Duke Criteria for Infective Endocarditis

 

Certainty in the Diagnosis of Infective Endocarditis

 

Definite infective endocarditis:

(A) based on pathologic criteria

(1) micro-organisms demonstrated (by culture, by histologic examination, by Gram stain) in a vegetation from a valve, from a vegetation that has embolized, or from an intracardiac abscess, or

(2) active endocarditis demonstrated by histologic examination in a vegetation from a valve or from an intracardiac abscess

(B) based on clinical criteria

(1) 2 major criteria, or

(2) 1 major and 3 minor criteria, or

(3) five minor criteria

 

Possible infective endocarditis:

(1) findings consistent with infective endocarditis

(2) findings insufficient for definite category

(3) findings insufficient for rejected category

 

Hypothesis of infective endocarditis rejected:

(1) firm alternate diagnosis explaining symptoms

(2) resolution of symptoms with antibiotic therapy of <= 4 days

(3) no pathologic evidence of infective endocarditis at surgery or at autopsy, following antibiotic therapy of <= 4 days

 

Clinical Criteria for the Diagnosis of Infective Endocarditis

 

Major Criteria:

(1) positive blood cultures

(1A). Typical micro-organisms consistent with infective endocarditis from 2 separate blood cultures

(1A1) viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella species, Kingella kingae)

(1A2) community-acquired Staphylococcus aureus or enterococci, in the absence of a primary extracardiac focus of infection (abscess, etc.)

(1B). Micro-organisms consistent with infective endocarditis from persistently positive blood cultures, defined as

(1B1) at least 2 positive blood cultures of blood samples drawn more than 12 hours part

(1B2) all of 3, or 3 out of 4, or the majority of >4 separate blood cultures with first and last specimens drawn at least 1 hour apart

 

(2) evidence of endocardial involvement

(2A). positive echocardiogram for endocarditis

(2A1). oscillating intracardiac mass

(2A1a) on valve or supporting structures

(2A1b) in path of regurgitant jet

(2A1c on implanted material in the absence of an alternative anatomic explanation

(2A2). abscess

(2A3). new partial dehiscence of prosthetic valve

 

(2B). new valvular regurgitation (worsening or change of a pre-existing murmur is not sufficient for diagnosis),

 

Minor Criteria:

(1) predisposing condition

(1a) native valve disease: aortic regurgitation, aortic stenosis, mitral regurgitation, congenital valve disease, mixed

(1b) prosthetic heart valve

(1c) endocavitary pacemaker

(1d) intravenous drug use

(2) fever >= 38 °C

(3) vascular phenomenon

(3a) major arterial emboli

(3b) septic pulmonary infarcts

(3c) mycotic aneurysm

(3d) intracranial hemorrhage

(3e) conjunctival hemorrhages

(3f) Janeway's lesions on palms or soles of feet

(4) immunologic phenomenon

(4a) glomerulonephritis

(4b) Osler's nodes on pads at fingertips or toes

(4c) Roth's spots

(4d) positive rheumatoid factor

(5) microbiological evidence

(5a) positive blood culture, but not meeting major criteria

(5b) serologic evidence of active infection with organism consistent with infective endocarditis

(5c) excluded: coagulase negative staphylococci in only a single positive culture

(5d) excluded: isolation of organisms not associated with endocarditis

(6) echocardiographic findings consistent with infective endocarditis but not sufficient to meet major criteria

(6a) nonoscillating target on aortic or mitral valve

(6b) nodular valve thickening of mitral valve

(6c) valve thickening with regurgitation in aortic and/or mitral valve

 

Performance:

• The Duke criteria are felt by some to be more sensitive than the Beth Israel criteria and to be highly specific (up to 99%).

• Nettles (1997) showed that the Duke criteria was more sensitive in cases of pathologically confirmed prosthetic valve endocarditis.