensic, etc.), is not commonly and effec‐ tively taught as a subject in its own right, the aim of this book is to provide both theoretical and practical information on the specified toxic agents and analytical techniques discussed. The materials presented here can be categorized into two groups. The first group of papers deals with clinical toxicology topics including poisoning by anticoagulant rodenticides, food toxins, carbon monoxide, and the toxicity of beta-lactam antibiotics. The second group of papers deals with forensic or analytical toxicology topics such as simplified methods for the analysis of gaseous toxic agents, rapid methods for the analysis and monitoring of patho‐ gens in drinking water and water-based solutions, as well as the linkages between clinical and forensic toxicology. Each chapter presents new information on the topic discussed

The introductory chapter provides an overview on issues, challenges, and resources for the establishment and running of clinical and forensic toxicological assessment services and concludes with a statement on how the two disciplines relate. The second chapter is a com‐ prehensive monograph on the use and utility of anticoagulants, their chemical properties, pharmacokinetics, mechanisms of action, human and animal exposures, and management of poisoning incidents. The third chapter discusses food poisoning caused by bacteria-emitting toxins and elaborates on its epidemiological characteristics including food-borne diseases, pathogens involved, and other risk factors. The fourth chapter is also a monograph on car‐ bon monoxide poisoning with emphasis with a case study illustrating a novel management approach implemented in Hungary. The fifth chapter is a detailed description on toxicologi‐ cal aspects of beta-lactam antibiotics including their structure-activity relationships, patho‐ physiology, molecular biology, and strategies to address their toxicity. The sixth chapter elaborates on acute poisoning by neonicotinoids, while the seventh chapter discusses occu‐ pational risk factors for acute pesticide poisoning. The eight chapter reports on how activat‐ ing carbon fibers and date pits can be useful in the management of liver toxicity. The ninth chapter describes novel simplified techniques for forensic analysis of gaseous substances su‐ chas carbon monoxide, hydrogen cyanide, hydrogen sulfide, and helium. The techniques used include color testing, gas chromatography, detector tube, oximeter, and spectrophoto‐ metric method. The tenth chapter elaborates on novel apparatus and methods for real-time detection and monitoring of viruses and pathogenic organisms in drinking water and aque‐ ous solutions based on nonlinear effects. The final chapter describes a practical tool for en‐

based on authors' experience while summarizing existing knowledge.

suring safety in agricultural produces, the Aflatoxin QuicktestTM.


Chapter 11 **The Aflatoxin Quicktest™—A Practical Tool for Ensuring Safety in Agricultural Produce 193** Francisco Sánchez-Bayo, Luis de Almeida, Robert Williams, Graeme Wright, Ivan R. Kennedy and Angus Crossan

## Preface

Chapter 7 **Occupational Risk Factors for Acute Pesticide Poisoning among**

Chapter 8 **Activating Carbon Fibers and Date Pits for Use in Liver Toxin**

Chapter 9 **Simplified Analysis of Toxic Gaseous Substance in Forensic**

**Practice: Experiences from Japan 157**

Chapter 10 **Optical Express Methods of Monitoring of Pathogens in Drinking Water and Water-Based Solutions 173**

Tatiana Moguilnaya and Aleksey Sheryshev

Wright, Ivan R. Kennedy and Angus Crossan

Chapter 11 **The Aflatoxin Quicktest™—A Practical Tool for Ensuring Safety**

Matsubara and Kiyoshi Ameno

**in Agricultural Produce 193**

Emine Selcen Darçın, Murat Darçın, Murat Alkan and Gürdoğan

Ameereh Seyedzadeh, Asel Mwafy, Waleed Khalil Ahmed, Kamala

Hiroshi Kinoshita, Naoko Tanaka, Ayaka Takakura, Mostofa Jamal, Asuka Ito, Mitsuru Kumihashi, Shoji Kimura, Kunihiko Tsutsui, Shuji

Francisco Sánchez-Bayo, Luis de Almeida, Robert Williams, Graeme

**Farmers in Asia 125**

**Adsorption 137**

**Section 3 Forensic Toxicology Topics 155**

Pandurangan and Ali Hilal-Alnaqbi

Doğrul

**VI** Contents

Poisoning, whether acute or chronic and whether accidental or deliberate, is one of the ma‐ jor causes of morbidity and mortality worldwide. This book is a collection of papers about some common causes of poisoning in humans and animals. Given the fact that applied toxi‐ cology, in its various forms (clinical, occupational, forensic, etc.), is not commonly and effec‐ tively taught as a subject in its own right, the aim of this book is to provide both theoretical and practical information on the specified toxic agents and analytical techniques discussed.

The materials presented here can be categorized into two groups. The first group of papers deals with clinical toxicology topics including poisoning by anticoagulant rodenticides, food toxins, carbon monoxide, and the toxicity of beta-lactam antibiotics. The second group of papers deals with forensic or analytical toxicology topics such as simplified methods for the analysis of gaseous toxic agents, rapid methods for the analysis and monitoring of patho‐ gens in drinking water and water-based solutions, as well as the linkages between clinical and forensic toxicology. Each chapter presents new information on the topic discussed based on authors' experience while summarizing existing knowledge.

The introductory chapter provides an overview on issues, challenges, and resources for the establishment and running of clinical and forensic toxicological assessment services and concludes with a statement on how the two disciplines relate. The second chapter is a com‐ prehensive monograph on the use and utility of anticoagulants, their chemical properties, pharmacokinetics, mechanisms of action, human and animal exposures, and management of poisoning incidents. The third chapter discusses food poisoning caused by bacteria-emitting toxins and elaborates on its epidemiological characteristics including food-borne diseases, pathogens involved, and other risk factors. The fourth chapter is also a monograph on car‐ bon monoxide poisoning with emphasis with a case study illustrating a novel management approach implemented in Hungary. The fifth chapter is a detailed description on toxicologi‐ cal aspects of beta-lactam antibiotics including their structure-activity relationships, patho‐ physiology, molecular biology, and strategies to address their toxicity. The sixth chapter elaborates on acute poisoning by neonicotinoids, while the seventh chapter discusses occu‐ pational risk factors for acute pesticide poisoning. The eight chapter reports on how activat‐ ing carbon fibers and date pits can be useful in the management of liver toxicity. The ninth chapter describes novel simplified techniques for forensic analysis of gaseous substances su‐ chas carbon monoxide, hydrogen cyanide, hydrogen sulfide, and helium. The techniques used include color testing, gas chromatography, detector tube, oximeter, and spectrophoto‐ metric method. The tenth chapter elaborates on novel apparatus and methods for real-time detection and monitoring of viruses and pathogenic organisms in drinking water and aque‐ ous solutions based on nonlinear effects. The final chapter describes a practical tool for en‐ suring safety in agricultural produces, the Aflatoxin QuicktestTM.

Taken together, this book will be a good teaching aid and can be a prescribed or recom‐ mended reading for postgraduate students and professionals in the fields of public health, medicine, pharmacy, nursing, biology, toxicology, and forensic sciences. The materials pre‐ sented by a team of international experts and authors make an enriching reading geared at improving the prevention, detection, and management of both acute and chronic poisoning due to the toxic agents described.

Many individuals have contributed to the preparation and production of this book; their dedication and selfless contribution are humbly acknowledged here. In particular, profes‐ sors and scientists Moguilnaya Tatiana and Sheryshev Aleksey from Moscow Aviation Insti‐ tute, Russia; Hiroshi Kinoshita, Naoko Tanaka, Ayaka Takakura, Mostofa Jamal, Asuka Ito, Mitsuru Kumihashi, Shoji Kimura, Kiyoshi Ameno, Kunihiko Tsutsui, and Shuji Matsubara from Kagawa University, Japan; Elif Bozcal from Istanbul University, Turkey; Melih Dagde‐ viren from Ege University, Turkey; Edit Gara from Semmelweis University, Hungary; Ceci‐ lia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís, and Graciela Castro-Escarpulli from the National Institute of Biological Sciences (Escuela Nacional de Ciencias Biológicas), Mexico; Sébastien Lefebvre, Isabelle Fourel, Etienne Benoit, and Virginie Lattard from the Universite de Lyon, France; Stéphane Queffélec from the Centre National d'Informations Toxicologiques Vétér‐ inaires (CNITV), France; Virginie Siguret from the Université Paris Descartes, France; Domi‐ nique Vodovar and Bruno Mégarbane from the Université Paris-Diderot, France; Francisco Sánchez-Bayo and his team from the School of Life and Environmental Sciences from the University of Sydney, Australia; Ameereh Seyedzadeh, Asel Mwafy, Waleed Khalil Ahmed, Kamala Pandurangan, and Ali Hilal-Alnaqbi from the Department of Mechanical Engineer‐ ing, United Arab Emirates University; Nicolai Nistor, Otilia Elena Frăsinariu and Violeta Ştreangă from Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania; and Selcen Darçın E, Murat Darçın, Murat Alkan, and Gürdoğan Doğrul from Gazi University, Ankara, Turkey. Moreover, my personal assistant Ornela Lofulo Niangi Malangu and Marti‐ na Blečić, Dajana Pemac, and the production and editorial teams from InTechOpen have all played a major role in ensuring that this book is published.

> **Prof. Ntambwe Malangu** Sefako Makgatho Health Sciences University, Pretoria, South Africa

**Section 1**

**Introduction**

**Section 1**

## **Introduction**

Taken together, this book will be

due to the toxic agents described.

played a major role in ensuring that this book is published.

sented by

VIII Preface

a good teaching aid and can be

a team of international experts and authors make an enriching reading geared at

mended reading for postgraduate students and professionals in the fields of public health, medicine, pharmacy, nursing, biology, toxicology, and forensic sciences. The materials pre‐

improving the prevention, detection, and management of both acute and chronic poisoning

Many individuals have contributed to the preparation and production of this book; their dedication and selfless contribution are humbly acknowledged here. In particular, profes‐ sors and scientists Moguilnaya Tatiana and Sheryshev Aleksey from Moscow Aviation Insti‐ tute, Russia; Hiroshi Kinoshita, Naoko Tanaka, Ayaka Takakura, Mostofa Jamal, Asuka Ito, Mitsuru Kumihashi, Shoji Kimura, Kiyoshi Ameno, Kunihiko Tsutsui, and Shuji Matsubara from Kagawa University, Japan; Elif Bozcal from Istanbul University, Turkey; Melih Dagde‐ viren from Ege University, Turkey; Edit Gara from Semmelweis University, Hungary; Ceci‐ lia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís, and Graciela Castro-Escarpulli from the National Institute of Biological Sciences (Escuela Nacional de Ciencias Biológicas), Mexico; Sébastien Lefebvre, Isabelle Fourel, Etienne Benoit, and Virginie Lattard from the Universite de Lyon, France; Stéphane Queffélec from the Centre National d'Informations Toxicologiques Vétér‐ inaires (CNITV), France; Virginie Siguret from the Université Paris Descartes, France; Domi‐ nique Vodovar and Bruno Mégarbane from the Université Paris-Diderot, France; Francisco Sánchez-Bayo and his team from the School of Life and Environmental Sciences from the University of Sydney, Australia; Ameereh Seyedzadeh, Asel Mwafy, Waleed Khalil Ahmed, Kamala Pandurangan, and Ali Hilal-Alnaqbi from the Department of Mechanical Engineer‐ ing, United Arab Emirates University; Nicolai Nistor, Otilia Elena Frăsinariu and Violeta Ştreangă from Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania; and Selcen Darçın E, Murat Darçın, Murat Alkan, and Gürdoğan Doğrul from Gazi University, Ankara, Turkey. Moreover, my personal assistant Ornela Lofulo Niangi Malangu and Marti‐ na Blečić, Dajana Pemac, and the production and editorial teams from InTechOpen have all

a prescribed or recom‐

**Prof. Ntambwe Malangu**

Pretoria, South Africa

Sefako Makgatho Health Sciences University,

**Chapter 1**

**Provisional chapter**

**Introductory Chapter: Linkages Between Clinical and**

**1. Overview on interconnections between sciences and professionals in** 

Poisoning, whether acute or chronic, and whether accidental or deliberate, is one of the major causes of morbidity and mortality worldwide. International data gathered by the World Health Organization (WHO) suggest that at least an estimated over 100.000 people died worldwide from poisoning every year [1]. Of the factors contributing to this high loss of lives, is the misdiagnosing of poisoning due to lack of qualified personnel and lack of appropriate

Strictly speaking studying poisoning incidents, how they occur, their symptoms and signs, the toxic agents involved, the diagnosis and management thereof as well as the outcomes of treatment, is a multi-disciplinary endeavour that requires skills and competences in injury

Although epidemiologists painstakingly work to study, describe, and quantify the determinants of both acute and chronic poisoning incidents, medical clinicians and clinical toxicologists, clinical pharmacists and nurses are the professionals who are confronted on a daily basis with cases of acute poisoning requiring their immediate attention to save or preserve the

Clinicians, particularly, emergency and critical care doctors, ought to decide on the basis of symptoms and signs, often not unique to the incident, whether it is a case of acute poisoning or not. The history related by patients themselves, their relatives and or sometimes by paramedics or police personnel who brought the victim constitutes more often the main evidence clinicians may get about the circumstances of the acute poisoning incident. Understandably, where such history is lacking or incomplete, forensic toxicological assessment of the victim's

**Introductory Chapter: Linkages Between Clinical and** 

DOI: 10.5772/intechopen.70303

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

specimen is another tool capable of providing clues to what may have happened [2].

**Forensic Toxicology**

**Forensic Toxicology**

Additional information is available at the end of the chapter

medical equipment for conducting relevant investigations.

epidemiology, clinical and forensic, or analytical toxicology.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70303

Ntambwe Malangu

**case of poisoning**

lives of victims of such incidents.

Ntambwe Malangu

**Provisional chapter**

## **Introductory Chapter: Linkages Between Clinical and Forensic Toxicology Forensic Toxicology**

**Introductory Chapter: Linkages Between Clinical and** 

DOI: 10.5772/intechopen.70303

Ntambwe Malangu Ntambwe Malangu Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70303

## **1. Overview on interconnections between sciences and professionals in case of poisoning**

Poisoning, whether acute or chronic, and whether accidental or deliberate, is one of the major causes of morbidity and mortality worldwide. International data gathered by the World Health Organization (WHO) suggest that at least an estimated over 100.000 people died worldwide from poisoning every year [1]. Of the factors contributing to this high loss of lives, is the misdiagnosing of poisoning due to lack of qualified personnel and lack of appropriate medical equipment for conducting relevant investigations.

Strictly speaking studying poisoning incidents, how they occur, their symptoms and signs, the toxic agents involved, the diagnosis and management thereof as well as the outcomes of treatment, is a multi-disciplinary endeavour that requires skills and competences in injury epidemiology, clinical and forensic, or analytical toxicology.

Although epidemiologists painstakingly work to study, describe, and quantify the determinants of both acute and chronic poisoning incidents, medical clinicians and clinical toxicologists, clinical pharmacists and nurses are the professionals who are confronted on a daily basis with cases of acute poisoning requiring their immediate attention to save or preserve the lives of victims of such incidents.

Clinicians, particularly, emergency and critical care doctors, ought to decide on the basis of symptoms and signs, often not unique to the incident, whether it is a case of acute poisoning or not. The history related by patients themselves, their relatives and or sometimes by paramedics or police personnel who brought the victim constitutes more often the main evidence clinicians may get about the circumstances of the acute poisoning incident. Understandably, where such history is lacking or incomplete, forensic toxicological assessment of the victim's specimen is another tool capable of providing clues to what may have happened [2].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In settings where published and widely publicized treatment guidelines exist, clinicians may have algorithms to guide their assessments and presumptions. In settings where such guidelines do not exist, the clinicians' instincts and experiences are the valuable tools for making a correct presumptive diagnosis and crafting a management care plan.

With regard to forensic or analytical toxicology, its role in the detection, identification, and quantification of drugs, chemicals, and other foreign compounds (xenobiotics) in biological and related specimens such as blood, saliva, hair, urine, etc., is of utmost importance in the diagnosis, treatment, prognosis, and prevention of poisoning. Sometimes, a forensic toxicological assessment is the only means by which objective evidence of the nature and magnitude of exposure to a particular toxic agent or a group of toxicants can be obtained

Introductory Chapter: Linkages Between Clinical and Forensic Toxicology

http://dx.doi.org/10.5772/intechopen.70303

5

There are several obstacles and limitations with regard to the existence and operation of forensic laboratory services. In several countries, firstly, the lack of properly trained clinical and forensic toxicologists is the main obstacle to the establishment and use of forensic laboratory services. The competences required for a trained analytical toxicologist include a fundamental knowledge of principles of emergency medicine and intensive care, a good grasp of pharmacology and clinical toxicology as well as a practical mastery of clinical chemistry and basic laboratory operations, including aspects of medical laboratory health and safety. Secondly, the lack of appropriate funding for the training and establishment of such services further compound the problem. Thirdly, it is noteworthy that even where relevant clinical personnel such as clinical pharmacists exist, equipment needed to run the services are lacking. It should be noted that several types of equipment are required for providing analytical

**a.** A carbon monoxide (CO)-Oximeter: normally very necessary for determining carboxyhaemoglobin and methaemoglobin measurements in case of a suspected incident by carbon

**b.** Standard clinical chemistry analysers and assay kits: for use in determining basic biochemical parameters such as glucose, total bilirubin, ALT, AST, cholesterol, triglycerides, creatinine, urea, uric acid, fibrinogen, calcium and phosphorus, aminotransferases, etc [16]. **c.** Machines for UV-visible spectrophotometry, thin-layer chromatography (TLC), high performance liquid chromatography (HPLC), and gas chromatography-mass spectrometry (GC-MS), and possibly high performance liquid chromatography-tandem mass spectrometry (HPLC-MS-MS): for use in the identification and quantification of a wide variety of

**d.** Machines for atomic absorption spectrophotometry or inductively coupled mass spec-

The need to treat the victim of acute poisoning as well as the need to apprehend the perpetrators of deliberate or criminal intoxication dictates the need for rapid methods for identifying

**4. Limitations of medical and forensic laboratory services**

toxicological assessments, this include:

medicines, drugs, chemicals, and pollutants [17].

trometry (ICP-MS): for use for metals analysis [18].

**5. Necessity for rapid methods in forensic toxicology**

monoxide [15].

[14].

## **2. Importance of guidelines and algorithms in diagnosis and management of a poisoning incident**

Several studies have reported the usefulness of treatment guidelines in general and for specific diseases notably epidemics such as HIV and noncommunicable diseases [3–6]. In summary, treatment guidelines and algorithms for management of specific diseases and conditions:


Unfortunately, with regard to poisoning incidents, national treatment guidelines of several countries have shortcomings as guidance and algorithms on specific poisoning agents are not presented there in [7]. It should be noted that the International Programme on Chemical Safety (IPCS) has published guidelines concerning the prevention and clinical management of poisoning including a manual on "Basic Analytical Toxicology" which provides practical guidance on clinical aspects and detailed monographs on tests to be conducted for specified chemicals [8].

## **3. Role of forensic toxicology and medical laboratory in the diagnosis and monitoring of treatment in case of a poisoning incident**

Medical laboratory and forensic toxicological assessments are important in establishing the diagnosis and identifying the toxic agents involved in a poisoning incident, and possibly the doses ingested. In case of deliberate poisoning, suicide or para-suicide as well as in case of intoxication or criminal poisoning, the identification of the toxic agents help not only in the management of the victim but also in providing clues that may lead to the possible culprit [9, 10].

Although, medical laboratory testing plays a crucial role in the detection, diagnosis and treatment of disease in patients; and that laboratory tests help determine the presence of a disease and monitor the effectiveness of treatment; in case of poisoning, detecting biochemical parameters modified as a result of the effects of the toxic agent is an important contribution for the purposes of making a diagnosis. Classical cases include the determination of acetylcholinesterase in case of acute poisoning due to pesticides as well as the identification of toxins produced by bacteria involved in food poisoning incidents [11–13].

With regard to forensic or analytical toxicology, its role in the detection, identification, and quantification of drugs, chemicals, and other foreign compounds (xenobiotics) in biological and related specimens such as blood, saliva, hair, urine, etc., is of utmost importance in the diagnosis, treatment, prognosis, and prevention of poisoning. Sometimes, a forensic toxicological assessment is the only means by which objective evidence of the nature and magnitude of exposure to a particular toxic agent or a group of toxicants can be obtained [14].

## **4. Limitations of medical and forensic laboratory services**

In settings where published and widely publicized treatment guidelines exist, clinicians may have algorithms to guide their assessments and presumptions. In settings where such guidelines do not exist, the clinicians' instincts and experiences are the valuable tools for making a

Several studies have reported the usefulness of treatment guidelines in general and for specific diseases notably epidemics such as HIV and noncommunicable diseases [3–6]. In summary, treatment guidelines and algorithms for management of specific diseases and conditions:

**c.** speed the consultation process as clinicians are guided on what tests to perform and what

Unfortunately, with regard to poisoning incidents, national treatment guidelines of several countries have shortcomings as guidance and algorithms on specific poisoning agents are not presented there in [7]. It should be noted that the International Programme on Chemical Safety (IPCS) has published guidelines concerning the prevention and clinical management of poisoning including a manual on "Basic Analytical Toxicology" which provides practical guidance on clinical aspects and detailed monographs on tests to be conducted for specified

**3. Role of forensic toxicology and medical laboratory in the diagnosis**

Medical laboratory and forensic toxicological assessments are important in establishing the diagnosis and identifying the toxic agents involved in a poisoning incident, and possibly the doses ingested. In case of deliberate poisoning, suicide or para-suicide as well as in case of intoxication or criminal poisoning, the identification of the toxic agents help not only in the management of the victim but also in providing clues that may lead to the possible culprit [9, 10].

Although, medical laboratory testing plays a crucial role in the detection, diagnosis and treatment of disease in patients; and that laboratory tests help determine the presence of a disease and monitor the effectiveness of treatment; in case of poisoning, detecting biochemical parameters modified as a result of the effects of the toxic agent is an important contribution for the purposes of making a diagnosis. Classical cases include the determination of acetylcholinesterase in case of acute poisoning due to pesticides as well as the identification of toxins produced by bacteria involved in food poisoning incidents [11–13].

**and monitoring of treatment in case of a poisoning incident**

correct presumptive diagnosis and crafting a management care plan.

4 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

**management of a poisoning incident**

to look for.

chemicals [8].

**b.** provide guidance in establishing differential diagnosis;

**2. Importance of guidelines and algorithms in diagnosis and** 

**a.** facilitate the choice of appropriate medicines and prescribing of correct doses;

There are several obstacles and limitations with regard to the existence and operation of forensic laboratory services. In several countries, firstly, the lack of properly trained clinical and forensic toxicologists is the main obstacle to the establishment and use of forensic laboratory services. The competences required for a trained analytical toxicologist include a fundamental knowledge of principles of emergency medicine and intensive care, a good grasp of pharmacology and clinical toxicology as well as a practical mastery of clinical chemistry and basic laboratory operations, including aspects of medical laboratory health and safety. Secondly, the lack of appropriate funding for the training and establishment of such services further compound the problem. Thirdly, it is noteworthy that even where relevant clinical personnel such as clinical pharmacists exist, equipment needed to run the services are lacking. It should be noted that several types of equipment are required for providing analytical toxicological assessments, this include:


## **5. Necessity for rapid methods in forensic toxicology**

The need to treat the victim of acute poisoning as well as the need to apprehend the perpetrators of deliberate or criminal intoxication dictates the need for rapid methods for identifying poisons involved in a poisoning incident. This is a subject of ongoing research and it requires massive investments particularly in developing countries where funding for research is scarce.

[4] Dybul M, Fauci AS, Bartlett JG, Kaplan JE, Pau AK. Guidelines for using antiretroviral agents among HIV-infected adults and adolescents. Recommendations of the panel on clinical practices for treatment of HIV. MMWR.Recommendations and reports: Morbidity

Introductory Chapter: Linkages Between Clinical and Forensic Toxicology

http://dx.doi.org/10.5772/intechopen.70303

7

and mortality weekly report. Recommendations and Reports. 2002;**51**(RR-7):1-55

The Journal of Clinical Hypertension. 2014;**16**(1):14-26

Childbirth. 2016;**16**(1):369

Heinemann; 2014

Hill Medical; 2016

and Carbamates. Elsevier; 2017

pp. 141-175

2003: pp. 337-58

2011;**65**(4):202-206

[5] Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG,... Cohen DL. Clinical practice guidelines for the management of hypertension in the community.

[6] Amoakoh-Coleman M, Klipstein-Grobusch K, Agyepong IA, Kayode GA, Grobbee DE, Ansah EK. Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: A Ghanaian cohort study. BMC Pregnancy and

[7] Malangu N. Contribution of plants and traditional medicines to the disparities and similarities in acute poisoning incidents in Botswana, South Africa and Uganda. African Journal of Traditional, Complementary and Alternative Medicines. 2014;**11**(2):425-438

[8] IPCS. Basic Analytical Toxicology. Available at: http://www.who.int/ipcs/publications/ training\_poisons/basic\_analytical\_tox/en/index1.html [Accessed 05-July-2017]

[9] Baker FJ, Silverton RE. Introduction to Medical Laboratory Technology. Butterworth-

[10] Masters SB, Trevor AJ. Basic & Clinical Pharmacology. In: Katzung BG, editor. McGraw-

[11] Roberts DM, Brett J. Clinical management of acute OP pesticide poisoning. In: Basic and Clinical Toxicology of Organophosphorus Compounds. London: Springer; 2014.

[12] Marxen S, Stark TD, Frenzel E, Rütschle A, Lücking G, Pürstinger G, Pohl EE, Scherer S, Ehling-Schulz M, Hofmann T. Chemodiversity of cereulide, the emetic toxin of Bacillus

[13] Ballantyne B, Marrs TC. Clinical and Experimental Toxicology of Organophosphates

[14] Flanagan RJ. Role of the laboratory in the diagnosis and management of poisoning. In: Dart RC, editor. Medical Toxicology. 3rd ed. Baltimore: Lippincott, Williams & Wilkins;

[15] Jang DH, Kelly M, Hardy K, Lambert DS, Shofer FS, Eckmann DM. A preliminary study in the alterations of mitochondrial respiration in patients with carbon monoxide poison-

[16] Zunic L, Skrbo A, Causevic A, Prnjavorac B, Sabanovic Z, Pandza H, Masic I. Role of laboratory diagnostic medical biochemistry services-analysis of requirements for the laboratory test in the laboratory of primary health care center. Medicinski Arhiv.

ing measured in blood cells. Clinical Toxicology. 2017;**55**(6):579-584

cereus. Analytical and Bioanalytical Chemistry. DOI: 10.1007/s00216-015-8511-y

Moreover, some of the methods mentioned above such as GC, HPLC and TLC require the presence of reference chemicals to be used for the identification and quantitation of toxicants [19]. However, the availability and access to these references and other reagents pose several challenges particularly to developing countries that may not have sufficient funds to purchase these products [14].

For the above reasons, newer and simpler methods, techniques, equipments, and devices that are more affordable and easy to operate are urgently required to develop and establish forensic toxicology services in several developing countries.

## **6. Concluding remarks**

Clinical toxicology and forensic toxicology share a mutually beneficial partnership; these two sciences support both the management of the patients who have been victims of poisoning; and the identification of the causative agent that may have inflicted toxicity, injury or death as a result of an acute accidental or deliberate poisoning incident. Several initiatives are required to develop and establish analytical toxicology services. These include educational interventions to train people with required competencies; and funding to establish and equip laboratories capable of assisting clinicians with meaningful findings to guide the management of victims of poisoning incidents.

## **Author details**

Ntambwe Malangu

Address all correspondence to: gustavmalangu@gmail.com

Sefako Makgatho Health Sciences University, Pretoria, South Africa

### **References**


[4] Dybul M, Fauci AS, Bartlett JG, Kaplan JE, Pau AK. Guidelines for using antiretroviral agents among HIV-infected adults and adolescents. Recommendations of the panel on clinical practices for treatment of HIV. MMWR.Recommendations and reports: Morbidity and mortality weekly report. Recommendations and Reports. 2002;**51**(RR-7):1-55

poisons involved in a poisoning incident. This is a subject of ongoing research and it requires massive investments particularly in developing countries where funding for research is scarce. Moreover, some of the methods mentioned above such as GC, HPLC and TLC require the presence of reference chemicals to be used for the identification and quantitation of toxicants [19]. However, the availability and access to these references and other reagents pose several challenges particularly to developing countries that may not have sufficient funds to purchase

For the above reasons, newer and simpler methods, techniques, equipments, and devices that are more affordable and easy to operate are urgently required to develop and establish

Clinical toxicology and forensic toxicology share a mutually beneficial partnership; these two sciences support both the management of the patients who have been victims of poisoning; and the identification of the causative agent that may have inflicted toxicity, injury or death as a result of an acute accidental or deliberate poisoning incident. Several initiatives are required to develop and establish analytical toxicology services. These include educational interventions to train people with required competencies; and funding to establish and equip laboratories capable of assisting clinicians with meaningful findings to guide the management of

[1] WHO. Summary Tables of Mortality Estimates by Cause, Age and Sex, by Country, 2000- 2015. Available at: http://www.who.int/healthinfo/global\_burden\_disease/estimates/en/

[2] Cooper G, Negrusz A. Clarke's Analytical Forensic Toxicology. Pharmaceutical Press;

[3] Davis DA, Taylor-Vaisey A. Translating guidelines into practice: A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical

practice guidelines. Canadian Medical Association Journal.1997;**157**(4):408-416

forensic toxicology services in several developing countries.

6 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

Address all correspondence to: gustavmalangu@gmail.com

index1.html [Accessed 05-July-2015]

Sefako Makgatho Health Sciences University, Pretoria, South Africa

these products [14].

**6. Concluding remarks**

victims of poisoning incidents.

**Author details**

Ntambwe Malangu

**References**

2013


[17] Peters FT. Recent advances of liquid chromatography–(tandem) mass spectrometry in clinical and forensic toxicology. Clinical Biochemistry. 2011;**44**(1):54-65

**Section 2**

**Clinical Toxicology Topics**


**Clinical Toxicology Topics**

[17] Peters FT. Recent advances of liquid chromatography–(tandem) mass spectrometry in

[19] Maurer HH. Current role of liquid chromatography–mass spectrometry in clinical and forensic toxicology. Analytical and Bioanalytical Chemistry. 2007;**388**(7):1315-1325

clinical and forensic toxicology. Clinical Biochemistry. 2011;**44**(1):54-65

[18] Goyer RA. Metal Toxicology: Approaches and Methods. Elsevier; 2016

8 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

**Chapter 2**

**Provisional chapter**

**Poisoning by Anticoagulant Rodenticides in Humans**

Anticoagulant rodenticides (ARs) are a keystone of the management of rodent populations in the world. The widespread use of these molecules raises questions on exposure and intoxication risks, which define the safety of these products. Exposures and intoxications can affect humans, domestic animals and wildlife. Consequences are different for each group, from the simple issue of intoxication in humans to public health concern if farm animals are exposed. After a rapid presentation of the mechanism of action and the use of anticoagulant rodenticides, this chapter assesses the prominence of poisoning by

anticoagulant rodenticides in humans, domestic animals and wildlife.

