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Infective Endocarditis: Sensitivity and Specificity

Introduction: Endocarditis refers to bacterial infection of the heart valves, manifested by vegetations of bacteria growing on the valves. Endocarditis will cause bacteremia and septic emboli; it may also destroy the valve involved.

Nowadays, the Duke Criteria are the clinical 'gold standard' diagnostic test (though obviously, pathology is the true gold standard) - but note that the Duke criteria are certainly not completely sensitive and may be nonspecific, depending on the case series (see below). The two papers cited below disagree about whether 'possible' endocarditis by Duke criteria should be considered as truly positive or not.

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Tags: Cardiac Problem Infection Tag this Diagnosis.

Prevalence

Population / CalculatorPrevalence Comments / Study / Link
Patients given TTE with suspicion of endocarditis 4% Q J Med 2006; 99:2331. PMID 16330508
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The sensitivity and specificity of findings for Infective Endocarditis are listed below. See the left navigation bar to change the display.

Sensitive and Specific Findings

Finding SensitivitySpecificity Comments, Study
Trans-Esophageal Echocardiography Edit 94%100%

vegetation seen on TEE

Study: J Am Coll Cardiol 1991 Aug;18(2):391-7. PMID: 1856406

Duke Criteria
Duplicate Edit
100%88%

Definite or possible endocarditis by Duke criteria. Possible endocarditis: does not meet criteria for definite (see other entry) but also does not meet criteria for 'rejected', namely 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.

Other study found sens and spec of 96% and 36% ! (http://www.psmid.org.ph/vol26/vol26num4topic5.pdf)

Study: Eur Heart J. 1997 Jul;18(7):1149-56. PMID: 9243150

Specific Findings

Finding SensitivitySpecificity Comments, Study
Trans-Thoracic Echocardiography Edit 44%98%

Vegetation seen on TTE. However, sensitivity is ~96% if abnormal valvular function is the criterion, i.e. the sensitivity of an abnormal TTE is virtually as good as TEE (though specificity obviously would be lower in that case).

Study: J Am Coll Cardiol 1991 Aug;18(2):391-7. PMID: 1856406

Am J Cardiol 1996 Jul 1;78(1):101-3. PMID 8712097

Duke Criteria
Duplicate Edit
76%97%

Need: 2 major OR 1 major + 3 minor OR 5 minor

Major Criteria:

  • positive blood cx with typical organisms
  • vegetations on echo
  • new murmur
  • serology or culture of Coxiella burnetii
  • Minor Criteria:

  • fever
  • predisposing valvular problem or IV drug use
  • evidence of emboli
  • evidence of immune complex deposition
  • positive blood cultures of non-typical organisms
  • Other study found sens and spec of 86% and 82% (http://www.psmid.org.ph/vol26/vol26num4topic5.pdf)

    Study: Eur Heart J. 1997 Jul;18(7):1149-56. PMID: 9243150

    Von Reyn Criteria Edit 69%92%

    Definite, Probable, or Possible (less sens, more spec if disregard 'possible')

  • 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
  • Study: Eur Heart J. 1997 Jul;18(7):1149-56. PMID: 9243150

    Poorly Diagnostic Findings

    Finding SensitivitySpecificity Comments, Study
    Blood Cultures Edit 83%68%

    35% were S aureus, 35% were Strep viridans. Most false negatives had been treated with antibiotics prior to culture.

    Study: Q J Med 2006; 99:2331. PMID 16330508

    Osler's Nodes Edit Sensitivity = 10%

    This sensitivity is for any cutaneous manifestation.

    These represent an inflammatory response to deposited immune complexes. They are "red-purple, tender, slightly raised cutaneous nodules often with a pale center" most often occurring on the fingers and toes.

    Study: Q J Med 2006; 99:2331. PMID 16330508

    Janeway Lesion Edit Sensitivity = 10%

    This sensitivity is for any cutaneous manifestation.

    These represent septic microemboli. They are "usually non-tender, haemorrhagic macules or papules, located on the palms or soles, especially thenar and hypothenar eminences".

    Study: Q J Med 2006; 99:2331. PMID 16330508