Instituto Nacional Archivos Peruanos de Cardiología y Cirugía Cardiovascular

Cardiovascular Arch Peru Cardiol Cir Cardiovasc. 2023;4(3):102-108. doi: 10.47487/apcyccv.v4i3.306.

Review article

Challenges and Insights in Aggregatibacter aphrophilus endocarditis:

a review of literature
Nathalie Victoria Zacarías Mendoza 1,a
, Norma Nicole Gamarra Valverde , Víctor Justo Robles Velarde
1,a 2,b,c

Received: Jul 15, 2023

Accepted: September 18, 2023 ABSTRACT
Online: September 30, 2023
Authors’ affiliation
1
Facultad de Medicina Alberto Infective endocarditis is a serious disease associated with high mortality despite recent advances
Hurtado, Universidad Peruana in diagnosis and treatment. Aggregatibacter aphrophilus is a fastidious Gram-negative member of
Cayetano Heredia. Lima, Perú.
2
Servicio de Cirugía Cardiovascular, the HACEK organisms (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium
Instituto Nacional de Cardiología.
Lima, Perú.
hominis, Eikenella corrodens, and Kingella kingae). A. aphrophilus is associated with dental infections but
a
Medical student.. has also been implicated in cases of infective endocarditis. We highlight the importance of a high index
b
Thoracic and Cardiovascular
Surgeon. of suspicion in symptomatic patients with an initial negative blood culture, particularly in high-risk
c
Assistant Professor. groups such as patients with congenital valve disease and prosthetic valve. The knowledge of this rare
Correspondence entity may lead to early diagnosis and appropriate management. We review the main characteristics of
Nathalie Victoria Zacarías Mendoza
Calle Anthon Van Dyck 137, Lima,
Aggregatibacter aphrophilus endocarditis reported in the medical literature.
Perú.

E-mail
[email protected] Keywords: Bacterial Endocarditis; Gram-negative Bacteria; Aggregatibacter aphrophilus (source: MeSH-NLM).

Source of funding
This research did not receive any
specific grant from funding agencies
in the public, commercial, or not-for-
profit sectors.

Conflicts of interest
None declared

Cite as: Zacarías Mendoza NV, Gama-

rra NN, Valverde Robles Velarde VJ.
RESUMEN
Challenges and Insights in Aggrega-
tibacter aphrophilus endocarditis: A
review of literature. Arch Peru Cardiol
Cir Cardiovasc. 2023;4(3):102-108.
doi: 10.47487/apcyccv.v4i3.306. Desafíos e ideas en la endocarditis por Aggregatibacter
aphrophilus: una revisión de la literatura
La endocarditis infecciosa es una enfermedad grave que está asociada con una alta mortalidad a pesar
This work is licensed under a Creative
Commons Attribution 4.0 Internatio- de los avances recientes en el diagnóstico y tratamiento. Aggregatibacter aphrophilus es un miembro
nal License. Gram-negativo de los organismos HACEK (Haemophilus spp., Aggregatibacter actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens y Kingella kingae). A. aphrophilus está relacionado con
infecciones dentales, pero también ha estado implicado en casos de endocarditis infecciosa. Se
destaca la importancia de tener un alto índice de sospecha en pacientes sintomáticos con un cultivo
sanguíneo inicial negativo, especialmente en grupos de alto riesgo como pacientes con enfermedad
valvular congénita y válvula protésica. El conocimiento de esta entidad poco común puede llevar
a un diagnóstico temprano y un manejo adecuado. Revisamos las principales características de la
endocarditis por Aggregatibacter aphrophilus reportadas en la literatura médica.

Palabras clave: Endocarditis Bacteriana; Bacterias Gramnegativas; Aggregatibacter aphrophilus (fuente:

DeCS-BIREME).

102 Arch Peru Cardiol Cir Cardiovasc. 2023;4(3):102-108.doi: 10.47487/apcyccv.v4i3.306.

Challenges and Insights in Aggregatibacter aphrophilus endocarditis Zacarías-Mendoza NV, et al.

