General diet - low microbial
This document is part of the ACI Diet Specifications for Adult Inpatients. It is not to be used for patient education.
Aim
To provide a diet that limits foods that are at high risk of carrying food-borne disease.
Characteristics
Avoids food with a high bacterial or fungal load. Sterile diets are no longer used because there is no evidence to support their use.
Indications
- With neutropenia (neutrophil count ≤ 1000 cells/μL)
- Who are severely immunosuppressed (e.g. some patients post-transplant or those undergoing some cancer treatments)
- With poor gut integrity.
Other risk factors that may need to be considered are age, pregnancy and polypharmacy.
However, as food safety management has improved, the standard hospital diet may be considered safe for the vast majority of immunocompromised patients.
Nutritional adequacy
Nutritionally adequate.
Precautions
Patients ordered this diet must be supervised by a dietitian. As these patients are often malnourished, nutritional supplements may be required. All salads and sandwiches must be served within 24 hours of preparation and contain allowed ingredients. Bottled water must be replaced as needed (at least daily), not topped up or refilled.
Food safety practices must ensure that clean, dry utensils are always used so that bulk packs are not contaminated.
Paediatrics
Suitable for use in paediatrics when combined with an age-appropriate diet.
Specific menu planning guidelines
| Allowed | Not allowed | |
|---|---|---|
| Hot main dishes | All well-cooked meat, poultry, seafood and vegetarian dishes Serve eggs that are cooked until the white is firm and yolk begins to thicken | Undercooked meat, poultry or seafood Raw tofu, smoked fish, tempeh Raw or soft-boiled eggs |
| Sauces, gravies | All cooked | All others |
| Starchy vegetables / pasta / rice | All cooked | All others |
| Vegetables | All cooked and canned vegetables Vegetables that can be sanitised whole# | All others including fresh fermented vegetables and pickles |
| Soups | All hot soups including pasteurised miso products without kelp/seaweed | Cold soups |
| Sandwiches | Sandwiches must be made on site, contain allowed ingredients and used within 24 hours Pasteurised meats and poultry (cooked in bag) and sliced acceptable with correct food hygiene practices# Hard boiled eggs, canned fish Commercially manufactured and packaged hard cheese (e.g. cheddar) Cottage cheese may be used if served on the day the package is opened Canned pâté and meat spreads | Unpasteurised processed meats and poultry (e.g. some hams, chicken roll) Smoked meat and fish All other pâté and meat spreads (e.g. those requiring refrigeration) Leafy green vegetables, e.g. lettuce, baby spinach, parsley, rocket |
| Salads, dressings | Vegetables and fruit that are canned or can be sanitised# as a whole uncut item e.g. tomato, cucumber, zucchini, capsicum, carrot, orange Salads must be made on site, contain allowed ingredients and used within 24 hours Canned salads (e.g. mixed beans, potato salad) Portion packs of commercially manufactured mayonnaise, dressings and condiments | Unwashed raw vegetables and sprouts, including mushrooms Leafy green vegetables e.g. lettuce, baby spinach, parsley, rocket Salad dressings made with blue cheese or raw eggs Unpasteurised sliced processed meats and poultry (e.g. some hams, chicken roll) Compound salads e.g. potato salad and coleslaw Cooked and peeled prawns to be served cold |
| Breads, cereals | All breads, pre-packaged, processed and ready-to-eat including raisin or fruit bread Cooked breakfast cereals (e.g. porridge, semolina) Plain commercially manufactured breakfast cereals without dried fruit, coconut or nuts (e.g. corn flakes, wheat biscuits, puffed rice) | Raw oats Raw muesli including Bircher All other breads and cereals |
| Spreads | Large commercially manufactured brands of jam, nut butters and pastes, yeast spreads, marmalade, chocolate hazelnut spread, mayonnaise Spreads in portion control packs or bulk containers which have been handled in a way to prevent contamination Canned pâté and meat spreads Pasteurised honey (including portion control packs) and honey as an ingredient in a cooked meal | Other spreads including tahini and hummus |
| Hot breakfast choices | All cooked breakfast items Pure maple syrup Pure golden syrup | All others |
| Fruit | Sanitised whole fresh fruit (e.g. apples, oranges, mandarins, pears, kiwi fruit, stone fruit, grapes etc.) Bananas served whole (unpeeled and uncut) All canned or stewed fruit Fruit from bulk packs must be used within 48hrs of decanting Cooked dried fruit (e.g. muffins and cakes containing dried fruit) | Cut fruit Fresh fruit with a rough texture (e.g. raspberries, strawberries, rockmelon) Uncooked dried fruit |
| Yoghurt | Commercially manufactured yoghurts, including those with fruit Yoghurt from bulk packs must be used within 48 hours after decanting | All other yoghurts, including home made and probiotic yoghurts |
| Desserts | Desserts and puddings served hot e.g. sticky date pudding, apple crumble Heat-treated portion-control cold desserts e.g. custard, creamy rice Shelf-stable commercially manufactured cakes, pastries and puddings Pastries with fillings cooked in e.g. apple Danish Other commercially manufactured ice creams using allowed ingredients | Desserts containing uncooked eggs e.g. mousse Pastries filled with cream or custard after cooking e.g. profiterole Ice cream with dried fruits, coconut and nuts |
| Milk and cheese | All pasteurised milk and milk products including cream and sour cream Commercially manufactured and packaged hard cheese (e.g. cheddar) including cheese slices Cottage cheese may be used if served on the day the package is opened | Surface-ripened cheese (e.g. brie, camembert, blue) Soft and semi soft cheese unless used as an ingredient in a cooked dish |
| Beverages | Pasteurised fruit juices in sealed portions Cordial made with potable water and chilled once prepared Bottled or portion controlled water Drinks made with chocolate powder Tea, coffee, carbonated drinks, commercially manufactured energy drinks | Fresh and unpasteurised juices Herbal teas Fermented drinks e.g. kombucha Wine and beer as a beverage |
| Biscuits | All baked, shelf-stable portion packs of biscuits and crackers | All others |
| Miscellaneous | Nutritional supplements Salt Cream Plain commercially manufactured popcorn Sugar and artificial sweeteners Chocolate with allowed ingredients Confectionery with allowed ingredients Potato crisps Baked, shelf-stable muesli bars | Raw nuts and nuts in shells Raw oysters Herbs, spices and pepper Raw coconut |
# As per NSW Food Authority vulnerable population requirements.
References
- Dietitians Association of Australia. Nutrition manual. 9th ed. Canberra: DAA; 2014.
- Centers for Disease Control and Prevention. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR 2009;58(RR-4):1-207.
- NSW Food Authority. Guidelines for food service to vulnerable persons. Sydney: NSW Food Authority, 2015. [Accessed 7 May 2021].
- Memorial Sloan Kettering Cancer Centre. Low-Microbial Diet. New York; 2017. [Accessed 23 June 2017]
- Queensland Health. Safe Eating for Poor Immune Function. QLD; 2019. [Accessed 24 April 2024].
- Lund, B M. Microbiological food safety and a low-microbial diet to protect vulnerable people. Foodborne Pathogens and disease. 2014 June;11(6):413-24.
- Lund, B.M Microbiological Food Safety for Vulnerable People. Int J Environ Res Public Health. 2015 Aug 21;12(8):10117-32.
- Lund, B. Microbiological safety of food, particularly for vulnerable people. J Fam Med Dis Prev. 2016:2:035
- Doron, S and Snydman, D. R. Risk and Safety of Probiotics. Clinical Infectious Diseases. 2015;60(S2):S129-34.