Gram Negative Endocarditis

Overall, Gram-negative agents cause 1-5% of IE cases. Although Pseudomonas spp. and the Enterobacteriacae are rare causes, the most common Gram-negative agents of native valve IE are members of the HACEK group. The HACEK group includes Haemophilus spp. (H. para-phrophilus, H. parainfluenzae, H. aphrophilus, H. influenzae), Actinobacillus actinomycetem-comitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella spp. (K. kingae, K. denitrificans). These slow-growing, fastidious Gram-negative bacilli cause IE with a subacute presentation and large vegetations with a propensity for embolization. In a recent review of studies published from 1993-2003, HACEK organisms were found to be responsible for 4% of native valve IE [3]. Actinobacillus actino-mycetemcomitans is the most common HACEK organism, with 93 published cases as of 2001 [16]. Prior dental disease was reported in half of patients and underlying valvular disease in nearly three-quarters. About 1% of endocarditis is caused by Haemophilus spp.; a recent review of 42 cases by Darras-Joly et al. showed H. parainfluenzae to be the most common cause (26/42, 62%) [17]. Approximately 10% of patients with Haemophilus spp. IE had a history of recent dental work, and 71% had underlying valve disease.

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