**Poisoning by Anticoagulant Rodenticides in Humans** 

DOI: 10.5772/intechopen.69955

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

The management of rodents around the world is a great concern, in many aspects. Rodents are ubiquitous and opportunistic animals, some such as the brown rats (*Rattus norvegicus*) and the black rats (*Rattus rattus*) are present at all continents except Antarctic [1]. These rodent populations are an ecological and an economic issue in the islands where they are not indigenous [2]. Agriculture is also affected by rodents; in France, for instance, water voles (*Arvicola terrestris*) devastate some lands [3]. Finally, rodents are a major nuisance in cities where their proximity to and interactions with human populations and infrastructure can cause impairments and become a hazard for the public health as they are reservoirs of many diseases. In

**and Animals: Causes and Consequences**

**and Animals: Causes and Consequences**

Sébastien Lefebvre, Isabelle Fourel,

Sébastien Lefebvre, Isabelle Fourel,

Bruno Mégarbane, Etienne Benoit, Virginie Siguret and Virginie Lattard

Siguret and Virginie Lattard

**Abstract**

**1. Introduction**

http://dx.doi.org/10.5772/intechopen.69955

Stéphane Queffélec, Dominique Vodovar,

Stéphane Queffélec, Dominique Vodovar, Bruno Mégarbane, Etienne Benoit, Virginie

Additional information is available at the end of the chapter

**Keywords:** anticoagulant, rodent, poisoning

Additional information is available at the end of the chapter

**Provisional chapter**

## **Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences and Animals: Causes and Consequences**

**Poisoning by Anticoagulant Rodenticides in Humans** 

DOI: 10.5772/intechopen.69955

Sébastien Lefebvre, Isabelle Fourel, Stéphane Queffélec, Dominique Vodovar, Bruno Mégarbane, Etienne Benoit, Virginie Siguret and Virginie Lattard Stéphane Queffélec, Dominique Vodovar, Bruno Mégarbane, Etienne Benoit, Virginie Siguret and Virginie Lattard Additional information is available at the end of the chapter

Sébastien Lefebvre, Isabelle Fourel,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69955

#### **Abstract**

Anticoagulant rodenticides (ARs) are a keystone of the management of rodent populations in the world. The widespread use of these molecules raises questions on exposure and intoxication risks, which define the safety of these products. Exposures and intoxications can affect humans, domestic animals and wildlife. Consequences are different for each group, from the simple issue of intoxication in humans to public health concern if farm animals are exposed. After a rapid presentation of the mechanism of action and the use of anticoagulant rodenticides, this chapter assesses the prominence of poisoning by anticoagulant rodenticides in humans, domestic animals and wildlife.

**Keywords:** anticoagulant, rodent, poisoning

## **1. Introduction**

The management of rodents around the world is a great concern, in many aspects. Rodents are ubiquitous and opportunistic animals, some such as the brown rats (*Rattus norvegicus*) and the black rats (*Rattus rattus*) are present at all continents except Antarctic [1]. These rodent populations are an ecological and an economic issue in the islands where they are not indigenous [2]. Agriculture is also affected by rodents; in France, for instance, water voles (*Arvicola terrestris*) devastate some lands [3]. Finally, rodents are a major nuisance in cities where their proximity to and interactions with human populations and infrastructure can cause impairments and become a hazard for the public health as they are reservoirs of many diseases. In

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

China, rodents destroyed the rice stock that would be sufficient to feed 200 millions of people [4] and the estimation of the cost induced by rodents' damage is about 19 billions of dollars [5]. Many similar cases have been recorded around the world [1, 6].

To deal with these concerns, rodent populations have to be controlled. One of the most used management methods is the chemical method based on the use of anticoagulant rodenticides (ARs). Anticoagulant rodenticides (ARs) have been used since the 1940s to control rodent populations. Warfarin was the first molecule used. But after its use for more than one decade, resistant strains of rodents to ARs have emerged [7]. To deal with resistance, this first generation of ARs has been supplemented by a second generation. ARs of the second generation are frequently named 'superwarfarins' or long-acting anticoagulant rodenticides. Indeed, these molecules are more potent than the first generation due to their longer half-life, which implies longer tissue-persistence and better efficacy.

Indeed, the consequence of the widespread use of ARs and more specifically the second generation of ARs, that are more efficient and more persistent, has been an increase of the exposure risks and the intoxication risks for non-target species such as pets, wildlife as well as humans. Nevertheless, anticoagulant rodenticides are renowned as a safe method to manage rodent populations. This safety is due to their mechanism of action as well as on the implementation of good practices in their use and by the respect of related regulations. Beyond this renown, it is important to monitor the impact of using ARs regarding the risk of untargeted species poisoning and to discuss on the remaining grey area in our knowledge on anticoagulant rodenticides.

Hence, after a rapid presentation of the mechanism of action and the use of anticoagulant rodenticides, this chapter assesses the importance of the exposure and the intoxication by anticoagulant rodenticides.

## **2. Anticoagulant rodenticides**

The current anticoagulant rodenticide molecules belong to the family of vitamin K antagonist (VKA) molecules. The effects of VKAs have been observed in the 'sweet clover' poisoning of bovines, which results in a haemorrhagic disease and often the death of the animal [8–10]. Clover (*Melilotus officinalis*), used as fodder, contains coumarin a precursor of dicoumarol which is a VKA (**Figure 1E**). If clover fodders are not stored under proper conditions, fermentations may occur. These fermentations change clover coumarin in dicoumarol. Thus, clover fodder become toxic [10]. Dicoumarol was synthesised by Paul and Stahmann in 1941, opening the opportunity of use VKA as medicine and rodenticide [11]. Then other VKA molecules have been synthesised, including the famous warfarin (**Figure 1D**) and all other products that are more potent than dicoumarol [12].

The main molecules used in the rodent population management are presented in **Figure 1**. VKA molecules are derived from a coumarin (**Figure 1A**), thiocoumarin (**Figure 1B**) or 1,3-indandione (**Figure 1C**) core. The distinction of the second generation of AR from the first generation is the radical. In second generation, radical includes three benzene structures,

**Figure 1.** Chemical structure of: (A) coumarin core; (B) thiocoumarin core; (C) 1,3-indandione core; (D) warfarin; (E) dicoumarol; (F) coumatetralyl; (G) chlorophacinone; (H) bromadiolone; (I) difenacoum; (J) brodifacoum; (K) difethialone;

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences

http://dx.doi.org/10.5772/intechopen.69955

13

and (L) flocoumafen.

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences http://dx.doi.org/10.5772/intechopen.69955 13

China, rodents destroyed the rice stock that would be sufficient to feed 200 millions of people [4] and the estimation of the cost induced by rodents' damage is about 19 billions of dollars

To deal with these concerns, rodent populations have to be controlled. One of the most used management methods is the chemical method based on the use of anticoagulant rodenticides (ARs). Anticoagulant rodenticides (ARs) have been used since the 1940s to control rodent populations. Warfarin was the first molecule used. But after its use for more than one decade, resistant strains of rodents to ARs have emerged [7]. To deal with resistance, this first generation of ARs has been supplemented by a second generation. ARs of the second generation are frequently named 'superwarfarins' or long-acting anticoagulant rodenticides. Indeed, these molecules are more potent than the first generation due to their longer half-life, which implies

Indeed, the consequence of the widespread use of ARs and more specifically the second generation of ARs, that are more efficient and more persistent, has been an increase of the exposure risks and the intoxication risks for non-target species such as pets, wildlife as well as humans. Nevertheless, anticoagulant rodenticides are renowned as a safe method to manage rodent populations. This safety is due to their mechanism of action as well as on the implementation of good practices in their use and by the respect of related regulations. Beyond this renown, it is important to monitor the impact of using ARs regarding the risk of untargeted species poisoning and to discuss on the remaining grey area in our knowledge on anticoagulant rodenticides.

Hence, after a rapid presentation of the mechanism of action and the use of anticoagulant rodenticides, this chapter assesses the importance of the exposure and the intoxication by

The current anticoagulant rodenticide molecules belong to the family of vitamin K antagonist (VKA) molecules. The effects of VKAs have been observed in the 'sweet clover' poisoning of bovines, which results in a haemorrhagic disease and often the death of the animal [8–10]. Clover (*Melilotus officinalis*), used as fodder, contains coumarin a precursor of dicoumarol which is a VKA (**Figure 1E**). If clover fodders are not stored under proper conditions, fermentations may occur. These fermentations change clover coumarin in dicoumarol. Thus, clover fodder become toxic [10]. Dicoumarol was synthesised by Paul and Stahmann in 1941, opening the opportunity of use VKA as medicine and rodenticide [11]. Then other VKA molecules have been synthesised, including the famous warfarin (**Figure 1D**) and all other products that

The main molecules used in the rodent population management are presented in **Figure 1**. VKA molecules are derived from a coumarin (**Figure 1A**), thiocoumarin (**Figure 1B**) or 1,3-indandione (**Figure 1C**) core. The distinction of the second generation of AR from the first generation is the radical. In second generation, radical includes three benzene structures,

[5]. Many similar cases have been recorded around the world [1, 6].

12 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

longer tissue-persistence and better efficacy.

anticoagulant rodenticides.

**2. Anticoagulant rodenticides**

are more potent than dicoumarol [12].

**Figure 1.** Chemical structure of: (A) coumarin core; (B) thiocoumarin core; (C) 1,3-indandione core; (D) warfarin; (E) dicoumarol; (F) coumatetralyl; (G) chlorophacinone; (H) bromadiolone; (I) difenacoum; (J) brodifacoum; (K) difethialone; and (L) flocoumafen.

which increase the fat solubility of the molecules and influence their pharmacokinetic properties. In order to understand the interest of VKAs and the key issue of their safety, it is important to present their mechanism of action and their pharmacokinetics.

key factors, which determine a part of their efficiency and their persistence. The elimination pathway depends on the molecule and on its enantiomeric form [20]. For example, enantiomers of warfarin are eliminated differently. The (S)-enantiomer is metabolised exclusively by the hepatic cytochrome P450 isoform 2C9 (CYP2C9) while (R)-enantiomer is metabolised by isoforms CYP1A2, CYP2C19, CYP3A and hepatic ketoreductase [21, 22]. Although the (R)-enantiomer has a longer half-life, it is less efficient and the modulation of its elimination does not have a significant impact on the coagulation [23–25]. There is a great discrepancy between tissue persistence of first generation and second generation of ARs. First-generation molecules have tissue persistence of few days while the second generation has tissue persistence of few weeks [26]. This point is a major concern for AR

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Moreover, second-generation ARs (i.e. bromadiolone, difenacoum, brodifacoum, flocoumafen and difethialone) contain two asymmetric carbons systematically. Therefore, commercial second-generation ARs are a mixture of two diastereoisomeric forms (1R,3R)(1S,3S)-isomers and (1R,3S)(1S,3R)-isomers with different pharmacokinetic properties. For each second-generation AR, there is systematically one diastereoisomeric form with a shorter half-life than the other one (**Table 1**) [20, 27]. Proportion between stereoisomers in commercial baits is defined by regulatory documents. For example, bromadiolone must be a mixture of more than 70 of trans-isomers and fewer than 30% of cis-isomers. These differences in half-life between stereoisomers could be a fundamental point in the development of future more eco-friendly AR

The first methods used to control rodent populations aim to kill them immediately. They were based on physical traps or on rapid killer molecules like strychnine. However, the neophobic behaviour of some rodents such as rats and their social organisation make these molecules ineffective. Indeed, the precocity of symptoms or death after a bait eating by congeners induces

ecotoxicity.

with modification of regulatory defined ratios.

**Molecules T1/2 (h)** Brodifacoum cis 120.8 Brodifacoum trans 68.7 Bromadiolone cis 26.9 Bromadiolone trans 75.6 Difenacoum cis 78.3 Difenacoum trans 24.2 Difethialone cis 71.6 Difethialone trans 52.9 Flocoumafene cis 76.7 Flocoumafene trans 177.4

**Table 1.** Half-lives of some anticoagulant rodenticide enantiomers.

**2.3. Interest of anticoagulants in rodent population management**

#### **2.1. Mechanism of action**

Vitamin K antagonists (VKA) are non-competitive inhibitors of the vitamin K epoxide reductase enzyme (VKORC1) [13, 14]. This membrane enzyme of endoplasmic reticulum is responsible for the recycling of vitamin K. Vitamin K is a cofactor essential to many biotransformations of proteins and more specifically to obtain an active form of some clotting factors, the factors II, VII, IX and X. These factors, called vitamin K-dependent clotting factors, have to go through a post-translational gamma-carboxylation of their glutamate residues into gamma-carboxyglutamic acid to be able to chelate calcium and have their physiological activity [15, 16]. This reaction is done by gamma-glutamyl carboxylase (GGCX), which is another membrane enzyme of endoplasmic reticulum, and needs the oxidation of vitamin K hydroquinone to vitamin K epoxide to provide the required reducing power [17, 18]. Then VKORC1 recycles vitamin K epoxides to vitamin K hydroquinones (**Figure 2**) [19].

The amount of vitamin K provided by the majorities of food is not sufficient to offset the complete arrest of vitamin K cycle. Consequently, when VKORC1 is inhibited by VKA, a sufficient amount of vitamin K hydroquinone cannot be recycled from vitamin K epoxides to ensure the gamma-carboxylation of vitamin K-dependent proteins, and more especially the vitamin K-dependent clotting factors. Consequently, the blood concentrations of active vitamin K-dependent clotting factors decrease and lead to an increase of clotting times then, with time, to the death by haemorrhages.

#### **2.2. Pharmacokinetics properties**

Vitamin K antagonists are reputed to be highly and rapidly absorbed after *per os* administration. Then they are mainly stocked in liver. Their liver storage and their elimination are

**Figure 2.** Vitamin K cycle.

key factors, which determine a part of their efficiency and their persistence. The elimination pathway depends on the molecule and on its enantiomeric form [20]. For example, enantiomers of warfarin are eliminated differently. The (S)-enantiomer is metabolised exclusively by the hepatic cytochrome P450 isoform 2C9 (CYP2C9) while (R)-enantiomer is metabolised by isoforms CYP1A2, CYP2C19, CYP3A and hepatic ketoreductase [21, 22]. Although the (R)-enantiomer has a longer half-life, it is less efficient and the modulation of its elimination does not have a significant impact on the coagulation [23–25]. There is a great discrepancy between tissue persistence of first generation and second generation of ARs. First-generation molecules have tissue persistence of few days while the second generation has tissue persistence of few weeks [26]. This point is a major concern for AR ecotoxicity.

Moreover, second-generation ARs (i.e. bromadiolone, difenacoum, brodifacoum, flocoumafen and difethialone) contain two asymmetric carbons systematically. Therefore, commercial second-generation ARs are a mixture of two diastereoisomeric forms (1R,3R)(1S,3S)-isomers and (1R,3S)(1S,3R)-isomers with different pharmacokinetic properties. For each second-generation AR, there is systematically one diastereoisomeric form with a shorter half-life than the other one (**Table 1**) [20, 27]. Proportion between stereoisomers in commercial baits is defined by regulatory documents. For example, bromadiolone must be a mixture of more than 70 of trans-isomers and fewer than 30% of cis-isomers. These differences in half-life between stereoisomers could be a fundamental point in the development of future more eco-friendly AR with modification of regulatory defined ratios.

#### **2.3. Interest of anticoagulants in rodent population management**

which increase the fat solubility of the molecules and influence their pharmacokinetic properties. In order to understand the interest of VKAs and the key issue of their safety, it is impor-

Vitamin K antagonists (VKA) are non-competitive inhibitors of the vitamin K epoxide reductase enzyme (VKORC1) [13, 14]. This membrane enzyme of endoplasmic reticulum is responsible for the recycling of vitamin K. Vitamin K is a cofactor essential to many biotransformations of proteins and more specifically to obtain an active form of some clotting factors, the factors II, VII, IX and X. These factors, called vitamin K-dependent clotting factors, have to go through a post-translational gamma-carboxylation of their glutamate residues into gamma-carboxyglutamic acid to be able to chelate calcium and have their physiological activity [15, 16]. This reaction is done by gamma-glutamyl carboxylase (GGCX), which is another membrane enzyme of endoplasmic reticulum, and needs the oxidation of vitamin K hydroquinone to vitamin K epoxide to provide the required reducing power [17, 18]. Then VKORC1

The amount of vitamin K provided by the majorities of food is not sufficient to offset the complete arrest of vitamin K cycle. Consequently, when VKORC1 is inhibited by VKA, a sufficient amount of vitamin K hydroquinone cannot be recycled from vitamin K epoxides to ensure the gamma-carboxylation of vitamin K-dependent proteins, and more especially the vitamin K-dependent clotting factors. Consequently, the blood concentrations of active vitamin K-dependent clotting factors decrease and lead to an increase of clotting times then,

Vitamin K antagonists are reputed to be highly and rapidly absorbed after *per os* administration. Then they are mainly stocked in liver. Their liver storage and their elimination are

tant to present their mechanism of action and their pharmacokinetics.

14 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

recycles vitamin K epoxides to vitamin K hydroquinones (**Figure 2**) [19].

**2.1. Mechanism of action**

with time, to the death by haemorrhages.

**2.2. Pharmacokinetics properties**

**Figure 2.** Vitamin K cycle.

The first methods used to control rodent populations aim to kill them immediately. They were based on physical traps or on rapid killer molecules like strychnine. However, the neophobic behaviour of some rodents such as rats and their social organisation make these molecules ineffective. Indeed, the precocity of symptoms or death after a bait eating by congeners induces


**Table 1.** Half-lives of some anticoagulant rodenticide enantiomers.

bait aversion in the rodent population [28, 29]. Conversely, the time to onset of anticoagulant action is sufficient to avoid that rodents link their symptoms and death to bait eating [29].

water pollution. Nevertheless, some rodents are reluctant to enter in bait stations which might involve failing in pest control. In spite of all described elements to prevent exposures and intoxications of human and untargeted animals to ARs, many cases have been reported.

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Therefore, some recent research makes effort to implement a third generation of ARs which is based on the stereochemistry concept, which would be efficient against resistant strains of

Intoxication with anticoagulant rodenticides is a major public health concern. The involvement of poison control centres is crucial in the record of poisoning cases in both rural and urban areas. Besides, emergency departments report rare cases of intoxication by suicide or homicide. Most of these poisonings occur following accidental exposure, especially ingestion in children. Bleeding severity is highly variable, depending on the rodenticide exposure and on the delay between the exposure and patient management. The diagnosis relies on simple coagulation tests. Emergency department physicians should be aware of anticoagulant poisonings since management differs according to the anticoagulant rodenticide including war-

The incidence of poisoning with anticoagulant rodenticides is difficult to assess, mostly based on national registries. In the literature, cases associated with bleeding are published as case

In the annual report based on the US National Poison Data System and published by the American Association of Poison Control Centers, data related to long-acting superwarfarinor warfarin-type rodenticides intoxication are given separately. Over the last 5-year period (2011–2015), the cumulated number of exposures is 44,095 for long-acting superwarfarintype and 1029 for warfarin-type drugs, with a single exposure in 97.3 and 95.6% of the cases, respectively [31–35]. Interestingly, the number of reported cases has slightly decreased since 2008 (**Figure 3**) [36–38]. The mean prevalence of exposure over the last 5 years is 3.4% for longacting superwarfarin-type and 4.9% for warfarin-type drugs. The age distribution shows that children, especially those of less than 5 years old, are the most involved (**Figure 4**); only 9% of the reported cases are adults. Finally, clinical outcomes are reported (**Figure 5**). Remarkably, outcome is favourable in 93.6% of the cases, probably due to the limited ingested doses in relation to the bad taste of numerous rodenticides. The bitterness brought by the excipients in the currently marketed rodenticides considerably limits the ingested amounts, especially in young children. In cases associated with significant complications, severe bleedings are observed in less than 10% of cases, with fatal bleedings occurring in only eight patients among the 44,095 exposed patients during the last 5-year period in the USA. Overall, poisoning with

reports or small series, probably corresponding to the most severe ones.

rodenticides remains a rare cause of morbidities and fatalities [31–35].

rodents and be less persistent and thus less involved in secondary poisoning [20, 27].

**3. Human exposures and intoxications**

farin or long-acting superwarfarin types.

**3.1. Epidemiology**

Moreover, the delay and the mechanism of action of ARs are the keystone of their safety of use comparatively to other rodenticides. Indeed, the delay allows the possibility to implement a treatment after an exposure to ARs and the mechanism of action can be easily bypassed which offers an efficient and safe antidotes, the vitamin K.

Nevertheless, some issues exist with anticoagulant rodenticides, first the resistance of some population to some AR molecules. This issue has led to the creation of the second generation of ARs, which are more efficient against resistant strains [30]. However, this generation is more persistent which involves other issues. This persistence extends the duration of antidote treatment after exposure. Moreover, it entails a greater concentration of AR molecules in rodents after its death; thus, it might increase the risk of secondary poisoning of predators or scavenger animals. Consequently, to prevent poisoning of humans and animals, many actions have been implemented in the use of ARs.

#### **2.4. Prevention of poisoning**

In Europe, an anticoagulant rodenticide product can be registered either as a plant protection product or as a biocide. According to the kind of registration, restriction and modality of use are defined in order to prevent human and animal intoxication. Nevertheless, there are important differences on the modality and restriction among the European Member States. Here, we present some member state (MS) actions to prevent poisoning.

The majority of MS distinguishes the individual use of ARs and the professional use. Professional users are mainly the pest control operator, they have to be trained. In some countries like France or Italy, the sale of ARs is restricted for the individual user, thus, in France, individuals cannot buy more than 1.5 kg of AR bait. In other countries, like Germany, only trained professionals are allowed to use the second generation of ARs. Moreover, some molecules can be allowed as biocides and be forbidden as plant protection products.

The presentation of ARs is also regulated. Baits are presented as poisoned seed, paste or foam. Previously concentred products like tracking powder and oil concentrate were used but they have been forbidden in many states. Thus, concentrations of the current AR baits are of the order of few dozen to few hundred milligrams of active product per kilogram of bait. The concentration depends on the efficiency of the active molecule. The main consequence of the use of products with low concentration is that it is difficult to reach the lethal dose at once for mammal heavier than rodents such as cats, dogs or humans. Nevertheless, the high halflife of some anticoagulants allows to reach this dose after a multi-exposure. The use of a bitter agent in bait is mandatory notably to avoid and limit exposure.

Finally, to avoid the exposure of untargeted species, in many states, baits have to be placed in secured bait stations. These stations have to be labelled to inform people on their content and on the action to perform in the case of exposure. Moreover, stations avoid the dispersion of baits which allows to control the consumption and they are waterproof, which prevent water pollution. Nevertheless, some rodents are reluctant to enter in bait stations which might involve failing in pest control. In spite of all described elements to prevent exposures and intoxications of human and untargeted animals to ARs, many cases have been reported.

Therefore, some recent research makes effort to implement a third generation of ARs which is based on the stereochemistry concept, which would be efficient against resistant strains of rodents and be less persistent and thus less involved in secondary poisoning [20, 27].

## **3. Human exposures and intoxications**

Intoxication with anticoagulant rodenticides is a major public health concern. The involvement of poison control centres is crucial in the record of poisoning cases in both rural and urban areas. Besides, emergency departments report rare cases of intoxication by suicide or homicide. Most of these poisonings occur following accidental exposure, especially ingestion in children. Bleeding severity is highly variable, depending on the rodenticide exposure and on the delay between the exposure and patient management. The diagnosis relies on simple coagulation tests. Emergency department physicians should be aware of anticoagulant poisonings since management differs according to the anticoagulant rodenticide including warfarin or long-acting superwarfarin types.

#### **3.1. Epidemiology**

bait aversion in the rodent population [28, 29]. Conversely, the time to onset of anticoagulant action is sufficient to avoid that rodents link their symptoms and death to bait eating [29].

Moreover, the delay and the mechanism of action of ARs are the keystone of their safety of use comparatively to other rodenticides. Indeed, the delay allows the possibility to implement a treatment after an exposure to ARs and the mechanism of action can be easily bypassed which

Nevertheless, some issues exist with anticoagulant rodenticides, first the resistance of some population to some AR molecules. This issue has led to the creation of the second generation of ARs, which are more efficient against resistant strains [30]. However, this generation is more persistent which involves other issues. This persistence extends the duration of antidote treatment after exposure. Moreover, it entails a greater concentration of AR molecules in rodents after its death; thus, it might increase the risk of secondary poisoning of predators or scavenger animals. Consequently, to prevent poisoning of humans and animals, many actions

In Europe, an anticoagulant rodenticide product can be registered either as a plant protection product or as a biocide. According to the kind of registration, restriction and modality of use are defined in order to prevent human and animal intoxication. Nevertheless, there are important differences on the modality and restriction among the European Member States.

The majority of MS distinguishes the individual use of ARs and the professional use. Professional users are mainly the pest control operator, they have to be trained. In some countries like France or Italy, the sale of ARs is restricted for the individual user, thus, in France, individuals cannot buy more than 1.5 kg of AR bait. In other countries, like Germany, only trained professionals are allowed to use the second generation of ARs. Moreover, some mol-

The presentation of ARs is also regulated. Baits are presented as poisoned seed, paste or foam. Previously concentred products like tracking powder and oil concentrate were used but they have been forbidden in many states. Thus, concentrations of the current AR baits are of the order of few dozen to few hundred milligrams of active product per kilogram of bait. The concentration depends on the efficiency of the active molecule. The main consequence of the use of products with low concentration is that it is difficult to reach the lethal dose at once for mammal heavier than rodents such as cats, dogs or humans. Nevertheless, the high halflife of some anticoagulants allows to reach this dose after a multi-exposure. The use of a bitter

Finally, to avoid the exposure of untargeted species, in many states, baits have to be placed in secured bait stations. These stations have to be labelled to inform people on their content and on the action to perform in the case of exposure. Moreover, stations avoid the dispersion of baits which allows to control the consumption and they are waterproof, which prevent

Here, we present some member state (MS) actions to prevent poisoning.

agent in bait is mandatory notably to avoid and limit exposure.

ecules can be allowed as biocides and be forbidden as plant protection products.

offers an efficient and safe antidotes, the vitamin K.

16 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

have been implemented in the use of ARs.

**2.4. Prevention of poisoning**

The incidence of poisoning with anticoagulant rodenticides is difficult to assess, mostly based on national registries. In the literature, cases associated with bleeding are published as case reports or small series, probably corresponding to the most severe ones.

In the annual report based on the US National Poison Data System and published by the American Association of Poison Control Centers, data related to long-acting superwarfarinor warfarin-type rodenticides intoxication are given separately. Over the last 5-year period (2011–2015), the cumulated number of exposures is 44,095 for long-acting superwarfarintype and 1029 for warfarin-type drugs, with a single exposure in 97.3 and 95.6% of the cases, respectively [31–35]. Interestingly, the number of reported cases has slightly decreased since 2008 (**Figure 3**) [36–38]. The mean prevalence of exposure over the last 5 years is 3.4% for longacting superwarfarin-type and 4.9% for warfarin-type drugs. The age distribution shows that children, especially those of less than 5 years old, are the most involved (**Figure 4**); only 9% of the reported cases are adults. Finally, clinical outcomes are reported (**Figure 5**). Remarkably, outcome is favourable in 93.6% of the cases, probably due to the limited ingested doses in relation to the bad taste of numerous rodenticides. The bitterness brought by the excipients in the currently marketed rodenticides considerably limits the ingested amounts, especially in young children. In cases associated with significant complications, severe bleedings are observed in less than 10% of cases, with fatal bleedings occurring in only eight patients among the 44,095 exposed patients during the last 5-year period in the USA. Overall, poisoning with rodenticides remains a rare cause of morbidities and fatalities [31–35].

**3.2. Clinical outcomes and laboratory diagnosis**

plasma by specific assays [42, 45, 50].

**3.3. Principles of poisoning management**

The threat in poisoning with rodenticides is the onset of severe bleeding. In humans like in rodents, anticoagulant rodenticides inhibit the enzyme vitamin K epoxide reductase complex (VKORC1) leading to the absence of vitamin K recycling, which is essential for the gammacarboxylation of vitamin K-dependent proteins in the hepatocytes, especially clotting prothrombin, factors VII, IX and X. This leads to impaired functioning of gamma-carboxylated vitamin-K-dependent factors due to their inability to bind activated platelets. Given the halflives of coagulation in humans, i.e. from 6 hours for FVII to ~60 hours for prothrombin, the onset of hypocoagulability and the risk of bleeding are delayed after the exposure to rodenticides. The risk of bleeding depends on the severity of the hypocoagulability state induced by rodenticides and on the duration of hypocoagulability. The spectrum of bleeding is wide: extended unexplained spontaneous ecchymosis, epistaxis, hematoma, bleeding from the gastro-intestinal or the genitourinary tract as well as intra-cerebral bleeding are reported [39–46]. The diagnosis of rodenticide intoxication has to be considered for any patient with prolonged prothrombin time (increased INR), prolonged activated partial prothrombin time; the vitamin K-dependent factor II, VII, X, IX coagulant activities are decreased while factor V coagulant activity and the fibrinogen level are normal [41, 43, 47, 48]. Liver dysfunction, cholestasis and severe starvation can be ruled out by normal liver enzymes and serum albumin concentration. Moderate to severe anaemia can be present, depending on the severity of bleeding. Special attention and high clinical suspicion are required in patients with apparent negative history of warfarin treatment. The diagnosis of rodenticide intoxication should be suspected when the international normalised ratio (INR) strongly fluctuates on vitamin K therapy, especially while high doses of vitamin K are required. The accessibility to anticoagulant rodenticides should be checked; monitoring of persons who deal with rodenticides in their home or workplace, especially those suffering from dementia or psychiatric disorders, is necessary [49]. The intoxication can be confirmed by the identification and measurement of the rodenticides in

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences

http://dx.doi.org/10.5772/intechopen.69955

19

Acute life-threatening complications can be prevented with timely intervention. Immediate administration of high doses of phytomenadione (vitamin K1) and/or factor prothrombin complex concentrate (30 UI/kg FIX) can successfully reverse the anticoagulant effects of anticoagulant rodenticides. With tissue half-lives estimated at between 16 and 220 days, reversal of superwarfarin toxicity is a long-term issue. Therefore, long-term daily treatment for several weeks of phytomenadione is necessary. Treatment courses averaged 168 days. To avoid re-bleeding, close monitoring of INR is necessary. Adjunctive haemostatic therapy with

recombinant factor VIIa and prothrombin complex concentrate has been used [50–54].

To assess the importance of animal intoxications, it is important to discriminate two situations: the domestic animals and the wildlife. Concerning wildlife, the evaluations of exposures

**4. Overview on animal exposures and intoxications**

**Figure 3.** Number of poisonings with anticoagulant rodenticides reported by the American Association of Poison Control Centers from 2008 to 2015. Black bars: intoxications with long-acting anticoagulant-type rodenticides; grey bars: intoxications with warfarin-type rodenticides.

**Figure 4.** Distribution of the cases of poisoning with anticoagulant rodenticides reported by the American Association of Poison Control Centers in 2011–2015 according to the patient age.

**Figure 5.** Distribution of the cases of poisoning with anticoagulant rodenticides reported by the American Association of Poison Control Centers in 2011–2015 according to the outcome.

#### **3.2. Clinical outcomes and laboratory diagnosis**

The threat in poisoning with rodenticides is the onset of severe bleeding. In humans like in rodents, anticoagulant rodenticides inhibit the enzyme vitamin K epoxide reductase complex (VKORC1) leading to the absence of vitamin K recycling, which is essential for the gammacarboxylation of vitamin K-dependent proteins in the hepatocytes, especially clotting prothrombin, factors VII, IX and X. This leads to impaired functioning of gamma-carboxylated vitamin-K-dependent factors due to their inability to bind activated platelets. Given the halflives of coagulation in humans, i.e. from 6 hours for FVII to ~60 hours for prothrombin, the onset of hypocoagulability and the risk of bleeding are delayed after the exposure to rodenticides. The risk of bleeding depends on the severity of the hypocoagulability state induced by rodenticides and on the duration of hypocoagulability. The spectrum of bleeding is wide: extended unexplained spontaneous ecchymosis, epistaxis, hematoma, bleeding from the gastro-intestinal or the genitourinary tract as well as intra-cerebral bleeding are reported [39–46].

