eMedicine Specialties > Infectious Diseases > Bacterial Infections

HACEK Group Infections: Follow-up

Author: Isaac P Humphrey, MD, Assistant Professor of Internal Medicine, Uniformed Services University of the Health Sciences; Clinical Assistant Professor of Internal Medicine, Wright State University Boonshoft School of Medicine
Coauthor(s): Mirabelle Kelly, MD, Fellow, Department of Microbiology and Infectious Disease, University of Sherbrooke, Canada; Barnett Gibbs, MD, Assistant Chief, Department of Clinical Trials, Walter Reed Army Institute of Research, Infectious Disease Service, National Capital Consortium; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Christian P Sinave, MD, Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke, Canada
Contributor Information and Disclosures

Updated: Nov 6, 2009

Follow-up

Further Inpatient Care

  • Careful clinical observation is the most important aspect of monitoring adequacy of therapy in HACEK group infections.
    • Persistent or recurrent fever may be a sign of treatment failure, but it also may be due to hypersensitivity reactions, thrombophlebitis, or sterile embolization.
    • Observe patients closely for signs of complications, such as embolic events or CHF.
  • Repeat blood cultures every 48 hours until they become negative.
  • Fever that lasts longer than 10 days after starting appropriate antibiotics should cause concern.
  • Causes of persistent fever include drug fever, antibiotic resistance, myocardial or septal abscesses, large vegetations that are difficult to sterilize, and metastatic infection (intracerebral mycotic aneurysms).

Further Outpatient Care

  • Relapse may occur during the first 6 months following the end of treatment. Patients should be counseled and observed regarding relapse.

Inpatient & Outpatient Medications

  • In general, the entire course should be with intravenous antibiotics. Once the patient is stable and cultures are negative, completing intravenous therapy on an outpatient basis is reasonable. However, even in the outpatient setting, frequent evaluations are necessary to assess for response to therapy and for drug toxicity.
  • Although little evidence exists to support its use in this setting, ciprofloxacin could be used in oral form in certain circumstances. However, given the lack of evidence, this be reserved for special circumstances and in consultation with an infectious disease specialist.7

Transfer

  • If HACEK infection is diagnosed early, managing the infection in a center that does not offer cardiovascular surgery services may be possible. However, consider transfer to a health center with complete cardiac and neurological care for any patient at high risk for complications.
  • If the patient is stable, has good social support, and is afebrile with negative blood cultures, outpatient therapy can then be offered for the remainder of the treatment course.

Deterrence/Prevention

  • The risk of endocarditis due to HACEK organisms may be reduced by maintenance of good dental hygiene.
  • Guidelines for infective endocarditis (IE) prophylaxis prior to dental procedures were updated in 2007. Current recommendations support the use of prophylactic antibiotics for high-risk lesions only.
  • Antibiotic prophylaxis should be considered before oral/dental procedures in patients with high-risk cardiac conditions.14
  • High-risk conditions include the following:
    • Prosthetic valves
    • Previous bacterial endocarditis
    • Complex cyanotic congenital heart disease
    • Surgically constructed systemic pulmonary shunts or conduits
    • Valvulopathy in cardiac transplantation recipients

Complications

  • Many complications can result from IE, regardless of the causative organisms.
    • CHF is the complication of IE that has the greatest impact on prognosis. It may develop acutely from perforation of a valve leaflet, rupture of an infected chordae, valve obstruction, or because of sudden intracardiac shunts from fistulous tracts. When it appears more insidiously, CHF usually develops during the first month of therapy. Any deterioration in heart function should be taken very seriously because operative mortality increases dramatically after frank ventricular decompensation.
    • Neurologic complications, whether from emboli, abscess, hemorrhage, or arteritis, are the most frequent causes of death in patients with IE. Mycotic aneurysms are usually clinically silent until they rupture. Consider performing a magnetic resonance angiogram or cerebral CT scan to look for aneurysm in patients with subacute IE.
    • Splenic infarctions can occur in more than one third of patients but are often clinically silent.
    • Septic or bland emboli may reach the lung in right-sided endocarditis. These may cause pulmonary infarction, pneumonia, and empyema.

