Endocarditis diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


The Duke criteria can be used to establish the diagnosis of endocarditis.[1]

Duke Clinical Criteria for the Diagnosis of Infective Endocarditis

Definitive Evidence

Pathological Criteria

  • Microorganisms demonstrated by culture or histological examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen
  • Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis

Criteria for Rejecting the Diagnosis

  • Firm alternate diagnosis to infective endocarditis
  • Resolution of infective endocarditis syndrome in under 4 days on antibiotics
  • Does not meet the criteria below

Criteria for Definitive Endocarditis

The Duke Clinical Criteria for definitive infective endocarditis require either:

  • Two major criteria
  • One major and three minor criteria
  • Five minor criteria

Major Criteria

1. Positive Blood Culture for Infective Endocarditis

A. Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, as noted below:
Template:Unicode Viridans streptococci, Streptococcus bovis, or
Template:Unicode HACEK group, or
Template:Unicode Community-acquired Staphylococcus aureus or enterococci, in the absence of a primary focus
B. Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:
Template:Unicode 2 positive cultures of blood samples drawn >12 hours apart, or
Template:Unicode 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:
Template:Unicode Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or
Template:Unicode On implanted material in the absence of an alternative anatomic explanation, or
Template:Unicode Abscess, or
Template:Unicode New partial dehiscence of prosthetic valve
Template:Unicode New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Minor criteria:

Template:Unicode Predisposition: predisposing heart condition or intravenous drug use
Template:Unicode Fever: temperature > 38.0° C (100.4° F)
Template:Unicode Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
Template:Unicode Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor
Template:Unicode 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 infectious endocarditis
Template:Unicode 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. Studies have evaluated the pre-test probability of endocarditis based upon signs and symptoms to predict occult endocarditis among patients with intravenous drug abuse[2][3][4] and among non drug abusing patients [5][6]. 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 [6] 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 [5] 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[4]. Weisse[2] found that 13% of 121 patients had endocarditis. Marantz [4] also found a prevalence of endocarditis of 13% among such patients in the emergency room with fever. Samet [3] 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[7]. However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance.


  1. Durack D, Lukes A, Bright D (1994). "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 96 (3): 200–9. PMID 8154507.
  2. 2.0 2.1 Weisse A, Heller D, Schimenti R, Montgomery R, Kapila R (1993). "The febrile parenteral drug user: a prospective study in 121 patients". Am J Med. 94 (3): 274–80. PMID 8452151.
  3. 3.0 3.1 Samet J, Shevitz A, Fowle J, Singer D (1990). "Hospitalization decision in febrile intravenous drug users". Am J Med. 89 (1): 53–7. PMID 2368794.
  4. 4.0 4.1 4.2 Marantz P, Linzer M, Feiner C, Feinstein S, Kozin A, Friedland G (1987). "Inability to predict diagnosis in febrile intravenous drug abusers". Ann Intern Med. 106 (6): 823–8. PMID 3579068.
  5. 5.0 5.1 Leibovici L, Cohen O, Wysenbeek A (1990). "Occult bacterial infection in adults with unexplained fever. Validation of a diagnostic index". Arch Intern Med. 150 (6): 1270–2. PMID 2353860.
  6. 6.0 6.1 Mellors J, Horwitz R, Harvey M, Horwitz S (1987). "A simple index to identify occult bacterial infection in adults with acute unexplained fever". Arch Intern Med. 147 (4): 666–71. PMID 3827454.
  7. Kaech C, Elzi L, Sendi P, Frei R, Laifer G, Bassetti S, Fluckiger U (2006). "Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre". Clin Microbiol Infect. 12 (4): 345–52. doi:10.1111/j.1469-0691.2005.01359.x. PMID 16524411.

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