The diagnosis of rodenticide intoxication has to be considered for any patient with prolonged prothrombin time (increased INR), prolonged activated partial prothrombin time; the vitamin K-dependent factor II, VII, X, IX coagulant activities are decreased while factor V coagulant activity and the fibrinogen level are normal [41, 43, 47, 48]. Liver dysfunction, cholestasis and severe starvation can be ruled out by normal liver enzymes and serum albumin concentration. Moderate to severe anaemia can be present, depending on the severity of bleeding. Special attention and high clinical suspicion are required in patients with apparent negative history of warfarin treatment. The diagnosis of rodenticide intoxication should be suspected when the international normalised ratio (INR) strongly fluctuates on vitamin K therapy, especially while high doses of vitamin K are required. The accessibility to anticoagulant rodenticides should be checked; monitoring of persons who deal with rodenticides in their home or workplace, especially those suffering from dementia or psychiatric disorders, is necessary [49]. The intoxication can be confirmed by the identification and measurement of the rodenticides in plasma by specific assays [42, 45, 50].

#### **3.3. Principles of poisoning management**

**Figure 5.** Distribution of the cases of poisoning with anticoagulant rodenticides reported by the American Association of

**Figure 3.** Number of poisonings with anticoagulant rodenticides reported by the American Association of Poison Control Centers from 2008 to 2015. Black bars: intoxications with long-acting anticoagulant-type rodenticides; grey bars:

18 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

**Figure 4.** Distribution of the cases of poisoning with anticoagulant rodenticides reported by the American Association of

Poison Control Centers in 2011–2015 according to the outcome.

Poison Control Centers in 2011–2015 according to the patient age.

intoxications with warfarin-type rodenticides.

Acute life-threatening complications can be prevented with timely intervention. Immediate administration of high doses of phytomenadione (vitamin K1) and/or factor prothrombin complex concentrate (30 UI/kg FIX) can successfully reverse the anticoagulant effects of anticoagulant rodenticides. With tissue half-lives estimated at between 16 and 220 days, reversal of superwarfarin toxicity is a long-term issue. Therefore, long-term daily treatment for several weeks of phytomenadione is necessary. Treatment courses averaged 168 days. To avoid re-bleeding, close monitoring of INR is necessary. Adjunctive haemostatic therapy with recombinant factor VIIa and prothrombin complex concentrate has been used [50–54].

### **4. Overview on animal exposures and intoxications**

To assess the importance of animal intoxications, it is important to discriminate two situations: the domestic animals and the wildlife. Concerning wildlife, the evaluations of exposures and intoxications are often realised during focused scientific campaign and are often based on contamination studies or after an important mortality in wildlife. In domestic animal, besides the scientific campaign, there are, in some countries, animal specialised poison control centres, which can provide data on exposure, intoxications and linked symptoms.

In this part, it is important to take account of the differences between exposure and intoxication. Concerning exposure, it is the fact to take a dose of anticoagulants, it can be suspected by an owner who sees its animal eating baits, sometimes without knowing what the active substance is, or find in wildlife by pinpointing the presence of VKA in the sample. Intoxication is when the active substance induced clinical signs. This distinction is fundamental in the study of VKA toxicology. Indeed, to observe intoxication, the exposure dose and the delay of action has to be sufficient. This issue is discussed further concerning the wildlife exposure/intoxication studies.

#### **4.1. Domestic animals**

In France, two control poison centres are specialised in animals. The most important in terms of call number is the 'Centre National d' Informations Toxicologiques Vétérinaires (CNITV)' which responds to questions from owners or veterinarians on a 24-hour/7 day basis. We used this important database to assess the importance of VKA exposures and intoxications in domestic animals.

The data of the last 9 years have been analysed. During this period, the CNITV has received about 150,000 calls. Each month, 10.73% (CI 10.41-11.06) of solicitations are about VKA exposure or intoxication. Moreover, about whole VKA appeal is on domestic animals (99.2%). Appeals accrue from veterinary (69%) and owner (29%) mainly.

During the analysis of data, an important seasonality of the calls concerning VKAs has been pinpointed (**Figure 6**). Significant (*p* < 0.05) increases of the number of calls for VKA exposure are observed during the months of August, September and October followed by a significant decrease of appeal numbers from December to April, which is surprising. Indeed, based on our experience, the periods when people apply rodenticides in cities are at the beginning of winter (late November) and at the beginning of spring (March), when rodents are active and when the scarcity of food encourages rodents to eat baits. Conversely, during summer and the beginning of autumn, rodents can find many sources of food; consequently, they are less likely to eat baits, which increase the risk that baits are eaten by untargeted animals, notably dogs. However, summer is also the time when there is less human in cities and this element with a lenient weather encourages the presence of rodents outside where they are more visible. In response, cities and individuals might increase the number of baits, which is unfavourable for the rodent population management and rocket up the risk of pet exposures to VKA.

Pets and more specifically dogs are over represented (**Figure 7**). This might be explained by the lack of use of secured bait station by private individuals and by the behaviour of dogs. Poisoning is mainly accidental even if some malicious poisoning are reported (2.03%). The proportion of suspected malicious case concerning cats is significantly higher than for the general case. Indeed, cats and dogs represent, respectively, 19.14 and 63.64% of malicious reports. These uses of anticoagulant rodenticides with harmful intent against animals but also against humans have led to restrict the sale of rodenticides in some countries such as

**Figure 6.** (A): Evolution of monthly calls for VKA exposure over time. Grey curve is the running means over 5 months. Dark lines are linear regression from January 2008 to September 2013 and from September 2013 to February 2017. (B) Variation of the number of calls for VKA exposure with the precedent month, values are represented as the mean of

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences

http://dx.doi.org/10.5772/intechopen.69955

21

observed variations for the concerned month over the period 2008–2016 and its 95% confidence interval.

Concerning molecules, in 22% of calls, the exact molecule is not identified. Nevertheless, exposures or intoxications with one of the six molecules authorised are reported, they are difenacoum, difethialone, brodifacoum, bromadiolone, chlorophacinone and coumatetralyl, which represent, respectively, 23, 18, 10, 9, 3 and 2% of the calls for AR. It is significant that the four main anticoagulants are second-generation ARs. This was predictable because firstgeneration ARs are less efficient on resistant strains of rodents consequently main ARs sold

Italy [55].

belong to the second generation.

More generally, data pinpoint a trend reversal; before September 2013, the number of cases has significantly increased with a slope of 3.9% per annum (*p* < 0.0001) whereas after this date it has significantly decreased of 10.5% per annum (*p* < 0.0001). The increase trend has to be relativised as the total number of calls significantly increases during this period. However, after 2013, the total number of calls was stable (*p* = 0.13). Consequently, a significant decrease in the number of calls for VKAs after 2013 is confirmed. We hypothesise that the source of this diminution is the evolution of the regulation. Indeed, regulation has enforced the use of secured bait station since 2013, which seems to reduce the exposure of domestic species.

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences http://dx.doi.org/10.5772/intechopen.69955 21

and intoxications are often realised during focused scientific campaign and are often based on contamination studies or after an important mortality in wildlife. In domestic animal, besides the scientific campaign, there are, in some countries, animal specialised poison control centres, which can provide data on exposure, intoxications and linked symptoms.

20 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

In this part, it is important to take account of the differences between exposure and intoxication. Concerning exposure, it is the fact to take a dose of anticoagulants, it can be suspected by an owner who sees its animal eating baits, sometimes without knowing what the active substance is, or find in wildlife by pinpointing the presence of VKA in the sample. Intoxication is when the active substance induced clinical signs. This distinction is fundamental in the study of VKA toxicology. Indeed, to observe intoxication, the exposure dose and the delay of action has to be sufficient. This issue is discussed further concerning the wildlife exposure/intoxication studies.

In France, two control poison centres are specialised in animals. The most important in terms of call number is the 'Centre National d' Informations Toxicologiques Vétérinaires (CNITV)' which responds to questions from owners or veterinarians on a 24-hour/7 day basis. We used this important database to assess the importance of VKA exposures and intoxications in

The data of the last 9 years have been analysed. During this period, the CNITV has received about 150,000 calls. Each month, 10.73% (CI 10.41-11.06) of solicitations are about VKA exposure or intoxication. Moreover, about whole VKA appeal is on domestic animals (99.2%).

During the analysis of data, an important seasonality of the calls concerning VKAs has been pinpointed (**Figure 6**). Significant (*p* < 0.05) increases of the number of calls for VKA exposure are observed during the months of August, September and October followed by a significant decrease of appeal numbers from December to April, which is surprising. Indeed, based on our experience, the periods when people apply rodenticides in cities are at the beginning of winter (late November) and at the beginning of spring (March), when rodents are active and when the scarcity of food encourages rodents to eat baits. Conversely, during summer and the beginning of autumn, rodents can find many sources of food; consequently, they are less likely to eat baits, which increase the risk that baits are eaten by untargeted animals, notably dogs. However, summer is also the time when there is less human in cities and this element with a lenient weather encourages the presence of rodents outside where they are more visible. In response, cities and individuals might increase the number of baits, which is unfavourable for the rodent population management and rocket up the risk of pet exposures to VKA. More generally, data pinpoint a trend reversal; before September 2013, the number of cases has significantly increased with a slope of 3.9% per annum (*p* < 0.0001) whereas after this date it has significantly decreased of 10.5% per annum (*p* < 0.0001). The increase trend has to be relativised as the total number of calls significantly increases during this period. However, after 2013, the total number of calls was stable (*p* = 0.13). Consequently, a significant decrease in the number of calls for VKAs after 2013 is confirmed. We hypothesise that the source of this diminution is the evolution of the regulation. Indeed, regulation has enforced the use of secured bait station since 2013, which seems to reduce the exposure of domestic species.

Appeals accrue from veterinary (69%) and owner (29%) mainly.

**4.1. Domestic animals**

domestic animals.

**Figure 6.** (A): Evolution of monthly calls for VKA exposure over time. Grey curve is the running means over 5 months. Dark lines are linear regression from January 2008 to September 2013 and from September 2013 to February 2017. (B) Variation of the number of calls for VKA exposure with the precedent month, values are represented as the mean of observed variations for the concerned month over the period 2008–2016 and its 95% confidence interval.

Pets and more specifically dogs are over represented (**Figure 7**). This might be explained by the lack of use of secured bait station by private individuals and by the behaviour of dogs. Poisoning is mainly accidental even if some malicious poisoning are reported (2.03%). The proportion of suspected malicious case concerning cats is significantly higher than for the general case. Indeed, cats and dogs represent, respectively, 19.14 and 63.64% of malicious reports. These uses of anticoagulant rodenticides with harmful intent against animals but also against humans have led to restrict the sale of rodenticides in some countries such as Italy [55].

Concerning molecules, in 22% of calls, the exact molecule is not identified. Nevertheless, exposures or intoxications with one of the six molecules authorised are reported, they are difenacoum, difethialone, brodifacoum, bromadiolone, chlorophacinone and coumatetralyl, which represent, respectively, 23, 18, 10, 9, 3 and 2% of the calls for AR. It is significant that the four main anticoagulants are second-generation ARs. This was predictable because firstgeneration ARs are less efficient on resistant strains of rodents consequently main ARs sold belong to the second generation.

in plasma is often associated with false-negatives. The dosing of VKA in faeces seems to be

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences

http://dx.doi.org/10.5772/intechopen.69955

23

As there is not any well-described toxicity dose, it is important to follow the possible effect of AR in order to prevent serious intoxication. Moreover, there is no correlation between the dose of VKA and the symptom severity [57]. Today, the gold standard to diagnose VKA intoxication is the prothrombin time [58]. It is advised realising a prothrombin time about 48 hours after the suspected exposure [59]. If the prothrombin time is elevated then a treatment has to be initiated. Other methods such as vitamin K clotting factor concentration measurement are explored to detect AR effects sooner. Factor VII seems to be a good candidate as its

If no treatment is given, symptoms may appear after 2–6 days [57, 58]. Symptoms are the classic signs of coagulopathy, which may be pinpointed by owner as bleeding, pale mucous membrane, haematomas, haematuria or haematemesis as well as their consequences on animal general condition as lameness, depression or lethargy [57, 58, 61]. Owing to intrathoracic

Animals exposed with an elevation of prothrombin time after exposure or with AR-linked

of the VKA inhibition depends on the pharmacokinetics of AR molecule with huge differences between molecules. Thus, the duration of treatment after an exposure to the first-generation AR is estimated to 3 weeks versus 5–7 for the second generation. Nevertheless, there is a lack of studies to support these durations of treatment. Thus, a treatment can be initiated during at least 1 month then stopped during 48 hours. After 2 days of treatment discontinuation, the vitamin K regeneration mechanism can be assessed by measuring prothrombin time. If prothrombin time is elevated, treatment has to be replicated until a new assessment of regen-

intoxication. The treatment of symptomatic animals may require fresh plasma to reconstitute the pool of clotting factors urgently, moreover, in this case, it is recommended initiating the vitamin K treatment by an intravenous administration. If there is a proper compliance of the

In farm animals, when an AR exposure occurs, the safety of the product has to be considered. Little information is available on the contamination of food following AR exposure. Nevertheless, many methods have been implemented to assess the residues in foodstuffs [65, 66]. Concerning meat, it has been shown that VKA molecules are present in muscle after exposure and that the cooking does not influence their activities [67]. Likewise, VKA molecules are also present in eggs after hen exposure, and are still detected in eggs 14 days after exposure [68]. Concerning the milk, it has been observed an excretion of VKA in human milk when a VKA is used as medication for the mother [69]. Consequently, it might be supposed that the same occurs in animals. Thus, when an animal is exposed, its litter should be separated of its mother and fed with relevant artificial milk. If separation is not possible or

provided by an exposed animal, their management would be done in accordance with rel-

supplementation as long as the recycling mechanism is

is inefficient to treat VKA

. Concerning foodstuffs

is given *per os* daily with a dose of 5 mg/kg of body weight. The duration

bleeding, respiratory distress occurs frequently in anticoagulant intoxications [62–64].

more reliable with an excretion that can be detected for several weeks.

half-life after a VKA administration is the shorter [60].

eration mechanism else, the treatment can be arrested. Vitamin K<sup>3</sup>

if diagnostic is late, litter should be supplemented with vitamin K<sup>1</sup>

vitamin K treatment, the prognostic is excellent [57].

symptoms have to receive vitamin K<sup>1</sup>

inhibited. Vitamin K<sup>1</sup>

evant authority.

**Figure 7.** Percentage of species concerned by calls on VKA.

The consequences of an exposure without intoxication are completely different for pets and farm animals. Indeed, for pets when an exposure occurs, the aim is to prevent intoxication. In farm animals, more than intoxication prevention, the presence of anticoagulant molecules in products such as meat, eggs or milk has to be considered. Further, we discuss issues of ARs in pets then in farm animals.

In pets, depending on caller, the circumstances of appeal are different. Indeed, 90% of calls from individuals report exposure without intoxication, whereas the proportion of this circumstance drops significantly to 75% when it is a call from a veterinary (*p* < 0.0001). This can be easily understood, if an animal shows a symptom, the owner priority is to bring it to the veterinarian to be healed. Differences according to species are also pinpointed. In dogs, 81% of calls for AR exposure do not report symptoms versus 62% in cats (*p* < 0.0001). The source of this distinction may be the detection of the exposure, which is earlier in dogs. Moreover, cats may be more prone to be secondary exposed to ARs from intoxicated rodents and this kind of exposure is not visible by the owner. It should be noted that according to the low doses of bait and to the difference between the toxic doses for a rodent versus a cat, a large number of intoxicated rodents should be eaten to induce intoxication.

In dogs and cats, when an exposure is suspected and when it is possible, the best way to prevent intoxication is to induce vomiting in the first hour after the exposure. If medicines are not available, it is possible to use 10 volume hydrogen peroxide. Hydrogen peroxide solution can be given orally to animals at 1 mL for every 5 kg of weight. Be careful, salt must not be used to induce vomiting. Indeed, excess of salt can cause fatal hypernatremia [56].

Sometimes, even the exposure is uncertain or the absorption of VKA after vomiting is unknown, to confirm exposure, two means are currently tested by our team: the dosing of VKAs in plasma and their dosing in faeces. The difficulty of dosing in plasma is that for some VKAs, the presence in the plasma is temporary then VKAs are stored in liver. Therefore, dosing in plasma is often associated with false-negatives. The dosing of VKA in faeces seems to be more reliable with an excretion that can be detected for several weeks.

As there is not any well-described toxicity dose, it is important to follow the possible effect of AR in order to prevent serious intoxication. Moreover, there is no correlation between the dose of VKA and the symptom severity [57]. Today, the gold standard to diagnose VKA intoxication is the prothrombin time [58]. It is advised realising a prothrombin time about 48 hours after the suspected exposure [59]. If the prothrombin time is elevated then a treatment has to be initiated. Other methods such as vitamin K clotting factor concentration measurement are explored to detect AR effects sooner. Factor VII seems to be a good candidate as its half-life after a VKA administration is the shorter [60].

If no treatment is given, symptoms may appear after 2–6 days [57, 58]. Symptoms are the classic signs of coagulopathy, which may be pinpointed by owner as bleeding, pale mucous membrane, haematomas, haematuria or haematemesis as well as their consequences on animal general condition as lameness, depression or lethargy [57, 58, 61]. Owing to intrathoracic bleeding, respiratory distress occurs frequently in anticoagulant intoxications [62–64].

Animals exposed with an elevation of prothrombin time after exposure or with AR-linked symptoms have to receive vitamin K<sup>1</sup> supplementation as long as the recycling mechanism is inhibited. Vitamin K<sup>1</sup> is given *per os* daily with a dose of 5 mg/kg of body weight. The duration of the VKA inhibition depends on the pharmacokinetics of AR molecule with huge differences between molecules. Thus, the duration of treatment after an exposure to the first-generation AR is estimated to 3 weeks versus 5–7 for the second generation. Nevertheless, there is a lack of studies to support these durations of treatment. Thus, a treatment can be initiated during at least 1 month then stopped during 48 hours. After 2 days of treatment discontinuation, the vitamin K regeneration mechanism can be assessed by measuring prothrombin time. If prothrombin time is elevated, treatment has to be replicated until a new assessment of regeneration mechanism else, the treatment can be arrested. Vitamin K<sup>3</sup> is inefficient to treat VKA intoxication. The treatment of symptomatic animals may require fresh plasma to reconstitute the pool of clotting factors urgently, moreover, in this case, it is recommended initiating the vitamin K treatment by an intravenous administration. If there is a proper compliance of the vitamin K treatment, the prognostic is excellent [57].

The consequences of an exposure without intoxication are completely different for pets and farm animals. Indeed, for pets when an exposure occurs, the aim is to prevent intoxication. In farm animals, more than intoxication prevention, the presence of anticoagulant molecules in products such as meat, eggs or milk has to be considered. Further, we discuss issues of ARs

In pets, depending on caller, the circumstances of appeal are different. Indeed, 90% of calls from individuals report exposure without intoxication, whereas the proportion of this circumstance drops significantly to 75% when it is a call from a veterinary (*p* < 0.0001). This can be easily understood, if an animal shows a symptom, the owner priority is to bring it to the veterinarian to be healed. Differences according to species are also pinpointed. In dogs, 81% of calls for AR exposure do not report symptoms versus 62% in cats (*p* < 0.0001). The source of this distinction may be the detection of the exposure, which is earlier in dogs. Moreover, cats may be more prone to be secondary exposed to ARs from intoxicated rodents and this kind of exposure is not visible by the owner. It should be noted that according to the low doses of bait and to the difference between the toxic doses for a rodent versus a cat, a large number of

In dogs and cats, when an exposure is suspected and when it is possible, the best way to prevent intoxication is to induce vomiting in the first hour after the exposure. If medicines are not available, it is possible to use 10 volume hydrogen peroxide. Hydrogen peroxide solution can be given orally to animals at 1 mL for every 5 kg of weight. Be careful, salt must not be used

Sometimes, even the exposure is uncertain or the absorption of VKA after vomiting is unknown, to confirm exposure, two means are currently tested by our team: the dosing of VKAs in plasma and their dosing in faeces. The difficulty of dosing in plasma is that for some VKAs, the presence in the plasma is temporary then VKAs are stored in liver. Therefore, dosing

to induce vomiting. Indeed, excess of salt can cause fatal hypernatremia [56].

in pets then in farm animals.

**Figure 7.** Percentage of species concerned by calls on VKA.

22 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

intoxicated rodents should be eaten to induce intoxication.

In farm animals, when an AR exposure occurs, the safety of the product has to be considered. Little information is available on the contamination of food following AR exposure. Nevertheless, many methods have been implemented to assess the residues in foodstuffs [65, 66]. Concerning meat, it has been shown that VKA molecules are present in muscle after exposure and that the cooking does not influence their activities [67]. Likewise, VKA molecules are also present in eggs after hen exposure, and are still detected in eggs 14 days after exposure [68]. Concerning the milk, it has been observed an excretion of VKA in human milk when a VKA is used as medication for the mother [69]. Consequently, it might be supposed that the same occurs in animals. Thus, when an animal is exposed, its litter should be separated of its mother and fed with relevant artificial milk. If separation is not possible or if diagnostic is late, litter should be supplemented with vitamin K<sup>1</sup> . Concerning foodstuffs provided by an exposed animal, their management would be done in accordance with relevant authority.

#### **4.2. Wildlife exposures and intoxication**

Wildlife expositions or intoxications to ARs have been reported around the world for many mammals such as minks [70], bobcats [71], stoats and weasels [72], foxes [73, 74] and boars [67] and as well for many birds [75–77]. Exposition of fish was reported near an island where an eradication of rodent with brodifacoum was performed and the risk for human through the consumption appeared very low [78].

[84]. According to these criteria, hepatic concentrations above 0.2 mg/kg have been associated with mortalities in raptors and small mustelids from Denmark [85], in raptors and hedgehogs from Mediterranean region of Spain [86], in six raptor species from Canary Islands, Spain [77].

Poisoning by Anticoagulant Rodenticides in Humans and Animals: Causes and Consequences

http://dx.doi.org/10.5772/intechopen.69955

25

It is difficult to discriminate a simple exposition and intoxication in wildlife. Indeed, as well as in domestic animal, toxic doses are not well described for all species. Moreover, the majorities of exposition studies are performed on dead animal, and as the lesion induced by ARs is not specific, so it might be difficult to conclude to its implications. Less than 10% of exposed and dead birds have been confirmed to be intoxicated by ARs [1, 87]. Currently, there are no reports of a significant incidence of ARs on non-targeted species populations [82]. Nevertheless, impact of ARs on wildlife has to be more monitored in order to limit the impact of rodent population management. The probable future design of eco-friendly baits with new isomer ratio will change the need the way AR hepatic residues are monitored. The recently described multi-residue LC-MS/MS method [88] is an appropriate tool to start investigating second-generation AR diastereoisomer proportions in non-target wildlife and to evaluate

Anticoagulant rodenticides are a keystone of the rodent population management. Like other poisons, there is a risk of human or non-targeted species poisoning. The wide use of anticoagulant rodenticides near human living space and agriculture space involves an important exposure of humans and domestic animals. Nevertheless, since few years, many risk mitigation measures have been taken and the number of exposure in humans and domestic animals has decreased. Moreover, in contrast to the majority of chemical biocide, anticoagulant rodenticides have an effective antidote, the vitamin K. Consequently, anticoagulant poisoning is rarely fatal. However, the impact of anticoagulant rodenticides on wildlife is least well known

, Stéphane Queffélec<sup>2</sup>

2 Centre National d'Informations Toxicologiques Vétérinaires (CNITV), Marcy l'étoile, France 3 Université Paris Descartes, INSERM UMR-S1140 and Service d'hématologie biologique, Hôpital

4 Université Paris-Diderot, INSERM UMRS-1144 and Réanimation Médicale et Toxicologique,

, Virginie Siguret3

, Dominique Vodovar<sup>4</sup>

and Virginie Lattard<sup>1</sup>

,

\*

their respective persistence in predators.

and deserves more investigation.

Lariboisière (AP-HP), Paris, France

Hôpital Lariboisière (AP-HP), Paris, France

, Isabelle Fourel<sup>1</sup>

\*Address all correspondence to: virginie.lattard@vetagro-sup.fr

1 USC 1233 RS2GP, VetAgro Sup, INRA, Univ Lyon, Marcy l'étoile, France

, Etienne Benoit<sup>1</sup>

**5. Conclusion**

**Author details**

Sébastien Lefebvre<sup>1</sup>

Bruno Mégarbane<sup>4</sup>

These intoxications may be primary when non-target species eat directly the bait. It is the case when baits are directly available without protection or when they are washed away and diluted in sea or river. In Spain, a study on water and soil samples revealed no imminent environmental risk in treated areas with chlorophacinone and brodifacoum [79]. However, the use of secured bait stations prevents this kind of exposition.

The secondary exposition occurs when a scavenger or a predator eats an exposed rodent. It is the most described exposition of wildlife to ARs and the most difficult to prevent. Many factors may influence the level of secondary exposition. First, due to the bait appetence, rodents can eat more AR than necessary to lead to their death, which might increase their concentration in AR. Moreover, if rodent is resistant to ARs, this phenomenon might be amplified. Indeed, a resistant rodent eats twice to fivefold more AR than susceptible rodent [1]. After the onset of symptoms in rodents, their behaviour evolves. They increase their activity during the day and stay longer in uncovered area, which enhances the risk to be hunted by predators [1]. The delayed action of ARs, inherent to its mechanism, allows rodents to eat several times the LD50 dose between the first bait intake and the death [1] and may as well increase the risk of secondary exposition. Pesticide usage has been correlated with non-target wildlife exposition [74, 75], and the intensity of treatment was related to incidence on local fox populations in France [80]. Finally, the diet is certainly going to influence secondary exposition and species like raptors, foxes and mustelids largely feeding on rodents when abundant are consequently the most at risk, as demonstrated for the red kite (Milvus milvus) [81]. The removal of visible rodent bodies helps to reduce the risk of secondary exposition [82] but is not always possible because of landscape limited access and in the case of aerial application [1]. Mitigation measures have been considered to protect predatory species but new approaches are still required [82].

Persistence and toxicity of the molecule are key factors. They depend on the used active ingredient [26, 83]. Historically, second-generation ARs had been designed to be more persistent and toxic on resistant strain. Thus, secondary poisonings of wildlife associated with the use of second generation are more often reported. But the development of new ARs recently proposed is based on the stereochemistry of second-generation ARs with reduced persistence but equivalent toxicity might greatly decrease the level of secondary exposition [20].

They are two types of consequences of the exposition of wildlife to ARs. First, if the species is eaten by human [67, 78], the consequences are comparable to those discussed for farm animals. Second, if the exposition is sufficiently important, it might lead to intoxication of the animals and to its death, which can be problematic mainly for endangered species. The rate of exposure of non-target species has often been evaluated, and summed liver concentrations above a limit of 0.2 mg/kg associated with clinical signs (i.e. macroscopic haemorrhages with no trauma) have been statistically characterised as representative of a high-risk toxic threshold [84]. According to these criteria, hepatic concentrations above 0.2 mg/kg have been associated with mortalities in raptors and small mustelids from Denmark [85], in raptors and hedgehogs from Mediterranean region of Spain [86], in six raptor species from Canary Islands, Spain [77].

It is difficult to discriminate a simple exposition and intoxication in wildlife. Indeed, as well as in domestic animal, toxic doses are not well described for all species. Moreover, the majorities of exposition studies are performed on dead animal, and as the lesion induced by ARs is not specific, so it might be difficult to conclude to its implications. Less than 10% of exposed and dead birds have been confirmed to be intoxicated by ARs [1, 87]. Currently, there are no reports of a significant incidence of ARs on non-targeted species populations [82]. Nevertheless, impact of ARs on wildlife has to be more monitored in order to limit the impact of rodent population management. The probable future design of eco-friendly baits with new isomer ratio will change the need the way AR hepatic residues are monitored. The recently described multi-residue LC-MS/MS method [88] is an appropriate tool to start investigating second-generation AR diastereoisomer proportions in non-target wildlife and to evaluate their respective persistence in predators.

## **5. Conclusion**

**4.2. Wildlife exposures and intoxication**

the consumption appeared very low [78].

the use of secured bait stations prevents this kind of exposition.

24 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

Wildlife expositions or intoxications to ARs have been reported around the world for many mammals such as minks [70], bobcats [71], stoats and weasels [72], foxes [73, 74] and boars [67] and as well for many birds [75–77]. Exposition of fish was reported near an island where an eradication of rodent with brodifacoum was performed and the risk for human through

These intoxications may be primary when non-target species eat directly the bait. It is the case when baits are directly available without protection or when they are washed away and diluted in sea or river. In Spain, a study on water and soil samples revealed no imminent environmental risk in treated areas with chlorophacinone and brodifacoum [79]. However,

The secondary exposition occurs when a scavenger or a predator eats an exposed rodent. It is the most described exposition of wildlife to ARs and the most difficult to prevent. Many factors may influence the level of secondary exposition. First, due to the bait appetence, rodents can eat more AR than necessary to lead to their death, which might increase their concentration in AR. Moreover, if rodent is resistant to ARs, this phenomenon might be amplified. Indeed, a resistant rodent eats twice to fivefold more AR than susceptible rodent [1]. After the onset of symptoms in rodents, their behaviour evolves. They increase their activity during the day and stay longer in uncovered area, which enhances the risk to be hunted by predators [1]. The delayed action of ARs, inherent to its mechanism, allows rodents to eat several times the LD50 dose between the first bait intake and the death [1] and may as well increase the risk of secondary exposition. Pesticide usage has been correlated with non-target wildlife exposition [74, 75], and the intensity of treatment was related to incidence on local fox populations in France [80]. Finally, the diet is certainly going to influence secondary exposition and species like raptors, foxes and mustelids largely feeding on rodents when abundant are consequently the most at risk, as demonstrated for the red kite (Milvus milvus) [81]. The removal of visible rodent bodies helps to reduce the risk of secondary exposition [82] but is not always possible because of landscape limited access and in the case of aerial application [1]. Mitigation measures have been considered to protect predatory species but new approaches are still required [82].

Persistence and toxicity of the molecule are key factors. They depend on the used active ingredient [26, 83]. Historically, second-generation ARs had been designed to be more persistent and toxic on resistant strain. Thus, secondary poisonings of wildlife associated with the use of second generation are more often reported. But the development of new ARs recently proposed is based on the stereochemistry of second-generation ARs with reduced persistence but

They are two types of consequences of the exposition of wildlife to ARs. First, if the species is eaten by human [67, 78], the consequences are comparable to those discussed for farm animals. Second, if the exposition is sufficiently important, it might lead to intoxication of the animals and to its death, which can be problematic mainly for endangered species. The rate of exposure of non-target species has often been evaluated, and summed liver concentrations above a limit of 0.2 mg/kg associated with clinical signs (i.e. macroscopic haemorrhages with no trauma) have been statistically characterised as representative of a high-risk toxic threshold

equivalent toxicity might greatly decrease the level of secondary exposition [20].

Anticoagulant rodenticides are a keystone of the rodent population management. Like other poisons, there is a risk of human or non-targeted species poisoning. The wide use of anticoagulant rodenticides near human living space and agriculture space involves an important exposure of humans and domestic animals. Nevertheless, since few years, many risk mitigation measures have been taken and the number of exposure in humans and domestic animals has decreased. Moreover, in contrast to the majority of chemical biocide, anticoagulant rodenticides have an effective antidote, the vitamin K. Consequently, anticoagulant poisoning is rarely fatal. However, the impact of anticoagulant rodenticides on wildlife is least well known and deserves more investigation.

## **Author details**

Sébastien Lefebvre<sup>1</sup> , Isabelle Fourel<sup>1</sup> , Stéphane Queffélec<sup>2</sup> , Dominique Vodovar<sup>4</sup> , Bruno Mégarbane<sup>4</sup> , Etienne Benoit<sup>1</sup> , Virginie Siguret3 and Virginie Lattard<sup>1</sup> \*

\*Address all correspondence to: virginie.lattard@vetagro-sup.fr

1 USC 1233 RS2GP, VetAgro Sup, INRA, Univ Lyon, Marcy l'étoile, France

2 Centre National d'Informations Toxicologiques Vétérinaires (CNITV), Marcy l'étoile, France

3 Université Paris Descartes, INSERM UMR-S1140 and Service d'hématologie biologique, Hôpital Lariboisière (AP-HP), Paris, France

4 Université Paris-Diderot, INSERM UMRS-1144 and Réanimation Médicale et Toxicologique, Hôpital Lariboisière (AP-HP), Paris, France

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27

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30 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

[56] Khanna C, Boermans H, Wilcock B. Fatal hypernatremia in a dog from salt ingestion. Journal of the American Animal Hospital Association. 1 Mar 1997;**33**(2):113-117

[57] Waddell LS, Poppenga RH, Drobatz KJ. Anticoagulant rodenticide screening in dogs: 123 cases (1996-2003). Journal of the American Veterinary Medical Association. 15 Feb

[58] Murphy MJ. Rodenticides. Veterinary Clinics of North America: Small Animal Practice.