Prognosis

  • The prognosis is quite variable, depending on many factors, such as delay in diagnosis, age of the patient, and occurrence of complications. Patients with uncomplicated IE caused by HACEK organisms generally respond well to therapy and have an excellent prognosis.1

Miscellaneous

Medicolegal Pitfalls

  • HACEK group infections are a diagnostic challenge. Infective endocarditis (IE), the most frequent infection caused by these organisms in adults, is often subacute and may present in myriad ways, resulting in a delay in diagnosis. The way to overcome this is to include IE in the differential diagnoses in any patient presenting with nonspecific symptoms, such as weight loss and fatigue, in the presence or absence of fever. Suspicion should be even greater in intravenous drug addicts, patients with periodontitis, and patients with a heart murmur.
  • The fastidious nature of these organisms makes microbiological identification difficult. Communication with the medical microbiologist is of important to optimize yield.
 


More on HACEK Group Infections

Overview: HACEK Group Infections
Differential Diagnoses & Workup: HACEK Group Infections
Treatment & Medication: HACEK Group Infections
Follow-up: HACEK Group Infections
References
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References

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  2. Baron EJ, Scott JD, Tompkins LS. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis. Dec 1 2005;41(11):1677-80. [Medline].

  3. Geraci JE, Wilson WR. Symposium on infective endocarditis. III. Endocarditis due to gram- negative bacteria. Report of 56 cases. Mayo Clin Proc. Mar 1982;57(3):145-8. [Medline].

  4. Morpeth S, Murdoch D, Cabell CH, Karchmer AW, Pappas P, Levine D, et al. Non-HACEK gram-negative bacillus endocarditis. Ann Intern Med. Dec 18 2007;147(12):829-35. [Medline].

  5. Ferreiros E, Nacinovich F, Casabé JH, Modenesi JC, Swieszkowski S, Cortes C, et al. Epidemiologic, clinical, and microbiologic profile of infective endocarditis in Argentina: a national survey. The Endocarditis Infecciosa en la República Argentina-2 (EIRA-2) Study. Am Heart J. Feb 2006;151(2):545-52. [Medline].

  6. Darras-Joly C, Lortholary O, Mainardi JL, Etienne J, Guillevin L, Acar J. Haemophilus endocarditis: report of 42 cases in adults and review. Haemophilus Endocarditis Study Group. Clin Infect Dis. Jun 1997;24(6):1087-94. [Medline].

  7. Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. Jun 14 2005;111(23):e394-434. [Medline].

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  15. Baron EJ, Scott JD, Tompkins LS. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis. Dec 1 2005;41(11):1677-80. [Medline].

  16. Bayer AS, Scheld WM. Endocarditis and intravascular infections. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000:857-902.

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  25. Westling K, Vondracek M. Actinobacillus (Aggregatibacter) actinomycetemcomitans (HACEK) identified by PCR/16S rRNA sequence analysis from the heart valve in a patient with blood culture negative endocarditis. Scand J Infect Dis. 2008;40(11-12):981-3. [Medline].

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Further Reading

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Keywords

species, endocarditis, gram-negative endocarditis

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Contributor Information and Disclosures

Author

Isaac P Humphrey, MD, Assistant Professor of Internal Medicine, Uniformed Services University of the Health Sciences; Clinical Assistant Professor of Internal Medicine, Wright State University Boonshoft School of Medicine
Isaac P Humphrey, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mirabelle Kelly, MD, Fellow, Department of Microbiology and Infectious Disease, University of Sherbrooke, Canada
Mirabelle Kelly, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Barnett Gibbs, MD, Assistant Chief, Department of Clinical Trials, Walter Reed Army Institute of Research, Infectious Disease Service, National Capital Consortium; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences
Disclosure: Nothing to disclose.

Christian P Sinave, MD, Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke, Canada
Christian P Sinave, MD is a member of the following medical societies: American Society for Microbiology and Canadian Infectious Disease Society
Disclosure: Nothing to disclose.

Medical Editor

Kenneth C Earhart, MD, Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3
Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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