Modified Duke Criteria for Infective Endocarditis

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Clinical Use

Assist diagnosis of infective endocarditis 

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Definition of terms in Modified Duke Criteria for the diagnosis of infective endocarditis
Major criteria

  1. Blood culture positive for IE
    1. Typical microorganisms consistent with IE from 2 separate blood culture
      • Viridans streptococci, Streptococcus bovis, HACEK group, Stapylococcus aureus; or
      • Community- acquired enterococci, in the absence of a primary focus; or
    2. Microorganism consistent with IE from persistently positive blood cultures, defined as follows:
      • At least 2 positive cultures of blood samples drawn >12 h apart; or
      • All of 3 or a majority of ≥4 separate cultures of blood (with first and last sample drawn at least 1h apart)
    3. Single positive blood culture for Coxiella burnetii or antiphase I Ig G antibody titer >1>800
  2. Evidence of endocardial involvement
    1. Echocardiogram positive for IE (TEE recommended in patient with prosthetic valves; rated at least „possible” IE by clinical criteria or complicated IE (paravalvular abscess); TTE as first test in other patients), defined as follows :
      • Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or
      • Abscess; or
      • New partial dehiscence of prosthetic valve
    2. New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)

Minor criteria

  • Predisposition, predisposing heart condition or injection drug use
  • Fever, temperature >38°C
  • Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages and Janeway’s lesions
  • Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots and rheumatoid factor
  • Microbiological evidence: positive blood culture but does not meet a major criterion as noted above* or serological evidence of active infection with organism consistent with IE
*Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis

 

Modified Duke Criteria
Definite infective endocarditis
Pathological criteria

  • Microorganism: demonstrated by culture or histology in a vegetation or in a vegetation that has embolized, or in a intracardiac abscess or
  • Pathologic lesions : vegetation or intracardiac abscess present confirmed by histology showing active endocarditis

Clinical criteria, using specific definitions for these terms as listed in the table above

  • 2 major criteria, or
  • 1 major and 3 minor,
  • or 5 minor

Possible infective endocarditis, at least

  • 1 major and 1 minor, or
  • 3 minor

Rejected

  • Firm alternate diagnosis explaining evidence of infective endocarditis, or
  • Resolution of infective endocarditis syndrome, with antibiotic therapy for 4 days or less, or
  • No pathologic evidence of infective endocarditis at surgery or autopsy, with antibiotic therapy for 4 days or less

Definitions

† Viridans streptococci, Streptococcus bovis, HACEK group, Stapylococcus aureus OR Community- acquired enterococci, in the absence of a primary focus

‡ At least 2 positive cultures of blood samples drawn >12 h apart, OR All of 3 or a majority of ≥4 separate cultures of blood (with first and last sample drawn at least 1h apart)

º TEE recommended as first test in 1) prosthetic valve endocarditis; or 2) those with at least “possible” endocarditis by clinical criteria; or 3) those with suspected complicated endocarditis, such as paravalvular abscess. TTE recommended as first test in all other patients.

References

1. Li SJ, Sexton DJ, Mick N, Nettles R, Fowler VG, Jr, Ryan T, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633–638. Full text

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Developer: Sirikarn Napan, MD, FACC