Assesment of the Duke criteria for the diagnosis of infective endocarditis after twenty-years. An analysis of 241 cases

Abstract

Background and aimsIn the absence of classical features (fever, cardiac murmur, and peripheral vascular stigmata) the diagnosis of infective endocarditis (IE) may be difficult. Current clinical guidelines for the diagnosis and management of IE recommend the use of modified Duke criteria. Correct and prompt diagnosis of IE is crucial for the treatment and outcome of the patients.The aim of this study was to evaluate the presence and the individual value of each criterion of the modified Duke criteria in our patients with infective endocarditis.MethodsWe performed a prospective observational study between January 2008 – June 2014, in which we enrolled consecutive adult patients admitted for suspicion of IE to the Hospital of Infectious Diseases and at the Heart Institute . We used and extensive database in order to collect demographic data, laboratory and echocardiography results, evolution and outcome of the patients. Using the modified Duke criteria we identified 3 categories of IE: definite, possible and rejected. In order to evaluate the importance of each criterion in the diagnosis of IE we tested two hypotheses. First, we excluded each criterion from the final diagnosis and we counted how many cases felt into a lower category. Second, after adding each major and minor criterion, we tested how many cases would have been classifiable as definite IE.ResultsThe study included 241 adult patients with a mean age 58.16 years and sex ratio male/female 1.94. According to the modified Duke criteria 137 patients had definite IE, 79 patients had possible IE and 25 cases had rejected IE We had blood cultures positive IE in 109 cases and blood culture negative IE (BCNE) in 132 (71.21%) cases. Antibiotic treatment prior to blood culture was recorded in 152 (63.07%) patients. In the absence of the echocardiography major criterion, 43% of cases would become possible. After extraction of major microbiological criterion, only one third of definite cases would become possible. Minor criteria such as fever and predisposition contributed to the diagnosis only in 10% of cases. In the presence of vascular or immunological phenomena, or in the presence of minor microbiological criterion, half of the possible IE cases could become possible.ConclusionTwenty-years after their launch, the Duke criteria for the diagnosis of IE continue to be important tools. Low index of suspicion of IE and inappropriate use of antibiotics may have a great negative impact on the diagnosis of IE. Nowadays, the scarcity of classical Osler manifestations - bacteremia, fever and peripheral stigmata - makes the diagnosis of IE a challenge.

Haemophilus parainfluenzaeendocarditis with systemic embolisation following maxillary sinusitis

“…Regarding our case, a clinical diagnosis of endocarditis was considered after suggestive clinical (persistent fever), imaging (signs of cerebral embolisation) and microbiological (isolation of the bacteria in several separate blood cultures) findings and before the echocardiographic identification of cardiac vegetations. As stated in the modified Duke criteria, the diagnosis of endocarditis is possible even in the absence of detectable valve vegetations, as in our case 3. The presence of bacteraemia by this agent should always warrant a transoesophageal echocardiogram to rule out endocarditis, as some studies have reported this condition in half of all H. parainfluenzae infections 4.…”

Laboratory Diagnosis of Infective Endocarditis

“…Blood cultures are negative in 2% to 40% of cases of endocarditis, with some studies reporting blood culture-negative rates up to 71% (4,5,(17)(18)(19). The causes of so-called "culture-negative endocarditis" fall into two categories: negative blood cultures due to concomitant or antecedent antibacterial therapy or the presence of an organism that does not grow in routine blood cultures, with the first being more common.…”

Prevalence of Staphylococcal Superantigens and their association among bacteremic and Infective Endocarditis patients in Egypt

“…The cornerstones of clinical diagnosis of IE rely on integration of clinical, microbiological, echocardiography and laboratory findings; these are underlined in the modified Duke criteria for diagnosis of IE. Several studies have reported the high sensitivity of the Duke criteria in the diagnosis of IE [29]. In the present study, the mean age of our patients was 33 ± 11.3 years.…”