This information will help you follow a low microbial diet. Eating a low microbial diet will reduce your risk of getting ill while you have a weakened immune system, such as after chemotherapy, radiation therapy, or a bone marrow transplant.

The first section of this booklet has information on how to keep your food safe. The second section explains what foods and beverages are safe to eat while on a low microbial diet. Don't make any changes to this diet until you have talked to someone on your healthcare team. This includes your doctor, nurse, nurse practitioner, or dietitian.

Food Safety Guidelines

What are microbes?

Microbes are tiny living organisms, such as bacteria, viruses, yeast, and molds. They can get into food by infecting the animal the food comes from. Microbes can also get into food when it is being processed or prepared. When microbes get into foods, they can cause infections, especially if you have a low white blood cell count (neutropenia).

Microbes can attach to foods and grow, but you can't always see, smell, or taste them. They are more likely to grow on

  • Milk and other dairy food items that are not refrigerated
  • Undercooked and raw eggs and foods that have raw eggs (e.g., cookie dough and Caesar salad dressing)
  • Undercooked or raw meat, poultry (chicken and turkey), and seafood
  • Certain fruits and vegetables (see the Fruits and Vegetable list in the “What to Eat on a Low Microbial Diet” section)
  • Unpasteurized or untreated juices (e.g., fresh-squeezed juices)
  • Vegetable sprouts (e.g., raw alfalfa, soy bean, and radish sprouts)

Buying foods that are safe to eat

  • Don't buy canned foods if the can has dents or is swollen.
  • Don't buy food in jars if the jar is cracked or the lid is not tightly closed.
  • Only buy eggs that are refrigerated in the store. Check the eggs by opening the carton to see if any are broken or cracked.
  • Separate ready-to-eat and raw foods. Put raw meat, poultry, seafood, and other raw foods in plastic bags before they go into your shopping cart.
  • Pick up your milk and other cold foods at the end of your shopping trip. This decreases the time these items will spend outside of the refrigerator.
  • Check containers for the expiration date. Buy and use food before that date.

Storing food safely

  • Store food immediately after shopping.
  • Put eggs and milk inside the refrigerator; don't store them in the door. The temperature inside the refrigerator will stay cooler than in the door area.

Keeping your kitchen clean

  • Keep an area of your kitchen clean for preparing and eating food. This will help prevent the spread of microbes.
  • Use paper towels or clean cloths instead of sponges to clean kitchen surfaces.
  • Use an antibacterial cleansing spray to clean surfaces. Look for products that have bleach or ammonia. Examples are Lysol® Food Surface Sanitizer and Clorox® Clean-Up® Cleaner.

Using cutting boards and equipment

  • Use cutting boards that are made out of thick plastic, marble, glass, or ceramic. These materials are nonporous, meaning that food or liquid substances can't absorb into them. Avoid using wood or other porous surfaces.
  • Wash cutting boards and knives with hot soapy water before using them to cut the next food. As an extra precaution, wash your cutting boards with a kitchen sanitizer. Throw out worn or hard-to-clean cutting boards.

Handling food safely

  • Wash your hands thoroughly
    • Before preparing or eating food
    • After preparing raw poultry, meat, fish, or seafood
    • After handling garbage
  • Thoroughly rinse fresh fruits and vegetables under running tap water. Rinse skins and rinds before cutting or peeling. Never use bleach or detergent to wash fresh fruits and vegetables.
  • Rub firm-skinned fruits and vegetables under running warm tap water or scrub them with a clean vegetable brush while rinsing with running tap water.
  • Remove and throw away any damaged or bruised areas on fruits or vegetables.
  • Cook all foods thoroughly.
  • Separate raw meats from ready-to-eat foods.
  • Thaw foods by using only 1 of the following methods:
    • Put the food item in the refrigerator 1 day before cooking.
    • Use the defrost setting on a microwave. Cook right away.
  • Keep your refrigerator at a temperature of 33° F to 40° F.
  • Keep your freezer at a temperature of 0° F or below.
  • Use a food thermometer to check the temperatures of cooked and reheated foods.
  • Don't eat hamburgers and other meat products if the meat looks undercooked. Cook the meat until it is grey and the juices run clear.
  • Cook fish until it flakes.
  • Cook egg whites and yolks until they are firm.
  • Cook all meats to the minimum internal temperatures listed in the chart below.