[59] Woody BJ, Murphy MJ, Ray AiC, Green RA. Coagulopathic effects and therapy of brodifacoum toxicosis in dogs. Journal of Veterinary Internal Medicine. 1 Jan 1992;**6**(1):23-28

[60] Lefebvre S, Hascoët C, Damin-Pernik M, Rannou B, Benoit E, Lattard V. Monitoring of antivitamin K-dependent anticoagulation in rodents – towards an evolution of the methodology to detect resistance in rodents. Pesticide Biochemistry and Physiology [Internet]. 2017. Available from: http://www.sciencedirect.com/science/article/pii/

[61] Sheafor SE, Couto CG. Anticoagulant rodenticide toxicity in 21 dogs. Journal of the

[62] Blocker TL, Roberts BK. Acute tracheal obstruction associated with anticoagulant rodenticide intoxication in a dog. Journal of Small Animal Practice. 1 Dec 1999;**40**(12):577-580

[63] Berry CR, Gallaway A, Thrall DE, Carlisle C. Thoracic radiographic features of anticoagulant rodenticide toxicity in fourteen dogs. Veterinary Radiology & Ultrasound. 1

[64] Bergh MS, Silverstein DC. What Is your diagnosis? Journal of the American Veterinary

[65] Shimshoni JA, Soback S, Cuneah O, Shlosberg A, Britzi M. New validated multiresidue analysis of six 4-hydroxy-coumarin anticoagulant rodenticides in hen eggs. Journal of

[66] Pouliquen H, Fauconnet V, Morvan ML, Pinault L. Determination of warfarin in the yolk and the white of hens' eggs by reversed-phase high-performance liquid chromatography. Journal of Chromatography B Biomedical Sciences and Applications. 21 Nov

[67] Pitt WC, Higashi M, Primus TM. The effect of cooking on diphacinone residues related to human consumption of feral pig tissues. Food and Chemical Toxicology. Sep 2011;

[68] Kammerer M, Pouliquen H, Pinault L, Loyau M. Residues depletion in egg after warfarin ingestion by laying hens. Veterinary and Human Toxicology. Oct 1998;**40**(5):273-275

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**Chapter 3**

**Provisional chapter**

**Food Poisoning Caused by Bacteria (Food Toxins)**

**Food Poisoning Caused by Bacteria (Food Toxins)**

DOI: 10.5772/intechopen.69953

In the environment, there are polluting substances that can cause adverse reactions in human beings when entering the body through different ways (ingestion, inhalation, injection, or absorption). The main pollutants can be poisons, chemical compounds, toxic gases, and bacterial toxins. These can be found in different places and their effects depend on the dose and exposure time. Furthermore, foodborne diseases (FBDs) can cause disability; these diseases can be caused by toxins produced by bacteria or other toxic substances in the food, which can cause severe diarrhea, toxic shock syndrome, debilitating infections such as meningitis and even death. FBDs are transmitted through food contaminated with pathogenic microorganisms that have multiple factors of virulence, which gives them the ability to cause an infection; some bacterial genres can produce toxins directly in the food, but other genres can produce them once they have colonized the intestine. Among the pathogens involved in FBDs that are also considered to be toxigenic are Salmonella spp., *Vibrio parahaemolyticus, Vibrio cholerae, Staphylococcus aureus, Clostridium botulinum, Clostridium perfringens, Bacillus cereus, Listeria monocytogenes*. Foodborne diseases can be prevented and acute diarrhea syndromes, fever and even death from dehydration can be avoided, especially in children under the age of 5

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

The main pollutants can be poisons, chemical compounds, toxic gases, and bacterial toxins. There are several diseases that human beings can acquire by ingesting some type of

Cecilia Hernández-Cortez, Ingrid Palma-Martínez,

Cecilia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís

Raúl Colmenero Solís and Graciela Castro-Escarpulli

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Luis Uriel Gonzalez-Avila,

**Abstract**

**1. Introduction**

Andrea Guerrero-Mandujano,

and Graciela Castro-Escarpulli

http://dx.doi.org/10.5772/intechopen.69953

and in immunocompromised people.

**Keywords:** toxins, bacteria, food poisoning, food-borne disease


**Provisional chapter**

## **Food Poisoning Caused by Bacteria (Food Toxins)**

**Food Poisoning Caused by Bacteria (Food Toxins)**

DOI: 10.5772/intechopen.69953

Cecilia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís and Graciela Castro-Escarpulli Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís and Graciela Castro-Escarpulli Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Cecilia Hernández-Cortez, Ingrid Palma-

http://dx.doi.org/10.5772/intechopen.69953

#### **Abstract**

[82] Rattner BA, Lazarus RS, Elliott JE, Shore RF, van den Brink N. Adverse outcome pathway and risks of anticoagulant rodenticides to predatory wildlife. Environmental Science &

[83] Erickson WA, Urban DJ. Potential Risks of Nine Rodenticides to Birds and Nontarget Mammals: A Comparative Approach [Internet]. US Environmental Protection Agency, Office of Prevention, Pesticides and Toxic Substances Washington, DC; 2004. Available from: http://pesticideresearch.com/site/docs/bulletins/EPAComparisonRodenticideRisks.pdf

[84] Thomas PJ, Mineau P, Shore RF, Champoux L, Martin PA, Wilson LK, et al. Second generation anticoagulant rodenticides in predatory birds: Probabilistic characterisation of toxic liver concentrations and implications for predatory bird populations in Canada.

[85] Christensen TK, Lassen P, Elmeros M. High exposure rates of anticoagulant rodenticides in predatory bird species in intensively managed landscapes in Denmark. Archives of

[86] López-Perea JJ, Camarero PR, Molina-López RA, Parpal L, Obón E, Solá J, et al. Interspecific and geographical differences in anticoagulant rodenticide residues of predatory wildlife from the Mediterranean region of Spain. Science of the Total Environment.

[87] Murray M. Anticoagulant rodenticide exposure and toxicosis in four species of birds of prey presented to a wildlife clinic in Massachusetts, 2006-2010. Journal of Zoo and Wildlife Medicine, Official Publication of American Association of Zoo Veterinarians.

[88] Fourel I, Damin-Pernik M, Benoit E, Lattard V. Core-shell LC–MS/MS method for quantification of second generation anticoagulant rodenticides diastereoisomers in rat liver in relationship with exposure of wild rats. Journal of Chromatography. Jan 2017;**1041-1042**:

Environmental Contamination and Toxicology. Oct 2012;**63**(3):437-444

Technology. Aug 2014;**48**(15):8433-8445

32 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

Environment International. Jul 2011;**37**(5):914-920

[Accessed: 10 April 2017]

Apr 2015;**511**:259-267

Mar 2011;**42**(1):88-97

120-132

In the environment, there are polluting substances that can cause adverse reactions in human beings when entering the body through different ways (ingestion, inhalation, injection, or absorption). The main pollutants can be poisons, chemical compounds, toxic gases, and bacterial toxins. These can be found in different places and their effects depend on the dose and exposure time. Furthermore, foodborne diseases (FBDs) can cause disability; these diseases can be caused by toxins produced by bacteria or other toxic substances in the food, which can cause severe diarrhea, toxic shock syndrome, debilitating infections such as meningitis and even death. FBDs are transmitted through food contaminated with pathogenic microorganisms that have multiple factors of virulence, which gives them the ability to cause an infection; some bacterial genres can produce toxins directly in the food, but other genres can produce them once they have colonized the intestine. Among the pathogens involved in FBDs that are also considered to be toxigenic are Salmonella spp., *Vibrio parahaemolyticus, Vibrio cholerae, Staphylococcus aureus, Clostridium botulinum, Clostridium perfringens, Bacillus cereus, Listeria monocytogenes*. Foodborne diseases can be prevented and acute diarrhea syndromes, fever and even death from dehydration can be avoided, especially in children under the age of 5 and in immunocompromised people.

**Keywords:** toxins, bacteria, food poisoning, food-borne disease

## **1. Introduction**

The main pollutants can be poisons, chemical compounds, toxic gases, and bacterial toxins. There are several diseases that human beings can acquire by ingesting some type of

pollutants, for example, chemical contamination can lead to acute poisoning or long-term diseases such as cancer. Furthermore, foodborne diseases (FBDs) can cause disability; these diseases can be caused by the toxins produced by the bacteria or other toxic substances in food [1].

bacteria; they are released into the medium after different processes such as lysis and cell division. This endotoxin is capable of causing endotoxic shock and tissue damage [5–7].

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 35

• Lipid A is a glycolipid formed by a disaccharide (glucosamine) bound to fatty acids, that are usually capric, lauric, myristic, palmitic, and stearic acids, which are inserted in the

• The O chain is a repeating unit polymer of 1–8 glycosidic residues; this polymer is highly

In addition to the pyrogenicity of the endotoxin, an important role has been attributed to the adherence mechanism of the bacteria to the host cell; since in previous studies, it has been observed that when LPS is modified or not expressed, the adherence observed is modified or inhibited.

• Exotoxins: These are the macromolecules of protein origin, which are produced and later released to the medium by the microorganism. Depending on their mechanism of action,

○ Toxins Type I. These toxins modify the host's cells without internalizing in the cells; for example, the superantigens produced by *Staphylococcus aureus* and *Streptococcus* 

○ Toxins Type II. Within this group there are hemolysins and phospholipases; this group of toxins is characterized by pore formation and/or destroying the membranes of the host cells. With this virulence factor, the pathogen can invade the host cell; for example,

○ Toxins Type III. These toxins are known as A/B due to their binary structure. Fraction B has the function of binding to the receptor of the cell and fraction A is the unit that possesses enzymatic activity, which, depending on the toxin and its mechanism of action, will be the damage to the cell; for example, the Shiga toxin produced by *Escherichia coli* O157:H7, the Cholera toxin (Ctx) produced by *Vibrio cholerae*, and the Anthrax toxin

Exotoxins of Gram-negative enteropathogenic bacteria play an important role in the pathogenesis of diarrheal disease, causing hypersecretion of liquids without the destruction and death of intestinal mucosal cells. These toxins are generically referred to as enterotoxins that

There are also two other groups of toxins, those that alter the cytoskeleton and those with neurotoxic activity; however, some toxins may present activity corresponding to more than

• Lipid A and the nucleus are bound by the sugar acid 2-keto-3-deoxyoctanate (KDO).

• The nucleus a heteropolysaccharide derived from hexoses and heptoses.

aerolysin and GCAT protein produced by *Aeromonas* spp.

LPS are formed by three regions [7]:

outer membrane of the bacterium.

exotoxins are divided as follows:

produced by *Bacillus anthracis* [5, 6].

are different from cytotoxins [8].

one of the groups described in **Table 1**.

*pyogenes*.

variable among bacterial species and genus.

It is important to know that poisoning is the cause of morbidity and mortality worldwide. There are different types of intoxication: (a) intoxication caused by chemical substances (such as drugs, pesticides, heavy metals, gases, and solvents) where the patient has direct contact with the toxic substance, and (b) food poisoning, of which the transmission vehicle is contaminated food with pathogens or chemical products. Nowadays, chemical poisoning is a health problem; about six million chemicals are known, of which 80,000 to 100,000 are commonly used in different daily products. In 2006, the World Health Organization (WHO) estimated that more than 25% of poisonings and 5% of cases of cancer, neuropsychiatric disorders, and vascular diseases worldwide were caused by chemical exposure [1, 2].

It is difficult to diagnose chemical poisoning, since a chronological record of the patient's life is required, considering the exposure routes, dose, and time of exposure to the chemical. However, there are protocols that facilitate the diagnosis of chemical poisoning and how to treat incidents from chemical poisoning [1].

Furthermore, food poisoning or foodborne disease (FBD) is one of the main problems in public health worldwide. According to the WHO, each year 600 million people around the world, or 1 out of 10, become ill after consuming contaminated food. Among all these people, 420,000 die, including 125,000 children under 5 years of age, due to the vulnerability of this population to develop a diarrheal syndrome, about 43% of FBDs occur in these patients. About 70% of FBDs result from food contaminated with a microorganism [2–4].

Among the microorganisms causing FBDs are bacteria that have different virulence factors that give them the ability to cause a disease; among these factors, we can find toxins that can be produced in food or once the pathogen has colonized the digestive tract.

It is to be noted that the aim of this chapter is to convey information about some characteristics of the main pathogens producing toxins in food, the diseases they can cause, their complications and treatment options as well as the main sources of contamination in restaurants or street markets.

#### **1.1. Types of bacterial toxins**

A bacterial toxin is a macromolecule mainly of protein origin, which can cause toxic damage in a specific organ of the host [5]. Toxins can be divided in endotoxins and exotoxins:

• Endotoxins or lipopolysaccharides (LPS): These are the components of the outer membrane of the Gram-negative bacteria; they are considered the most important antigen of the bacteria; they are released into the medium after different processes such as lysis and cell division. This endotoxin is capable of causing endotoxic shock and tissue damage [5–7].

LPS are formed by three regions [7]:

pollutants, for example, chemical contamination can lead to acute poisoning or long-term diseases such as cancer. Furthermore, foodborne diseases (FBDs) can cause disability; these diseases can be caused by the toxins produced by the bacteria or other toxic sub-

34 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

It is important to know that poisoning is the cause of morbidity and mortality worldwide. There are different types of intoxication: (a) intoxication caused by chemical substances (such as drugs, pesticides, heavy metals, gases, and solvents) where the patient has direct contact with the toxic substance, and (b) food poisoning, of which the transmission vehicle is contaminated food with pathogens or chemical products. Nowadays, chemical poisoning is a health problem; about six million chemicals are known, of which 80,000 to 100,000 are commonly used in different daily products. In 2006, the World Health Organization (WHO) estimated that more than 25% of poisonings and 5% of cases of cancer, neuropsychiatric disorders, and vascular diseases worldwide were caused by

It is difficult to diagnose chemical poisoning, since a chronological record of the patient's life is required, considering the exposure routes, dose, and time of exposure to the chemical. However, there are protocols that facilitate the diagnosis of chemical poisoning and how to

Furthermore, food poisoning or foodborne disease (FBD) is one of the main problems in public health worldwide. According to the WHO, each year 600 million people around the world, or 1 out of 10, become ill after consuming contaminated food. Among all these people, 420,000 die, including 125,000 children under 5 years of age, due to the vulnerability of this population to develop a diarrheal syndrome, about 43% of FBDs occur in these patients. About 70% of FBDs result from food contaminated with a micro-

Among the microorganisms causing FBDs are bacteria that have different virulence factors that give them the ability to cause a disease; among these factors, we can find toxins that can

It is to be noted that the aim of this chapter is to convey information about some characteristics of the main pathogens producing toxins in food, the diseases they can cause, their complications and treatment options as well as the main sources of contamination in restaurants

A bacterial toxin is a macromolecule mainly of protein origin, which can cause toxic damage

• Endotoxins or lipopolysaccharides (LPS): These are the components of the outer membrane of the Gram-negative bacteria; they are considered the most important antigen of the

in a specific organ of the host [5]. Toxins can be divided in endotoxins and exotoxins:

be produced in food or once the pathogen has colonized the digestive tract.

stances in food [1].

chemical exposure [1, 2].

organism [2–4].

or street markets.

**1.1. Types of bacterial toxins**

treat incidents from chemical poisoning [1].


In addition to the pyrogenicity of the endotoxin, an important role has been attributed to the adherence mechanism of the bacteria to the host cell; since in previous studies, it has been observed that when LPS is modified or not expressed, the adherence observed is modified or inhibited.

	- Toxins Type I. These toxins modify the host's cells without internalizing in the cells; for example, the superantigens produced by *Staphylococcus aureus* and *Streptococcus pyogenes*.
	- Toxins Type II. Within this group there are hemolysins and phospholipases; this group of toxins is characterized by pore formation and/or destroying the membranes of the host cells. With this virulence factor, the pathogen can invade the host cell; for example, aerolysin and GCAT protein produced by *Aeromonas* spp.
	- Toxins Type III. These toxins are known as A/B due to their binary structure. Fraction B has the function of binding to the receptor of the cell and fraction A is the unit that possesses enzymatic activity, which, depending on the toxin and its mechanism of action, will be the damage to the cell; for example, the Shiga toxin produced by *Escherichia coli* O157:H7, the Cholera toxin (Ctx) produced by *Vibrio cholerae*, and the Anthrax toxin produced by *Bacillus anthracis* [5, 6].

Exotoxins of Gram-negative enteropathogenic bacteria play an important role in the pathogenesis of diarrheal disease, causing hypersecretion of liquids without the destruction and death of intestinal mucosal cells. These toxins are generically referred to as enterotoxins that are different from cytotoxins [8].

There are also two other groups of toxins, those that alter the cytoskeleton and those with neurotoxic activity; however, some toxins may present activity corresponding to more than one of the groups described in **Table 1**.


In some countries, food poisoning caused by *S. aureus* is the most prevalent; reports indicate that *S. aureus* can be responsible for up to 41% of food poisoning outbreaks. Although it can affect people of any age, the range with the highest incidence goes from 20 to 49 years of age, where up to 48% of the cases can be concentrated. The main food products related to food poisoning caused by *S. aureus* are chicken and eggs, cakes, pastas, sauces, milk, and its derived

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 37

Globally, the highest number of cases is caused by ETEC, 233 million cases, and *Shigella* spp., 188 million cases; however, the highest numbers of deaths are caused by EPEC, 121,455 deaths; ETEC, 73,041 deaths, and *Shigella* spp., 64,993 deaths. In total, 40% of the cases and 43% of the deaths caused by FBDs occurred in children under the age of 5 years old [17].

Food poisoning caused by *B. cereus* can occur any time of the year; it does not present a defined geographical distribution, and because it is naturally found in the environment, its distribution in various types of food occurs easily, especially in those of plant origin such as cereals and rice. Reports about food poisoning outbreaks caused by *B. cereus* are underestimated due to the lack of diagnostic tools; however, globally, there are figures where food poisoning caused by this pathogen occupies from 1 to 17.5% of the total cases of food poisoning

Food poisoning caused by *C. botulinum* is less frequent and the epidemiological information about it is scarce; outbreaks of food poisoning caused by this pathogen usually include members of one family, that is, they do not involve a large number of individuals and the main

Food poisoning caused by *C. perfringens* occurs at any time of the year, but it is more frequent in the last months of the year. It does not present a geographical distribution; in some countries like the United States, the outbreaks caused by this pathogen occupy the second place in foodborne diseases. Generally, this type of outbreaks affect a large number of individuals, therefore, they have a high range of morbidity. In total, 90% of the cases are caused by the intake of meat and poultry products; the contamination of meat and other food products

Nevertheless, the distribution of pathogens varies depending on the region, due to cultural and economic factors that allow both incidence and mortality to be different for each pathogen associated with FBDs. For example, in Europe, *Campylobacter* and *Salmonella* are reported pathogens; their reservoirs are livestock and domestic animals, and food contamination is produced due to bad practices in the food production chain and by crosscontaminations; however, although they play an important role in enteric diseases, they are less frequent than in countries defined by the World Health Organization (WHO) as high-mortality countries (Western Pacific Region and Africa Region), where the sanitary conditions and food and water contamination are factors that increase the incidence and

In 2010, WHO wrote a report about the main pathogens involved in FBDs, dividing all countries in regions; these regions were grouped based on adult and infant mortality (**Figure 1**).

cause of such outbreaks is the consumption of canned food at home [23, 24].

occurs by the contact of pipelines with feces or contaminated surfaces [24, 25].

products [20].

caused by bacteria [21, 22].

mortality of these genera [17].

**Table 1.** Classification of enteric toxins.

Toxins produced by pathogens involved in foodborne diseases are as follows:

Cholera toxin (Ctx) (*Vibrio cholerae*), Thermolabile toxin (LT) Thermostable toxin (ST) (Enterotoxigenic *E. coli*), Shiga Toxin (*Shigella dysenteriae* and *E. coli* O157:H7) Botulinum toxin (BTX) (*Clostridium botulinum*), CPE Enterotoxin (*Clostridium perfringens*), Alpha-Toxin, Beta-Toxin, Epsilon-Toxin and Iota-Toxin (*C. perfringens*), Toxin A/Toxin B (*Clostridium difficile*), Enterotoxins (A, B, C1, C2, D and E, G, H, I, J), Toxic Shock Syndrome Toxin (TSST-1), Cereulide, and hemolysin BL (HBL), nonhemolytic enterotoxin (NHE) (*S. aureus*), Citotoxin K or CytK (*Bacillus cereus*) [9–15].

#### **1.2. Epidemiology**

The high population growth and the food marketing, have generated pathogens causing FBDs to be quickly transported, this has produced outbreaks in different regions, affecting the morbidity, mortality, and economy of the population involved. The trend seen in the United States, the United Kingdom, and Europe indicates that the incidence of FBDs is increasing; this will be a health problem in the following years [4, 16].

There are different types of genus commonly associated with FBDs such as *Campylobacter* spp., enterotoxigenic *E. coli* (ETEC), enteropathogenic *E. coli* (EPEC), *Salmonella* spp., *Shigella* spp., Shiga toxin-producing *E. coli* (STEC) and *V. cholerae* [4, 17].

A total of 66% of foodborne diseases is caused by bacteria. Major diseases include botulism caused by *C. botulinum*, gastroenteritis caused by *E. coli* strains, Salmonellosis and Staphylococcal poisoning. Moreover, *B. cereus* and *V. cholerae* are bacteria frequently reported as causative agents of toxicoinfection by food [18, 19].

In some countries, food poisoning caused by *S. aureus* is the most prevalent; reports indicate that *S. aureus* can be responsible for up to 41% of food poisoning outbreaks. Although it can affect people of any age, the range with the highest incidence goes from 20 to 49 years of age, where up to 48% of the cases can be concentrated. The main food products related to food poisoning caused by *S. aureus* are chicken and eggs, cakes, pastas, sauces, milk, and its derived products [20].

Globally, the highest number of cases is caused by ETEC, 233 million cases, and *Shigella* spp., 188 million cases; however, the highest numbers of deaths are caused by EPEC, 121,455 deaths; ETEC, 73,041 deaths, and *Shigella* spp., 64,993 deaths. In total, 40% of the cases and 43% of the deaths caused by FBDs occurred in children under the age of 5 years old [17].

Food poisoning caused by *B. cereus* can occur any time of the year; it does not present a defined geographical distribution, and because it is naturally found in the environment, its distribution in various types of food occurs easily, especially in those of plant origin such as cereals and rice. Reports about food poisoning outbreaks caused by *B. cereus* are underestimated due to the lack of diagnostic tools; however, globally, there are figures where food poisoning caused by this pathogen occupies from 1 to 17.5% of the total cases of food poisoning caused by bacteria [21, 22].

Food poisoning caused by *C. botulinum* is less frequent and the epidemiological information about it is scarce; outbreaks of food poisoning caused by this pathogen usually include members of one family, that is, they do not involve a large number of individuals and the main cause of such outbreaks is the consumption of canned food at home [23, 24].

Toxins produced by pathogens involved in foodborne diseases are as follows:

models in intestinal epithelial cells.

36 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

epithelial cells.

this will be a health problem in the following years [4, 16].

as causative agents of toxicoinfection by food [18, 19].

spp., Shiga toxin-producing *E. coli* (STEC) and *V. cholerae* [4, 17].

(*Bacillus cereus*) [9–15].

Source: Adapted from Sears et al. [8].

**Table 1.** Classification of enteric toxins.

**Toxin type Definition**

**1.2. Epidemiology**

Cholera toxin (Ctx) (*Vibrio cholerae*), Thermolabile toxin (LT) Thermostable toxin (ST) (Enterotoxigenic *E. coli*), Shiga Toxin (*Shigella dysenteriae* and *E. coli* O157:H7) Botulinum toxin (BTX) (*Clostridium botulinum*), CPE Enterotoxin (*Clostridium perfringens*), Alpha-Toxin, Beta-Toxin, Epsilon-Toxin and Iota-Toxin (*C. perfringens*), Toxin A/Toxin B (*Clostridium difficile*), Enterotoxins (A, B, C1, C2, D and E, G, H, I, J), Toxic Shock Syndrome Toxin (TSST-1), Cereulide, and hemolysin BL (HBL), nonhemolytic enterotoxin (NHE) (*S. aureus*), Citotoxin K or CytK

Enterotoxin It produces a net secretion in ligated intestinal segments without histological evidence

Cytoskeleton-altering toxin It alters the cellular form and has been frequently shown to be caused by the F-actin

Cytotoxin It causes cell or tissue damage, usually ending with cell death. The toxin may or may

Neurotoxins It involves the release of one or more neurotransmitters from the enteric nervous system. It alters the activity of smooth muscle in the intestine.

of intestinal lesion or damage to nonerythrocytic cells in *in vitro* tests.

It stimulates the increase in the short circuit current (Isc) and the potential difference (PD) in the using chamber without evidence of intestinal damage; this result involves the secretion of (active) electrogenic anions. Additionally, a toxin can impair electrically neutral NaCl absorption, which also results in a net secretion of ions.

rearrangement. The toxin can cause limited cell damage but is not lethal, and it may or may not be associated with the evidence of net secretion in *in vivo* or *in vitro* disease

not be associated with net secretion in *in vivo* or *in vitro* disease models in intestinal

The high population growth and the food marketing, have generated pathogens causing FBDs to be quickly transported, this has produced outbreaks in different regions, affecting the morbidity, mortality, and economy of the population involved. The trend seen in the United States, the United Kingdom, and Europe indicates that the incidence of FBDs is increasing;

There are different types of genus commonly associated with FBDs such as *Campylobacter* spp., enterotoxigenic *E. coli* (ETEC), enteropathogenic *E. coli* (EPEC), *Salmonella* spp., *Shigella*

A total of 66% of foodborne diseases is caused by bacteria. Major diseases include botulism caused by *C. botulinum*, gastroenteritis caused by *E. coli* strains, Salmonellosis and Staphylococcal poisoning. Moreover, *B. cereus* and *V. cholerae* are bacteria frequently reported Food poisoning caused by *C. perfringens* occurs at any time of the year, but it is more frequent in the last months of the year. It does not present a geographical distribution; in some countries like the United States, the outbreaks caused by this pathogen occupy the second place in foodborne diseases. Generally, this type of outbreaks affect a large number of individuals, therefore, they have a high range of morbidity. In total, 90% of the cases are caused by the intake of meat and poultry products; the contamination of meat and other food products occurs by the contact of pipelines with feces or contaminated surfaces [24, 25].

Nevertheless, the distribution of pathogens varies depending on the region, due to cultural and economic factors that allow both incidence and mortality to be different for each pathogen associated with FBDs. For example, in Europe, *Campylobacter* and *Salmonella* are reported pathogens; their reservoirs are livestock and domestic animals, and food contamination is produced due to bad practices in the food production chain and by crosscontaminations; however, although they play an important role in enteric diseases, they are less frequent than in countries defined by the World Health Organization (WHO) as high-mortality countries (Western Pacific Region and Africa Region), where the sanitary conditions and food and water contamination are factors that increase the incidence and mortality of these genera [17].

In 2010, WHO wrote a report about the main pathogens involved in FBDs, dividing all countries in regions; these regions were grouped based on adult and infant mortality (**Figure 1**).

**Figure 1.** Geographical distribution of countries by region. Subregions are defined on the basis of infant and adult mortality. Stratum/Layer A = very low infant and adult mortality; stratum B = low infant mortality and very low adult mortality; stratum C = low infant mortality and high adult mortality; stratum D = high infant and adult mortality; and stratum E = high infant mortality and very high adult mortality. AFR: African subregion, AMR: American subregion, EMR: Eastern Mediterranean, EUR: European subregion, SEAR: South-East Asian subregions, WPR: Western Pacific subregion. Adapted from World Health Organization [26].

The risk group causing FBDs depends on the region, in developing countries such as African regions, South America, and South Asia, pathogens causing diarrheal diseases and the invasive pathogens causing infectious diseases and bacteria are the group that causes FBDs, followed by some cestodes and helminths; nevertheless, African regions, cestodes, and helminths are the group that causes FBDs because health and economic conditions limit proper food handling and preservation [17, 26].

With the above, as each risk group is different for each region, in the same way, the distribution of the main pathogens involved in FBDs depends on each region, as well as their incidence; however, developing countries continue to show a great number of cases of FBDs. In addition, the prevalence of pathogens in these countries is higher than in developed countries (**Figure 2**) [4, 26].

Additionally, each region has different socioeconomic characteristics, this creates an impact on the incidence and the mortality of FBDs associated with different bacterial pathogens; the *Shigella* genus occupies the first place in deaths in all regions; however, each region shows a different distribution among the genus that produce the highest number of deaths; this is due to the fact that medical care is different in each region, which means that in some regions a genus causes high mortality and in other regions it is only of medical relevance (**Figure 3**) [4, 17, 26].

In accordance with the above, it is emphasized the importance of medical authorities to know the incidence of the pathogens causing FBDs that circulate in their regions; not only to know the morbidity and mortality rate, but also to provide the population with the appropriate

**Figure 3.** Median rate per 100,000 of diarrheal illnesses and deaths by region. The scale is on logarithmic basis 10.

**Figure 2.** Global burden of FBDs by subregion (DALYS per 100,000 inhabitants) caused by major pathogens. DAYLs: Disability-adjusted life years metric, AFR: African subregion, AMR: American subregion, EMR: Eastern Mediterranean, EUR: European subregion, SEAR: South-East Asian subregions, WPR: Western Pacific subregion. Adapted from World

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 39

medical care directed to the pathogen causing FBDs.

Health Organization [26].

Adapted from Pires et al. [17].

**Figure 2.** Global burden of FBDs by subregion (DALYS per 100,000 inhabitants) caused by major pathogens. DAYLs: Disability-adjusted life years metric, AFR: African subregion, AMR: American subregion, EMR: Eastern Mediterranean, EUR: European subregion, SEAR: South-East Asian subregions, WPR: Western Pacific subregion. Adapted from World Health Organization [26].

The risk group causing FBDs depends on the region, in developing countries such as African regions, South America, and South Asia, pathogens causing diarrheal diseases and the invasive pathogens causing infectious diseases and bacteria are the group that causes FBDs, followed by some cestodes and helminths; nevertheless, African regions, cestodes, and helminths are the group that causes FBDs because health and economic conditions limit proper

**Figure 1.** Geographical distribution of countries by region. Subregions are defined on the basis of infant and adult mortality. Stratum/Layer A = very low infant and adult mortality; stratum B = low infant mortality and very low adult mortality; stratum C = low infant mortality and high adult mortality; stratum D = high infant and adult mortality; and stratum E = high infant mortality and very high adult mortality. AFR: African subregion, AMR: American subregion, EMR: Eastern Mediterranean, EUR: European subregion, SEAR: South-East Asian subregions, WPR: Western Pacific

38 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

With the above, as each risk group is different for each region, in the same way, the distribution of the main pathogens involved in FBDs depends on each region, as well as their incidence; however, developing countries continue to show a great number of cases of FBDs. In addition, the prevalence of pathogens in these countries is higher than in developed countries

Additionally, each region has different socioeconomic characteristics, this creates an impact on the incidence and the mortality of FBDs associated with different bacterial pathogens; the *Shigella* genus occupies the first place in deaths in all regions; however, each region shows a different distribution among the genus that produce the highest number of deaths; this is due to the fact that medical care is different in each region, which means that in some regions a genus causes high mortality and in other regions it is only of medical relevance (**Figure 3**) [4, 17, 26].

food handling and preservation [17, 26].

subregion. Adapted from World Health Organization [26].

