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Definitions of infective endocarditis according to the 2023 Duke-ISCVID IE Criteria: Table B

Definitions of infective endocarditis according to the 2023 Duke-ISCVID IE Criteria: Table B
  1. Major criteria
  1. Microbiologic criteria (either positive blood cultures or positive laboratory test)
  1. Positive blood cultures (1 of the following):
    • Microorganisms that commonly cause IE* isolated from 2 or more separate blood culture sets
    • Microorganisms that occasionally or rarely cause IE, isolated from 3 or more separate blood culture sets
  1. Positive laboratory test (1 of the following):
    • Positive PCR or other nucleic acid-based techniqueΔ from blood for Coxiella burnetii, Bartonella spp, or Tropheryma whipplei
    • Coxiella burnetii antiphase I IgG antibody titer ≥1:800◊ or Coxiella burnetii isolated from a single blood culture
    • Indirect immunofluorescence assays for detection of IgM and IgG antibodies to Bartonella henselae or Bartonella quintana, with IgG titer ≥1:800◊
  1. Imaging criteria (either of the following):
  1. Echocardiography and/or cardiac CT imaging (any of the following):
    • Echocardiography and/or cardiac CT demonstrating vegetation§, valvular/leaflet perforation¥, valvular/leaflet aneurysm‡, abscess†, pseudoaneurysm**, or intracardiac fistula¶¶
    • Significant new valvular regurgitation on echocardiography, compared with previous imaging; worsening or changing of pre-existing regurgitation is not sufficient
    • New partial dehiscence of prosthetic valve (compared with previous imaging)
  1. [18F]-FDG PET/CT imaging
    • Abnormal metabolic activity involving a native or prosthetic valve (at least 3 months after implantation), ascending aortic graft (with concomitant evidence of valve involvement), intracardiac device leads, or other prosthetic materialΔΔ
  1. Surgical major criterion
  • Evidence of IE observed by direct inspection during cardiac surgery, in the absence of major microbiologic or imaging criteria, and in the absence of pathologic (microbiologic or histologic) criteria◊◊
  1. Minor criteria
  1. Predisposition
  • Previous history of IE
  • Prosthetic valve§§
  • Previous valve repair§§
  • Congenital heart disease¥¥
  • More than mild regurgitation or stenosis (of any etiology)
  • Endovascular CIED
  • Hypertrophic obstructive cardiomyopathy
  • Injection drug use
  1. Fever
  • Temperature ≥38.0°C (100.4°F)
  1. Vascular phenomena
  • Clinical or radiographic evidence of arterial emboli, septic pulmonary infarcts, cerebral or splenic abscess, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions, purulent purpura
  1. Immunologic phenomena
  • Positive rheumatoid factor, Osler nodes, Roth spots, or immune complex-mediated glomerulonephritis‡‡
  1. Microbiologic evidence (falling short of major criteria)
  1. Positive blood cultures for a microorganism consistent with IE but not meeting requirements for major criteria††
  2. Positive culture, PCR or other nucleic acid-based test (amplicon or shotgun sequencing, in situ hybridization) for an organism consistent with IE†† from a sterile body site other than cardiac tissue, cardiac prosthesis, or embolus; or a single finding of a skin bacterium by PCR on a valve or wire without additional clinical or microbiological supporting evidence
  1. Imaging criteria
  • Abnormal metabolic activity detected by [18F]-FDG PET/CT within 3 months of implantation of prosthetic valve, ascending aortic graft (with concomitant evidence of valve involvement), intracardiac device leads or other prosthetic material
  1. Physical examination criteria (if echocardiography is not available)
  • New valvular regurgitation identified on auscultation (based on expert opinion); worsening or changing of pre-existing murmur not sufficient

CIED: cardiac implantable electronic device; CT: computed tomography; [18F]-FDG PET/CT: 18-fluorodeoxyglucose positron emission tomography with computed tomography; IE: infective endocarditis; NVE: native valve endocarditis; PCR: polymerase chain reaction; PVE: prosthetic valve endocarditis.

