Endocarditis diagnostic study of choice

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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.

Diagnostic Study of Choice

Study of choice

Sequence of Diagnostic Studies

The various investigations must be performed in the following order:

Endocarditis Fever Cardiac murmur leukocytosis CRP Blood culture Echo
Infective endocarditis
+ + + + +
  • Mobile mass,
  • Variable size
  • Localised on the auricular surface of the auriculoventricular valves or aortic surface of aortic valve
  • Valve abscess and rupture are common
Nonbacterial thrombotic endocarditis
  • Vegetations are typically small, <1 cm in diameter, broad based and irregular in shape.
  • Valve abscess and rupture uncommon

Duke Diagnostic Criteria For Infective Endocarditis

Definite infective endocarditis

  • Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
  • Clinical criteria
  • 2 major clinical criteria
  • 1 major and 3 minor clinical criteria
  • 5 minor clinical criteria

Possible infective endocarditis

  • 1 major and 1 minor clinical criteria


  • 3 minor clinical criteria

Rejected infective endocarditis

  • Presence of alternate diagnosis


  • Improving clinical manifestations with antibiotic therapy ≤4 days



  • 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
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

  • 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.


  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.

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