(**Figure 2**) [4, 26].

**Figure 3.** Median rate per 100,000 of diarrheal illnesses and deaths by region. The scale is on logarithmic basis 10. Adapted from Pires et al. [17].

In accordance with the above, it is emphasized the importance of medical authorities to know the incidence of the pathogens causing FBDs that circulate in their regions; not only to know the morbidity and mortality rate, but also to provide the population with the appropriate medical care directed to the pathogen causing FBDs.

## **2. Risk factors and prevention measures associated with food poisoning**

of pests, as well as measures to avoid their nesting and proliferation. Finally, pest eradication must be carried out by any physical, chemical, or biological method that does not represent a

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 41

Within the food chain, food transportation plays an important role in preventing contamination and proliferation of microorganisms in food; thus, it is necessary to consider measures to prevent any type of contamination and to provide an environment to control the proliferation of pathogenic microorganisms and the production of bacterial toxins. Some important factors to consider during food transportation are temperature, direct exposure to sunlight, humidity, and airflows. At this stage, the type of containers and the type of packaging also play an important role; the aforementioned and transport conditions should be chosen based on the

Another important measure is the information that producers and suppliers offer to consumers regarding the characteristics and proper handling of prepackaged foods; this is why, generally, food must be packaged and labeled in such a way that the consumer has enough information to handle, store, and prepare the products appropriately without threatening his or her health. Labels should also include a batch number allowing rapid identification and market recalls of products potentially being dangerous for human consumption [37, 38].

In general, microorganisms, more specifically bacteria, can proliferate under very different conditions; that is why they can be found in any type of environment. Even though bacteria are good at adapting to the environments they are in, there are certain conditions that promote bacterial growth more than others. These conditions include food, humidity, acidity, temperature, time, and oxygen; all of these are grouped in what is known as FATTOM (Food, Acidity, Time, Temperature, Oxygen, and Moisture). Knowing and avoiding these optimal conditions

Most foods contain nutrients required for microbial growth, which makes them easy targets for the microorganisms to develop; therefore, perishable. To reduce the breakdown of food and to prevent foodborne diseases, the proliferation of microorganisms under certain conditions must be controlled, as well as the conditions that must be used to reduce food spoilage to lengthen the time during which physicochemical and organoleptic characteristics must be kept under minimum acceptance parameters. Factors affecting the proliferation rate of micro-

Intrinsic factors affecting the proliferation rate are more related to the internal characteristics of food products, and the way in which these characteristics maintain or affect the growth of microorganisms; these factors include water activity, pH, oxidation-reduction potential, con-

It is defined as the amount of water available for the growth of microorganisms; microbial proliferation decreases when water availability also decreases. The water available for metabolic

tent and type of nutrients, inhibiting substances, and biological structures [44, 45].

can help to prevent bacterial growth, bacterial infections, and food poisoning [39–41].

organisms can be considered as intrinsic and extrinsic [42, 43].

**2.1. Intrinsic parameters**

*2.1.1. Water activity*

threat to health and food safety [27, 31].

characteristics of the food that is being transported [36].

The main risk factor involved in bacterial food poisoning is food contamination by pathogenic bacteria that produce toxins; such contamination can occur at any time, that is, from the crop, in the case of vegetables or, just before eating them, due to the consumer's manipulation; in this way, all the people living on the earth are susceptible to food poisoning. Therefore, food poisoning is a worldwide public health problem, generally the most affected are children, the elderly, pregnant women, and immunocompromised people. As expected, individual factors such as age, gender, place of residence, socioeconomic factors, among others, are crucial in food poisoning acquisition and development [27–29].

Food contamination can occur from primary production to the final consumer, consequently, there are different contamination risks according to the practices carried out in the different stages such as agricultural, livestock, and fish production; industrialization (in the case of processed food); marketing (points of sale), and transportation to the final consumer (homes, community dining rooms, and restaurants) [30].

During the primary production, producers should consider the particular characteristics of the environment where they grow or breed and reproduce livestock, by applying measures to prevent any pollution caused by the air, water, or natural fertilizers. In general, the main risk of contamination in primary production is the unsafe agricultural practices such as the use of manure as natural fertilizer and irrigation with sewage, which violates the fundamental principle of preventing, at all costs and contamination of raw materials from fecal matter [31, 32].

Additionally, another important factor to ensure food safety and good quality is the adequate control of time and temperature when cooking, processing, cooling, and storing food. To achieve a good control of such parameters, it is necessary to consider the physical, chemical, and microbiological characteristics of each type of food, for example, water activity, pH and type, and the initial number of microorganisms presented there. Similarly, other aspects need to be taken into account such as shelf life and usage, that is, whether it is a raw, processed, packaged, or ready-to-eat food [33, 34].

Microbiological contamination can occur through direct contact or through air, utensils, contact surfaces, or the handler's hands; therefore, ready-to-eat foods must be separated in space and time from raw or unprocessed foods. In addition, the latter must always be washed or disinfected. In all stages of the food chain, it is indispensable to use water; hence, this could be the main source of food contamination. It is then necessary to control and monitor the type and the source of the water used at each stage; however, when it is used for food handling, water has to be drinkable water that meets the physical, chemical, and microbiological criteria that its name requires [29, 31, 35].

In terms of facilities, it is important to establish and monitor systems that ensure their maintenance, cleaning, and sanitation. These systems also include an adequate waste management and an effective pest control. The latter constitute a potential risk of any type of contamination; that is why it is necessary to implement measures that prevent the entrance of any type of pests, as well as measures to avoid their nesting and proliferation. Finally, pest eradication must be carried out by any physical, chemical, or biological method that does not represent a threat to health and food safety [27, 31].

Within the food chain, food transportation plays an important role in preventing contamination and proliferation of microorganisms in food; thus, it is necessary to consider measures to prevent any type of contamination and to provide an environment to control the proliferation of pathogenic microorganisms and the production of bacterial toxins. Some important factors to consider during food transportation are temperature, direct exposure to sunlight, humidity, and airflows. At this stage, the type of containers and the type of packaging also play an important role; the aforementioned and transport conditions should be chosen based on the characteristics of the food that is being transported [36].

Another important measure is the information that producers and suppliers offer to consumers regarding the characteristics and proper handling of prepackaged foods; this is why, generally, food must be packaged and labeled in such a way that the consumer has enough information to handle, store, and prepare the products appropriately without threatening his or her health. Labels should also include a batch number allowing rapid identification and market recalls of products potentially being dangerous for human consumption [37, 38].

In general, microorganisms, more specifically bacteria, can proliferate under very different conditions; that is why they can be found in any type of environment. Even though bacteria are good at adapting to the environments they are in, there are certain conditions that promote bacterial growth more than others. These conditions include food, humidity, acidity, temperature, time, and oxygen; all of these are grouped in what is known as FATTOM (Food, Acidity, Time, Temperature, Oxygen, and Moisture). Knowing and avoiding these optimal conditions can help to prevent bacterial growth, bacterial infections, and food poisoning [39–41].

Most foods contain nutrients required for microbial growth, which makes them easy targets for the microorganisms to develop; therefore, perishable. To reduce the breakdown of food and to prevent foodborne diseases, the proliferation of microorganisms under certain conditions must be controlled, as well as the conditions that must be used to reduce food spoilage to lengthen the time during which physicochemical and organoleptic characteristics must be kept under minimum acceptance parameters. Factors affecting the proliferation rate of microorganisms can be considered as intrinsic and extrinsic [42, 43].

#### **2.1. Intrinsic parameters**

**2. Risk factors and prevention measures associated with food poisoning**

40 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

food poisoning acquisition and development [27–29].

community dining rooms, and restaurants) [30].

packaged, or ready-to-eat food [33, 34].

that its name requires [29, 31, 35].

matter [31, 32].

The main risk factor involved in bacterial food poisoning is food contamination by pathogenic bacteria that produce toxins; such contamination can occur at any time, that is, from the crop, in the case of vegetables or, just before eating them, due to the consumer's manipulation; in this way, all the people living on the earth are susceptible to food poisoning. Therefore, food poisoning is a worldwide public health problem, generally the most affected are children, the elderly, pregnant women, and immunocompromised people. As expected, individual factors such as age, gender, place of residence, socioeconomic factors, among others, are crucial in

Food contamination can occur from primary production to the final consumer, consequently, there are different contamination risks according to the practices carried out in the different stages such as agricultural, livestock, and fish production; industrialization (in the case of processed food); marketing (points of sale), and transportation to the final consumer (homes,

During the primary production, producers should consider the particular characteristics of the environment where they grow or breed and reproduce livestock, by applying measures to prevent any pollution caused by the air, water, or natural fertilizers. In general, the main risk of contamination in primary production is the unsafe agricultural practices such as the use of manure as natural fertilizer and irrigation with sewage, which violates the fundamental principle of preventing, at all costs and contamination of raw materials from fecal

Additionally, another important factor to ensure food safety and good quality is the adequate control of time and temperature when cooking, processing, cooling, and storing food. To achieve a good control of such parameters, it is necessary to consider the physical, chemical, and microbiological characteristics of each type of food, for example, water activity, pH and type, and the initial number of microorganisms presented there. Similarly, other aspects need to be taken into account such as shelf life and usage, that is, whether it is a raw, processed,

Microbiological contamination can occur through direct contact or through air, utensils, contact surfaces, or the handler's hands; therefore, ready-to-eat foods must be separated in space and time from raw or unprocessed foods. In addition, the latter must always be washed or disinfected. In all stages of the food chain, it is indispensable to use water; hence, this could be the main source of food contamination. It is then necessary to control and monitor the type and the source of the water used at each stage; however, when it is used for food handling, water has to be drinkable water that meets the physical, chemical, and microbiological criteria

In terms of facilities, it is important to establish and monitor systems that ensure their maintenance, cleaning, and sanitation. These systems also include an adequate waste management and an effective pest control. The latter constitute a potential risk of any type of contamination; that is why it is necessary to implement measures that prevent the entrance of any type Intrinsic factors affecting the proliferation rate are more related to the internal characteristics of food products, and the way in which these characteristics maintain or affect the growth of microorganisms; these factors include water activity, pH, oxidation-reduction potential, content and type of nutrients, inhibiting substances, and biological structures [44, 45].

#### *2.1.1. Water activity*

It is defined as the amount of water available for the growth of microorganisms; microbial proliferation decreases when water availability also decreases. The water available for metabolic activity determines the degree of microbial growth instead of the total moisture content. The unit of measurement for the water that microorganisms require is usually expressed as water activity (*A*w), which is defined as the water vapor pressure of food substrate, divided by the water vapor pressure of pure water, at the same temperature. This concept is related to relative humidity (RH), thus: RH = 100 × *A*w. The approximate optimal *A*w for the growth of most microorganisms is 0.99; most bacteria require an *A*w greater than 0.91 to grow. Gram-negative bacteria require higher values than Gram-positive bacteria. Most of the natural food products have an *A*w of 0.99 or more. Generally, bacteria have the highest requirements of water activity, fungi have the lowest, and yeasts have intermediate requirements. Most bacteria that decompose food do not grow with an *A*w less than 0.91, but fungi and yeasts can grow with values of 0.80 or less, including surfaces partially dehydrated. The lowest value reported for bacteria in food is 0.75 for halophytes, while xerophilic fungi and osmophilic yeasts have shown growth at *A*w values of 0.65 and 0.61, respectively [46, 47].

which a substrate loses or gains electrons (when a food product loses electrons, it oxidizes, whereas, when it gains electrons it is reduced; thus, a food product that easily gives electrons is a good reducing agent and the one that receives electrons is a good oxidizing agent). To achieve optimum growth, some microorganisms require reducing conditions and others require oxidizing conditions. The O/R potential of a system is expressed with the Eh symbol (when electrons are transferred from one compound to another, a potential difference is created between the two compounds; this difference can be measured and expressed as millivolts [mV]). The more oxidized a substance is, the more positive the electrical potential will be; and the more reduced a substance is, the more negative the electrical potential will be. When the concentration of oxidant and reducer is equal, there is an electrical potential of zero [39].

oxygen are aerobic; that is, aerobic microorganisms require positive Eh values (oxidized) for their growth, whereas anaerobic microorganisms require negative values of Eh (reduced). Facultative microorganisms can grow under any of the conditions. It has to be considered that maximum and minimum Eh values (in mV) necessary for aerobic and anaerobic growth could be lethal to the other group. Among food substances that help to maintain reducing conditions are the –SH groups in meats and the ascorbic acid, as well as, reducing sugars in fruits and vegetables. Some aerobic bacteria grow better under slightly reducing conditions being known as microaerophiles such as *Lactobacillus* and *Campylobacter*. Most of fungi and yeasts found in food are aerobic, although a few tend to be facultative anaerobes. Regarding the Eh value of food, vegetables, especially juices, tend to have Eh values of +300 to +400 mV; so, it is not surprising to find that aerobic bacteria and fungi are the common cause of decomposition in this type of products. Meats have Eh values around −200 mV; in ground meats, Eh is usually around +200 mV. Various types of cheese show Eh values between −20 and −200 mV [46].

Microorganisms have nutritional requirements, most of them need external sources of nitrogen, energy, minerals, as well as vitamins, and related growth factors; these requirements are found in our food, so if they have the right conditions to develop, they will. In general, fungi have the lowest nutrient requirement, followed by Gram-negative bacteria, then yeasts and

The primary sources of nitrogen used by heterotrophic microorganisms are amino acids. A great number of other nitrogen compounds may serve for this function for several types of organisms. For example, some of them can use free nucleotides and amino acids, while others can be capable of using peptides and proteins. In general, simple compounds like amino acids will be used by almost all of the organisms before attacking more complex compounds such as high molecular weight proteins. The same applies to polysaccharides and lipids [39, 51].

Microorganisms in food tend to use as energy sources, sugars, alcohols, and amino acids. Fungi are the most efficient in the use of proteins, complex carbohydrates, and lipids because they contain enzymes capable of hydrolyzing these molecules into simpler components; many bacteria have a similar capacity, but most yeasts require simpler molecules. All microorganisms need minerals, although vitamin requirements vary. Fungi and some bacteria can

finally, Gram-positive bacteria, which have the highest requirements [46, 50].

and e<sup>−</sup>

(electrons) to molecular

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 43

Saprophytes that are capable of transferring hydrogen as H+

*2.1.4. Content of nutrients*

#### *2.1.2. pH*

The pH is defined as the negative logarithm of hydronium ions concentration; it is considered as a unit of measure to establish acidity or alkalinity levels of a substance, in this case food, and it is determined by the number of free hydrogen ions (H<sup>+</sup> ). The effects of adverse pH affect at least two aspects of the microbial cell-functioning of its enzymes and nutrients transportation to the cell.

The cytoplasmic membrane of microorganisms is relatively impermeable to H+ and OH<sup>−</sup> ions; its concentration in the cytoplasm remains reasonably constant, despite the wide variations that may occur in the pH of the surrounding medium. When microorganisms are in an environment below or above the neutral level, their ability to proliferate depends on their ability to change the environmental pH to a more appropriate range, since key components like DNA or ATP require a neutral medium [42, 43, 47].

The pH for the optimal growth of most microorganisms is close to neutrality (pH = 6.6– 7.5). Yeasts can grow in an acid environment and thrive in an intermediate range (4.0–4.5), although they survive in values between 1.5 and 8.5. Fungi tolerate a wide range (0.5–11.0), but their growth is generally higher in an acid pH (too acid for bacteria and yeast). Bacterial growth is usually favored by pH values closer to the neutral level. Nevertheless, acidophilic bacteria grow on substrates with a pH of up to 5.2 and below that point the growth reduces dramatically [42, 48].

In general, fruits, vinegars, and wines have pH values lower than those required for bacterial growth, so they can usually be decomposed by fungi and yeasts. Most vegetables have pH values lower than those from fruits, and consequently, vegetables are more exposed to bacterial or fungi decomposition. In contrast, most meats and sea products have pH values equal or greater than 5.6, making them susceptible to decomposition by bacteria, fungi, and yeasts [44, 48, 49].

#### *2.1.3. Oxidation-reduction potential*

The oxidation-reduction potential (O/R) is an indicator of the oxidizing and reducing power of a substrate; that is, the O/R potential of a substrate can be generally defined as the ease with which a substrate loses or gains electrons (when a food product loses electrons, it oxidizes, whereas, when it gains electrons it is reduced; thus, a food product that easily gives electrons is a good reducing agent and the one that receives electrons is a good oxidizing agent). To achieve optimum growth, some microorganisms require reducing conditions and others require oxidizing conditions. The O/R potential of a system is expressed with the Eh symbol (when electrons are transferred from one compound to another, a potential difference is created between the two compounds; this difference can be measured and expressed as millivolts [mV]). The more oxidized a substance is, the more positive the electrical potential will be; and the more reduced a substance is, the more negative the electrical potential will be. When the concentration of oxidant and reducer is equal, there is an electrical potential of zero [39].

Saprophytes that are capable of transferring hydrogen as H+ and e<sup>−</sup> (electrons) to molecular oxygen are aerobic; that is, aerobic microorganisms require positive Eh values (oxidized) for their growth, whereas anaerobic microorganisms require negative values of Eh (reduced). Facultative microorganisms can grow under any of the conditions. It has to be considered that maximum and minimum Eh values (in mV) necessary for aerobic and anaerobic growth could be lethal to the other group. Among food substances that help to maintain reducing conditions are the –SH groups in meats and the ascorbic acid, as well as, reducing sugars in fruits and vegetables. Some aerobic bacteria grow better under slightly reducing conditions being known as microaerophiles such as *Lactobacillus* and *Campylobacter*. Most of fungi and yeasts found in food are aerobic, although a few tend to be facultative anaerobes. Regarding the Eh value of food, vegetables, especially juices, tend to have Eh values of +300 to +400 mV; so, it is not surprising to find that aerobic bacteria and fungi are the common cause of decomposition in this type of products. Meats have Eh values around −200 mV; in ground meats, Eh is usually around +200 mV. Various types of cheese show Eh values between −20 and −200 mV [46].

#### *2.1.4. Content of nutrients*

activity determines the degree of microbial growth instead of the total moisture content. The unit of measurement for the water that microorganisms require is usually expressed as water activity (*A*w), which is defined as the water vapor pressure of food substrate, divided by the water vapor pressure of pure water, at the same temperature. This concept is related to relative humidity (RH), thus: RH = 100 × *A*w. The approximate optimal *A*w for the growth of most microorganisms is 0.99; most bacteria require an *A*w greater than 0.91 to grow. Gram-negative bacteria require higher values than Gram-positive bacteria. Most of the natural food products have an *A*w of 0.99 or more. Generally, bacteria have the highest requirements of water activity, fungi have the lowest, and yeasts have intermediate requirements. Most bacteria that decompose food do not grow with an *A*w less than 0.91, but fungi and yeasts can grow with values of 0.80 or less, including surfaces partially dehydrated. The lowest value reported for bacteria in food is 0.75 for halophytes, while xerophilic fungi and osmophilic yeasts have

The pH is defined as the negative logarithm of hydronium ions concentration; it is considered as a unit of measure to establish acidity or alkalinity levels of a substance, in this case food,

at least two aspects of the microbial cell-functioning of its enzymes and nutrients transporta-

its concentration in the cytoplasm remains reasonably constant, despite the wide variations that may occur in the pH of the surrounding medium. When microorganisms are in an environment below or above the neutral level, their ability to proliferate depends on their ability to change the environmental pH to a more appropriate range, since key components like

The pH for the optimal growth of most microorganisms is close to neutrality (pH = 6.6– 7.5). Yeasts can grow in an acid environment and thrive in an intermediate range (4.0–4.5), although they survive in values between 1.5 and 8.5. Fungi tolerate a wide range (0.5–11.0), but their growth is generally higher in an acid pH (too acid for bacteria and yeast). Bacterial growth is usually favored by pH values closer to the neutral level. Nevertheless, acidophilic bacteria grow on substrates with a pH of up to 5.2 and below that point the growth reduces

In general, fruits, vinegars, and wines have pH values lower than those required for bacterial growth, so they can usually be decomposed by fungi and yeasts. Most vegetables have pH values lower than those from fruits, and consequently, vegetables are more exposed to bacterial or fungi decomposition. In contrast, most meats and sea products have pH values equal or greater than 5.6, making them susceptible to decomposition by bacteria, fungi, and yeasts [44, 48, 49].

The oxidation-reduction potential (O/R) is an indicator of the oxidizing and reducing power of a substrate; that is, the O/R potential of a substrate can be generally defined as the ease with

The cytoplasmic membrane of microorganisms is relatively impermeable to H+

). The effects of adverse pH affect

and OH<sup>−</sup>

ions;

shown growth at *A*w values of 0.65 and 0.61, respectively [46, 47].

42 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

and it is determined by the number of free hydrogen ions (H<sup>+</sup>

DNA or ATP require a neutral medium [42, 43, 47].

*2.1.2. pH*

tion to the cell.

dramatically [42, 48].

*2.1.3. Oxidation-reduction potential*

Microorganisms have nutritional requirements, most of them need external sources of nitrogen, energy, minerals, as well as vitamins, and related growth factors; these requirements are found in our food, so if they have the right conditions to develop, they will. In general, fungi have the lowest nutrient requirement, followed by Gram-negative bacteria, then yeasts and finally, Gram-positive bacteria, which have the highest requirements [46, 50].

The primary sources of nitrogen used by heterotrophic microorganisms are amino acids. A great number of other nitrogen compounds may serve for this function for several types of organisms. For example, some of them can use free nucleotides and amino acids, while others can be capable of using peptides and proteins. In general, simple compounds like amino acids will be used by almost all of the organisms before attacking more complex compounds such as high molecular weight proteins. The same applies to polysaccharides and lipids [39, 51].

Microorganisms in food tend to use as energy sources, sugars, alcohols, and amino acids. Fungi are the most efficient in the use of proteins, complex carbohydrates, and lipids because they contain enzymes capable of hydrolyzing these molecules into simpler components; many bacteria have a similar capacity, but most yeasts require simpler molecules. All microorganisms need minerals, although vitamin requirements vary. Fungi and some bacteria can synthesize enough B vitamins to meet their needs, while others need to have a source of vitamins, food products being an excellent source of them [39, 50].

is another atmospheric gas with antimicrobial properties, and for decades, it has been used as an agent to lengthen shelf life of certain types of food. Although being effective against a variety of microorganisms, it is a highly oxidizing agent;thus, it cannot be used in food products with high lipid content, as it could accelerate rancidity. Normally, ozone levels of 0.15–5.00 ppm in the air inhibit the growth of some bacteria that decompose food as well as

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 45

Relative humidity (RH) of the environment is important from the point of view of water activity within food and the growth of microorganisms on surfaces. This extrinsic factor affects microbial growth and can be influenced by temperature. All microorganisms have a high-

When the *A*w of a food product is set at 0.60, it is important that this food is stored under RH conditions that do not allow food to draw humidity from the air and, therefore, it increases its own *A*w from the surface and subsurface to an extent where microbial growth can occur. A high relative humidity can cause humidity condensation in food, equipment, walls, and ceilings. Condensation causes wet surfaces, which lead to microbial growth and decomposition. Microbial growth is inhibited by a low relative humidity. When food products with low *A*<sup>w</sup> values are placed in high RH environments, food takes in moisture until they reach balance. Similarly, food products with high *A*w lose moisture when placed in an environment with low RH. There is a relationship between RH and temperature that must be taken into account when selecting the appropriate storage environments for food products. Overall, the higher

Bacteria require higher humidity than yeasts and fungi. The optimal relative humidity for bacteria is 92% or higher, while yeasts prefer 90% or higher, and fungi thrive if the relative humidity is between 85 and 90%. Food products suffering superficial decomposition by fungi, yeasts, and specific bacteria, should be stored under low RH conditions. Poorly packed meats such as whole chickens and beef cuts, tend to suffer a lot of superficial decomposition inside the refrigerator before internal decomposition occurs, usually, due to high RH in refrigerators, and to the fact that the biota decomposing meat is essentially aerobic in nature [46, 59]. Although it is possible to decrease the possibility of superficial decomposition in certain food products by storing them in low RH conditions, it should be remembered that the food itself will lose moisture into the atmosphere under such conditions, and thus, it will become undesirable. When selecting appropriate RH conditions, there should be taken into account both the possibility of superficial microbial growth and the quality that the food product needs to have. By altering the gas atmosphere, it is possible to delay superficial decomposition without

Some food origin organisms produce substances that can inhibit or be lethal for other organisms; these include antibiotics, bacteriocins, hydrogen peroxide, and organic acids. Bacteriocins produced by lactic acid-producing bacteria originated in various food products

water requirement, this being needed for their growth and activity [46, 54].

the temperature, the less the RH, and vice versa [46, 54, 58].

lowering the relative humidity [46, 60].

*2.2.4. Presence and activities of other microorganisms*

yeast growth [46, 57].

*2.2.3. Relative humidity in the environment*

Gram-positive bacteria are the ones that have lower synthesized capacity, so they need one or more of these components to grow. In contrast, Gram-negative bacteria and fungi are capable of synthesizing the most, if not all, of their requirements and consequently, these two groups of organisms can grow in food products with low content of B vitamins [46, 52, 53].

#### **2.2. Extrinsic parameters**

Food factors are very important for the development of microorganisms; there are external or extrinsic factors. This term refers to environmental factors that affect the growth rate of microorganisms; these factors include temperature, oxygen availability, and relative humidity, as well as, the presence and activities of other microorganisms [46].

#### *2.2.1. Storage temperature*

Microorganisms have an optimal range, as well as a minimum and maximum temperature to grow. Therefore, ambient temperature determines not only the proliferation rate, but also the genera of microorganisms that are going to be developed, along with the microbial activity degree that is registered. The change in only a few degrees in temperature will favor the growth of completely different organisms, and it will result in a different type of food decomposition and/or foodborne disease. Due to these characteristics, thermal treatment is employed as a method to control microbial activity [46, 54].

The optimal temperature for the proliferation of most microorganisms ranges from 14 to 40°C, although some genera develop below 0°C, and other genera grow at temperatures above 100°C. Nevertheless, food quality must be taken into account when selecting storage temperature. Although it can be desirable to storage all food products at temperatures equal or less to those of refrigeration, this is not the best thing to do to maintain a desirable quality in some food products such as banana, whose quality is best maintained in storage at 13–17°C than at 5–7°C. Similarly, many vegetables are favored at temperatures near 10°C such as potatoes, celery, cabbage, and many others. In each case, the success of storage temperature depends, to a large extent, on the relative humidity and the presence or absence of gases such as carbon dioxide and ozone [46, 55].

#### *2.2.2. Oxygen availability and presence of other gases in the environment*

Like temperature, the oxygen availability determines the microorganisms that will be active. Some have an absolute requirement for oxygen, while others grow in total absence of it, and others may grow with or without oxygen. Microorganisms that require free oxygen are called aerobic microorganisms, while those that thrive in the absence of oxygen are called anaerobic; and those that grow both in presence or absence of free oxygen are known as facultative microorganisms [43, 46, 56].

Carbon dioxide is the most important atmospheric gas that is used to control food microorganisms. Along with oxygen, it is used in packaged food with modified atmosphere. Ozone is another atmospheric gas with antimicrobial properties, and for decades, it has been used as an agent to lengthen shelf life of certain types of food. Although being effective against a variety of microorganisms, it is a highly oxidizing agent;thus, it cannot be used in food products with high lipid content, as it could accelerate rancidity. Normally, ozone levels of 0.15–5.00 ppm in the air inhibit the growth of some bacteria that decompose food as well as yeast growth [46, 57].

#### *2.2.3. Relative humidity in the environment*

synthesize enough B vitamins to meet their needs, while others need to have a source of vita-

Gram-positive bacteria are the ones that have lower synthesized capacity, so they need one or more of these components to grow. In contrast, Gram-negative bacteria and fungi are capable of synthesizing the most, if not all, of their requirements and consequently, these two groups

Food factors are very important for the development of microorganisms; there are external or extrinsic factors. This term refers to environmental factors that affect the growth rate of microorganisms; these factors include temperature, oxygen availability, and relative humidity, as

Microorganisms have an optimal range, as well as a minimum and maximum temperature to grow. Therefore, ambient temperature determines not only the proliferation rate, but also the genera of microorganisms that are going to be developed, along with the microbial activity degree that is registered. The change in only a few degrees in temperature will favor the growth of completely different organisms, and it will result in a different type of food decomposition and/or foodborne disease. Due to these characteristics, thermal treatment is

The optimal temperature for the proliferation of most microorganisms ranges from 14 to 40°C, although some genera develop below 0°C, and other genera grow at temperatures above 100°C. Nevertheless, food quality must be taken into account when selecting storage temperature. Although it can be desirable to storage all food products at temperatures equal or less to those of refrigeration, this is not the best thing to do to maintain a desirable quality in some food products such as banana, whose quality is best maintained in storage at 13–17°C than at 5–7°C. Similarly, many vegetables are favored at temperatures near 10°C such as potatoes, celery, cabbage, and many others. In each case, the success of storage temperature depends, to a large extent, on the relative humidity and the presence or absence of gases such as carbon

Like temperature, the oxygen availability determines the microorganisms that will be active. Some have an absolute requirement for oxygen, while others grow in total absence of it, and others may grow with or without oxygen. Microorganisms that require free oxygen are called aerobic microorganisms, while those that thrive in the absence of oxygen are called anaerobic; and those that grow both in presence or absence of free oxygen are known as facultative

Carbon dioxide is the most important atmospheric gas that is used to control food microorganisms. Along with oxygen, it is used in packaged food with modified atmosphere. Ozone

of organisms can grow in food products with low content of B vitamins [46, 52, 53].

mins, food products being an excellent source of them [39, 50].

44 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

well as, the presence and activities of other microorganisms [46].

employed as a method to control microbial activity [46, 54].

*2.2.2. Oxygen availability and presence of other gases in the environment*

**2.2. Extrinsic parameters**

*2.2.1. Storage temperature*

dioxide and ozone [46, 55].

microorganisms [43, 46, 56].

Relative humidity (RH) of the environment is important from the point of view of water activity within food and the growth of microorganisms on surfaces. This extrinsic factor affects microbial growth and can be influenced by temperature. All microorganisms have a highwater requirement, this being needed for their growth and activity [46, 54].

When the *A*w of a food product is set at 0.60, it is important that this food is stored under RH conditions that do not allow food to draw humidity from the air and, therefore, it increases its own *A*w from the surface and subsurface to an extent where microbial growth can occur. A high relative humidity can cause humidity condensation in food, equipment, walls, and ceilings. Condensation causes wet surfaces, which lead to microbial growth and decomposition. Microbial growth is inhibited by a low relative humidity. When food products with low *A*<sup>w</sup> values are placed in high RH environments, food takes in moisture until they reach balance. Similarly, food products with high *A*w lose moisture when placed in an environment with low RH. There is a relationship between RH and temperature that must be taken into account when selecting the appropriate storage environments for food products. Overall, the higher the temperature, the less the RH, and vice versa [46, 54, 58].

Bacteria require higher humidity than yeasts and fungi. The optimal relative humidity for bacteria is 92% or higher, while yeasts prefer 90% or higher, and fungi thrive if the relative humidity is between 85 and 90%. Food products suffering superficial decomposition by fungi, yeasts, and specific bacteria, should be stored under low RH conditions. Poorly packed meats such as whole chickens and beef cuts, tend to suffer a lot of superficial decomposition inside the refrigerator before internal decomposition occurs, usually, due to high RH in refrigerators, and to the fact that the biota decomposing meat is essentially aerobic in nature [46, 59].

Although it is possible to decrease the possibility of superficial decomposition in certain food products by storing them in low RH conditions, it should be remembered that the food itself will lose moisture into the atmosphere under such conditions, and thus, it will become undesirable. When selecting appropriate RH conditions, there should be taken into account both the possibility of superficial microbial growth and the quality that the food product needs to have. By altering the gas atmosphere, it is possible to delay superficial decomposition without lowering the relative humidity [46, 60].