* Microorganisms that commonly cause IE include:

  • Staphylococcus aureus
  • Staphylococcus lugdunensis
  • Enterococcus faecalis
  • All streptococcal species except for S. pneumoniae and S. pyogenes
  • Granulicatella and Abiotrophia spp
  • Gemella spp
  • HACEK group microorganisms (Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae)

In the setting of intracardiac prosthetic material, the following additional bacteria should be included as "typical" pathogens: coagulase negative staphylococci, Corynebacterium striatum, Corynebacterium jeikeium, Serratia marcescens, Pseudomonas aeruginosa, Cutibacterium acnes, non-tuberculous mycobacteria (especially M. chimaerae), and Candida spp.

¶ "Blood culture set" is defined as a simultaneously drawn pair of 1 aerobic and 1 anaerobic bottle. "Positive" blood culture set is defined as microbial growth from at least 1 of the bottles. Blood cultures from separate venipuncture sites are strongly recommended whenever possible for evaluating suspected IE.

Δ Amplicon (16S or 18S) or metagenomic (shotgun) sequencing.

◊ Or equivalent titer result with alternative methodology.

§ Vegetation refers to an oscillating intracardiac mass on a valve (or other cardiac tissue, endovascular CIED, or other implanted material), in the absence of an alternative anatomic explanation.

¥ Valvular/leaflet perforation refers to interruption of valvular endocardial tissue.

‡ Valvular/leaflet aneurysm refers to elongation with saccular outpouching of valvular tissue.

† Abscess refers to perivalvular (or perigraft) soft tissue lesion with variable degree of evolution to an organized collection.

** Pseudoaneurysm refers to perivalvular cavity communicating with the cardiovascular lumen.

¶¶ Intracardiac fistula refers to communication between 2 neighboring cardiac chambers through a perforation.

ΔΔ Abnormal FDG-PET metabolic activity for PVE (performed at least 3 months after surgical implantation) refers to intense, focal/multifocal or heterogeneous FDG uptake patterns. Abnormal metabolic activity for NVE and cardiac device leads refers to any abnormal uptake pattern. Some prosthetic valves may have intrinsic non-pathological FDG uptake; an isolated FDG-PET positive generator pocket in the absence of intracardiac infection does not qualify as a major criterion.

◊◊ Inclusion of the surgical criterion should not be interpreted as giving license to forgo sending appropriate samples for histopathology and microbiological studies.

§§ Prosthetic valve or previous valve repair via either open-heart surgical or transcatheter approach.

¥¥ Congenital heart disease includes cyanotic CHD (tetralogy of Fallot, univentricular heart, complete transposition, truncus arteriosus, hypoplastic left heart); endocardial cushion defects; ventricular septal defect; left-sided lesions (bicuspid aortic valve; aortic stenosis and insufficiency, mitral valve prolapse, mitral stenosis and insufficiency); right-sided lesions (Ebstein anomaly, anomalies of the pulmonary valve, congenital tricuspid valve disease); patent ductus arteriosus; and other congenital anomalies, with or without repair.

‡‡ Immune complex-mediated glomerulonephritis defined as either:

  • Unexplained presence of either acute kidney injury or acute on chronic kidney injury (defined below) plus 2 of the following: hematuria, proteinuria, cellular casts on inspection of urinary sediment, or serologic perturbations (hypocomplementemia, cryoglobulinemia, and/or presence of circulating immune complexes); or
  • Renal biopsy consistent with immune complex-mediated renal disease.

AKI: New unexplained reduction of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2.

Acute on chronic kidney injury: Reduction by at least 1 ordinal level of function: eg, from "moderately" to "severely" decreased or from "severely decreased" to "kidney failure".

Interpretive ranges for eGFR: Normal >60 mL/min/1.73 m2; moderately decreased 30 to 59 mL/min/1.73 m2; severely decreased 15 to 29 mL/min/1.73 m2; kidney failure <15 mL/min/1.73 m2.

†† This excludes single positive blood cultures or sequence-based assays for microorganisms which commonly contaminate blood cultures or rarely cause IE.

Adapted from: Vance G Fowler, Jr, et al. 'The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria.' Clinical Infectious Diseases (77) 4 (2023): 518-526, https://doi.org/10.1093/cid/ciad271. Reproduced by permission of Oxford University Press on behalf of the Infectious Diseases Society of America. Adapted by permission of Dr. Vance Fowler, Jr.
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