Only one case (5%) received a dual-chamber pacemaker

placement for complete heart block. A 25% of the patients
Introduction presented with congenital valvulopathy: true bicuspid aortic
valve and ascending aortopathy were reported in one of the
Aggregatibacter aphrophilus is a member of the HACEK orga- patients; while the second patient had a calcific aortic stenosis
nisms (Haemophilus spp., Aggregatibacter actinomycetem- due to a congenital bicuspid aortic valve and a poor dentition.
comitans, Cardiobacterium hominis, Eikenella corrodens, and The third patient had a pierced tongue two months before onset
Kingella kingae). A. aphrophilus is a fastidious Gram-negative of illness and a history of aortic valvuloplasty at eight years of age
associated with dental infections but has also been implicated for correction of congenital aortic stenosis. Also, the patient had
in cases of infective endocarditis (1). previous dental work with endocarditis prophylaxis. Among other
HACEK endocarditis is a rare disease with an excellent reported conditions, one of the patients had a calcific aortic stenosis
prognosis and simple management if the organism is properly due to a congenital bicuspid aortic valve and a poor dentition.
identified. Due to the difficulty of Aggregatibacter aphrophilus Three cases (15%) had congenital heart disease. One patient
isolation, this bacterium is rarely seen in blood cultures (2). In this had a perimembranous ventricular septal defect (PMVSD); a
paper, we review the main characteristics of Aggregatibacter second patient had a Contegra D-valved conduit (CVC) placement
aphrophilus endocarditis reported in the medical literature. due to a D-transposition of the great arteries with ventricular
septal defect and pulmonary stenosis at two years old; a third
patient underwent a surgical patch closure of patent foramen
Literature review ovale at the age of 9 and dental care at five months before his
admission. Only one case (5%) had a history of nicotine and
We reviewed PubMed® for cases of Aggregatibacter aphrophilus alcohol abuse.
endocarditis. We used the MeSH database to search the terms
“infective endocarditis” and “Aggregatibacter aphrophilus” in order Clinical presentation and physical examination
to increase the sensibility and specificity of the search. The 20 The initial presentations of 20 patients with endocarditis
cases with the most significant data are summarized in Table 1. due to Aggregatibacter aphrophilus were detailed. The mean
The articles were reviewed to gather information about patient duration of symptoms before diagnosis in 16 patients was 10
demographics, preexisting heart diseases, and treatment options. days (range, 5 - 14 days). The clinical presentation was available
In total, 91 studies were identified, of which 20 met the inclusion for 19 patients. The most common symptoms were fever in
criteria, describing a total of 20 patients (Table 1). The identified 16 (80%), fatigue/general malaise in 5 (25%), weight loss in
studies were performed between 2002 and 2021. 5 (25%), and headache in 3 (15%) patients. On the physical
examination, cardiac murmurs were found in 6 patients (30%).
Demographics A total of seven patients (35%) showed embolic complications
We have reviewed 20 cases (15 men (75%) and 5 women (25%)); as initial presentation, neurological involvement being the most
median age: 46,8 years old (range 5-74 years) of Aggregatibacter common. Four patients (25%) had an ischemic stroke; 1 patient
aphrophilus endocarditis reported in the medical literature (3-22). presented a brain abscess; 1 splenic abscess and 1 ANCA-
The data on gender, age, clinical features, diagnostic tests, surgical positive glomerulonephritis were also described. Two patients
treatment, and survival are summarized in Table 1. (10%) were admitted with the initial diagnosis of heart failure.

