Graduate Medical Education University of Pennsylvania Medical Center Guidelines for Antimicrobial Therapy

Modified Duke Infective Endocarditis Criteria

Criteria	Definite Infective Endocarditis	Possible Infective Endocarditis	Not Infective Endocarditis
Pathologic
Histologic	Vegetation or intracardiac abscess present, confirmed by histology showing active endocarditis	Short of definite, but not rejected	No pathologic evidence of infective endocarditis with antibiotic therapy for 4 days or less
OR
Bacteria	Demonstrated by culture or histology in a vegetation, or in a vegetation that has embolized, or in an intracardiac abscess	Short of definite, but not rejected	No pathologic evidence of infective endocarditis with antibiotic therapy for 4 days or less
Clinical - any one of following:			Resolution of manifestations of endocarditis, with antibiotic therapy for 4 days or less, or firm alternate diagnosis for manifestations of endocarditis. Does not meet criteria for possible infective endocarditis
Major criteria	2	Does not apply
Minor criteria	5	3
Major and minor	1 major + 3 minor	1 major and 1 minor

Major Criteria

A. Supportive laboratory evidence Typical microorganism for infective endocarditis from two separate blood cultures: viridans streptococci, Staphylococcus aureus, Streptococcus bovis, HACEK group (Haemophilus spp. Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae) or Community-acquired enterococci, in the absence of a primary focus

Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from blood cultures drawn more than 12 hours apart or Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from all of three or a majority of four or more separate blood cultures, with first and last drawn at least 1 hour apart.

Single positive blood culture for Coxiella burnetti or phase I antibody titer >1:800

B. Evidence of endocardial involvement Echocardiogram supportive of infective endocarditis. 1. Type of study TEE recommended as first test in the following patients: a) prosthetic valve endocarditis; or b) those with at least "possible" endocarditis by clinical criteria; or c) those with suspected complicated endocarditis, such as paravalvular abscess. TTE recommended as first test in all other patients 2. Definition of positive findings: oscillating intracardiac mass, on valve or supporting structures, or in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation or myocardial abscess or new partial dehiscence of prosthetic valve

C. New valvular regurgitation (increase or change in pre-existing murmur not sufficient).

Minor Criteria

Predisposing heart condition or intravenous drug use

Fever >= 38.0 C (100.4 F)

Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions

Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor

Positive blood culture not meeting major criterion as noted previously (Excluding single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of active infection with organism consistent with infective endocarditis

Modified from Li, et. al. Clin. Infect. Dis. 2000;30:633-8

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