Food

Safe Minimum Internal Temperatures

Egg and Egg Dishes  

Eggs

Cook until yolk and white are firm

Egg dishes

160° F

Egg sauces

160° F

Ground Meat and Meat Mixtures  

Turkey and chicken

165° F

Beef, hamburgers, veal, lamb, and pork

160° F

Fresh Beef, Veal, and Lamb

160° F

Well done

170° F

Fresh Pork  

Well done

170° F

Ham  

Raw/fresh

160° F

Precooked, cured ham

140° F

Poultry  

All products

165° F

Seafood  

All (raw/fresh)

145° F

Eating leftovers

  • Refrigerate leftovers in shallow containers immediately after eating.
  • Leftovers should be reheated to the proper internal temperature, based on the Reheating Guidelines below.
    When reheating leftovers in the microwave, stir, cover, and rotate the food so that it heats evenly. Heat the food until it reaches 165° F throughout, as measured with a food thermometer.
  • Sauces, soups, and gravies should be reheated by bringing them to a boil.
  • Be sure to let the food cool so you don't burn your mouth.
  • Eat reheated leftovers within 1 hour of reheating.
  • Don't eat leftovers more than 2 days old.
  • Don't eat any food that has already been reheated once.
Food Reheating Guidelines

Poultry

Cook at a temperature of at least 165° F for at least 15 seconds

Stuffed meat, poultry, or fish

Cook at a temperature of at least 165° F for at least 15 seconds

Ground meat

Cook at a temperature of at least 160° F for at least 15 seconds

Pork, beef, veal, and lamb

Cook at a temperature of at least 160° F for at least 15 seconds

Fish

Cook at a temperature of at least 160° F for at least 15 seconds

Hard-boiled eggs

Cook at a temperature of at least 160° F for at least 15 seconds

What to Eat on a Low Microbial Diet

Food Group What to Eat What to Avoid
Breads, Grains, and Cereals
  • All breads, rolls, bagels, English muffins, waffles, French toast, muffins, pancakes, and sweet rolls
  • Potato chips, corn chips, tortilla chips, popcorn, and pretzels
  • Any cooked or ready-to-eat cereal purchased prepackaged from a store
  • Rice, pasta, and other cooked grains
  • Foods with raw (not cooked or baked) grains (e.g., uncooked corn or raw oats)
  • Undercooked or raw brewer's yeast
Milk and Dairy Products

Pasteurized

  • Grade A commercially available milk and milk products
  • Yogurts including those made with live cultures (e.g., Dannon®)
  • Sour cream
  • Puddings made at home or bought prepackaged from a store
  • Prepackaged ice cream, frozen yogurt, sherbet, popsicles, ice cream bars, and fresh homemade milkshakes
  • Eggnog
  • Commercially sterile, ready-to-feed, and liquid concentrate infant formulas
  • Dry, refrigerated, or frozen pasteurized whipped topping

 

Pasteurized Cheese

  • Processed cheese slices and spreads, cream cheese, cottage cheese, and ricotta cheese
  • Commercially packaged hard and semi-soft cheese such as American, mild cheddar, pasteurized mozzarella, Monterey jack, Swiss, and shelf-stable (foods that can be safely stored at room temperature) grated Parmesan (e.g., Kraft®)
  • Cooked soft cheeses, such as Brie, Camembert, feta, and farmer's cheese

Unpasteurized

  • Dairy products, such as raw milk
  • Eggnog (homemade)
  • Yogurt (usually homemade)
  • Soft serve ice cream or yogurt
  • Unrefrigerated, cream-filled
    pastry products

 

Cheese

  • Made from unpasteurized milk
  • Not well-cooked in foods
  • All mold-ripened cheeses and soft cheeses, such as Roquefort, Muenster, Stilton, havarti, Edam, Gorgonzola, blue cheese, sharp cheddar, and feta

 