Underlying diseases and risk factors Diagnosis

A combination of the previous medical history of prosthetic valve, In 20 cases for which data were recorded, the mean positive blood
pacemaker placement, congenital heart disease, congenital culture was 0.59 (range: 1-8 taken) with a mean incubation time
valvular disease, prior rheumatic fever, poor dentition, chronic of 5 days (range: 3-7 days). In 8 patients, blood cultures yielded
disease, drug abuse, and tongue piercings has been reported in no organisms, but a definitive diagnosis of endocarditis was
the majority of the cases. Only six patients (30%) did not present established by PCR/sequencing (Br-PCR) of the 16S ribosomal
risk factors. RNA gene in the resected valve or arterial embolus or by culture
According to previous reports, five patients (25%) had of the valve in surgery. In 1 case, Aggregatibacter aphrophilus was
received a prosthetic valve. One patient had undergone aortic identified in the cerebrospinal fluid culture.
valve replacement (AVR) twice due to infective endocarditis (IE) An echocardiogram was performed on 19 patients, of
and a subsequent failed bioprosthetic valve; a second patient whom 6 underwent Trans thoracic echocardiogram (TTE) and 4
had a bioprosthetic aortic valve replacement at the age of 17 for Trans-esophageal echocardiogram (TEE). In one patient, 2D-TEE,
bicuspid aortic stenosis; a third patient had undergone AVR twice 2D-TTE and 3D-TTE were performed, of which only a positive
and a mitral valve replacement (MVR) at 51 years old, also, the result was obtained through 3D-TTE; 8 patients had both a TTE,
patient presented rheumatic fever at 15 years old; he was being and a TEE. In five patients, the vegetations were visible on the
treated with beta-blocker (atenolol) and a vitamin K antagonist TEE, but not on the TTE. The size of the vegetations, determined
(acenocoumarol); the fourth patient had undergone AVR due to by echocardiography, was described in only 8 cases. The mitral
a bicuspid aortic stenosis, also the patient presented diabetes valve was involved in 8 of the 20 (40%) patients, the aortic valve
mellitus; and the fifth patient had rheumatic fever. in 1 (5%) patient, and both valves in 1 (5%) patient. One case of

Arch Peru Cardiol Cir Cardiovasc. 2023;4(3):102-108.doi: 10.47487/apcyccv.v4i3.306. 103

104
Table 1. Main characteristics of patients at hospital admission from the 20 cases of Aggregatibacter aphrophilus endocarditis reported in the medical literature. (Continues on next page)
Images
Case No.
Age(y)/ Extra-cardiac Type of Veg Antibiotics
(Reference Initial clinical presentation Risk factors Diagnostic test Size of Surgery Death
sex Complications Exams Images findings Valve local- and duration
citation) Veg
infected ization
1 (3) Nausea, headache and TTE (-)
22/M - - Blood culture (+) Veg on MV Native 5×4 mm MV CRO, 4 weeks. No No
2013 exhaustion TEE (+)
(4) History of 2 AVR due to 2D-TEE (-), Pros-
2 Veg on prosthet- Biologi-
71/M Fever for 2 weeks. IE and a subsequent fail No Blood culture (+) 2D- TTE (-), 15 mm thetic NA, 2 weeks. AVR No
2016 ic AV cal p.
bioprosthetic valve. 3D-TTE (+) AV
16S rRNA gene se- Severe AR with Debridement, AVR,
3 (5) quencing (+), Blood ARA complicated Biologi- annular reconstruction
32/M Pyrexia, dyspnea and HF History of AVR due to BAV. No TEE (+) No - CRO, NA. No
2021 culture (-), Valve cul- by perforation into cal p. and graft replacement
ture (-) the RV. of the ascending aorta.
CRO + VAN +
16S rRNA polymerase
4 (6) Intermittent fever, chills, and CIP + teico-
chain reaction MVR and ring annu-
47/M decreased urine output for 2 No Roth’s spots TEE (+) Veg on MV Native NA MV planin + dapto- No
(PCR) and sequencing, loplasty
2017 weeks. Systolic murmur IV/VI mycin + ertape-
Blood culture (-)
nem, NA.
General malaise, vomiting,
5 (7) Embolic stroke and 16S rRNA sequencing,
51/M diarrhea, fever, sweats No TTE (+) Moderate AR Native No No CRO, 6 weeks. No No
2021 digital infarction. Blood culture (-)
and myalgia for 2 weeks.
Challenges and Insights in Aggregatibacter aphrophilus endocarditis

