Endocarditis diagnosis


 * Associate Editors-in-Chief:

Overview
The Duke Criteria can be used to establish the diagnosis of endocarditis.

Duke Clinical Criteria for the Diagnosis of Infective Endocarditis
The Duke Clinical Criteria for Infective Endocarditis requires either:


 * Two major criteria, or


 * One major and three minor criteria, or


 * Five minor criteria

1. Positive Blood Culture for Infective Endocarditis
Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, as noted below:


 * Viridans streptococci, Streptococcus bovis, or


 * HACEK group, or


 * Community-acquired Staphylococcus aureus or enterococci, in the absence of a primary focus

or

Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:
 * 2 positive cultures of blood samples drawn >12 hours apart, or


 * All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)

2. Evidence of endocardial involvement
Positive echocardiogram for infective endocarditis defined as:


 * 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

or


 * New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Minor criteria:

 * Predisposition: predisposing heart condition or intravenous drug use


 * Fever: temperature > 38.0° C (100.4° F)


 * Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions


 * Immunologic phenomena: glomerulonephritis, Osler's nodes,Roth spots, and rheumatoid factor


 * Microbiological evidence: positive blood culture but does not meet a major criterion as noted above (see footnote) or serological evidence of active infection with organism consistent with infectiosu endocarditis


 * Echocardiographic findings: consistent with infectious endocarditis but do not meet a major criterion as noted above

Footnote: It should be noted that the criteria exclude single positive cultures for coagulase-negative staphylococci, diphtheroids, and organisms that do not commonly cause endocarditis.

Pre-Test Probability of Endocarditis and When to Perform an Echocardiogram
In so far as the Duke Criteria rely heavily upon the results of echocardiography, it is important to know when to order an echocardiogram. Sutdies have evaluated the pre test probability of endocarditis based upon signs and symptoms to predict occult endocarditis among patients with intravenous drug abuse  and among non drug abusing patients. Unfortunately, this research is over 20 years old and it is possible that changes in the epidemiology of endocarditis and bacteria such as staphylococcus make the following estimates incorrectly low.

Among patients who do not use illicit drugs and have a fever in the emergency room, there is a less than 5% chance of occult endocarditis. Mellors in 1987 found no cases of endocarditis nor of staphylococcal bacteremia among 135 febrile patients in the emergency room. The upper confidence interval for 0% of 135 is 5%, so for statistical reasons alone, there is up to a 5% chance of endocarditis among these patients. In contrast, Leibovici found that among 113 non-selected adults admitted to the hospital because of fever there were two cases (1.8% with 95%CI: 0% to 7%) of endocarditis.

Among patients who do use illicit drugs and have a fever in the emergency room, there is about a 10% to 15% prevalence of endocarditis. This estimate is not substantially changed by whether the doctor believes the patient has a trivial explanation for their fever. Weisse found that 13% of 121 patients had endocarditis. Marantz also found a prevalence of endocarditis of 13% among such patients in the emergency room with fever. Samet found a 6% incidence among 283 such patients, but after excluding patients with initially apparent major illness to explain the fever (including 11 cases of manifest endocarditis), there was a 7% prevalence of endocarditis.

Among patients with staphylococcal bacteremia (SAB), one study found a 29% prevalence of endocarditis in community-acquired SAB versus 5% in nosocomial SAB. However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance.