HACEK:

 Haemophilus
 Aggregatibacter
 Cardiobacterium
 Eikenella
 Kingella

OVERVIEW:

•implicated in up to 3% of all cases of infective endocarditis

• typically produce infection in individuals with prosthetic heart valves or other underlying heart disease

• part of the microbiota of the oral cavity and upper respiratory tract in humans

• produce syndromes that are insidious in onset and challenging to diagnose

• treatment with third-generation cephalosporins

• favorable outcome in 80% to 90% of cases

Endocarditis = inflammation of inner lining of the heart

PATHOGENESIS:

1. Bacteria enters blood during dental procedures, toorh brushing, trauma

2. gets trapped in thin blood clots that form around deformed heart valves
3. Multiplies and forms protective biofilm
4. Bacteria continually wash into circulation, infected clot (septic emboli) breaks off and blocks
important vessels and leads to tissue death
5. Cause vessel weakening and balloon out = aneurysm
6. High antibody levels to harmful immune complexes trigger inflammatory response =
glomerulonephritis in kidneys
7. Penetrates heart tissue= abscesses, damaged valves

• Causes of bacteremia that can lead to infective endocarditis:

a. Intravascular catheters are now most common.

b. Dental manipulations (extraction, periodontal surgery), oral

irrigators (Waterpik)

c. Tonsillectomy

d. Urology procedures (urethral dilatation, cystoscopy, prostatectomy)

e. Pulmonary procedures (rigid bronchoscopy, intubation)

f. GI procedures (upper GI endoscopy, sigmoidoscopy, colonoscopy)

EPIDEMIOLOGY POF INFECTIVE ENDOCARDITIS:

 Patients with IV catheters, prosthetic heart valves

 Usually infected with S.aureus, S.epidermidis, enterococci

HACEK:

 Gram(-) bacilli,
 Opportunistic pathogens with affinity to heart walves
 Rare but important cause of endocardit
 Normal microbiota of oral cavity
 Opportunistic and require susceptible host
 Capnophilic = loves CO2
 Non-motile
 Fastidious, slow-growing

MACCONKEY AGAR:

• selective and differential culture medium

• designed to selectively isolate Gram-negative enteric bacteria

• differentiate them based on lactose fermentation; lactose fermenters turn red or pink and
nonfermenters do not change color

• inhibits growth of Gram-positive organisms with crystal violet and bile salts, allowing for the

selection and isolation of gram-negative bacteria.

AGGREGATIBACTER:

 A. Actinomycetemcomitans
 A. aphrophilus (“foam-loving”) formerly H. aphrophilus
 A. paraphrophilus formerly H. paraphrophilus
 A. segnis formerly H. segnis
A.ACTINOMYCETEMCOMITANS:

 Small rods to coocid gram(-) bacilli

 Nonmotile
 6 serotypes
 Individuals with juvenile periodontal disease or other dental disease harbor organism = cause
periodontitis and destruction of alveolar bone that supports teeth
 Isolated from blood as causative agent of subacute bacterial endocarditis
 Most common cause of endocarditis within HACEK group
 Member of a genus that includes animal pathogens or animal endogenous flora
 Member of the Pasteurellaceae family
 Does not routinely cause infections in humans
 Human tissue infections attributed to cattle, sheep, pig, and horse bites, or through contact with
these animals
 Cause subacute bacterial endocarditis
 Virulence factors: collagenase and leukotoxin (toxic to PMN and monocytes)
 Isolates require 24h + for visible growth
 UNIQUE: distinctive “star-shape” in the center of colonies see at 48 h
 Grows on mackoney agar, trypticase soy agar and brain-heart infusion agar
 Sensitive to penicillin
 Resistant to vancomycin and erythromycin

CARDIOBACTERIUM:

2 species:

C.Hominis

C.Valvarum

C.HOMINIS:

 Gram(-) bacilli
 Nonmotile, fastidious, pleomorphic
 Normal flora of nose, mouth, GIS
 Oral infections and dental procedures usually precede endocarditis
 Clinical manifestation of endocarditis = large, tumor-like vegetations and no fever
 Infects aortic valve more frequently than the other HACEKs
 Gram stain= false gram(+)
 Form rosettes, swelling, and stick like structures in yeast extract
 Grows on Sabouraud dextrose agar and chocolate agar, not on mackonkey agar
 Sensitive to penicillin,
EIKENELLA CORRODENS:

 Gram(-) fastidious coccobacilli

 Grows best under conditions: increased CO2 with hemin
 Member of the usual flora of the oral and bowel cavities.
 Causes mixed infections and often occur as a result of trauma, especially after
 human bites or fights.= caused by human bites
 Poor dental hygiene, oral surgery or infection
 Eikenella infections: Meningitis
 In drug addicts, it has been implicated in cellulitis (direct inoculation of the organism into the
skin after oral contamination of needles).
 is the least common isolate of the HACEK group in adult infectious endocarditis
 nonmotile
 produce yellow pigment
 bleach-like odor from agar surface
 characteristic pitting on agar= surface pits on colonies

KINGELLA:

 squared ends= perfect rectangles

 typically nonmotile
 colonize upper resp.tract
 K. denitrificans may grow on Thayer-Martin medium and may resemble Neisseria gonorrhoae
(if it does not pit the agar).
 Gram stain should aid in distinguishing Kingella spp. from Neisseria gonorrhoae.
 Can grow at 42 degrees
 Most isolates are from joint and bone infections in children younger than 5 yrs old