Unpasteurized Cheese

  • Soft cheeses, such as Brie, farmer's cheese, Camembert, Mexican-style cheese (queso blanco and queso fresco), and goat cheese
  • Unpasteurized mozzarella cheese
  • Cheeses from delis
  • Cheeses that contain chili peppers or other uncooked vegetables
  • Unrefrigerated, cream-filled
    pastry products
Eggs
  • Well-cooked eggs (firm white
    and yolk)
  • Pasteurized eggs, pasteurized egg substitutes (such as Egg Beaters®), and powdered egg whites
  • Undercooked or raw eggs and unpasteurized egg substitutes
  • Salad dressings containing raw eggs (e.g., Caesar salad dressing)
Meat, Meat Substitutes, Poultry, and Seafood
  • Well-cooked meats, such as pork, beef, lamb, chicken, and turkey
    (see Food Safety Guidelines for cooking temperatures)
  • Cooked tofu (cut into 1 inch cubes and boiled for at least 5 minutes) or pasteurized tofu
  • Bacon that is crisp and made at home
  • Hotdogs cooked at home until steaming hot
  • Commercially prepared deli meats sold in a sealed package, such as salami, bologna, ham, turkey, and other deli meats that are cooked until steaming hot (throw away within
    48 hours of opening)
  • Thoroughly cooked fish and other seafood, including shrimp, lobster, crab, canned tuna, and canned salmon
  • Canned meats (beef, pork, lamb, poultry, fish, shellfish, game, ham, bacon, sausage, and hot dogs)
  • Canned and shelf-stable smoked fish (refrigerate after opening)
  • Undercooked or raw meats, poultry, and fish, including rare or medium-rare items
  • Miso products
  • Tempeh
  • Freshly sliced deli meats and meats from street vendors
  • Hard-cured salami in natural wrap
  • Beef jerky
  • Raw shellfish, raw fish (including caviar), sashimi, sushi, and ceviche (“lemon-cooked” or cured fish)
  • Raw or cooked clams, mussels,
    and oysters
  • Smoked seafood, such as salmon or trout labeled as “nova style,” “lox,” “kippered,” “smoked,” or “jerky” (unless cooked to 160° F or contained in a cooked dish or casserole)
  • Refrigerated pâtés and meat spreads
Fruits and Vegetables
  • Well-washed and peeled raw fruits and vegetables
  • Cooked and canned fruits
    and vegetables
  • Cooked frozen fruits and vegetables
  • Well-washed and peeled thick-skinned fruits without bruises, such as citrus fruits, bananas, and melons
  • Well-washed and peeled apples (thorough washing is important because slicing through the skin
    or rind can contaminate the
    inner fruit)
  • Pasteurized juices and
    frozen concentrates
  • Commercially packaged dried fruits
  • Shelf-stable bottled salsa (refrigerate after opening)
  • Cooked vegetable sprouts
    (e.g., mung bean)
  • Fresh, well-washed herbs and dried herbs and spices (added to allowed raw or cooked foods)
  • Unwashed and unpeeled raw fruits, vegetables, or herbs
  • Any fresh or raw fruits and vegetables that can't be thoroughly washed and peeled or cooked (e.g., blueberries, strawberries, raspberries, peaches, plums, and grapes that tend to get mold around their stems)
  • Any frozen berries and other thin-skinned frozen fruits
  • Unpasteurized fruit and
    vegetable juices
  • Fresh fruit salsa or fresh vegetable salsa found in the grocery refrigerator case
  • Vegetarian sushi
  • Unpasteurized items containing raw fruits or raw vegetables found in the grocery refrigerator case
  • All vegetable sprouts (alfalfa, bean, clover, and all others)
  • All salads from delis or salad bars
Beverages
  • Boiled well water
  • Tap water and ice made from tap water
  • Commercially bottled distilled, spring, and natural waters
  • Pasteurized fruit and vegetable juices
  • Bottled, canned, or
    powdered beverages
  • Instant and brewed coffee
  • Hot-brewed teas using commercially packaged tea bags
  • Pasteurized soy milk
  • Commercially made liquid nutritional supplements (Ensure®, Boost)
  • Unpasteurized eggnog or apple cider and other unpasteurized fruit or vegetables juices
  • Reconstituted protein powder beverages, unless approved by
    your dietitian
  • Unpasteurized beer (e.g., microbrewery beers and those
    that are not shelf-stable)
  • Wine
  • Fountain beverages
  • Tea made with loose leaves
Nuts and Dried Fruits
  • Factory-packaged nuts and
    dried fruits
  • Roasted nuts from a can or bottle
  • Nuts in baked goods such as peanut butter cookies
  • Commercially packaged nut butters (such as peanut, almond, and soybean)
  • All nuts or dried fruits that are sold open and in bulk, as in some health food or specialty stores
  • Raw nuts
  • Freshly made peanut butter (not commercially packaged)
  • Roasted nuts in the shell
Condiments/Miscellaneous
  • Salt and sugar
  • Jellies, syrup, and jams (refrigerate after opening)
  • Individually packaged ground black pepper and herbs and spices added before the cooking process
  • Catsup, mustard, BBQ sauce, and soy sauce, (refrigerate after opening)
  • Pickles, pickle relish, and olives (refrigerate after opening)
  • Vinegar
  • Vegetable oils and shortening
  • Refrigerated lard, margarine,
    and butter
  • Commercially made, shelf-stable mayonnaise and salad dressings, including blue cheese and other
    cheese-based salad dressings (refrigerate after opening)
  • Cooked gravy and sauces
  • Raw or unpasteurized honey
    and honeycomb
  • Whole or fresh ground black pepper, unless thoroughly cooked in food
  • Fresh salad dressings (stored in grocer's refrigerated case) containing raw eggs or cheeses
  • Herbal and nutritional
    supplement preparations
Desserts
  • Refrigerated, commercially made, and homemade cakes, pies, pastries,
    and pudding
  • Refrigerated cream-filled pastries
  • Cookies, both homemade and commercially prepared
  • Shelf-stable, cream-filled cupcakes (such as Twinkies®and Ding Dongs®) and fruit pies (such as Pop-Tarts® and Hostess® fruit pies)
  • Candy and gum
  • Unrefrigerated, cream-filled pastry products (not shelf stable)
Eating Outside the Home
  • All foods recommended in previous food groups must come directly off the grill or stove and not served on steam tables or stored under heat lamps (e.g., freshly made pizza or a hamburger directly off a grill)
  • Single-serving condiment packages (no pump serve containers)
  • Unpasteurized fruit juices
    and dairy products (e.g., juice
    bar establishments such as
    Jamba Juice®)
  • Raw fruits and vegetables served
    at salad bars and desserts with
    fresh fruit
  • Deli meats and cheeses
  • Buffets/smorgasbords
  • Potlucks and sidewalk vendors
  • Soft serve ice cream and yogurt
Take Out
  • Freshly made pizza (not sliced
    or reheated)
  • Well-done hamburger just off the grill
  • French fries (just cooked)
  • Any food that is not freshly made
    to order
  • Fast food (e.g., McDonalds®, Subway®)
  • Reheated foods
  • Juice bar establishments
    (i.e., Jamba Juice®)

