Duke criteria

At Duke University, clinical criteria for the diagnosis of infective endocarditis (IE) were drafted in 1994 and referred to as the "Duke criteria" (Erdmann 2006). Since then, these criteria have been modified several times (Herold 2022).

The modified Duke criteria represent a highly sensitive and specific diagnostic procedure for infective endocarditis (IE) (Kasper 2015). In addition, the Duke criteria can exclude the most important differential diagnoses of IE (Knirsch 2022).

The criteria are based on clinical, laboratory chemistry, imaging findings, and major or minor criteria (Knirsch 2022).

Sensitivity and specificity are around 80%. Subsequent modifications have resulted in a sensitivity for pediatric patients of nearly 90% (Knirsch 2022). For prosthetic valve endocarditis, the sensitivity is also 90% (Saha 2022).

The modified Duke criteria are defined as follows:

Main criteria are:

1. blood culture positive for IE:

• 1. a. Typical pathogens in at least 2 separate blood cultures such as.
  • Streptococcus bovis, Staphylococcus viridans or HACEK- group.
• or
  • Staphylococcus aureus "community-acquired".
• or
  • Enterococci without primary focus (Knirsch 2022)
• or
  • 1. b. Pathogens compatible with IE in multiple positive blood cultures:
  • at an interval of > 12 hours in at least 2 blood cultures
• or
  • Regardless of spacing in 3 or majority of ≥ 4 blood cultures.
• or
  • 1. c. A single culture positive for Coxiella burnetii or an increase in phase I IgG antibody titer to > 1: 800 (Knirsch 2022).

2. positive imaging for IE:

• 2. a. Echocardiographic evidence of:
  • Valve perforation or aneurysm.
  • Vegetation
  • new occurred dehiscence at a prosthetic valve
  • Pseudoaneurysm, intracardiac fistula, abscess (Knirsch 2022)
• or
• 2. b. F- FDG PET / CT or SPECT / CT:
  • abnormal activity in the position of a prosthetic valve after implantation > 3 months (Knirsch 2022)
• or
• 2. c. Cardiac computed tomography:
  • evidence of a paravalvular lesion (Knirsch 2022)

Secondary criteria are:

• 3. a. Predisposing conditions such as Z. n. IE, history of known cardiac defect, i. v. drug abuse, etc. (Knirsch 2022)
• 3. b. > 38 degrees C fever (Knirsch 2022).
• 3. c. Vascular phenomena (including detected in imaging) such as:
  • septic pulmonary infarction
  • arterial embolism
  • intracranial hemorrhage
  • mycotic aneurysms
  • Janeway lesions
  • conjunctival hemorrhage (Knirsch 2022)
• 3. d. Occurrence of immunological changes such as:
  • Osler nodules
  • Glomerulonephritis
  • Rheumatoid factors
  • Roth spots (Knirsch 2022)
• 3. e. Microbiological evidence by:
  • positive blood cultures, but not fulfilling the main criteria
• or
  • serological evidence of active infection by pathogens compatible with IE (Knirsch 2022)

The diagnosis is considered confirmed in the presence of:

• 2 main criteria

or

• 1 major criterion and 3 minor criteria

or

• 5 secondary criteria (Knirsch 2022)

or

Pathologic criteria for the definite presence of an IE are met such as:

• histological evidence of IE

or

• microbiological evidence of IE

or

• histological preparation with evidence of active endocarditis (Knirsch 2022).

There is a suspected diagnosis of:

• 1 major criterion and 1 minor criterion.

or

• 3 minor criteria (Knirsch 2022)

If the Duke criteria are not met, IE cannot be ruled out. This is only the case if (Girndt 2022):

• Resolution of symptoms after ≤ 4 days of antibiotic therapy.

or

• Existence of a clear alternative diagnosis

or

• the criteria of a possible IE are not fulfilled

or

• Lack of pathologic evidence at surgery or autopsy after ≤ 4 days of antibiotic therapy (Knirsch 2022).

If only a possible but not definite IE is present when using the modified Duke criteria, repeated testing of the Duke criteria and, if necessary, supplementary diagnostics are recommended (Knirsch 2022).

1. Erdmann E (2006) Clinical cardiology: diseases of the heart, circulation, and cardiac vessels. Springer Medizin Verlag Heidelberg 590
2. Girndt M, Michl P (2022) Internal medicine high 2. Elsevier Urban und Fischer Verlag Germany 361.
3. Herold G et al (2022) Internal medicine. Herold Publishers 160 - 161
4. Kasper D L, Fauci A S, Hauser S L, Longo D L, Jameson J L, Loscalzo J et al (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education 819
5. Knirsch W, Mackenzie C R, Schäfers H J, Heying R, Turarel O, Rickers C. (2022) Infective endocarditis and endocarditis prophylaxis. German society for pediatric cardiology and congenital heart defects e. V. S2k-guideline.
6. Saha S, Schnackenburg P, Sadoni S, Joskowiak D, Hagl C (2022) Infective endocarditis. Die Kardiologie 16, 483 - 493