Glomerulone-
Persistent phritis, positive
6 (8) br-PCR and sequencing Severe MR and
72/F high fever and acute renal No PR3-ANCA, cere- TTE (+) Native 1 cm MV CRO, 4 weeks MVR No
2017 (+), Blood culture (-) veg on MV
failure bral embolism and
hemorrhage
Native
TV (1.2
and
Dual-chamber pacemaker cm × 0.7
Fever, chills, night sweats, fa- right Device removal and
placement in 1996 for Veg on TV and on cm) and
7 (9) tigue, and ten-pound weight ven- temporary jugular
62/M complete heart block with No Blood culture (+) TEE (+) the RV pacemaker Native pace- CRO, 6 weeks. No
2014 loss over a four-month period. tricular venous pacing wires
subsequent lead manipula- lead maker
Systolic murmur and JVD pace- were placed
tion in 2007 lead
maker
(NA)
lead.
Debridement and redo
Congenital
Bentall operation with
8 (10) Fever, myalgia and a non-pro- heart disease with a true
25/M No Blood culture (+) TTE (+) ARA No No No CRO + GEN, NA a mechanical AV and No
2021 ductive cough. BAV and ascending
replacement of the RV
aortopathy
to PA conduit
Pros-
Left hemiparesis, frontal and
thetic
(11) nasal headaches, rotational 15 years: rheumatic fever. TTE (-)
9 Veg on MV, Veg Mechani- MV and
65/F vertigo when getting up, Cerebral embolism Blood culture (+) 3/6 TEE (+) 6 x 5 mm CRO, 6 weeks No No
2017 on AV cal p. Pros-
afebrile. 51 years: 2 AVR and MVR PET/CT (+)
thetic
Grade 2/6 systolic murmur.
AV
Persistent pain in the right
10 (12) shoulder, general weakness, TEE (+) Severe MR and
74/M No No Blood culture (+) 1/6 Native NA MV CRO, 3 weeks No No
2022 chills, palpitations and lack of TTE (+) veg on MV
appetite. 98.6° F temperature.
Lethargy, night sweats, fever
History of AVR due to BAV. Anterior
11 (13) of 100° F, decreased appetite, Splinter hemor- TEE (+) Protease CRO, 4 weeks +
61/M Blood culture (+) 7/8 Veg on MV No mitral No No
2013 and erratic low blood glucose rhage in one finger TTE (+) valve GEN, 2 weeks
Diabetes leaflet
without weight loss.

MV: Mitral valve; AV: Aortic valve; AR: Aortic regurgitation; ARA: Aortic Root Abscess; RV: Right ventricle; ASDs: Atrial septal defects; TTE: transthoracic echocardiogram; TEE: Transesophageal echocardiogram; 2D-TEE: 2D Transesophageal
echocardiogram; 2D-TTE: 2D transthoracic echocardiogram; 3D-TTE: 3D transthoracic echocardiogram; PET-CT: Positron emission tomography; TV: Tricuspid valve; MR: Mitral regurgitation; MVR: Mitral valve replacement; AVR: Aortic valve re-
placement; BAV: Balloon aortic valvuloplasty; VSD: Ventricular septal defect; PS: Pulmonic stenosis; AS: Aortic stenosis; JVD: Jugular venous distension; HF: heart failure; CRO: Ceftriaxone; CIP: Ciprofloxacin; VAN: Vancomycin; GEN: Gentamycin;
FOF: Fosfomycin; AMP: ampicillin; MEM: Meropenem; DO: Doxycycline.

Arch Peru Cardiol Cir Cardiovasc. 2023;4(3):102-108.doi: 10.47487/apcyccv.v4i3.306.

