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.
- The following result of echocardiogram is confirmatory of endocarditis:
- For more information, click here.
- Among the patients who present with clinical signs of endocarditis, transoesophageal echo (TEE) has a higher sensitivity (90%) in comparison to transthoracic echo (TTE).
Duke Diagnostic Criteria For Infective Endocarditis
Definite infective endocarditis
- Pathological Criteria[1][2]
- 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 of clinical manifestations with antibiotic therapy ≤4 days
OR
- No pathologic evidence of infective endocarditis is 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.[3][4][5][6][7]
- 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 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
- ↑ 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.
- ↑ 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.