Infective endocarditis: Duke criteria excluded better than von Reyn criteria.

Clinical bottom line (level 4)

  1. Roughly half of patients with suspected infective endocarditis were eventually diagnosed with it.
  2. Both von Reyn and Duke criteria were good at diagnosing infective endocarditis.
  3. Duke criteria was better at excluding infective endocarditis than von Reyn.
Cecchi et al: European Heart Journal 1997; 18: 1149-1156
Expires July 2003

The study

Setting: university hospital, Italy (1991 to 1994)

143 patients (aged range 17 to 75 years; mean 38, 64% male) suspected infective endocarditis. All patients were referred for echo within five days of admission

?independent unblinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • Final diagnosis was made on the basis of:
    • diagnosis at discharge
    • blind re-evaluation of echocardiographic tapes
    • final diagnosis at the time of the first control, three months after discharge. (28 cases confirmed by surgery or autopsy, 41 cases confirmed by 'clinical diagnosis)
Diagnostic test: (1) von Reyn criteria:
  • definite: direct evidence of infective endocarditis based on histology from surgery or autopsy or on bacteriology (Gram's stain or culture) of valvular vegetation or peripheral embolus
  • probable: (a) persistently positive blood culture, plus one of: new regurgitant murmur; predisposing heart disease and vascular phenomena (petechiae, splinter haemorrhages, conjunctival haemorrhages, Roth spots, Osler's nodes, Janeway lesions, aseptic meningitis, glomerulonephritis and pulmonary, CNS, coronary or peripheral emboli) . (b) negative or intermittently positive blood cultures plus three of the following: fever; new regurgitant murmur; vascular phenomena
  • possible: (a) persistently positive blood cultures plus one of the following: predisposing heart disease; vascular phenomena. (b) negative or intermittently positive blood cultures with all three of the following: fever; predisposing heart disease; valvular phenomena, (c) for viridans streptococcal cases only- at least two positive blood cultures without an extra-cardiac source and fever
  • rejected: (a) endocarditis unlikely- alternative diagnosis already apparent. (b) endocarditis likely, empiric antibiotic therapy warranted. (c) culture negative endocarditis diagnosed clinically, but excluded by post-mortem
(2) Duke criteria:
  • definite: any of: (a) pathological criteria: micro-organism- demonstrated by culture or histology in a vegetation, or in a vegetation that has embolised or in an intracardiac abscess or pathological lesions- vegetation or intracardiac abscess present confirmed by histology showing active endocarditis. (b) clinical criteria: any of (see below for definitions): two major criteria; one major and three minor criteria; five minor criteria
  • possible: findings consistent with infective endocarditis that fall short of 'definite' but not 'rejected'
  • rejected: any of: firm alternative diagnosis explaining evidence of infective endocarditis; resolution of infective endocarditis syndrome with antibiotic treatment for 4 or less days; no pathologic evidence of infective endocarditis at surgery or autopsy with antibiotic therapy for 4 or less days

  • Major criteria:
    • (1) positive blood culture for infective endocarditis: (a) typical microorganisms for infective endocarditis from two separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK group; commonly-acquired Staphylococcus aureus or enterococci in absence of primary focus. (b) persistently positive blood culture defined as a microorganism consistent with infective endocarditis from: blood cultures drawn more than 12 hours apart; all three, or a majority of 4 or more blood cultures with first and last drawn at least one hour apart
    • (2) evidence of endocardial involvement- positive echocardiogram for infective endocarditis: oscillating intracardiac mass on valve or supporting structure in the path of regurgitant jets or on iatrogenic devices in the absence of an alternative anatomical explanation; abscess; new partial dehiscence of prosthetic valve new valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)
  • Minor criteria:
    • predisposing heart condition or iv drug use
    • fever 38 ° C or more
    • vascular phenomenon- arterial embolism, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, Janeway lesions
    • immunological phenomena- glomerulonephritis, Osler's nodes, Roth spots
    • echocardiogram consistent with infective endocarditis but not meeting major criteria as noted previously, or serological evidence of active infection with organism consistent with infective endocarditis

The evidence

pre-test probability of infective endocarditis: 48%, (95% CI: 40% to 56%)

diagnostic test infective endocarditis no infective endocarditis LR
(95% CI)		 post-test probability
Duke criteria: definite 53 2 28
(7.2 to 110) 		96%
Duke criteria: possible 16 7 2.5
(1.1 to 5.6) 		70%
Duke criteria: rejected 0 65 0.0
(0.0 to 0.048) 		0.0%
total 69 74


diagnostic test infective endocarditis no infective endocarditis LR
(95% CI)		 post-test probability
von Reyn criteria: definite or probable 35 1 38
(5.3 to 270) 		97%
von Reyn criteria: possible 13 5 2.8
(1.1 to 7.4) 		72%
von Reyn criteria: rejected 21 68 0.33
(0.23 to 0.48) 		24%
total 69 74

  • All patients underwent transthoracic echocardiography.
  • A transoesophageal was performed in all patients with a prosthetic valve or when the transthoracic was not considered diagnostic.

Citation

  1. Cecchi E, et al: New diagnostic criteria for infective endocarditis. A study of sensitivity and specificity. European Heart Journal 1997; 18: 1149-1156
Search Terms: endocarditis and diagnosis
Contributor: Carl Heneghan, Sumit Dhingra and Chris Ball, July 2000
Reviewer:

Clinical Question.
Patient suspected infective endocarditis
Intervention or Exposure Duke criteria
Comparison von Reyn criteria
Outcome diagnosis