Zacarías-Mendoza NV, et al.
 Table 1. Main characteristics of patients at hospital admission from the 20 cases of Aggregatibacter aphrophilus endocarditis reported in the medical literature. (comes from previous page)
Images
Case No.
Age(y)/ Extra-cardiac Type of Veg Antibiotics
(Reference Initial clinical presentation Risk factors Diagnostic test Size of Surgery Death
sex Complications Exams Images findings Valve local- and duration
citation) Veg
infected ization
Confusion, fever, night sweats, Pos-
12 (14) Large weakly
chills, and an unintentional TEE (+) 1.5 x 1.0 terior MVR with biopros-
53/M No No Blood culture (-) echogenic MV Native CRO, 6 weeks No
twenty-pound weight loss TTE (+) cm mitral thetic valve
2019 veg.
over the past two months. valve
High right left
Headache, acute decrease in 9 years: closure of ASDs by shunt confirming
13 (15) TTE (-) CRO, 8 weeks + Surgical patch
56/M psychomotor function, and patent foramen ovale with Cerebral abscess Blood culture (-) dehiscence of the NA NA No No
2016 TEE (+) RF, 8 weeks. removal
fever of 40° C. surgical patch. surgical patch
closure of ASDs.
Large irregu-
larly bordered
Fatigue, weight loss, intermit-
echogenic mass
14 (16) tent fever, chills, cough and 3 cm x MEM + DO +
12/F Perimembranous VSD. No Blood culture (+) 2/2 TTE (+) attached to the Native TV - NA
2018 night sweats. Pan-systolic II/VI 2.5 cm GEN, NA.
right atrial side
heart murmur.
of TV.
MVR.
Challenges and Insights in Aggregatibacter aphrophilus endocarditis

The infected mitral

valve prosthesis
(17) Blood culture (+) 1/1, Thrombus and
15 17 years: MVR due to rheu- TTE (-) Protease and the left upper
42/M Fever and jaundice. Cerebral embolism 16S rRNA sequencing veg in mechanical NA No CRO, 8 weeks. No
2017 matic fever. TEE (+) valve pulmonary vein
(+) MV.
thrombus were

Arch Peru Cardiol Cir Cardiovasc. 2023;4(3):102-108.doi: 10.47487/apcyccv.v4i3.306.

removed
Fatigue and discomfort on the
left side of the chest, vomit-
Mobile veg on the
16 (18) ing, and increasing lethargy. Bilateral infarction of
42/F Nicotine and alcohol abuse Blood culture (-) TEE (+) noncoronary cusp Native NA No CRO + VA. No No
2009 Reduced level of conscious- the cerebral arteries
of the aortic valve.
ness and urinary incontinence.
Fever of 40.2° C
2 years: Contegra D-valved Veg on the pulmo-
17 (19) conduit (CVC) placement nary side of the Protease 4×5
4/F Signs of heart failure No Blood culture (-) TTE (+) No CRO No No
2015 - transposition of the great prosthetic valved valve mm
arteries with VSD and PS. conduit
Left flank pain followed by
Severe AR and
18 (20) fever with chills for 2 weeks. Congenital valvular heart
58/M Spleen abscess Blood culture (+) 2/2 TTE (+) a flail Mv with Native No No CRO, 2 weeks No No
2012 Systolic murmur disease
severe MR.
(Grade 3)
Fevers lasting 1 week with rig-
ors and diaphoresis. A grade
Calcific aortic stenosis due BAV with moder-
19 (21) 3/6 systolic crescendo-decre- TTE (+) CRO + GEN, 5
62/M to a congenital BAV. Poor No Blood culture (+) 2/3 ate AS with mild Native No No No No
2002 scendo ejection murmur and TEE (+) days.
dentition AR.
a soft 1/4 blowing diastolic
murmur
Aortic valvuloplasty at 8
years for correction of con-
20 (22) genital AS. Previous dental
25/M No Blood culture (+) 2/2 No No Native No No No AVR No
2002 work with endocarditis
prophylaxis. Pierced tongue
(2 months before).

