Duke Criteria for Infective Endocarditis
Why Use
Patients with IE can have a wide range of clinical features and the diagnosis can be challenging. This criteria is sensitive for disease detection, and has a high negative predictive value.
When to Use
Suspect IE and consider the Duke Criteria in patients with: Prolonged fever (Fever of Unknown Origin). Fever and vascular phenomena (stroke, limb ischemia, physical findings of septic emboli). Persistently positive blood cultures (2 or more). Prosthetic valves who are febrile. Injection drug users who are febrile. A pre-disposing heart condition who are febrile. Fever with a recent history of hospitalization.
Formula
Pearls / Pitfalls
Formal criteria to diagnose and stratify patients suspected of having infective endocarditis (IE) into “definite”, “possible”, and “rejected”. Should be applied to patients in whom there is a high clinical suspicion of IE. Negative cultures may be confounded by a recent history of treatment with antibiotics. The IE Mortality Risk Score can help risk stratify patients’ 6 month outcome once IE is confirmed.
Management
“Definite” IE: One or more Pathologic criteria, or 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. “Possible” IE: 1 major criterion and 1 minor criterion, or 3 minor criterion. “Rejected”: Firm alternative diagnosis explaining evidence of IE, or Resolution of IE symptoms with antibiotics for less than or equal to 4 days, or No pathological evidence of IE at surgery or autopsy, with antibiotic therapy < 4 days, or Does not meet criteria of “possible”, as above.
Critical Actions
Prior treatment with even a few days of antibiotics may mask pathological evidence of IE(micro-organisms in the tissue or histological evidence). Consider trans-esophageal echocardiography if the clinical suspicion is high and the patient is in the “possible” group. Consider IE, if previously not suspected, if persistently positive (2 or more) blood cultures. For patients who have subacute IE and are hemodynamically stable, empiric antibiotics can be avoided so that additional blood cultures can be obtained without the confounding effect of empiric treatment.
Advice
The diagnosis of infective endocarditis must be made as soon as possible to initiate therapy. “Definite”: Start antibiotic treatment based on guidelines and microbiology. Identify candidates who need surgical treatment. “Possible”: Use clinical judgment to decide if the patient has IE. Consider trans-esophageal echocardiography (TEE), if not done. Identify candidates who need surgical treatment. Examine the patient regularly to watch for major or minor signs of IE. Examine for physical findings suggestive of IE (Roth’s spots, Osler’s nodes, Janeway lesions. Draw blood cultures regularly if not positive earlier to look for microbiologic evidence. “Rejected”: Consider other causes of fever, like other infectious sources, or rheumatologic or oncologic.
More Information
These are technically the “modified” or “revised” Duke Criteria, which were updated in 2000. The updates included: “Possible” IE modified to include patients having 1 major and 1 minor criterion, or 3 minor criteria. Nosocomially acquired Staphylococcus aureus bacteremia also included. Coxiella burnetii criteria mentioned above included. Trans-esophageal echocardiography (TEE) recommended for patients with prosthetic valves, rated at least “possible” by clinical criteria, or complicated IE (paravalvular abcess); Trans-thoracic echocardiography (TTE) in other patients. Echocardiographic minor criteria eliminated.