#### *2.2.4. Presence and activities of other microorganisms*

Some food origin organisms produce substances that can inhibit or be lethal for other organisms; these include antibiotics, bacteriocins, hydrogen peroxide, and organic acids. Bacteriocins produced by lactic acid-producing bacteria originated in various food products such as meat, are of high interest. Bacteriocins produced by Gram-positive bacteria are biologically active proteins with bactericidal action. Some bacteriocins produced by these bacteria inhibit a variety of food pathogens including, *B. cereus*, *C. perfringens*, *Listeria* spp., *A. hydrophila*, and *S. aureus*, among others [39, 46].

To meet the ideal conditions, microorganisms in food grow and produce toxins. By ingesting contaminated food, toxins are absorbed through the intestinal epithelial lining, and it causes local tissue damage. In some cases, toxins can reach organs such as the kidney or the liver, the central nervous system or the peripheral nervous system, where they can cause some damage [18].

The most common clinical symptoms of foodborne diseases are diarrhea, vomit, abdominal cramps, headaches, nausea, pain, fever, vomit, diarrhea with mucus and blood (dysentery), and rectal tenesmus. Some of the microorganisms causing foodborne diseases, either from poisoning, intoxication or toxicoinfection are described in **Tables 2**–**4**. These diseases are gen-

Toxins produced by pathogens involved in foodborne diseases have different characteristics,

This section will be addressed to some diseases caused by consuming food contaminated with bacterial toxins or microorganisms that produce them. Among some of the most important diseases are the ones transmitted by *V. cholerae, S. aureus, B. cereus C. perfringens, C. botulinum* 

*V. cholerae* has a free life cycle, it is ubiquitous in aquatic environments; it is able to remain virulent without multiplying in fresh water and sea water for a long time. They are more frequent

Typhimurium, *Salmonella* Enteritidis).

diseases or people who are taking immunosuppressive drugs or

intestinal lesions, chronic cutaneous

pregnant women, intrauterine or cervical infection that can lead to miscarriage or birth of a dead child.

Crohn's disease. Pasteurized milk.

Typhoid and paratyphoid fever. Undercooked pork, beef and poultry,

contaminated eggs, and milk.

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 47

Seafood, usually oysters.

Contaminated milk.

fish, and raw fish.

and tomatoes.

Undercooked poultry, cauliflowers,

Raw beef, pork, poultry, vegetables and milk, cheese, ice cream, smoked

**Bacteria Disease/medical complications Food products involved**

erally diagnosed based on the patient's clinical record or their symptoms [18–20].

some of them are shown in **Table 5** [9, 11–15, 67].

**3.1. Foodborne diseases caused by bacterial toxins**

*Salmonella* spp. Salmonellosis (*Salmonella*

*Mycobacterium bovis* Cervical lymphadenopathy,

*Listeria monocytogenes* Meningitis, encephalitis, sepsis in

*Vibrio vulnificus* Septicemia in people with underlying

steroids.

tuberculosis.

*and Listeria monocytogenes.*

*Salmonella enterica* serovar Typhi and *Salmonella enterica* serovar Paratyphi

*Mycobacterium avium,* subspecies

Modified from Refs: [18–20].

**Table 2.** Pathogens that cause infection.

*paratuberculosis*

*3.1.1. Vibrio cholerae*

Normally food products can reach the final consumer at home, in community dining rooms, or restaurants. Measures to prevent food poisoning should be implemented at these locations, particularly in areas where large volumes of food are distributed such as cold chain, frozen chain, hot chain, and vacuum cooking. Likewise, in the frozen chain, food temperature is gradually lowered to −18°C and defrosted at temperatures higher than 65°C at the time it will be served to the costumer (not before); while in the hot chain, for example, in a buffet, food is kept at temperatures higher than 65°C and it should be consumed within 12 h maximum [61].

Other important measures are the use of food preservation methods, which can be physical or chemical. Within the physical methods, there are the traditional or industrial pasteurization, dehydration, preservation in modified atmosphere, and irradiation. In order to maintain an adequate quality control and to minimize the risk of food poisoning, microbial markers can be used; these markers do not represent a potential health risk, however, a large number of them indicate deficiencies in hygiene and sanitary quality of food products; it also leads to a decrease in the shelf-life and could be related to the presence of pathogenic microorganisms. The main microbial markers are aerobic mesophilic, total coliforms, fecal coliforms, Enterococci, *E. coli*, *S. aureus*, and lactic acid bacteria [62].

Once the risk factors are identified, it is necessary to establish a system that allows to prevent and decrease all of them; to do this, a method with scientific basis and systematic profile has been established, this is known as Hazard Analysis and Critical Control Point (HACCP). A microbiological approach should consider the type of microorganism or metabolite (toxins) that threatens human health; the analytical methods for its detection and quantification; the number of samples to be taken and the size of the analytical unit; and the microbiological limits considered to be adequate at specific points in the food chain [63].

## **3. Foodborne diseases**

In food products, we can find different types of toxins such as, bacterial, fungal (mycotoxins), algae or plant toxins, as well as metals, toxic chemicals (zinc, copper, and pesticides), and physical contaminants that can cause diseases in people who eat them; all of these can cause the well-known "foodborne diseases" [64].

Foodborne diseases can be classified into two groups: poisoning and infection.


To meet the ideal conditions, microorganisms in food grow and produce toxins. By ingesting contaminated food, toxins are absorbed through the intestinal epithelial lining, and it causes local tissue damage. In some cases, toxins can reach organs such as the kidney or the liver, the central nervous system or the peripheral nervous system, where they can cause some damage [18].

The most common clinical symptoms of foodborne diseases are diarrhea, vomit, abdominal cramps, headaches, nausea, pain, fever, vomit, diarrhea with mucus and blood (dysentery), and rectal tenesmus. Some of the microorganisms causing foodborne diseases, either from poisoning, intoxication or toxicoinfection are described in **Tables 2**–**4**. These diseases are generally diagnosed based on the patient's clinical record or their symptoms [18–20].

Toxins produced by pathogens involved in foodborne diseases have different characteristics, some of them are shown in **Table 5** [9, 11–15, 67].

#### **3.1. Foodborne diseases caused by bacterial toxins**

This section will be addressed to some diseases caused by consuming food contaminated with bacterial toxins or microorganisms that produce them. Among some of the most important diseases are the ones transmitted by *V. cholerae, S. aureus, B. cereus C. perfringens, C. botulinum and Listeria monocytogenes.*

#### *3.1.1. Vibrio cholerae*

such as meat, are of high interest. Bacteriocins produced by Gram-positive bacteria are biologically active proteins with bactericidal action. Some bacteriocins produced by these bacteria inhibit a variety of food pathogens including, *B. cereus*, *C. perfringens*, *Listeria* spp., *A.* 

46 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

Normally food products can reach the final consumer at home, in community dining rooms, or restaurants. Measures to prevent food poisoning should be implemented at these locations, particularly in areas where large volumes of food are distributed such as cold chain, frozen chain, hot chain, and vacuum cooking. Likewise, in the frozen chain, food temperature is gradually lowered to −18°C and defrosted at temperatures higher than 65°C at the time it will be served to the costumer (not before); while in the hot chain, for example, in a buffet, food is kept at temperatures higher than 65°C and it should be consumed within 12 h maximum [61]. Other important measures are the use of food preservation methods, which can be physical or chemical. Within the physical methods, there are the traditional or industrial pasteurization, dehydration, preservation in modified atmosphere, and irradiation. In order to maintain an adequate quality control and to minimize the risk of food poisoning, microbial markers can be used; these markers do not represent a potential health risk, however, a large number of them indicate deficiencies in hygiene and sanitary quality of food products; it also leads to a decrease in the shelf-life and could be related to the presence of pathogenic microorganisms. The main microbial markers are aerobic mesophilic, total coliforms, fecal coliforms,

Once the risk factors are identified, it is necessary to establish a system that allows to prevent and decrease all of them; to do this, a method with scientific basis and systematic profile has been established, this is known as Hazard Analysis and Critical Control Point (HACCP). A microbiological approach should consider the type of microorganism or metabolite (toxins) that threatens human health; the analytical methods for its detection and quantification; the number of samples to be taken and the size of the analytical unit; and the microbiological

In food products, we can find different types of toxins such as, bacterial, fungal (mycotoxins), algae or plant toxins, as well as metals, toxic chemicals (zinc, copper, and pesticides), and physical contaminants that can cause diseases in people who eat them; all of these can cause

• Poisoning is caused by the intake of chemical or biological toxins; or toxins produced by

• Infection is caused by the intake of food containing viable pathogens. Furthermore, a toxic infection (toxicoinfection), formerly known as a toxin-mediated infection, is caused by eat-

*hydrophila*, and *S. aureus*, among others [39, 46].

Enterococci, *E. coli*, *S. aureus*, and lactic acid bacteria [62].

**3. Foodborne diseases**

the well-known "foodborne diseases" [64].

limits considered to be adequate at specific points in the food chain [63].

Foodborne diseases can be classified into two groups: poisoning and infection.

pathogens, the latter can be found in food, even if the bacterium is not there.

ing food with bacteria that grow and produce a toxin inside the body [18, 64–66].

*V. cholerae* has a free life cycle, it is ubiquitous in aquatic environments; it is able to remain virulent without multiplying in fresh water and sea water for a long time. They are more frequent


**Table 2.** Pathogens that cause infection.


**Name Biological effect**

Thermolabile toxin (LT) (A-5B) Similar effect as the Cholera toxin.

Cholera toxin (Ctx) (A-5B) It activates the adenylyl cyclase; increases the levels of intracellular cAMP

Thermostable toxin (ST) The binding of ST to the guanylyl cyclase receptor results in an increase

Shiga toxin (A-5B) Inactivates the ribosomal subunit 60S and inhibits protein synthesis causing the death of susceptible cells. Botulinum toxin (A/B) It is a neurotoxin consisting of a heavy and a light chain linked by a

CPE enterotoxin Lethal, cytotoxic and enterotoxic activity. Stimulates the adenylyl cyclase

Alpha-toxin It produces gas gangrene. It has phospholipase (PLC), sphingomyelinase,

in the presence of calcium. Beta-toxin It forms selective pores for monovalent cations in lipid bilayers and

producing arterial constriction. Epsilon-toxin Produced and secreted by a prototoxin that, when it suffers a specific

dependent metalloproteinase. Iota-toxin It has dermonecrotic, cytotoxic, enterotoxic activities, and it causes

Toxin A/Toxin B It modifies the Rho, a subfamily of GTP-binding proteins that regulate

diarrhea associated with colitis.

role in emesis is not known.

Enterotoxins (A, B, C1, C2, D and E,

G, H, I, J)

to form a heptameric pore that allows the K<sup>+</sup>

effect of the proteases present in the intestinal tract.

Enterotoxins are thermostable; they differ in toxicity.

causing diarrhea. It is a potent exotoxin.

promoting fluid and electrolytes secretion in the intestinal epithelium,

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 49

of cyclic GMP, affecting the flow of electrolytes. It promotes water and electrolytes secretion from the intestinal epithelium by causing diarrhea.

disulfide bond. It is a Zn++-dependent protease. It inhibits the presynaptic release of acetylcholine from peripheral cholinergic neurons, resulting in flaccid paralysis. The neurotoxin exists in seven different serotypes (A-G).

allowing the increase of cAMP in epithelial cells, which causes diarrhea.

hemolytic, and dermonecrotic activities. The mature protein is organized into two domains; the amino-terminal, which contains the PLC activity, and the carboxyl-terminal binding that depends on calcium. Depending on the lipid composition of the cell membrane, the Alpha-toxin may be hemolytic

sensitive cells membranes, so it functions as a neurotoxin capable of

proteolytic cleavage, it acquires its maximum biological activity. Activation can be catalyzed by proteases such as trypsin, chymotrypsin, and a zinc-

intestinal histopathological damage. This toxin is binary and consists of a binding peptide (Ib) and an enzymatic peptide (ADP-ribosyltransferase) (Ia). The first one is necessary to internalize the second one. The Iota-toxin requires proteolytic removal of a propeptide fragment, which allows the Ib unit to be inserted into the membrane and to interact with the Ia portion

in addition to the Ia portion entrance into the cell where it ribosylates the G-actin to depolymerize the actin filaments, with the consequent destruction of the cytoskeleton. The Iota-toxin is generally activated by the

cytoskeletal actin. The deamination of the glutamine residue at position 63 of Rho to a glutamic acid produces a dominant-active Rho protein incapable of hydrolyzing the GTP, resulting in cellular necrosis and bloody

Staphylococcal enterotoxins are superantigens that cause massive activation of the immune system, including lymphocytes and macrophages; the exact

and Na+

ions to escape;

**Table 3.** Pathogens that cause intoxication.


**Table 4.** Pathogens that cause toxico-infection.


**Bacteria Disease/medical complications Food products involved**

**Bacteria Disease/medical complications Food products involved**

*Bacillus cereus* Fried rice syndrome. Rice cooked at high temperatures,

*Staphylococcus aureus* Toxic shock syndrome. Meat and meat products cooked

respiratory muscles.

48 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

uremic syndrome in children.

hemolytic uremic syndrome, necrotizing fasciitis in wounds.

developmental deficits; death.

wound infection. Severe infections in immunocompromised people.

*Clostridium perfringens* Clostridial necrotizing enteritis. Meat juice, stews, cooked beans, meat

meningitis, *Campylobacter jejuni* can cause Guillain-Barré Syndrome.

pseudoappendicitis, mesenteric lymphadenitis, infections in wounds, joints and the urinary tract, and

gastrointestinal infections, sepsis.

Reiter's syndrome.

*Shigella* spp. Hemolytic Uremic Syndrome. Salads, lettuce, raw vegetables, and

Hamburgers, nonpasteurized milk, contaminated water, spinach, and

Mixture of oil and nonacid garlic, potatoes cooked at high temperatures, and stews.

sauces, soups, and puddings.

at high temperatures, poultry, and salads with mayonnaise.

Meat (beef, sheep, pork and chicken), vegetables, eggs, fish, seafood, and

lettuce.

milk.

prepared food.

usually oysters.

chicken meat.

seafood.

Cholera. Contaminated water and raw

Powdered infant formula.

Raw or undercooked seafood,

cooked at high temperatures.

Nonpasteurized milk, tofu, nonchlorinated water, undercooked

meat, oysters and fish.

Cheese made with raw milk and

Raw, semicooked or recontaminated fish and shellfish after cooking.

*Escherichia coli* O157:H7 Hemorrhagic colitis, Hemolytic

Source: Modified from Refs: [18–20].

**Table 3.** Pathogens that cause intoxication.

*Clostridium botulinum* Paralysis of arms, legs, trunk, and

*Aeromonas* spp. Meningitis, peritonitis, myocarditis,

*Cronobacter sakazakii* Permanent neurological or

*Vibrio parahaemolyticus* Gastroenteritis, septicemia and

*Campylobacter* spp. Campylobacteriosis, arthritis,

*Yersinia enterocolitica* Yersiniosis, enterocolitis,

*Vibrio cholerae* serogroup no-O1 Less severe than Cholera;

*Vibrio cholerae* serogroup O1 or

Source: Modified from Refs: [18–20].

**Table 4.** Pathogens that cause toxico-infection.

serogroup O139


populations in areas where the disease is endemic. Experience in different mass vaccination campaigns in countries such as Mozambique, Indonesia, Sudan, and Zanzibar clearly indicates that vaccination requires careful and early planning and preparation, and therefore, it

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 51

The lack of toxicity combined with stability and the relative ease to express the Cholera Toxin Subunit B (CTB) has contributed to be an easily manageable adjuvant. The ability to express protein in a wide variety of organisms broadens even further its application potential. CTB is currently being used in vaccines such as Dukoral, a vaccine against *V. cholerae* that consists of dead bacteria and recombinant CTB. It has been approved as adjuvant for vaccines in Europe and in Canada; and given the excellent adjuvant effect, this protein is likely to play an impor-

Staphylococcal foodborne illness is one of the most common diseases acquired by *S. aureus*. It is one of the most concerned diseases by public health programs in the world; it is due to the production of one or more toxins by the bacteria during their growth at permissive temperatures; however, the incubation period of the disease depends on the amount of ingested toxin. Small doses of enterotoxins can cause the disease; for example, a concentration of 0.5 ng/mL

*S. aureus* produces various toxins. Staphylococcal enterotoxins are a family of nine thermostable enterotoxin serotypes belonging to a large family of pyrogenic toxins (superantigens). Pyrogenic toxins can cause immunosuppression and nonspecific T cell proliferation. Enterotoxins are highly stable and they resist high temperatures (which makes them suitable for industrial use) and environmental conditions of drying and freezing. They are also resistant to proteolytic enzymes (pepsin and trypsin) at low pH, enabling them to be fully func-

The mechanism by which poisoning is caused is not entirely clear yet. However, enterotoxins have been observed to directly affect the intestinal epithelium and the vagus nerve causing stimulation of the emetic center. It is estimated that 0.1 μg of enterotoxin can cause staphylococcal poisoning in humans. Apart from causing poisoning, *S. aureus* can also cause toxic shock syndrome due to the production of the Toxic Shock Syndrome Toxin 1 (TSST-1) and

Symptoms include nausea, vomit, abdominal cramps, salivation, diarrhea could be present or absent. The first three symptoms are the most common ones. Usually, it is a self-limiting disease and can be cured in 24–48 h, but it can become severe, especially in children, the elderly, and immunocompromised people. Toxic shock syndrome is characterized by high fever, hypotension, erythematous rash (similar to scarlet fever, peeling of the skin during

The diagnosis of the disease is carried out by detecting the staphylococcal enterotoxin in the food or by recovering at least 105 *S. aureus*/g from food leftovers. The enterotoxin can be

in contaminated chocolate milk has been reported to cause large outbreaks [73].

cannot be improvised at the last minute [71].

tant role in vaccine formulation in the future [72].

tional in the digestive tract after infection [73].

recovery, flu-like symptoms, vomiting, and diarrhea) [73–75].

Enterotoxin Type B [65, 73, 74].

*3.1.2. Staphylococcus aureus*

Note: A-5B indicates that the subunits are separately synthesized but associated by noncovalent bonds during secretion and binding to target. 5B indicates that the binding domain of the protein is composed by five identical subunits. A/B denotes a toxin synthesized as a simple polypeptide divided into domains A and B that can be separated by proteolytic cleavage. HBL: hemolysin BL, NHE: nonhemolytic enterotoxin.

Source: Modified from Refs: [9, 11–15, 67].

**Table 5.** Main toxins produced by pathogens involved in foodborne diseases and their biological effect.

in temperate waters and can be isolated in seafood and fish. The most notable species are *V. cholerae* O1 and O139, causative serogroups of Cholera. Non-O1 strains and the rest of the species cause cholera-like diarrheal syndromes, but they are not as severe, although they frequently produce extraintestinal infections [68–70].

The CTX toxin (Cholera toxin) is the main virulence factor of *V. cholerae* O1 (Ogawa, Inaba, and Hikojima serotypes, Classical and El Tor biotypes) and O139; it contributes to cause profuse diarrhea, after an incubation period from 2 h to 5 days; stools have the appearance of rice water, there is dehydration and electrolyte imbalance, which can lead to death. Approximately 75% of the infected people are asymptomatic, that is, they do not develop the symptoms aforementioned; however, the pathogen is shed in their feces for 7–14 days, which is a very serious source of contamination since it is possible to infect others. The most vulnerable groups are children, adults, and people infected with the HIV virus [68, 69, 71].

This toxin can be identified by the presence of the *ctxAB* gene. *V. cholerae* no-O1 has the *ctx* gene but it is rarely expressed; nevertheless, a faster test is not yet available, although the WHO is currently in the process of validating new rapid diagnoses. The bacteria can be isolated and identified from stool samples by using laboratory procedures [24, 69, 71].

Efficient treatment resides in prompt rehydration through oral solutions or intravenous fluids. The use of antibiotics is suggested only when there is severe dehydration. The supply of safe drinking water, the adequate sanitation, and food security are essential to prevent the emergence of Cholera. Moreover, vaccines administration has emerged because control measures to prevent contamination are insufficient; this is the reason why oral vaccines have been developed as tools to prevent outbreaks. These vaccines are given to more vulnerable populations in areas where the disease is endemic. Experience in different mass vaccination campaigns in countries such as Mozambique, Indonesia, Sudan, and Zanzibar clearly indicates that vaccination requires careful and early planning and preparation, and therefore, it cannot be improvised at the last minute [71].

The lack of toxicity combined with stability and the relative ease to express the Cholera Toxin Subunit B (CTB) has contributed to be an easily manageable adjuvant. The ability to express protein in a wide variety of organisms broadens even further its application potential. CTB is currently being used in vaccines such as Dukoral, a vaccine against *V. cholerae* that consists of dead bacteria and recombinant CTB. It has been approved as adjuvant for vaccines in Europe and in Canada; and given the excellent adjuvant effect, this protein is likely to play an important role in vaccine formulation in the future [72].

#### *3.1.2. Staphylococcus aureus*

in temperate waters and can be isolated in seafood and fish. The most notable species are *V. cholerae* O1 and O139, causative serogroups of Cholera. Non-O1 strains and the rest of the species cause cholera-like diarrheal syndromes, but they are not as severe, although they fre-

**Table 5.** Main toxins produced by pathogens involved in foodborne diseases and their biological effect.

Note: A-5B indicates that the subunits are separately synthesized but associated by noncovalent bonds during secretion and binding to target. 5B indicates that the binding domain of the protein is composed by five identical subunits. A/B denotes a toxin synthesized as a simple polypeptide divided into domains A and B that can be separated by proteolytic

Toxic Shock Syndrome Toxin (TSST-1) Superantigen that acts on the vascular system causing inflammation, fever,

Cereulide Thermostable peptide, toxic for the mitochondria when acting as a potassium ionophore.

HBL, NHE, Citotoxin K or CytK HBL is a three-component hemolysin; two protein subunits, L2 and L1

(cytolytic components), and a B protein (favors binding to the host cell), apart from the hemolytic effect, it is cytotoxic, dermonecrotic and causes vascular permeability. NHE also consists of three components (NheA is a cytolytic component and NhB and NheC favor binding to cells of small intestine). Both toxins are organized into operons (*hbl* and *nhe*), where the genes encoded the NHE components are transcribed together. CytK forms pores in the epithelial cells membrane, and it has necrotizing and cytotoxic

and shock.

50 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

activity.

The CTX toxin (Cholera toxin) is the main virulence factor of *V. cholerae* O1 (Ogawa, Inaba, and Hikojima serotypes, Classical and El Tor biotypes) and O139; it contributes to cause profuse diarrhea, after an incubation period from 2 h to 5 days; stools have the appearance of rice water, there is dehydration and electrolyte imbalance, which can lead to death. Approximately 75% of the infected people are asymptomatic, that is, they do not develop the symptoms aforementioned; however, the pathogen is shed in their feces for 7–14 days, which is a very serious source of contamination since it is possible to infect others. The most vulner-

able groups are children, adults, and people infected with the HIV virus [68, 69, 71].

lated and identified from stool samples by using laboratory procedures [24, 69, 71].

This toxin can be identified by the presence of the *ctxAB* gene. *V. cholerae* no-O1 has the *ctx* gene but it is rarely expressed; nevertheless, a faster test is not yet available, although the WHO is currently in the process of validating new rapid diagnoses. The bacteria can be iso-

Efficient treatment resides in prompt rehydration through oral solutions or intravenous fluids. The use of antibiotics is suggested only when there is severe dehydration. The supply of safe drinking water, the adequate sanitation, and food security are essential to prevent the emergence of Cholera. Moreover, vaccines administration has emerged because control measures to prevent contamination are insufficient; this is the reason why oral vaccines have been developed as tools to prevent outbreaks. These vaccines are given to more vulnerable

quently produce extraintestinal infections [68–70].

cleavage. HBL: hemolysin BL, NHE: nonhemolytic enterotoxin.

Source: Modified from Refs: [9, 11–15, 67].

**Name Biological effect**

Staphylococcal foodborne illness is one of the most common diseases acquired by *S. aureus*. It is one of the most concerned diseases by public health programs in the world; it is due to the production of one or more toxins by the bacteria during their growth at permissive temperatures; however, the incubation period of the disease depends on the amount of ingested toxin. Small doses of enterotoxins can cause the disease; for example, a concentration of 0.5 ng/mL in contaminated chocolate milk has been reported to cause large outbreaks [73].

*S. aureus* produces various toxins. Staphylococcal enterotoxins are a family of nine thermostable enterotoxin serotypes belonging to a large family of pyrogenic toxins (superantigens). Pyrogenic toxins can cause immunosuppression and nonspecific T cell proliferation. Enterotoxins are highly stable and they resist high temperatures (which makes them suitable for industrial use) and environmental conditions of drying and freezing. They are also resistant to proteolytic enzymes (pepsin and trypsin) at low pH, enabling them to be fully functional in the digestive tract after infection [73].

The mechanism by which poisoning is caused is not entirely clear yet. However, enterotoxins have been observed to directly affect the intestinal epithelium and the vagus nerve causing stimulation of the emetic center. It is estimated that 0.1 μg of enterotoxin can cause staphylococcal poisoning in humans. Apart from causing poisoning, *S. aureus* can also cause toxic shock syndrome due to the production of the Toxic Shock Syndrome Toxin 1 (TSST-1) and Enterotoxin Type B [65, 73, 74].

Symptoms include nausea, vomit, abdominal cramps, salivation, diarrhea could be present or absent. The first three symptoms are the most common ones. Usually, it is a self-limiting disease and can be cured in 24–48 h, but it can become severe, especially in children, the elderly, and immunocompromised people. Toxic shock syndrome is characterized by high fever, hypotension, erythematous rash (similar to scarlet fever, peeling of the skin during recovery, flu-like symptoms, vomiting, and diarrhea) [73–75].

The diagnosis of the disease is carried out by detecting the staphylococcal enterotoxin in the food or by recovering at least 105 *S. aureus*/g from food leftovers. The enterotoxin can be detected by several methods: bioassays, molecular biology, and immunological techniques. The isolated strains can be genetically characterized by multilocus sequences from the *spa* or *SCCmec* gene, and pulsed-field electrophoresis [73].

cytotoxic, and dermonecrotic effect, and it induces vascular permeability. NHE also consists of three components: NheA, NheB, and NheC. It has been demonstrated that strains producing emetic toxin do not produce enterotoxin. The cytotoxin K is similar to the Alpha-toxin of

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 53

Furthermore, the enterotoxin FM (EntFM) has been described; it is a 45 kDa polypeptide encoded by the *entFM* gene, located in the bacterial chromosome. It has not been directly involved in food poisoning; however, the presence of the gene in strains that cause diarrheal outbreaks has been detected; in experiments with mice and rabbits, it causes vascular perme-

The emetic syndrome is characterized by nausea and vomit similar to those produced by *S. aureus* poisoning. Symptoms appear soon after consuming food contaminated with the preformed toxin. Generally, poisoning develops with mild symptoms, usually lasting no more than 1 day, but severe cases require hospitalization. The diarrhea that is caused belongs to the secretory type, similar to the one produced by *V. cholerae*. Colic pain occurs similar to that of

Enterotoxins can be detected by immunoassays or molecular biology (conventional PCR and multiple PCR) by looking for the *ces* gene (nonribosomal production of cereulide); by detecting the *hblD, hblC*, and *hblA* genes encoding the L1, L2, and B protein components of the HBL toxin, respectively; or the *nheA, nheB*, and *nheC* genes of the NHE toxin components. The *16S*

Apart from causing food poisoning, *B. cereus* can also cause local and systemic infections in immunocompromised patients, neonates, people taking drugs, and patients with surgical or

The most susceptible food products to be contaminated include flours, meats, milk, cheese, vegetables, fish, rice and its derived products; generally, in food with high content of starch. The strains produced by the emetic toxin grow well in rice dishes (fried and cooked) and other starchy products; although, there have been studies where it has been demonstrated that the toxin can be in different types of food products; while strains producing diarrheagenic toxins grow in a wide variety of food products, from vegetables to

Strains isolated from infections have been shown to be sensitive to chloramphenicol, clindamycin, vancomycin, gentamicin, streptomycin, and erythromycin; they are resistant to β-lactam

Inadequate cooking temperatures, contaminated equipment, and poor hygiene conditions at the food processing and preparation sites are the major factors that contribute to food poisoning by *B. cereus* and its toxins; that is why, it is suggested to store food at temperatures lower than 4°C or to cook them at temperatures higher than 100°C, and to reheat or cool food rapidly, to avoid prolonged exposure to temperatures that allow spore germination and to

*S. aureus* and the Beta-toxin of *C. perfringens* [13, 15, 76].

*C. perfringens* poisoning. Both syndromes are self-limiting [13, 15, 77].

ribosomal gene can be looked for by real-time PCR [11, 13, 77].

antibiotics, including third-generation cephalosporins [15].

diminish the risks of a possible poisoning [11].

traumatic wounds, or catheters [15].

sauces and stews [15, 77].

ability [11].

The mainly involved food products in outbreaks and where *S. aureus* can grow optimally, since they are stored at room temperature, are meat and its derived products, poultry and eggs, milk and its derived products, salads, and bakery products (cream-filled cakes and stuffed sandwiches) [65, 73].

Other factors that must be taken into account are the emergence of methicillin resistant strains, which may be found in food (mainly in meat and milk). It is important to note that many of the isolates obtained from outbreaks are not tested for antimicrobial susceptibility; due to the various problems that these strains can create, the antimicrobial susceptibility test should be performed. They have been reported to be causative agents of outbreaks in blood infections and wounds in immunocompromised patients in hospitals [65, 73].

Foodborne illness due to *S. aureus* may be preventable. It is known that the permissible temperature for the growth and production of the enzyme is between 6 and 46°C; thus, food products could be cooked above 60°C and refrigerated below 5°C. Therefore, maintaining the cold chain of food can prevent the growth of the microorganism. By using good manufacturing practices and good hygiene practices, the contamination by *S. aureus* can be prevented [73].

#### *3.1.3. Bacillus cereus*

*B. cereus* is a ubiquitous microorganism in the environment, and it can easily contaminate any food production and processing system, due to the formation of endospores. The bacterium can survive pasteurization and cooking processes [11, 15].

