Duke Criteria for Infectious Endocarditis Diagnosis

Aka: Duke Criteria for Infectious Endocarditis Diagnosis, Endocarditis Diagnosis, Modified Duke Criteria for Infectious Endocarditis

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II. Indications

  1. Bacterial Endocarditis Diagnosis

III. Background

  1. Duke Criteria
    1. Duke Criteria were originally released in 1994
    2. Modified Duke Criteria were released in 2000 and are summarized on this page
  2. Additional Diagnostic Criteria
    1. ESC Criteria (2015) added PET-CT and Cardiac CT to diagnostic options
    2. Duke ISCVID Criteria (2023) made additional modifications (not included on this page)
      1. Added additional causative Bacteria (including e. faecalis and most Streptococcus species)
      2. Added additional molecular diagnostics
      3. Added surgical major criteria
      4. Reduced Blood Culture restrictions (e.g. Blood Culture timing)

IV. Criteria: Endocardititis causative organisms (used in criteria below)

  1. Viridans Streptococcus
  2. Staphylococcus aureus
  3. Streptococcus gallolyticus (previously Streptococcus bovis) and variants (Granulicatella, Abiotrophia defectiva)
  4. Community-acquired enterococci without findings of primary focus
  5. Gram negative HACEK Bacilli
    1. Haemophilus species
    2. Aggregatibacter (previously ActinobacillusActinomycetes comitans)
    3. Cardiobacterium hominis
    4. Eikenella corrodens
    5. Kingella kingae

V. Criteria: Major

  1. Positive Blood Culture
    1. Two separate Blood Cultures positive for causative organisms or
    2. Two Blood Cultures drawn >12 hours apart demonstrate causative organism or
    3. Blood Cultures drawn with at least 3/3 or 3/4 positive for typical skin contaminant Bacteria
      1. Samples must be separated in time, with >1 hour between first and last blood draw or
    4. Single Blood Culture positive for Coxiella Burnetii or
    5. Phase 1 Immunoglobulin GAntibody titer >1:800
  2. Endocardial involvement
    1. New valvular regurgitation (beyond simply a change in pre-existing murmur) or
    2. Positive Echocardiogram
      1. Intracardiac abscess or
      2. New partial dehiscence of prosthetic valve or
      3. Oscillating intracardiac mass without an alternative anatomic explanation
        1. On valve
        2. On supporting structures
        3. In path of regugitant jets
        4. On implanted material

VI. Criteria: Minor

  1. Fever (>38 C or 100.4 F)
  2. Predisposing condition
    1. Heart Valve Disorder
    2. IV Drug Abuse
  3. Immunologic findings
    1. Focal Segmental Glomerulonephritis
    2. Osler Nodes
    3. Roth Spots
    4. Rheumatoid Factor
  4. Microbiologic findings
    1. Positive Blood Culture that does not meet major criteria
    2. Serologic evidence of active infection with endocarditis causative organism (see above list)
  5. Vascular findings
    1. Major arterial emboli
    2. Septic Pulmonary Infarctions
    3. Mycotic aneurysm
    4. Intracranial Hemorrhage
    5. Conjunctival Hemorrhage
    6. Janeway Lesion
      1. Blanching, erythematous, painless hemorrhagic Nodules on palms or soles
    7. Petechiae on mucus membranes (mouth, Conjunctiva)
      1. Non-specific, but most common skin finding on presentation
    8. Splinter Hemorrhages
      1. Non-blanching linear lesions beneath nails

VII. Interpretation: Endocarditis Diagnosis

  1. Definitive Endocarditis Diagnosis
    1. Pathology specimens (Microorganisms, vegetations, intracardiac abscess) from surgery or autopsy OR
    2. Clinical Criteria (one of the following)
      1. Two major criteria or
      2. One major criteria and three minor criteria or
      3. Five minor criteria
  2. Possible Endocarditis Diagnosis
    1. One major criteria and 1-2 minor criteria OR
    2. Three minor criteria
  3. Rejected Diagnosis (findings NOT consistent with Infective Endocarditis)
    1. Firm alternative diagnosis is established instead of Infectious Endocarditis OR
    2. Resolution of findings with <=4 days of Antibiotic therapy OR
    3. No evidence of Infective Endocarditis at surgery or autopsy and <=4 days of Antibiotic therapy OR
    4. Does not meet definitive or possible Endocarditis Diagnosis criteria (see above)

VIII. References

  1. Baloor and Nayak (2018) Exam Preparatory Manual for Undergraduate Medicine, Jaypee Brothers Medical Publication
  2. Durack (1994) Am J Med 96(3): 200-9 [PubMed]
  3. Li (2000) Clin Infect Dis 30(4):633-8 [PubMed]

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