MV: Mitral valve; AV: Aortic valve; AR: Aortic regurgitation; ARA: Aortic Root Abscess; RV: Right ventricle; ASDs: Atrial septal defects; TTE: transthoracic echocardiogram; TEE: Transesophageal echocardiogram; 2D-TEE: 2D Transesophageal
echocardiogram; 2D-TTE: 2D transthoracic echocardiogram; 3D-TTE: 3D transthoracic echocardiogram; PET-CT: Positron emission tomography; TV: Tricuspid valve; MR: Mitral regurgitation; MVR: Mitral valve replacement; AVR: Aortic valve re-
placement; BAV: Balloon aortic valvuloplasty; VSD: Ventricular septal defect; PS: Pulmonic stenosis; AS: Aortic stenosis; JVD: Jugular venous distension; HF: heart failure; CRO: Ceftriaxone; CIP: Ciprofloxacin; VAN: Vancomycin; GEN: Gentamycin;
FOF: Fosfomycin; AMP: ampicillin; MEM: Meropenem; DO: Doxycycline.

105
Zacarías-Mendoza NV, et al.
Challenges and Insights in Aggregatibacter aphrophilus endocarditis Zacarías-Mendoza NV, et al.

ventricular pacemaker lead infection was presented. In 9 patients Aggregatibacter aphrophilus endocarditis is remarkably
(45%) the valve involved was not identified. insidious in its presentation (8). The course of symptoms before
the diagnosis has been reported to be prolonged, with a mean
Treatment and susceptibility of 10 days, compared to endocarditis caused by traditional
The treatment of the 20 patients was detailed, all of whom organisms (24,25). Systemic symptoms, fever, weight loss, and
received cephalosporins at some point during the course anorexia were reported in most cases; however, embolic
of therapy. The therapy was almost always administered complications stood out as the initial clinical presentation.
intravenously. The most frequently administered therapy was Embolic neurological involvement is the most common. The
cephalosporin monotherapy (10 patients, 47.6%) followed by most reported conditions were cerebrovascular accidents and
dual cephalosporin and aminoglycoside therapy (3 patients, brain abscesses, patients can also have splenic infarction and
15%). One patient received the combination of a cephalosporin other extracardiac emboli complications. The mitral valve is
plus a glycopeptide, while other regimens included tetracyclines, the most commonly infected valve, with a tendency to infect
rifamycins, and penicillins. One patient received a cephalosporin, normal valves more often than other microorganisms do (7).
a fluoroquinolone, a glycopeptide, and 3 other antimicrobial The presence of factor V on its structure is necessary for the
agents. Cephalosporins were part of the antimicrobial therapy in infection of the native valve (26).
17 (89.5%) cases. The mean duration of treatment in 12 patients The diagnosis is extraordinarily challenging (27). Knowing
was 4.9 ± 6 weeks (range: 2 weeks to 8 weeks). The median that the identification of the pathogen is the key to the success
duration of treatment for native valve endocarditis was 2.6 weeks of the treatment of the endocarditis with HACEK organisms
and for prosthetic valve endocarditis 3.6 weeks; 50% of the the problem is that they are well known as culture negative. It
patients (10) underwent valve replacement surgery. is currently suggested that the PCR/sequencing study (Br-PCR)
of the 16S ribosomal RNA gene overcomes the difficulty of
Outcome finding this microorganism in a blood culture. The diagnosis
Complications included ischemic stroke in 4 patients (20%), of Aggregatibacter aphrophilus endocarditis with the modified
glomerulonephritis in 1 patient (5%), brain abscess in 1 patient Duke criteria has limitations (28). The median number of cultures
(5%), and splenic abscess in 1 patient (5%). Nineteen of twenty taken was 2.1 (range, 1-8 taken), of which 47% were positive
patients (95%) were cured; the outcome was not specified for for Aggregatibacter aphrophilus with a mean incubation
1 case. In cases related to native valves, valve replacement was time of 5 days (range, 3-7 days). In 8 patients, no organisms
required in 4 (20%) patients; 2 (33.33%) of the 6 patients with were isolated in the blood cultures, even though despite the
involvement of the prosthetic valve required valve replacement. fact that serial samples of more than 3 blood cultures were
Of the 4 cases of native valve endocarditis, the aortic valve was taken, separated by 24 hours each with an interval between
replaced in 1 and the mitral valve in 3 patients. Of the 6 cases of samples of 60 minutes. Aggregatibacter aphrophilus needs to
prosthetic valve endocarditis, 2 (33.33%) required aortic valve be considered as difficult organisms to culture and, therefore,
replacement. they are classified within the group of “culture-negative
endocarditis” (3).
For the diagnosis of endocarditis, the identification of
Discussion vegetation on the heart valve was made principally by a
transesophageal echocardiogram. Most patients who had an
Aggregatibacter aphrophilus is a member of the group of HACEK TEE report a previous negative transthoracic echocardiogram.
organisms. Typically, Aggregatibacter aphrophilus is part of the Normally the first exam is the TTE, but in cases where vegetation
normal oropharyngeal flora and is frequently found in dental cannot be observed, the primary second-line examination
plaques and gingival scrapings (1). Khiarat et al. described the is a TEE. In our review, we identified that the vegetation was
first case of valvular Aggregatibacter aphrophilus infection identified in 13 (65%) of the 20 patients using transesophageal
in 1940 (23). Aggregatibacter aphrophilus is an uncommon echocardiography; of which 8 presented a negative initial
cause of EI (1-3%). The highest incidence of A. aphrophilus transthoracic echocardiography.
endocarditis is among middle-aged adults and preferentially The American Heart Association (AHA) and European
infects males (2). It is believed that the microorganism located Society of Cardiology (ESC) recommend as a first-line
in the oropharynx, enters the vascular chamber at the time of treatment with intravenous third or fourth-generation
dental work or in the context of periodontal disease, normally cephalosporins and fluoroquinolones (27). Of the 20 cases
in patients with poor dentition or recent dental work (1). presented, 17 used ceftriaxone as central treatment, 8 of
Therefore, the literature data suggest that the which used only monotherapy with a third-generation
microorganism is generally considered to be low virulence cephalosporin for a mean of 4 weeks (range 2-8 weeks). Eight
and structurally damaged, or prosthetic cardiac valves seem patients used double therapy where fluoroquinolones were
to be the predisposing conditions most strongly associated used in 60%. In 10 of the 20 patients, the condition resolved
with the incidence of Aggregatibacter aphrophilus endocarditis. after 6 weeks of antibiotic therapy without the need for
Other groups at risk include those with pacemaker placement, surgical intervention. The routine duration of treatment is four-
congenital heart disease, prior rheumatic fever, poor dentition, weeks for non-valvular endocarditis (NVE) and six-weeks for
chronic disease, drug abuse, and those with tongue piercings (1). prosthetic-valve endocarditis (PVE). Patients with endocarditis

106 Arch Peru Cardiol Cir Cardiovasc. 2023;4(3):102-108.doi: 10.47487/apcyccv.v4i3.306.

Challenges and Insights in Aggregatibacter aphrophilus endocarditis Zacarías-Mendoza NV, et al.

due to Aggregatibacter aphrophilus achieve resolution of the The review highlights the importance of a high index of
condition through antibiotic therapy, valve replacement suspicion in symptomatic patients with an initial negative blood
surgery is not frequent. Valve replacement surgery was culture as a Aggregatibacter aphrophilus endocarditis, particularly
necessary for 5 patients (25%), the aortic valve was replaced in in high-risk groups such as patients with congenital valve disease
2 patients, and the mitral valve in 3 patients. No perioperative and prosthetic valve. The knowledge of this rare entity may lead
complications were reported. to early diagnosis and appropriate management.
Endocarditis secondary to HACEK organisms generally
has an excellent prognosis with a significantly lower mortality Author’s contributions
rate at one year compared to IE due to EGV (13). Most of the NVZM: Writing - Original Draft, Writing - Review & Editing.
patients did not report complications, death, or recurrence of NNGV: Writing - Original Draft, Writing - Review & Editing. VJRV:
a new episode at follow-up for 1 year. Supervision.

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