It has been demonstrated that this microorganism produces, cereulide or emetic toxin; three enterotoxins, hemolysin BL (HBL), nonhemolytic (NHE), cytotoxin K (CytK), which are responsible for the emetic syndrome and diarrhea; and three phospholipases, phosphatidylinositol hydrolase, phosphatidylcholine hydrolase, and hemolytic sphingomyelinase. Cereulide is a thermostable cyclic peptide that causes emesis by stimulating the afferent vagal pathway through its bond to the serotonin receptor. The toxin is produced during the stationary phase of growth of the microorganism and it accumulates in food over time. The structure of the toxin explains its resistance to food processing methods. In contrast, inside the small intestine of the host, the thermolabile enterotoxins, HBL and NHE, produced during the exponential phase of the vegetative growth of the bacterium are the cause of diarrheal syndrome; the proteins that form enterotoxins (binding and lithic factors) are unable to traverse intact the gastric barrier; that is why it is considered that preformed or extracellular enterotoxins in food are not involved in the pathogenesis of the bacterium. It is believed that the spore germination that reaches the small intestine, the growth, and the simultaneous production of the enterotoxin are the ones that cause diarrhea. HBL is a hemolysin formed by three components, two protein subunits (L2 and L1), and one B protein; it has hemolytic, cytotoxic, and dermonecrotic effect, and it induces vascular permeability. NHE also consists of three components: NheA, NheB, and NheC. It has been demonstrated that strains producing emetic toxin do not produce enterotoxin. The cytotoxin K is similar to the Alpha-toxin of *S. aureus* and the Beta-toxin of *C. perfringens* [13, 15, 76].

detected by several methods: bioassays, molecular biology, and immunological techniques. The isolated strains can be genetically characterized by multilocus sequences from the *spa* or

The mainly involved food products in outbreaks and where *S. aureus* can grow optimally, since they are stored at room temperature, are meat and its derived products, poultry and eggs, milk and its derived products, salads, and bakery products (cream-filled cakes and

Other factors that must be taken into account are the emergence of methicillin resistant strains, which may be found in food (mainly in meat and milk). It is important to note that many of the isolates obtained from outbreaks are not tested for antimicrobial susceptibility; due to the various problems that these strains can create, the antimicrobial susceptibility test should be performed. They have been reported to be causative agents of outbreaks in blood infections

Foodborne illness due to *S. aureus* may be preventable. It is known that the permissible temperature for the growth and production of the enzyme is between 6 and 46°C; thus, food products could be cooked above 60°C and refrigerated below 5°C. Therefore, maintaining the cold chain of food can prevent the growth of the microorganism. By using good manufacturing practices and good hygiene practices, the contamination by *S. aureus* can be

*B. cereus* is a ubiquitous microorganism in the environment, and it can easily contaminate any food production and processing system, due to the formation of endospores. The bacterium

It has been demonstrated that this microorganism produces, cereulide or emetic toxin; three enterotoxins, hemolysin BL (HBL), nonhemolytic (NHE), cytotoxin K (CytK), which are responsible for the emetic syndrome and diarrhea; and three phospholipases, phosphatidylinositol hydrolase, phosphatidylcholine hydrolase, and hemolytic sphingomyelinase. Cereulide is a thermostable cyclic peptide that causes emesis by stimulating the afferent vagal pathway through its bond to the serotonin receptor. The toxin is produced during the stationary phase of growth of the microorganism and it accumulates in food over time. The structure of the toxin explains its resistance to food processing methods. In contrast, inside the small intestine of the host, the thermolabile enterotoxins, HBL and NHE, produced during the exponential phase of the vegetative growth of the bacterium are the cause of diarrheal syndrome; the proteins that form enterotoxins (binding and lithic factors) are unable to traverse intact the gastric barrier; that is why it is considered that preformed or extracellular enterotoxins in food are not involved in the pathogenesis of the bacterium. It is believed that the spore germination that reaches the small intestine, the growth, and the simultaneous production of the enterotoxin are the ones that cause diarrhea. HBL is a hemolysin formed by three components, two protein subunits (L2 and L1), and one B protein; it has hemolytic,

*SCCmec* gene, and pulsed-field electrophoresis [73].

and wounds in immunocompromised patients in hospitals [65, 73].

52 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

can survive pasteurization and cooking processes [11, 15].

stuffed sandwiches) [65, 73].

prevented [73].

*3.1.3. Bacillus cereus*

Furthermore, the enterotoxin FM (EntFM) has been described; it is a 45 kDa polypeptide encoded by the *entFM* gene, located in the bacterial chromosome. It has not been directly involved in food poisoning; however, the presence of the gene in strains that cause diarrheal outbreaks has been detected; in experiments with mice and rabbits, it causes vascular permeability [11].

The emetic syndrome is characterized by nausea and vomit similar to those produced by *S. aureus* poisoning. Symptoms appear soon after consuming food contaminated with the preformed toxin. Generally, poisoning develops with mild symptoms, usually lasting no more than 1 day, but severe cases require hospitalization. The diarrhea that is caused belongs to the secretory type, similar to the one produced by *V. cholerae*. Colic pain occurs similar to that of *C. perfringens* poisoning. Both syndromes are self-limiting [13, 15, 77].

Enterotoxins can be detected by immunoassays or molecular biology (conventional PCR and multiple PCR) by looking for the *ces* gene (nonribosomal production of cereulide); by detecting the *hblD, hblC*, and *hblA* genes encoding the L1, L2, and B protein components of the HBL toxin, respectively; or the *nheA, nheB*, and *nheC* genes of the NHE toxin components. The *16S* ribosomal gene can be looked for by real-time PCR [11, 13, 77].

Apart from causing food poisoning, *B. cereus* can also cause local and systemic infections in immunocompromised patients, neonates, people taking drugs, and patients with surgical or traumatic wounds, or catheters [15].

The most susceptible food products to be contaminated include flours, meats, milk, cheese, vegetables, fish, rice and its derived products; generally, in food with high content of starch. The strains produced by the emetic toxin grow well in rice dishes (fried and cooked) and other starchy products; although, there have been studies where it has been demonstrated that the toxin can be in different types of food products; while strains producing diarrheagenic toxins grow in a wide variety of food products, from vegetables to sauces and stews [15, 77].

Strains isolated from infections have been shown to be sensitive to chloramphenicol, clindamycin, vancomycin, gentamicin, streptomycin, and erythromycin; they are resistant to β-lactam antibiotics, including third-generation cephalosporins [15].

Inadequate cooking temperatures, contaminated equipment, and poor hygiene conditions at the food processing and preparation sites are the major factors that contribute to food poisoning by *B. cereus* and its toxins; that is why, it is suggested to store food at temperatures lower than 4°C or to cook them at temperatures higher than 100°C, and to reheat or cool food rapidly, to avoid prolonged exposure to temperatures that allow spore germination and to diminish the risks of a possible poisoning [11].

#### *3.1.4. Clostridium perfringens*

*C. perfringens* is an anaerobic bacterium that creates spores that survive in soil, sediments, and areas subject to both human and animal fecal contamination. It is widely distributed in the environment and is frequently found in the human intestine and in several domestic and wild animals' intestines [78].

Among the main food products involved are meat and its derived products. The disease can be prevented if the food has been properly cooked; although, there may be a risk of crosscontamination if the cooked food comes in contact with raw and contaminated ingredients, as

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 55

There is no specific treatment or established cure for the infections caused by the toxins of the bacteria. Supportive care includes administration of intravenous fluids, oral rehydration salts solutions, and medication for fever and pain control. The treatment of gas gangrene is based on surgical measures with debridement and removal of the affected tissue and administration of high doses of antibiotics. Necrotizing enterocolitis is treated systemically with penicillin G, metronidazole or chloramphenicol; 50% of the cases require surgical treatment in which a segmental jejunum resection is performed. The antibiotics active against anaerobic bacteria are effective; however, there are strains resistant to penicillin and clindamycin, therefore, it is suggested to perform antimicrobial susceptibility tests, especially in patients with severe

*C. botulinum* is a spore-forming microorganism; these spores can remain viable for long periods of time when the environmental conditions are absolutely unfavorable for the develop-

Four groups are recognized in *C. botulinum*, as well as seven antigenic variants of botulinum neurotoxins (A–G). Groups I and II are primarily responsible for botulism in humans; Group III is responsible for causing botulism in several animal species, and Group IV appears not to be associated with the disease in either humans or animals. Group I is also known as *C. botulinum*-proteolytic (mesophilic microorganisms), while group II is known as *C. botulinum*-non-proteolytic (psychrophilic microorganisms). Group I forms spores that are highly resistant to heat, the "Botulinum cook" (121°C/3 min) given to canned foods with a low content of acid is designed to inactivate them; neurotoxins formed in this group are A, B, F, and H. Group II forms moderately heat-resistant spores, and the neurotoxins formed are B, E, and F. Botulism types A, B, E, and F rarely cause the disease in humans, whereas in animals it is caused by types C and D. Toxins are resistant to proteolytic reactions and to denaturation into the gastric apparatus. Botulinum toxins are metalloproteins with endopeptidase activity that require zinc; the general structure shows two chains with a molecular weight of 150 kDa, the double chain is subdivided into a heavy (H) structure constituted by a nitrogen terminal domain (HN), and a carboxyl-terminal (HC), and a lighter structure (L) that performs the catalytic function of the toxin. HC is responsible for binding to presynaptic receptors for inter-

*C. botulinum,* is a bacterial species known simply for producing the botulinum toxin. The number of genes in Group II strains coding for the neurotoxin is variable; there may be one to three genes that encode one to three different neurotoxins; if there are two genes, there can be one active toxin and an inactive toxin, or both toxins can be active. In Group II, the presence of only one gene has been described, that is why there is only one neurotoxin; however, in other studies it has been demonstrated that in Type F strains the toxin has part of Type B and

well as contaminated surfaces [78].

*3.1.5. Clostridium botulinum*

ment of the microorganism [60].

disease and those requiring long-term treatments [9, 80].

nalization, and HN is called translocation domain [81–83].

*C. perfringens* is classified into five groups (A, B, C, D, and E), due to the different toxins it produces (alpha, beta, epsilon, and iota). The Alpha-toxin is produced by all the five groups. The Beta-toxin forms selective pores for monovalent ions in the lipid bilayers, functioning as a neurotoxin capable of producing arterial constriction. The Epsilon-toxin is the most potent clostridial toxin after tetanus and botulinum neurotoxins (BoNTs). It is produced and secreted by a prototoxin that acquires its maximum biological activity by undergoing a specific proteolytic cleavage; its activation can be catalyzed by trypsin, chymotrypsin, and a zinc metalloprotease [12].

The toxin receptor is unknown, but it is known to be a surface protein anchored by glycosylphosphatidylinositol. Its main biological activity is the edema generation; it is lethal but not hemolytic. The Iota-toxin is a member of the binary toxin family, since it is formed by a binding peptide (Ib) necessary for the internalization of the enzymatic peptide (Ia; ADPribosyltransferase). Proteolytic removal of a propeptide fragment is required to allow Ib to be inserted into the membrane and to interact with Ia. Ib, when inserted into the membrane, forms a heptameric pore that allows the exit of K<sup>+</sup> and Na+ ions, and the entry of Ia, which once inside the cell, is ribosylated by the G-actin; it depolymerizes the filaments of Actin by destroying the cellular cytoskeleton. The Iota-toxin is dermonecrotic, cytotoxic, enterotoxic, and induces intestinal histopathological damage [12].

However, the virulence of this bacterium is not only due to the presence of these 4 toxins; there have also been described 15 toxins within which the CPE enterotoxin is responsible for causing diarrhea in humans and animals, and it is produced by Type A strains. This toxin is associated with 5 or 15% of gastrointestinal diseases in humans different from food poisoning such as diarrhea produced by antibiotics; the NetB toxin is frequently related to necrotic enteritis in birds and the Beta2-toxin is apparently associated with enteritis. The production of toxins in the digestive tract is associated with sporulation. The disease is foodborne; and only one case has implied the possibility of poisoning caused by the preformed toxin [12, 78, 79].

*C. perfringens* causes food poisoning characterized by severe abdominal cramps and diarrhea beginning after 8–22 h of food intake, the disease ends 24 h after the intake; although, in some cases the disease may persist for 1–2 weeks. Additionally, there is a more severe but less frequent disease caused by eating a food product contaminated with type C strains; this disease is known as necrotic enteritis or pig-bel disease, and it is often fatal. Deaths caused by necrotic enteritis are due to intestinal infection and necrosis, as well as by septicemia, the elderly people being the most affected population [78].

The disease diagnosis is confirmed by the presence of the toxin in the stools of patients; either by traditional methods (culture from the stools or the food involved) or by molecular methods by looking for the following genes: *cpe* (CPE toxin), *plc* (Alpha-toxin), and *etx* (Epsilon-toxin) [12, 78, 79].

Among the main food products involved are meat and its derived products. The disease can be prevented if the food has been properly cooked; although, there may be a risk of crosscontamination if the cooked food comes in contact with raw and contaminated ingredients, as well as contaminated surfaces [78].

There is no specific treatment or established cure for the infections caused by the toxins of the bacteria. Supportive care includes administration of intravenous fluids, oral rehydration salts solutions, and medication for fever and pain control. The treatment of gas gangrene is based on surgical measures with debridement and removal of the affected tissue and administration of high doses of antibiotics. Necrotizing enterocolitis is treated systemically with penicillin G, metronidazole or chloramphenicol; 50% of the cases require surgical treatment in which a segmental jejunum resection is performed. The antibiotics active against anaerobic bacteria are effective; however, there are strains resistant to penicillin and clindamycin, therefore, it is suggested to perform antimicrobial susceptibility tests, especially in patients with severe disease and those requiring long-term treatments [9, 80].

#### *3.1.5. Clostridium botulinum*

*3.1.4. Clostridium perfringens*

animals' intestines [78].

*C. perfringens* is an anaerobic bacterium that creates spores that survive in soil, sediments, and areas subject to both human and animal fecal contamination. It is widely distributed in the environment and is frequently found in the human intestine and in several domestic and wild

*C. perfringens* is classified into five groups (A, B, C, D, and E), due to the different toxins it produces (alpha, beta, epsilon, and iota). The Alpha-toxin is produced by all the five groups. The Beta-toxin forms selective pores for monovalent ions in the lipid bilayers, functioning as a neurotoxin capable of producing arterial constriction. The Epsilon-toxin is the most potent clostridial toxin after tetanus and botulinum neurotoxins (BoNTs). It is produced and secreted by a prototoxin that acquires its maximum biological activity by undergoing a specific proteolytic cleavage; its activation can be

The toxin receptor is unknown, but it is known to be a surface protein anchored by glycosylphosphatidylinositol. Its main biological activity is the edema generation; it is lethal but not hemolytic. The Iota-toxin is a member of the binary toxin family, since it is formed by a binding peptide (Ib) necessary for the internalization of the enzymatic peptide (Ia; ADPribosyltransferase). Proteolytic removal of a propeptide fragment is required to allow Ib to be inserted into the membrane and to interact with Ia. Ib, when inserted into the membrane,

once inside the cell, is ribosylated by the G-actin; it depolymerizes the filaments of Actin by destroying the cellular cytoskeleton. The Iota-toxin is dermonecrotic, cytotoxic, enterotoxic,

However, the virulence of this bacterium is not only due to the presence of these 4 toxins; there have also been described 15 toxins within which the CPE enterotoxin is responsible for causing diarrhea in humans and animals, and it is produced by Type A strains. This toxin is associated with 5 or 15% of gastrointestinal diseases in humans different from food poisoning such as diarrhea produced by antibiotics; the NetB toxin is frequently related to necrotic enteritis in birds and the Beta2-toxin is apparently associated with enteritis. The production of toxins in the digestive tract is associated with sporulation. The disease is foodborne; and only one case has implied the possibility of poisoning caused by the preformed toxin [12, 78, 79]. *C. perfringens* causes food poisoning characterized by severe abdominal cramps and diarrhea beginning after 8–22 h of food intake, the disease ends 24 h after the intake; although, in some cases the disease may persist for 1–2 weeks. Additionally, there is a more severe but less frequent disease caused by eating a food product contaminated with type C strains; this disease is known as necrotic enteritis or pig-bel disease, and it is often fatal. Deaths caused by necrotic enteritis are due to intestinal infection and necrosis, as well as by septicemia, the

The disease diagnosis is confirmed by the presence of the toxin in the stools of patients; either by traditional methods (culture from the stools or the food involved) or by molecular methods by looking for the following genes: *cpe* (CPE toxin), *plc* (Alpha-toxin), and *etx* (Epsilon-toxin)

and Na+

ions, and the entry of Ia, which

catalyzed by trypsin, chymotrypsin, and a zinc metalloprotease [12].

54 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

forms a heptameric pore that allows the exit of K<sup>+</sup>

and induces intestinal histopathological damage [12].

elderly people being the most affected population [78].

[12, 78, 79].

*C. botulinum* is a spore-forming microorganism; these spores can remain viable for long periods of time when the environmental conditions are absolutely unfavorable for the development of the microorganism [60].

Four groups are recognized in *C. botulinum*, as well as seven antigenic variants of botulinum neurotoxins (A–G). Groups I and II are primarily responsible for botulism in humans; Group III is responsible for causing botulism in several animal species, and Group IV appears not to be associated with the disease in either humans or animals. Group I is also known as *C. botulinum*-proteolytic (mesophilic microorganisms), while group II is known as *C. botulinum*-non-proteolytic (psychrophilic microorganisms). Group I forms spores that are highly resistant to heat, the "Botulinum cook" (121°C/3 min) given to canned foods with a low content of acid is designed to inactivate them; neurotoxins formed in this group are A, B, F, and H. Group II forms moderately heat-resistant spores, and the neurotoxins formed are B, E, and F. Botulism types A, B, E, and F rarely cause the disease in humans, whereas in animals it is caused by types C and D. Toxins are resistant to proteolytic reactions and to denaturation into the gastric apparatus. Botulinum toxins are metalloproteins with endopeptidase activity that require zinc; the general structure shows two chains with a molecular weight of 150 kDa, the double chain is subdivided into a heavy (H) structure constituted by a nitrogen terminal domain (HN), and a carboxyl-terminal (HC), and a lighter structure (L) that performs the catalytic function of the toxin. HC is responsible for binding to presynaptic receptors for internalization, and HN is called translocation domain [81–83].

*C. botulinum,* is a bacterial species known simply for producing the botulinum toxin. The number of genes in Group II strains coding for the neurotoxin is variable; there may be one to three genes that encode one to three different neurotoxins; if there are two genes, there can be one active toxin and an inactive toxin, or both toxins can be active. In Group II, the presence of only one gene has been described, that is why there is only one neurotoxin; however, in other studies it has been demonstrated that in Type F strains the toxin has part of Type B and Type E neurotoxins. Botulinum neurotoxins form complexes with accessory proteins (hemagglutinin and nonhemagglutinin), which protect the neurotoxin and facilitate their adsorption into the host. The hemagglutinin complex of the neurotoxin type A specifically binds the cell adhesion protein, E-cadherin, by binding the epithelial cell and facilitating the adsorption of the neurotoxin complex from the intestinal lumen. Dual toxin-producing strains have been isolated from botulism in humans, the environment, and food; recently there have been found strains that produce three botulinum toxins called F4, F5, and A2. The significance of producing two or more toxins on virulence, as well as the evolutionary consequences are not yet clear. Phylogenetic studies show evidence of horizontal gene transfer; the production of the dual toxin in Group I and the production of a single toxin in Group II is still not clear. Therefore, studies with toxins isolated and purified from the different groups of *C. botulinum* are still being carried out [81–83].

*3.1.6. Listeria monocytogenes*

4a, 4c, and an atypical 4b [84].

and avoiding the perforation of the membranes [84–86].

*L. monocytogenes* is a facultative intracellular microorganism widely distributed in nature, capable of surviving both in the soil and the cytosol of a eukaryotic cell. Considering somatic (O) and flagellar (H) antigens, this bacterium can be classified into 13 serotypes (1/2a, 1/2b, 1/2c, 3a, 3b, 3c, 4a, 4b, 4b, 4c, 4d, 4e, 7), but only the serotypes 1/2a, 1/2b, and 4b are responsible for more than 98% of the cases of human listeriosis. Furthermore, it has also been grouped into four lineages (I, II, III, and IV), where lineage I (serotypes: 1/2b, 3b, and 4b) and lineage II (serotypes: 1/2a, 1/2c, 3a, and 3c) include most strains isolated from clinical cases; lineage I strains have a greater pathogenic potential. Lineages III and IV include strains of serotypes

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 57

*L. monocytogenes* expresses multiple virulence factors, which allow to enter and survive in several nonphagocytic cells. After cellular internalization, listeriolysin O (LLO) and two phospholipases mediate the escape of the bacterium from the endocytic vesicle into the cytoplasm, where the microorganism divides and submits the F-actin based on mobility to spread from cell to cell. The LLO (coded by the gene *hly*) is a cholesterol-dependent toxin; it is able to form pores in the membrane of phagosomes, allowing *L. monocytogenes* to escape from primary and secondary vacuoles. The cytolytic activity of LLO increases with the action of a phosphatidylinositol phospholipase C (PI-PLC), the substrate of which is phosphatidylinositol; and a phosphatidylcholine phospholipase C (PC-PLC), which is a lecithinase with enzymatic activity over phosphatidylcholine, phosphatidylserine, and phosphatidylethanolamine. PC-PLC is expressed as a protoenzyme and zinc-dependent metalloprotease Mpl is required for its maturation; so once free in the cytosol, the bacterium acquires the necessary nutrients for intracellular multiplication. Some studies have shown that LLO is a critical invasion factor, which perforates the plasma membrane of the host cell to activate the internalization of the bacterium in human hepatocytes. Moreover, other studies have shown that LLO fails to mediate the intracellular survival of *L. monocytogenes* in neutrophils, where early degranulation leads to the release of proteases such as matrix metalloproteinase (MMP)-8, degrading LLO

*L. monocytogenes* causes a severe infection known as listeriosis, which is usually acquired after the intake of food contaminated with the microorganism. The disease mainly affects pregnant women, newborns, the elderly, and immunocompromised people, so it is rare for the disease to occur outside the aforementioned groups. Listeriosis is a mild disease in pregnant women, but it is severe in fetus and newborns. People over 65 years of age or immunosuppressed people can develop infection in the bloodstream (sepsis) or in the brain (meningitis or encephalitis). Sometimes the infection can affect bones, joints, thorax, and abdomen. Listeriosis can cause fever and diarrhea similar to that caused by other foodborne microorganisms and is rarely diagnosed. Pregnant women with listeriosis have fever, fatigue, and muscle pain (flulike symptoms). During pregnancy, the organism can cause miscarriage, stillbirth, premature labor, and infection in the newborn. In the other risk groups, the symptoms are headaches, neck stiffness, confusion, loss of balance, seizures, fever and muscle pain. People with invasive listeriosis usually develop symptoms from 1 to 4 weeks after ingesting food contaminated with the bacterium; although symptoms have been reported after 70 days of exposure or on

Botulism is a severe disease with a high fatality rate. The typical symptoms are flaccid muscle paralysis, sometimes it starts with blurred vision followed by an acute symmetrical decrease of bilateral paralysis that, if untreated, can lead to paralysis of the respiratory and cardiac muscles. If severe cases are not fatal, the patient may improve his/her condition after months or even years. There are three types of botulism: infant/adult intestinal botulism, wound botulism, and foodborne botulism. The first type (infant/adult intestinal botulism) is an infection associated with the multiplication of the microorganism and neurotoxin formation in the intestine; the second type (wound botulism) is an infection associated with cell multiplication and toxin formation in the wound, often acquired after drug abuse; and the third type (foodborne botulism) is a poisoning caused by the consumption of neurotoxin preformed in food. An amount of 30 ng of toxin is enough to cause the disease and sometimes death. Symptoms appear between 2 h and 8 days after the intake of contaminated food, although they may occasionally appear between 12 and 72 h [81, 82].

Botulism can be diagnosed only by clinical symptoms, but its differentiation from other diseases can be difficult. The most effective and direct way of confirming the disease in the laboratory is by demonstrating the presence of the toxin in the serum, in stools of patients, or in food products consumed by them. One of the most sensitive and widely used methods to detect the toxin is through neutralization in a rodent. This test takes 48 h, and culture of specimens takes from 5 to 7 days. Infant botulism is diagnosed by detecting botulinum toxins and the microorganism in the stools of children [78].

Approximately 90% of the reported cases are related to the consumption of home-made preserved food, especially vegetables; the industrial preparation of meat and fish is rarely associated with botulism. Food products where spores of the bacteria or the botulinum toxin can be found are canned corn, pepper, soups, beets, asparagus, ripe olives, spinach, tuna chicken, chicken liver, ham, sausages, stuffed eggplants, lobster, and honey, just to name a few [78, 82].

To prevent the chances of getting botulism through food, it is necessary to carry out appropriate control measures in food processing and handling, especially when new technologies are introduced or modified. Applying the "Botulinum cook" in the modern industry allows to secure canned foods. The use of chlorine and chlorinated compounds can help sanitize places that handle food industrially. Spores can also be inactivated with ozone and ethylene oxide [81, 82].

#### *3.1.6. Listeria monocytogenes*

Type E neurotoxins. Botulinum neurotoxins form complexes with accessory proteins (hemagglutinin and nonhemagglutinin), which protect the neurotoxin and facilitate their adsorption into the host. The hemagglutinin complex of the neurotoxin type A specifically binds the cell adhesion protein, E-cadherin, by binding the epithelial cell and facilitating the adsorption of the neurotoxin complex from the intestinal lumen. Dual toxin-producing strains have been isolated from botulism in humans, the environment, and food; recently there have been found strains that produce three botulinum toxins called F4, F5, and A2. The significance of producing two or more toxins on virulence, as well as the evolutionary consequences are not yet clear. Phylogenetic studies show evidence of horizontal gene transfer; the production of the dual toxin in Group I and the production of a single toxin in Group II is still not clear. Therefore, studies with toxins isolated and purified from the different groups of *C. botulinum*

56 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

Botulism is a severe disease with a high fatality rate. The typical symptoms are flaccid muscle paralysis, sometimes it starts with blurred vision followed by an acute symmetrical decrease of bilateral paralysis that, if untreated, can lead to paralysis of the respiratory and cardiac muscles. If severe cases are not fatal, the patient may improve his/her condition after months or even years. There are three types of botulism: infant/adult intestinal botulism, wound botulism, and foodborne botulism. The first type (infant/adult intestinal botulism) is an infection associated with the multiplication of the microorganism and neurotoxin formation in the intestine; the second type (wound botulism) is an infection associated with cell multiplication and toxin formation in the wound, often acquired after drug abuse; and the third type (foodborne botulism) is a poisoning caused by the consumption of neurotoxin preformed in food. An amount of 30 ng of toxin is enough to cause the disease and sometimes death. Symptoms appear between 2 h and 8 days after the intake of contaminated food, although they may

Botulism can be diagnosed only by clinical symptoms, but its differentiation from other diseases can be difficult. The most effective and direct way of confirming the disease in the laboratory is by demonstrating the presence of the toxin in the serum, in stools of patients, or in food products consumed by them. One of the most sensitive and widely used methods to detect the toxin is through neutralization in a rodent. This test takes 48 h, and culture of specimens takes from 5 to 7 days. Infant botulism is diagnosed by detecting botulinum toxins and

Approximately 90% of the reported cases are related to the consumption of home-made preserved food, especially vegetables; the industrial preparation of meat and fish is rarely associated with botulism. Food products where spores of the bacteria or the botulinum toxin can be found are canned corn, pepper, soups, beets, asparagus, ripe olives, spinach, tuna chicken, chicken liver, ham, sausages, stuffed eggplants, lobster, and honey, just to name a few [78, 82]. To prevent the chances of getting botulism through food, it is necessary to carry out appropriate control measures in food processing and handling, especially when new technologies are introduced or modified. Applying the "Botulinum cook" in the modern industry allows to secure canned foods. The use of chlorine and chlorinated compounds can help sanitize places that handle food industrially. Spores can also be inactivated with ozone and ethylene oxide [81, 82].

are still being carried out [81–83].

occasionally appear between 12 and 72 h [81, 82].

the microorganism in the stools of children [78].

*L. monocytogenes* is a facultative intracellular microorganism widely distributed in nature, capable of surviving both in the soil and the cytosol of a eukaryotic cell. Considering somatic (O) and flagellar (H) antigens, this bacterium can be classified into 13 serotypes (1/2a, 1/2b, 1/2c, 3a, 3b, 3c, 4a, 4b, 4b, 4c, 4d, 4e, 7), but only the serotypes 1/2a, 1/2b, and 4b are responsible for more than 98% of the cases of human listeriosis. Furthermore, it has also been grouped into four lineages (I, II, III, and IV), where lineage I (serotypes: 1/2b, 3b, and 4b) and lineage II (serotypes: 1/2a, 1/2c, 3a, and 3c) include most strains isolated from clinical cases; lineage I strains have a greater pathogenic potential. Lineages III and IV include strains of serotypes 4a, 4c, and an atypical 4b [84].

*L. monocytogenes* expresses multiple virulence factors, which allow to enter and survive in several nonphagocytic cells. After cellular internalization, listeriolysin O (LLO) and two phospholipases mediate the escape of the bacterium from the endocytic vesicle into the cytoplasm, where the microorganism divides and submits the F-actin based on mobility to spread from cell to cell. The LLO (coded by the gene *hly*) is a cholesterol-dependent toxin; it is able to form pores in the membrane of phagosomes, allowing *L. monocytogenes* to escape from primary and secondary vacuoles. The cytolytic activity of LLO increases with the action of a phosphatidylinositol phospholipase C (PI-PLC), the substrate of which is phosphatidylinositol; and a phosphatidylcholine phospholipase C (PC-PLC), which is a lecithinase with enzymatic activity over phosphatidylcholine, phosphatidylserine, and phosphatidylethanolamine. PC-PLC is expressed as a protoenzyme and zinc-dependent metalloprotease Mpl is required for its maturation; so once free in the cytosol, the bacterium acquires the necessary nutrients for intracellular multiplication. Some studies have shown that LLO is a critical invasion factor, which perforates the plasma membrane of the host cell to activate the internalization of the bacterium in human hepatocytes. Moreover, other studies have shown that LLO fails to mediate the intracellular survival of *L. monocytogenes* in neutrophils, where early degranulation leads to the release of proteases such as matrix metalloproteinase (MMP)-8, degrading LLO and avoiding the perforation of the membranes [84–86].

*L. monocytogenes* causes a severe infection known as listeriosis, which is usually acquired after the intake of food contaminated with the microorganism. The disease mainly affects pregnant women, newborns, the elderly, and immunocompromised people, so it is rare for the disease to occur outside the aforementioned groups. Listeriosis is a mild disease in pregnant women, but it is severe in fetus and newborns. People over 65 years of age or immunosuppressed people can develop infection in the bloodstream (sepsis) or in the brain (meningitis or encephalitis). Sometimes the infection can affect bones, joints, thorax, and abdomen. Listeriosis can cause fever and diarrhea similar to that caused by other foodborne microorganisms and is rarely diagnosed. Pregnant women with listeriosis have fever, fatigue, and muscle pain (flulike symptoms). During pregnancy, the organism can cause miscarriage, stillbirth, premature labor, and infection in the newborn. In the other risk groups, the symptoms are headaches, neck stiffness, confusion, loss of balance, seizures, fever and muscle pain. People with invasive listeriosis usually develop symptoms from 1 to 4 weeks after ingesting food contaminated with the bacterium; although symptoms have been reported after 70 days of exposure or on the same day of the poisoning. The disease is usually diagnosed by culturing the bacterium from tissues or fluids such as blood, cerebrospinal fluid, or placenta. From food products, this microorganism can be detected by various methods such as the use of chromogenic media; immunological methods, although some are nonspecific; molecular methods (hybridization, PCR, and real-time PCR); microarrays or biosensors; and also specific commercial methods. The detection of the *plcA* virulence gene coding for PI-PLC is generally employed to differentiate hemolytic and nonhemolytic strains. Pathogenic and nonpathogenic *Listeria* species can be differentiated by their activities of hemolysin or PI-PLC [87, 88].

food handlers from inoculating the bacteria they carry on the skin on their hands. Along with other measures, they must ensure food safety, and for this, food sectors will establish policies and activities to ensure maximum quality and food safety throughout the food chain (from

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 59

Some of these standards are described and taken care by the *Codex Alimentarius*, which, together with the World Health Organization and the Food and Agriculture Organization of the United Nations, has the responsibility to develop and standardize the international food standards. Their objective is to ensure the quality of food products and to protect human health, as well as the correct and fair implementation of these standards. The standards of the *Codex Alimentarius* apply to processed, semiprocessed, or raw food products. In addition to all the factors used in food processing, food quality standards seek to ensure that food products are produced in hygienic conditions, and that they preserve their nutritional quality. The main standards include microbiological processes, regarding the use of food additives, pesticide use and pest control, as well as, the permissible limits of drugs or hormones used in

For proper handling of food products, facilities, materials, instruments, and equipment must be kept accessible for the cleaning and disinfection process, in order to prevent food contamination by toxigenic bacteria. Cleaning procedures will include the effective removal of food residues or other contaminants; these procedures must be continuous, because some microorganisms have the ability to settle on these surfaces and to survive in adverse conditions by forming biofilm, thus, cleaning with soap and water is not enough. The methods can be chemical, with alkaline and acidic detergents; and physical, with heat, turbulent washes, or vacuum washes. Moreover, brushes or sponges can be used to remove dirt; however, the correct method of use must be considered to ensure efficiency, as well as, not using the same cleaning instrument in areas of processed and unprocessed food. Detergents or disinfectant substances should be used under the conditions proposed by the manufacturer regarding the concentration and time of action, which will depend on the type of surface and the product's presentation (liquid, solid, or semisolid). Such cleaning processes will be subject to regular monitoring and quality control, registering the areas that were cleaned and the person responsible for the cleaning. The cleaning method will be used depending on what is intended to be cleaned; in the case of smooth surfaces, the use of disinfectant and sponges or brushes to remove residues will be enough; this is done *in situ*, contrary to those dismantled equipment that require to be cleaned piece by piece. All of the above related to the establishment's cleaning must be submitted in writing to the personnel responsible for this task for the correct and

Another important aspect in this sector is pest control. A variety of pests lurk at sites where food is produced; special care must be taken because in most cases these pests act as vehicles for toxigenic bacteria and other pathogens, endangering the consumer's health. The most common pests are rodents, flies, and cockroaches. To prevent the presence of pests, food facilities should avoid air vents and cracks; regarding food products, these should be stored in high places, inside sealed containers or bags to prevent rodents from smelling the food. For pest control, insect monitoring should be carried out on a continuous basis, through catch

procurement and production to consumption) [92, 95–98].

efficient implementation of cleaning methods [98, 104–106].

animal production [66, 99–103].

