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New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings

  • David T. Durack
    Correspondence
    Request for reprints should be addressed to David T. Durack, M.B., D. Phil., Box 3867, Division of Infectious Disease and International Health, Duke University Medical Center, Durham, North Carolina 27710.
    Affiliations
    Department of Medicine Durham, North Carolina 27710 USA
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  • Author Footnotes
    1 Support was also provided by the American Heart Association.
    ,
    Author Footnotes
    2 Adrea Lukes and David Bright are each the recipient of a Stead Scholarship.
    Andrea S. Lukes
    Footnotes
    1 Support was also provided by the American Heart Association.
    2 Adrea Lukes and David Bright are each the recipient of a Stead Scholarship.
    Affiliations
    Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina 27710 USA
    Search for articles by this author
  • Author Footnotes
    2 Adrea Lukes and David Bright are each the recipient of a Stead Scholarship.
    David K. Bright
    Footnotes
    2 Adrea Lukes and David Bright are each the recipient of a Stead Scholarship.
    Affiliations
    Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina 27710 USA
    Search for articles by this author
  • Author Footnotes
    * The Duke Endocarditis Service is comprised of Mark J. Alberts, M.D., Thomas M. Bashore, M.D., G. Ralph Corey, M.D., James M. Douglas, M.D., Linda Gray, M.D., Frank E. Harrell, Jr., Ph.D., J. Kevin Harrison, M.D., Sheila A. Heinle, M.D., Arthur Morris, M.D., Joseph A. Kisslo, M.D., L.M. Nicely, R.C.V.T., Newland Oldham, M.D., Lisa M. Penning, B.S., Daniel J. Sexton, M.D., Michael Towns, M.D., and Robert A. Waugh, M.D., Durham, North Carolina.
    Duke Endocarditis Service
    Footnotes
    * The Duke Endocarditis Service is comprised of Mark J. Alberts, M.D., Thomas M. Bashore, M.D., G. Ralph Corey, M.D., James M. Douglas, M.D., Linda Gray, M.D., Frank E. Harrell, Jr., Ph.D., J. Kevin Harrison, M.D., Sheila A. Heinle, M.D., Arthur Morris, M.D., Joseph A. Kisslo, M.D., L.M. Nicely, R.C.V.T., Newland Oldham, M.D., Lisa M. Penning, B.S., Daniel J. Sexton, M.D., Michael Towns, M.D., and Robert A. Waugh, M.D., Durham, North Carolina.
    Search for articles by this author
  • Author Footnotes
    1 Support was also provided by the American Heart Association.
    2 Adrea Lukes and David Bright are each the recipient of a Stead Scholarship.
    * The Duke Endocarditis Service is comprised of Mark J. Alberts, M.D., Thomas M. Bashore, M.D., G. Ralph Corey, M.D., James M. Douglas, M.D., Linda Gray, M.D., Frank E. Harrell, Jr., Ph.D., J. Kevin Harrison, M.D., Sheila A. Heinle, M.D., Arthur Morris, M.D., Joseph A. Kisslo, M.D., L.M. Nicely, R.C.V.T., Newland Oldham, M.D., Lisa M. Penning, B.S., Daniel J. Sexton, M.D., Michael Towns, M.D., and Robert A. Waugh, M.D., Durham, North Carolina.
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      Abstract

      purpose: This study was designed to develop improved criteria for the diagnosis of infective endocarditis and to compare these criteria with currently accepted criteria in a large series of cases.
      patients and methods: A total of 405 consecutive cases of suspected infective endocarditis in 353 patients evaluated in a tertiary care hospital from 1985 to 1992 were analyzed using new diagnostic criteria for endocarditis. We defined two “major criteria” (typical blood culture and positive echocardiogram) and six “minor criteria” (predisposition, fever, vascular phenomena, immunologic phenomena, suggestive echocardiogram, and suggestive microbiologic findings). We also defined three diagnostic categories: (1) “definite” by pathologic or clinical criteria, (2) “possible,” and (3) “rejected.” Each suspected case of endocarditis was classified using both old and new criteria. Sixty-nine pathologically proven cases were reclassified after exclusion of the surgical or autopsy findings, enabling comparison of clinical diagnostic criteria in proven cases.
      results: Fifty-five (80%) of the 69 pathologically confirmed cases were classified as clinically definite endocarditis. The older criteria classified only 35 (51%) of the 69 pathologically confirmed cases into the analogous probable category (p <0.0001). Twelve (17%) pathologically confirmed cases were rejected by older clinical criteria, but none were rejected by the new criteria. Seventy-one (21%) of the remaining 336 cases that were not proven pathologically were probable by older criteria, whereas the new criteria almost doubled the number of definite cases, to 135 (40%, p <0.01). Of the 150 cases rejected by older criteria, 11 were definite, 87 were possible, and 52 were rejected by the new criteria.
      conclusion: Application of the proposed new criteria increases the number of definite diagnoses. This should be useful for more accurate diagnosis and classification of patients with suspected endocarditis and provide better entry criteria for epidemiologic studies and clinical trials.
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