Non-HACEK gram-negative bacillus endocarditis

Ann Intern Med. 2007 Dec 18;147(12):829-35. doi: 10.7326/0003-4819-147-12-200712180-00002.


Background: Infective endocarditis caused by non-HACEK (species other than Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella species) gram-negative bacilli is rare, is poorly characterized, and is commonly considered to be primarily a disease of injection drug users.

Objective: To describe the clinical characteristics and outcomes of patients with non-HACEK gram-negative bacillus endocarditis in a large, international, contemporary cohort of patients.

Design: Observations from the International Collaboration on Infective Endocarditis Prospective Cohort Study (ICE-PCS) database.

Setting: 61 hospitals in 28 countries.

Patients: Hospitalized patients with definite endocarditis.

Measurements: Characteristics of non-HACEK gram-negative bacillus endocarditis cases were described and compared with those due to other pathogens.

Results: Among the 2761 case-patients with definite endocarditis enrolled in ICE-PCS, 49 (1.8%) had endocarditis (20 native valve, 29 prosthetic valve or device) due to non-HACEK, gram-negative bacilli. Escherichia coli (14 patients [29%]) and Pseudomonas aeruginosa (11 patients [22%]) were the most common pathogens. Most patients (57%) with non-HACEK gram-negative bacillus endocarditis had health care-associated infection, whereas injection drug use was rare (4%). Implanted endovascular devices were frequently associated with non-HACEK gram-negative bacillus endocarditis compared with other causes of endocarditis (29% vs. 11%; P < 0.001). The in-hospital mortality rate of patients with endocarditis due to non-HACEK gram-negative bacilli was high (24%) despite high rates of cardiac surgery (51%).

Limitations: Because of the small number of patients with non-HACEK gram-negative bacillus endocarditis in each treatment group and the lack of long-term follow-up, strong treatment recommendations are difficult to make.

Conclusion: In this large, prospective, multinational cohort, more than one half of all cases of non-HACEK gram-negative bacillus endocarditis were associated with health care contact. Non-HACEK gram-negative bacillus endocarditis is not primarily a disease of injection drug users.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Bacterial Agents / therapeutic use
  • Cardiac Surgical Procedures
  • Community-Acquired Infections / microbiology
  • Community-Acquired Infections / therapy
  • Cross Infection / microbiology
  • Cross Infection / therapy
  • Endocarditis, Bacterial / epidemiology*
  • Endocarditis, Bacterial / microbiology*
  • Endocarditis, Bacterial / therapy
  • Gram-Negative Bacteria*
  • Gram-Negative Bacterial Infections / epidemiology*
  • Gram-Negative Bacterial Infections / microbiology*
  • Gram-Negative Bacterial Infections / therapy
  • Humans
  • Prospective Studies
  • Prostheses and Implants / microbiology
  • Substance Abuse, Intravenous / microbiology
  • Treatment Outcome


  • Anti-Bacterial Agents