*L. monocytogenes* is a microorganism that can be present in many food products, mainly in dairy products, soft cheeses, cheeses made with unpasteurized milk, celery, cabbage, ice cream, hot dogs, and processed meats [87].

Infection with *L. monocytogenes* can be treated with antibiotics such as ampicillin, although penicillin is more effective. Some experts recommend the use of gentamicin in people with impaired immunity, including neonates, and in cases of meningitis and endocarditis. Ampicillin is only used in pregnant women with isolated listerial bacteremia. Other antibiotics that can be used are trimethoprim-sulfamethoxazole and vancomycin. Cephalosporins should not be used to treat listeriosis because they are ineffective against the microorganism [89, 90].

The general guidelines to prevent listeriosis are similar to those recommended for other foodborne pathogens. For people at high risk, it is recommended not to consume soft cheeses such as Feta, Brie and Camembert, blue cheeses, or Mexican style cheeses (white cheese, fresh cheese, or panela cheese) unless they are made with pasteurized milk; it is also recommended not to consume smoked seafood, *pâté* or refrigerated meat spreads, hot dogs, processed meats or cold cuts, unless they have been reheated at high temperatures; these are just some of the food products that people at high risk should avoid [91].

## **4. Strategies for disease prevention**

Multiple factors associated with the procurement, handling, and food preparation contribute to an increase in the likelihood of contamination, and consequently, consumer's poisoning. Due to the importance of foodborne diseases, the number of cases presented and their severity, it is necessary to know those measures that help preventing or avoiding them; or getting a disease caused by food poisoning related to bacterial toxins [92–94].

Toxigenic microorganisms arrive to food products by cross-contamination; they come from the environment or they belong to the normal microbiota, in the case of animals. Once the contaminated food is ingested and reaches the intestines, the microorganisms get established, colonize, and, if the strain is toxigenic, produce the toxins responsible for the damage. Likewise, an incubation process must occur prior to the first symptoms. To prevent the occurrence of such diseases, health care measures, especially hand hygiene of food handlers, should be carried out; in that way, all food sectors such as restaurants, manufacturing, and distribution companies, pay special attention to hygiene measures for food handling to prevent food handlers from inoculating the bacteria they carry on the skin on their hands. Along with other measures, they must ensure food safety, and for this, food sectors will establish policies and activities to ensure maximum quality and food safety throughout the food chain (from procurement and production to consumption) [92, 95–98].

the same day of the poisoning. The disease is usually diagnosed by culturing the bacterium from tissues or fluids such as blood, cerebrospinal fluid, or placenta. From food products, this microorganism can be detected by various methods such as the use of chromogenic media; immunological methods, although some are nonspecific; molecular methods (hybridization, PCR, and real-time PCR); microarrays or biosensors; and also specific commercial methods. The detection of the *plcA* virulence gene coding for PI-PLC is generally employed to differentiate hemolytic and nonhemolytic strains. Pathogenic and nonpathogenic *Listeria* species can

*L. monocytogenes* is a microorganism that can be present in many food products, mainly in dairy products, soft cheeses, cheeses made with unpasteurized milk, celery, cabbage, ice

Infection with *L. monocytogenes* can be treated with antibiotics such as ampicillin, although penicillin is more effective. Some experts recommend the use of gentamicin in people with impaired immunity, including neonates, and in cases of meningitis and endocarditis. Ampicillin is only used in pregnant women with isolated listerial bacteremia. Other antibiotics that can be used are trimethoprim-sulfamethoxazole and vancomycin. Cephalosporins should not be used to treat listeriosis because they are ineffective against the microorganism [89, 90]. The general guidelines to prevent listeriosis are similar to those recommended for other foodborne pathogens. For people at high risk, it is recommended not to consume soft cheeses such as Feta, Brie and Camembert, blue cheeses, or Mexican style cheeses (white cheese, fresh cheese, or panela cheese) unless they are made with pasteurized milk; it is also recommended not to consume smoked seafood, *pâté* or refrigerated meat spreads, hot dogs, processed meats or cold cuts, unless they have been reheated at high temperatures; these are just some of the

Multiple factors associated with the procurement, handling, and food preparation contribute to an increase in the likelihood of contamination, and consequently, consumer's poisoning. Due to the importance of foodborne diseases, the number of cases presented and their severity, it is necessary to know those measures that help preventing or avoiding them; or getting

Toxigenic microorganisms arrive to food products by cross-contamination; they come from the environment or they belong to the normal microbiota, in the case of animals. Once the contaminated food is ingested and reaches the intestines, the microorganisms get established, colonize, and, if the strain is toxigenic, produce the toxins responsible for the damage. Likewise, an incubation process must occur prior to the first symptoms. To prevent the occurrence of such diseases, health care measures, especially hand hygiene of food handlers, should be carried out; in that way, all food sectors such as restaurants, manufacturing, and distribution companies, pay special attention to hygiene measures for food handling to prevent

be differentiated by their activities of hemolysin or PI-PLC [87, 88].

58 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

cream, hot dogs, and processed meats [87].

food products that people at high risk should avoid [91].

a disease caused by food poisoning related to bacterial toxins [92–94].

**4. Strategies for disease prevention**

Some of these standards are described and taken care by the *Codex Alimentarius*, which, together with the World Health Organization and the Food and Agriculture Organization of the United Nations, has the responsibility to develop and standardize the international food standards. Their objective is to ensure the quality of food products and to protect human health, as well as the correct and fair implementation of these standards. The standards of the *Codex Alimentarius* apply to processed, semiprocessed, or raw food products. In addition to all the factors used in food processing, food quality standards seek to ensure that food products are produced in hygienic conditions, and that they preserve their nutritional quality. The main standards include microbiological processes, regarding the use of food additives, pesticide use and pest control, as well as, the permissible limits of drugs or hormones used in animal production [66, 99–103].

For proper handling of food products, facilities, materials, instruments, and equipment must be kept accessible for the cleaning and disinfection process, in order to prevent food contamination by toxigenic bacteria. Cleaning procedures will include the effective removal of food residues or other contaminants; these procedures must be continuous, because some microorganisms have the ability to settle on these surfaces and to survive in adverse conditions by forming biofilm, thus, cleaning with soap and water is not enough. The methods can be chemical, with alkaline and acidic detergents; and physical, with heat, turbulent washes, or vacuum washes. Moreover, brushes or sponges can be used to remove dirt; however, the correct method of use must be considered to ensure efficiency, as well as, not using the same cleaning instrument in areas of processed and unprocessed food. Detergents or disinfectant substances should be used under the conditions proposed by the manufacturer regarding the concentration and time of action, which will depend on the type of surface and the product's presentation (liquid, solid, or semisolid). Such cleaning processes will be subject to regular monitoring and quality control, registering the areas that were cleaned and the person responsible for the cleaning. The cleaning method will be used depending on what is intended to be cleaned; in the case of smooth surfaces, the use of disinfectant and sponges or brushes to remove residues will be enough; this is done *in situ*, contrary to those dismantled equipment that require to be cleaned piece by piece. All of the above related to the establishment's cleaning must be submitted in writing to the personnel responsible for this task for the correct and efficient implementation of cleaning methods [98, 104–106].

Another important aspect in this sector is pest control. A variety of pests lurk at sites where food is produced; special care must be taken because in most cases these pests act as vehicles for toxigenic bacteria and other pathogens, endangering the consumer's health. The most common pests are rodents, flies, and cockroaches. To prevent the presence of pests, food facilities should avoid air vents and cracks; regarding food products, these should be stored in high places, inside sealed containers or bags to prevent rodents from smelling the food. For pest control, insect monitoring should be carried out on a continuous basis, through catch patches that may contain pheromones to attract insects, electric lamps against flying insects, among others. Of all insects, flies are the most common pest in food establishments, and they are an important source of disease transmission to food and other forms of food poisoning. It is important that food establishments eradicate flies pest to avoid any contamination of food products, in restaurants, kitchens, and other establishments where food is prepared; adhesive traps can be employed. Traps are used when managing rodent pests; however, an exhaustive planning must be done to determine the number of traps to be placed, as well as location; pest prevention include specifics such as covering air vents, avoiding cracks, and storage of food in high places, inside sealed containers or in bags to prevent rodents from smelling the food. At this point, the cleaning of the workplaces is of high importance, mainly the kitchen and the surfaces that are in contact with food, to ensure quality and food safety [87, 107, 108].

• Keep food at safe temperatures: Do not leave cooked food at room temperature for more than 2 h to avoid bacteria proliferation, and try not to store frozen food for long periods of

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 61

• Use safe water and raw materials: Safe treated water must be used when preparing food; use fresh food products and wash adequately. Pre-processed products such as pasteurized

The field of research about bacterial toxins is very wide; the determination of the toxins structure and function has allowed the development of biotechnological applications such as the

Almost all projects focus on the research of vaccines containing portions of attenuated toxin, in order to protect the patient against the effects of the disease. A study carried out by Secore *et al.*, in 2017, showed the efficiency of the tretavalent vaccine against *C. difficile*, which causes nosocomial infections; this vaccine contains TcdA- and TcdB-attenuated toxins and toxin components CDTa and CDTb. This vaccine showed greater effeciency in golden hamsters and in Rhesus monkeys compared to vaccines containing only the TcdA and TcdB antigens. In the case of the botulinum neurotoxin (BoNT), it is known to be of use in the treatment of muscle atrophies, mainly in facial paralysis, muscular hyperactivity, and dystonias. The BoNT has also been used to prevent facial wrinkles. However, it was found to have a preventive effect on headaches, as it is able to lessen it in some diseases such as neuropathic pain, low back pain, myofascial pain, and bladder pain. Studies supporting this statement have been carried out with studies based on human pain, these studies have shown positive and negative results. They are double-blind studies with placebo control. The positive action of the Botulinum toxin (BTX) has been characterized when administered to cells previously exposed to cigarette smoke; this suggests that it is a preventive agent to reduce the risk of necrosis in

Another notable example of toxin research is the use of toxins for medical treatments. For example, in studies by Lai et al.*,* they found that the *C. jejuni* distal cytolethal toxin can be incorporated to the lipid rafts on the membrane with the Cj-CdtA/CdtC subunit; the Cj-CdtB subunit goes through the cell membrane, it translocates to the interior of the cell and reaches the nucleus. This is an advantage that can be used to create drugs paired with the attenuated toxin or to a part of it, so that it can be able to reach the nucleus, be separated from the drug, and act as therapy against cancer, without the toxin causing any damage. Several *in vivo* and

The mechanisms that develop in the pathway that creates the pore have been revealed in the study of pore-forming toxins (PFT) in the cell membrane. Nowadays, the mechanism of formation is almost completely known stage by stage. The challenge in the research is to know the process in detail and, from that, design therapies with antibodies, drugs, or other

*in vitro* studies will be needed to establish it as an alternative cancer therapy [114].

milk, should be used as directed and not be used beyond their expiry dates.

development of antimicrobial drugs, anti-cancer therapy, and vaccine creation.

the respiratory tissue of patients who smoke [111–113].

time.

**5. Research**

Food safety is a human right and an obligation of all the governments to ensure it; it refers to the preserved quality of food products without organoleptic alterations, the presence of chemical, physical, or biological pathogens, or other undesirable alterations in the products that may affect the consumer's health. In order to ensure this characteristic, good practices must be put into operation; identification and control of the potential sources of contamination by the establishment, proper storage of food by separating raw food from processed food, and handling of food products depending on their origin (animal or vegetable). Proper waste management and drainage installation need to be taken into account. Regarding the design and equipment distribution, and the areas where the food is prepared, raw food should be separated, and previously processed food should not be exposed in the same surface. Staff restrooms must be distant from food preparation areas to avoid fecal contamination. The use of suitable uniforms and footwear, air quality, ventilation, and temperature control are essential for a working environment that allows a good development of food processing, and reduces, as much as possible, food poisoning by toxigenic bacteria [101, 109].

The Hazard Analysis and Critical Control Point (HACCP) system can be an efficient and systematic alternative to prevent toxico-infection; its function is to identify specific hazards and develop control measures to solve them, guaranteeing food safety by seven basic principles: identifying hazards and preventive measures, identifying critical control points, establishing limits, monitoring critical control points, using corrective measures, verifying processes, and registering the applied processes [63, 110].

As a preventive measure to avoid food contamination and foodborne diseases, World Health Organization (WHO) proposes the five keys for food safety [94].


## **5. Research**

patches that may contain pheromones to attract insects, electric lamps against flying insects, among others. Of all insects, flies are the most common pest in food establishments, and they are an important source of disease transmission to food and other forms of food poisoning. It is important that food establishments eradicate flies pest to avoid any contamination of food products, in restaurants, kitchens, and other establishments where food is prepared; adhesive traps can be employed. Traps are used when managing rodent pests; however, an exhaustive planning must be done to determine the number of traps to be placed, as well as location; pest prevention include specifics such as covering air vents, avoiding cracks, and storage of food in high places, inside sealed containers or in bags to prevent rodents from smelling the food. At this point, the cleaning of the workplaces is of high importance, mainly the kitchen and the

60 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

surfaces that are in contact with food, to ensure quality and food safety [87, 107, 108].

reduces, as much as possible, food poisoning by toxigenic bacteria [101, 109].

Organization (WHO) proposes the five keys for food safety [94].

registering the applied processes [63, 110].

keep them away from insects and animals.

different equipment for each type of food.

The Hazard Analysis and Critical Control Point (HACCP) system can be an efficient and systematic alternative to prevent toxico-infection; its function is to identify specific hazards and develop control measures to solve them, guaranteeing food safety by seven basic principles: identifying hazards and preventive measures, identifying critical control points, establishing limits, monitoring critical control points, using corrective measures, verifying processes, and

As a preventive measure to avoid food contamination and foodborne diseases, World Health

• Keep clean: It refers to washing hands before and during food preparation; after going to the toilet; washing and sanitizing surfaces and equipment for food preparation, and to

• Separate raw and cooked food: Prepare in different surfaces raw and cooked food and use

• Cook thoroughly: Food cooked thoroughly allow the removal of bacteria and other patho-

gens; toxins produced by bacteria and pathogens can also be destroyed.

Food safety is a human right and an obligation of all the governments to ensure it; it refers to the preserved quality of food products without organoleptic alterations, the presence of chemical, physical, or biological pathogens, or other undesirable alterations in the products that may affect the consumer's health. In order to ensure this characteristic, good practices must be put into operation; identification and control of the potential sources of contamination by the establishment, proper storage of food by separating raw food from processed food, and handling of food products depending on their origin (animal or vegetable). Proper waste management and drainage installation need to be taken into account. Regarding the design and equipment distribution, and the areas where the food is prepared, raw food should be separated, and previously processed food should not be exposed in the same surface. Staff restrooms must be distant from food preparation areas to avoid fecal contamination. The use of suitable uniforms and footwear, air quality, ventilation, and temperature control are essential for a working environment that allows a good development of food processing, and The field of research about bacterial toxins is very wide; the determination of the toxins structure and function has allowed the development of biotechnological applications such as the development of antimicrobial drugs, anti-cancer therapy, and vaccine creation.

Almost all projects focus on the research of vaccines containing portions of attenuated toxin, in order to protect the patient against the effects of the disease. A study carried out by Secore *et al.*, in 2017, showed the efficiency of the tretavalent vaccine against *C. difficile*, which causes nosocomial infections; this vaccine contains TcdA- and TcdB-attenuated toxins and toxin components CDTa and CDTb. This vaccine showed greater effeciency in golden hamsters and in Rhesus monkeys compared to vaccines containing only the TcdA and TcdB antigens. In the case of the botulinum neurotoxin (BoNT), it is known to be of use in the treatment of muscle atrophies, mainly in facial paralysis, muscular hyperactivity, and dystonias. The BoNT has also been used to prevent facial wrinkles. However, it was found to have a preventive effect on headaches, as it is able to lessen it in some diseases such as neuropathic pain, low back pain, myofascial pain, and bladder pain. Studies supporting this statement have been carried out with studies based on human pain, these studies have shown positive and negative results. They are double-blind studies with placebo control. The positive action of the Botulinum toxin (BTX) has been characterized when administered to cells previously exposed to cigarette smoke; this suggests that it is a preventive agent to reduce the risk of necrosis in the respiratory tissue of patients who smoke [111–113].

Another notable example of toxin research is the use of toxins for medical treatments. For example, in studies by Lai et al.*,* they found that the *C. jejuni* distal cytolethal toxin can be incorporated to the lipid rafts on the membrane with the Cj-CdtA/CdtC subunit; the Cj-CdtB subunit goes through the cell membrane, it translocates to the interior of the cell and reaches the nucleus. This is an advantage that can be used to create drugs paired with the attenuated toxin or to a part of it, so that it can be able to reach the nucleus, be separated from the drug, and act as therapy against cancer, without the toxin causing any damage. Several *in vivo* and *in vitro* studies will be needed to establish it as an alternative cancer therapy [114].

The mechanisms that develop in the pathway that creates the pore have been revealed in the study of pore-forming toxins (PFT) in the cell membrane. Nowadays, the mechanism of formation is almost completely known stage by stage. The challenge in the research is to know the process in detail and, from that, design therapies with antibodies, drugs, or other compounds that can inhibit its effects to know how the cell senses the presence of the pore, if it is at a concentration level of ions or by cytoplasmic signals, allowing it to run repair mechanisms of membrane damage [115].

**Acknowledgements**

**Author details**

**References**

the English version of the manuscript of the chapter.

\*Address all correspondence to: chelacastro@hotmail.com

Nacional, Ciudad de Mexico, Mexico

mates/es/ [Accessed: February 2017]

review. Virulence. 2014;**5**(1):213-218

2001;**12**(4):234-240

This study was supported by the Grant Secretaría de Investigación y Posgrado del Instituto Politécnico Nacional (SIP 20160609, 20161129, 20172091, 20171254, and 20171099). Andrea Guerrero Mandujano, Luis Uriel Gonzalez Avila, and Ingrid Palma Martinez held a scholarship from CONACyT. The authors are also grateful to Sofia Mulia for her help in preparing

Food Poisoning Caused by Bacteria (Food Toxins) http://dx.doi.org/10.5772/intechopen.69953 63

Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico

[1] Ospina MML, Martínez DME, Pacheco GOE, Quijada BH. Vigilancia y análisis de riesgo en salud pública. Protocolo de Vigilancia en Salud Pública. Intoxicaciones por sustancias

[2] World Health Organization. Informe Estimación de la carga mundial de las enfermedades de transmisión alimentaria. Ginebra [Internet]. 2015 [Updated: 2017]. Available from: http://www.who.int/mediacentre/news/releases/2015/foodborne-disease-esti-

[3] Ramírez-Peña EO. Etiology of acute diarrheal disease: An improved system for monitoring outbreaks of foodborne diseases in Peru. Revista Cuerpo Médico. HNAAA. 2014;**7**(1):54

[4] Kirk MD, Pires SM, Black RE, Caipo M, Crump JA, Devleesschauwer B, Döpfer D, Fazil A, Fischer-Walker CL, Hald T, Hall AJ, Keddy KH, Lake RJ, Lanata CF, Torgerson PR, Havelaar AH, Angulo FJ. World Health Organization estimates of the global and regional disease burden of 22 foodborne bacterial, protozoal, and viral diseases, 2010: A

data synthesis. PLoS Med. 2015;**12**:e1001921. DOI: 10.1371/journal.pmed.1001921

[5] Iriarte MJ, Ugarte JC, Salazar L. Utility of the airbone endotoxins assay in different occupational environments as a risk indicator by biological agents. Mapfre Medicina.

[6] Ramachandran G. Gram-positive and Gram-negative bacterial toxins in sepsis. A brief

químicas. Instituto Nacional de Salud. 2016;**PRO-R02.006**(Versión 02):1-75

Cecilia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís and Graciela Castro-Escarpulli\*

An interesting group of toxins are the immunotoxins, which are formed by a portion of antibody and a portion of toxin; the toxin has an intracellular action to kill the target cells. Most immunotoxins are designed to attack cancer cells; therefore, they are alternative to chemotherapy. The regulation of immunological signals and the treatment against viral and parasite infections are also applications of immunotoxins. Nevertheless, studies should focus on the methods for obtaining the toxin-antibody compounds, because molecular cloning to obtain a hybrid immunotoxin has not been efficient. Therefore, the methods for obtaining and purifying must be improved. The recent results are the creation of smaller immunotoxins with less immunogenicity, leaving only the site of action with the membrane, or the immunogenic site allowing its insertion into the target cell. Related studies are based on the creation and purification of monoclonal antibodies against toxins; for example, the use of an optimized anti-Alpha-toxin antibody of *S. aureus* causing pneumonia. This study showed a decrease in the number of bacteria in lungs and kidneys of the evaluated mice; mice showed minimal swelling and intact lung tissue. Thus, the mice had a higher percentage of survival, even with the combined treatment of the anti-Alpha-toxin antibody plus vancomycin or linezolid [95, 116].

Another alternative is the use of chemicals that inhibit the effect of bacterial toxins. A large number of research papers have been looking for substances that may inhibit the effect of bacterial toxins in human tissue; for example, the use of Bi3<sup>+</sup> ion to prevent or treat the hemolytic uremic syndrome caused by *E. coli* producing shiga toxin; this ion can be applied to animals and humans. Due to the importance of toxins in the food area, with clinical and pathological consequences, these mechanisms of action and the nature of toxins should be thoroughly investigated, in order to design strategies to prevent and manage effectively toxicoinfections [117].

It should be of particular attention, the use of toxins as an alternative treatment that allows to have tools for treating diseases such as cancer, the use of immunotoxins and pharmacotoxins.

## **6. Conclusions**

Governments should raise food safety as a public health priority, by establishing effective food safety systems to ensure that food producers and suppliers, throughout the food chain, act responsibly and provide safe food to consumers.

Food contamination can occur at any stage of the manufacturing or distribution process, although the responsibility lies primarily with the producers. Nevertheless, a large part of the foodborne diseases are caused by food that has been improperly prepared or handled at home, in food establishments, or in street markets.

It is a joint responsibility for consumers, traders, and governments to work together to implement regulations, enforce laws that support, increase, and sustain food safety.

## **Acknowledgements**

compounds that can inhibit its effects to know how the cell senses the presence of the pore, if it is at a concentration level of ions or by cytoplasmic signals, allowing it to run repair mecha-

62 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

An interesting group of toxins are the immunotoxins, which are formed by a portion of antibody and a portion of toxin; the toxin has an intracellular action to kill the target cells. Most immunotoxins are designed to attack cancer cells; therefore, they are alternative to chemotherapy. The regulation of immunological signals and the treatment against viral and parasite infections are also applications of immunotoxins. Nevertheless, studies should focus on the methods for obtaining the toxin-antibody compounds, because molecular cloning to obtain a hybrid immunotoxin has not been efficient. Therefore, the methods for obtaining and purifying must be improved. The recent results are the creation of smaller immunotoxins with less immunogenicity, leaving only the site of action with the membrane, or the immunogenic site allowing its insertion into the target cell. Related studies are based on the creation and purification of monoclonal antibodies against toxins; for example, the use of an optimized anti-Alpha-toxin antibody of *S. aureus* causing pneumonia. This study showed a decrease in the number of bacteria in lungs and kidneys of the evaluated mice; mice showed minimal swelling and intact lung tissue. Thus, the mice had a higher percentage of survival, even with the combined treatment of the anti-Alpha-toxin antibody plus vancomycin or linezolid [95, 116]. Another alternative is the use of chemicals that inhibit the effect of bacterial toxins. A large number of research papers have been looking for substances that may inhibit the effect of

lytic uremic syndrome caused by *E. coli* producing shiga toxin; this ion can be applied to animals and humans. Due to the importance of toxins in the food area, with clinical and pathological consequences, these mechanisms of action and the nature of toxins should be thoroughly investigated, in order to design strategies to prevent and manage effectively toxi-

It should be of particular attention, the use of toxins as an alternative treatment that allows to have tools for treating diseases such as cancer, the use of immunotoxins and pharmacotoxins.

Governments should raise food safety as a public health priority, by establishing effective food safety systems to ensure that food producers and suppliers, throughout the food chain,

Food contamination can occur at any stage of the manufacturing or distribution process, although the responsibility lies primarily with the producers. Nevertheless, a large part of the foodborne diseases are caused by food that has been improperly prepared or handled at

It is a joint responsibility for consumers, traders, and governments to work together to imple-

ment regulations, enforce laws that support, increase, and sustain food safety.

ion to prevent or treat the hemo-

nisms of membrane damage [115].

coinfections [117].

**6. Conclusions**

bacterial toxins in human tissue; for example, the use of Bi3<sup>+</sup>

act responsibly and provide safe food to consumers.

home, in food establishments, or in street markets.

This study was supported by the Grant Secretaría de Investigación y Posgrado del Instituto Politécnico Nacional (SIP 20160609, 20161129, 20172091, 20171254, and 20171099). Andrea Guerrero Mandujano, Luis Uriel Gonzalez Avila, and Ingrid Palma Martinez held a scholarship from CONACyT. The authors are also grateful to Sofia Mulia for her help in preparing the English version of the manuscript of the chapter.

## **Author details**

Cecilia Hernández-Cortez, Ingrid Palma-Martínez, Luis Uriel Gonzalez-Avila, Andrea Guerrero-Mandujano, Raúl Colmenero Solís and Graciela Castro-Escarpulli\*

\*Address all correspondence to: chelacastro@hotmail.com

Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Ciudad de Mexico, Mexico

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**Chapter 4**

**Provisional chapter**

**Carbon Monoxide Intoxication: Experiences from**

**Carbon Monoxide Intoxication: Experiences from** 

DOI: 10.5772/intechopen.70010

Carbon monoxide (CO) is odorless, colorless, tasteless, and nonirritating gas. Hence, mild CO poisoning often remains unrecognized and appears lethally. Carbon and gas systems, unfavorable architectural designs and machines may also cause intoxications. The prevalence rates in Hungary ranged from 2.37 to 3.80 cases per 100,000 people per year between 2013 and 2015; fatality rates have been decreased from 5.96 in 2013 to 3.38 in 2015. Given the vagueness and the broad spectrum of complaints, misdiagnosis of CO toxicity is common. The gold standard diagnosis is detecting the level of circulating carboxyhemoglobin (CO-Hgb). The measurement of CO-Hgb can be performed via blood-gas analyses or by spectrophotometry. Treatment protocol should follow the ACBDE rule. Administration of 100% oxygen should be performed as soon as possible. Later in-hospital management includes evaluation, treatment and prevention of further peripheral organ damage and long-term neurological complications. Fetuses and children are prone to suffer more severe intoxication due to higher oxygen demand. Though hyperbaric oxygen is the mainstay therapy, a prompt cesarean section is effective in preventing further intoxication. In conclusion, fatal CO intoxication can occur due to plain early signs and symptoms. Hyperbaric oxygen therapy should be considered in severe

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Keywords:** carbon monoxide poisoning, pathophysiology, differential diagnose, intoxication

Carbon monoxide (CO) is an odorless, colorless, tasteless, and nonirritating gas product of carbon and gas combustion. CO is also present in cigarette smoke and vehicle combustion

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70010

intoxication, in fetal and children.

in pregnancy, treatment options, prevalence in Hungary

**Hungary**

**Hungary**

Edit Gara

**Abstract**

**1. Introduction**

Edit Gara


**Provisional chapter**

## **Carbon Monoxide Intoxication: Experiences from Hungary Hungary**

**Carbon Monoxide Intoxication: Experiences from** 

DOI: 10.5772/intechopen.70010

#### Edit Gara Edit Gara Additional information is available at the end of the chapter

[114] Lai CK, Chen YA, Lin CJ, Lin HJ, Kao MC, Huang MZ, Lin YH, Chiang-Ni C, Chen CJ, Lo UG, Lin LC, Lin H, Hsieh JT, Lai CH. Molecular mechanisms and potential clinical applications of *Campylobacter jejuni* cytolethal distending toxin. Frontiers in Cellular

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and Infection Microbiology. 2016;**6**(9):1-8. DOI: 10.3389/fcimb.2016.00009

72 Poisoning - From Specific Toxic Agents to Novel Rapid and Simplified Techniques for Analysis

Chemotherapy. 2014;**58**(2):1108-1117. DOI: 10.1128/AAC.02190-13

2014;**7**(1):875. DOI: 10.1186/1756-0500-7-875

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70010

#### **Abstract**

Carbon monoxide (CO) is odorless, colorless, tasteless, and nonirritating gas. Hence, mild CO poisoning often remains unrecognized and appears lethally. Carbon and gas systems, unfavorable architectural designs and machines may also cause intoxications. The prevalence rates in Hungary ranged from 2.37 to 3.80 cases per 100,000 people per year between 2013 and 2015; fatality rates have been decreased from 5.96 in 2013 to 3.38 in 2015. Given the vagueness and the broad spectrum of complaints, misdiagnosis of CO toxicity is common. The gold standard diagnosis is detecting the level of circulating carboxyhemoglobin (CO-Hgb). The measurement of CO-Hgb can be performed via blood-gas analyses or by spectrophotometry. Treatment protocol should follow the ACBDE rule. Administration of 100% oxygen should be performed as soon as possible. Later in-hospital management includes evaluation, treatment and prevention of further peripheral organ damage and long-term neurological complications. Fetuses and children are prone to suffer more severe intoxication due to higher oxygen demand. Though hyperbaric oxygen is the mainstay therapy, a prompt cesarean section is effective in preventing further intoxication. In conclusion, fatal CO intoxication can occur due to plain early signs and symptoms. Hyperbaric oxygen therapy should be considered in severe intoxication, in fetal and children.

**Keywords:** carbon monoxide poisoning, pathophysiology, differential diagnose, intoxication in pregnancy, treatment options, prevalence in Hungary

## **1. Introduction**

Carbon monoxide (CO) is an odorless, colorless, tasteless, and nonirritating gas product of carbon and gas combustion. CO is also present in cigarette smoke and vehicle combustion

gas. CO diffuses through general building constructions (brick and wood). Generally, atmospheric concentration of CO is low, however, in urban and industrial regions it may be elevated. Poisoning usually occurs via impaired operating heating and mechanical systems and fire emergencies.

is stored in the tissues, and continued release results in elevated CO levels for at least twice as long as with direct CO inhalation. The half-time of CO in a healthy adult takes 4 hours breathing on air, 1.5 hours breathing on 100% oxygen, and 20 minutes in hyperbaric oxygen

Carbon Monoxide Intoxication: Experiences from Hungary

http://dx.doi.org/10.5772/intechopen.70010

75

Carbon monoxide intoxication cases have been documented in Hungary from 2012. Hence, as shown in **Figure 1**, the total number of cases was, respectively, 235 in 2013, 375 in 2014, and

**Figure 1.** Prevalence of carbon monoxide poisoning in Hungary. Figure shows total number of cases and lethal cases in

**Parameters 2013 2014 2015** # Cases 235 375 355
