Endocarditis diagnostic study of choice
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The Duke criteria can be used to establish the diagnosis of endocarditis.
Diagnostic Study of Choice
Study of choice
- Echocardiogram is the gold standard test for the diagnosis of endocarditis.[1][2]
- The following result of echocardiogram is confirmatory of endocarditis:
- For more information, click here.
- Among the patients who present with clinical signs of endocarditis, transesophageal echo (TEE) has a higher sensitivity (90%) in comparison to transthoracic echo (TTE).
Sequence of Diagnostic Studies
The various investigations must be performed in the following order:
- History and symptom
- laboratory data
- Echocardiography
| Endocarditis | Fever | Cardiac murmur | leukocytosis | CRP | Blood culture | Echo |
|---|---|---|---|---|---|---|
|
+ | + | + | + | + |
|
|
− | − | − | −/+ | − |
|
Duke Diagnostic Criteria For Infective Endocarditis
Definite infective endocarditis
- Pathological Criteria[3][4][5][6][7]
- Microorganisms demonstrated by culture or histological examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen
- OR
- Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
- Clinical criteria
- 2 major clinical criteria
- OR
- 1 major and 3 minor clinical criteria
- OR
- 5 minor clinical criteria
- 5 minor clinical criteria
Possible infective endocarditis
- 1 major and 1 minor clinical criteria
OR
- 3 minor clinical criteria
Rejected infective endocarditis
- Presence of alternate diagnosis
OR
- Improving clinical manifestations with antibiotic therapy ≤4 days
OR
- No pathologic evidence of infective endocarditisis found at surgery or autopsy after antibiotic therapy for 4 days or less
OR
- Lack of clinical criteria for possible or definite infective endocarditis
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
- OR
- 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
- OR
- 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.[8][9][10][11][12]
- Studies 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 a 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.
References
- ↑ Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz C, Iversen S, Oelert H, Meyer J (1988). "Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study". Eur Heart J. 9 (1): 43–53. PMID 3345769.
- ↑ Shively B, Gurule F, Roldan C, Leggett J, Schiller N (1991). "Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis". J Am Coll Cardiol. 18 (2): 391–7. PMID 1856406.
- ↑ 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.
- ↑ Li, J. S.; Sexton, D. J.; Mick, N.; Nettles, R.; Fowler, V. G.; Ryan, T.; Bashore, T.; Corey, G. R. (2000). "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 30 (4): 633–638. doi:10.1086/313753. ISSN 1058-4838.
- ↑ Durack DT, Lukes AS, Bright DK (March 1994). "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am. J. Med. 96 (3): 200–9. doi:10.1016/0002-9343(94)90143-0. PMID 8154507.
- ↑ Prendergast BD (June 2004). "Diagnostic criteria and problems in infective endocarditis". Heart. 90 (6): 611–3. doi:10.1136/hrt.2003.029850. PMC 1768277. PMID 15145855.
- ↑ Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T, Bashore T, Corey GR (April 2000). "Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis". Clin. Infect. Dis. 30 (4): 633–8. doi:10.1086/313753. PMID 10770721.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.