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.

Background The clinical profile and outcome of nosocomial and non-nosocomial health care–associated native valve endocarditis are not well defined. Objective To describe the prevalence, clinical characteristics, and outcomes of nosocomial and non-nosocomial health care–associated native valve endocarditis. Design Prospective observational study. Setting 61 hospitals in 28 countries. Patients Patients with definite native valve endocarditis and no history of injection drug use who were enrolled in the International Collaboration on Endocarditis–Prospective Cohort Study from June 2000 to August 2005. Measurements Characteristics of nosocomial and non-nosocomial health care–associated native valve endocarditis cases were described and compared with those cases acquired in the community. Results Health care–associated native valve endocarditis was present in 557 (34%) of 1622 patients with native valve endocarditis and no history of injection drug use (nosocomial native valve endocarditis 303 patients [54%]; non-nosocomial health care–associated native valve endocarditis 254 patients [46%]). Staphylococcus aureus was the most common cause of health care-associated native valve endocarditis (nosocomial native valve endocarditis, 47%; non-nosocomial health care–associated native valve endocarditis, 42%; p=0.3), with a notable proportion of methicillin-resistant S. aureus (nosocomial native valve endocarditis, 57%; non-nosocomial health care–associated native valve endocarditis, 41%; p=0.014). Patients with health care–associated native valve endocarditis had lower rates of cardiac surgery (41% health care–associated native valve endocarditis vs 51% community-acquired native valve endocarditis, p<0.001) and higher in-hospital mortality rates than patients with community-acquired native valve endocarditis (25% health care–associated native valve endocarditis vs. 13% community-acquired native valve endocarditis vs., p<0.001). Multivariable analysis confirmed a higher mortality associated with health care–associated native valve endocarditis (incidence risk ratio=1.20 (CI 95%, 1.03–1.61). Limitations This study involves tertiary hospitals with cardiac surgery programs. The results may not be generalized to patient populations receiving care in other types of facility. Conclusions More than one-third of all cases of native valve endocarditis in non-drug users involve contact with health care. S. aureus is the leading cause of health care–associated native valve endocarditis. Non-nosocomial health care–associated native valve endocarditis is common, especially in the US. Patients with health care-associated and community-acquired native valve endocarditis differ in their presentation, microbiology, and outcome. By contrast, patients with nosocomial and non-nosocomial healthcare-associated endocarditis are similar.

The HACEK organisms (Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species) are rare causes of infective endocarditis (IE). The objective of this study is to describe the clinical characteristics and outcomes of patients with HACEK endocarditis (HE) in a large multi-national cohort. Patients hospitalized with definite or possible infective endocarditis by the International Collaboration on Endocarditis Prospective Cohort Study in 64 hospitals from 28 countries were included and characteristics of HE patients compared with IE due to other pathogens. Of 5591 patients enrolled, 77 (1.4%) had HE. HE was associated with a younger age (47 vs. 61 years; p<0.001), a higher prevalence of immunologic/vascular manifestations (32% vs. 20%; p<0.008) and stroke (25% vs. 17% p = 0.05) but a lower prevalence of congestive heart failure (15% vs. 30%; p = 0.004), death in-hospital (4% vs. 18%; p = 0.001) or after 1 year follow-up (6% vs. 20%; p = 0.01) than IE due to other pathogens (n = 5514). On multivariable analysis, stroke was associated with mitral valve vegetations (OR 3.60; CI 1.34–9.65; p<0.01) and younger age (OR 0.62; CI 0.49–0.90; p<0.01). The overall outcome of HE was excellent with the in-hospital mortality (4%) significantly better than for non-HE (18%; p<0.001). Prosthetic valve endocarditis was more common in HE (35%) than non-HE (24%). The outcome of prosthetic valve and native valve HE was excellent whether treated medically or with surgery. Current treatment is very successful for the management of both native valve prosthetic valve HE but further studies are needed to determine why HE has a predilection for younger people and to cause stroke. The small number of patients and observational design limit inferences on treatment strategies. Self selection of study sites limits epidemiological inferences.

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The aim of this study was to assess changes in antibiotic resistance, epidemiology and outcome among patients with Enterococcus faecalis infective endocarditis (EFIE) and to compare the efficacy and safety of the combination of ampicillin and gentamicin (A+G) with that of ampicillin plus ceftriaxone (A+C). The study was a retrospective analysis of a prospective cohort of EFIE patients treated in our centre from 1997 to 2011. Thirty patients were initially treated with A+G (ampicillin 2 g/4 h and gentamicin 3 mg/kg/day) and 39 with A+C (ampicillin 2 g/4 h and ceftriaxone 2 g/12 h) for 4-6 weeks. Increased rates of high-level aminoglycoside resistance (HLAR; gentamicin MIC ≥512 mg/L, streptomycin MIC ≥1024 mg/L or both) were observed in recent years (24% in 1997-2006 and 49% in 2007-2011; p 0.03). The use of A+C increased over time: 1997-2001, 4/18 (22%); 2002-2006, 5/16 (31%); 2007-2011, 30/35 (86%) (p <0.001). Renal failure developed in 65% of the A+G group and in 34% of the A+C group (p 0.014). Thirteen patients (43%) in the A+G group had to discontinue treatment, whereas only one patient (3%) treated with A+C had to discontinue treatment (p<0.001). Only development of heart failure and previous chronic renal failure were independently associated with 1-year mortality, while the individual antibiotic regimen (A+C vs. A+G) did not affect outcome (OR, 0.7; 95% CI, 0.2-2.2; p 0.549). Our study shows that the prevalence of HLAR EFIE has increased significantly in recent years and that alternative treatment with A+C is safer than A+G, with similar clinical outcomes, although the sample size is too small to draw firm conclusions. Randomized controlled studies are needed to confirm these results.