Always remember: when in doubt, throw it out!

Avoid herbal supplements

Don't take homeopathic remedies or herbal products (e.g., traditional Chinese medicines). Because there are no federal standards for these products in the US, the way they are processed and stored may pose a health risk. Microbes in these items can also cause an infection. Also, the products themselves could interfere with or change the activity of a prescription medication.

Safe drinking water

Never drink from lakes, rivers, streams, springs, or wells.

If you are unsure if the tap water is safe, check with the local health department or boil or filter the water. Drink bottled water if you think the tap water may not be safe.

Eating out at restaurants

You can eat out while on a low microbial diet, as long as you choose the restaurant carefully. Local health departments inspect restaurants to make sure that they are clean, and that they follow safe food practices.
You can find out how your local restaurants did on a recent health inspection by going to your local Department of Health (DOH) website. To find out about restaurants in New York City, go to the following website:
http://www.nyc.gov/html/doh/html/rii/index.shtml.

You can also ask your local restaurants about their food safety training rules. When you go out to eat, follow the guidelines below.

  • Order all foods to be fully cooked and meats to be well done.
  • Don't order foods that may have raw eggs (e.g., Caesar salad dressing and hollandaise sauce).
  • Ask the waitstaff if you are not sure of the ingredients in your meal.
  • Don't eat foods from buffets and salad bars.
  • Ask that your foods be cooked fresh and not served from steam tables or stored under heat lamps.
  • Ask for single-serving condiments, such as catsup and mustard packets. Open containers may be used by many customers.
  • Don't eat soft serve ice cream and soft serve frozen yogurt. The dispensers may not be cleaned on a regular basis.
  • Always order a whole or personal pizza. Don't order individual slices, since they are often stored under heat lamps.

Resources

United States Department of Agriculture (USDA) Food Safety and Inspection Service

www.fsis.usda.gov

www.fsis.usda.gov/PDF/Cutting_Boards_and_Food_Safety.pdf

US Department of Health and Human Services (USDHHS) Food Safety Information

www.foodsafety.gov

USDHHS Food and Drug Administration (FDA)

http://www.fda.gov/ForConsumers/default.htm

Centers for Disease Control and Prevention Food Safety

http://www.cdc.gov/foodsafety/

Fight BAC! Partnership for Food Safety Education

www.fightbac.org

USDA “Ask Karen” (web-based question and answer system)

http://www.fsis.usda.gov/wps/portal/informational/askkaren

NYC Department of Health and Mental Hygiene Restaurant Inspection Information

http://www.nyc.gov/html/doh/html/rii/index.shtml

FDA (toll-free numbers)

(888) SAFE-FOOD (723-3366)

(888) INFO-FDA (463-6332)