MDCalc

Duke Criteria for Infective Endocarditis

Diagnostic criteria for endocarditis.

Check out the updated 2023 Duke-ISCVID criteria here!

Pathological Criteria

If either is positive, diagnosis is definite (see Evidence for exceptions)

Demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen.
Vegetation or intracardiac abscess confirmed by histologic examination showing active endocarditis.

Major Clinical Criteria

If both are positive, diagnosis is definite (see Evidence for exceptions)

Typical microorganisms consistent with IE from 2 separate blood cultures, microorganisms consistent with IE from persistently positive blood cultures, single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800.
Echocardiogram positive for IE, abscess, new partial dehiscence of prosthetic valve, new valvular regurgitation. Note: Worsening or changing of pre-existing murmur NOT sufficient.

Minor Clinical Criteria

If all are positive, diagnosis is definite (see Evidence for exceptions)

Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions.
Glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor.
Positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with IE.

Diagnostic Result

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Advice

The diagnosis of infective endocarditis must be made as soon as possible to initiate therapy.

“Definite”:

  • Start antibiotic treatment based on guidelines and microbiology.
  • Identify candidates who need surgical treatment.

“Possible”:

  • Use clinical judgment to decide if the patient has IE.
  • Consider trans-esophageal echocardiography (TEE), if not done.
  • Identify candidates who need surgical treatment.
  • Examine the patient regularly to watch for major or minor signs of IE.
  • Examine for physical findings suggestive of IE (Roth’s spots, Osler's nodes, Janeway lesions.
  • Draw blood cultures regularly if not positive earlier to look for microbiologic evidence.

“Rejected”:

  • Consider other causes of fever, like other infectious sources, or rheumatologic or oncologic.
Management

“Definite” IE:

  • One or more Pathologic criteria, or
  • 2 major criteria, or
  • 1 major and 3 minor criteria, or
  • 5 minor criteria.

“Possible” IE:

  • 1 major criterion and 1 minor criterion, or
  • 3 minor criterion.

“Rejected”:

  • Firm alternative diagnosis explaining evidence of IE, or
  • Resolution of IE symptoms with antibiotics for less than or equal to 4 days, or
  • No pathological evidence of IE at surgery or autopsy, with antibiotic therapy < 4 days, or
  • Does not meet criteria of “possible”, as above.
Critical Actions
  • Prior treatment with even a few days of antibiotics may mask pathological evidence of IE(micro-organisms in the tissue or histological evidence).
  • Consider trans-esophageal echocardiography if the clinical suspicion is high and the patient is in the “possible” group.
  • Consider IE, if previously not suspected, if persistently positive (2 or more) blood cultures.
  • For patients who have subacute IE and are hemodynamically stable, empiric antibiotics can be avoided so that additional blood cultures can be obtained without the confounding effect of empiric treatment.
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